Telemedicine: Networks in the Service of Healthcare

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

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Telemedicine

• Using telecommunications and computers to
  exchange information to support medical decision
  making
• Medical Records EMR and PHR
• Literature search
• Decision support
• Consultation and Conferencing

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Telemedicine

• Signal processing
• Physiologic samples
• Electrocardiogram
• Blood pressure
• Heart or chest sounds
• Image enhancement
• X-ray, CT, MRI
• Ultra-sound
• Skin lesions
• Patient visage

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Telemedicine

• Arrangements to practice medicine at a distance
• Network infrastructure
• Licensure / Credentialing
• Start-up Costs / Reimbursement / Long Term
  Financial Sustainability
• Re-engineering Practice / Clinical Acceptance
• Liability
• Security
• Privacy

HIPAA
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1971 Telemedicine to Alaska via satellite
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So whats new?
1994
1924
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TELEMedicine
The Internet
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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 http//www.nap.edu/catalog/5595.html
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Networking Health Prescriptions for the
Internet

• A study by theU.S. National Research
  CouncilComputer Science Technology Board
  http//www.nap.edu/catalog/9750.html

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Commodity Internet vs. NGN

• Current Internet
• Passive, unintelligent
• Best effort
• Next Generation Network
• Active, intelligent
• Guaranteed effort
• The difference
• Quality of Service - QoS

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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

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QoS Features for Healthcare

• Bandwidth reservation
• Low latency
• Low jitter
• Variable priority

• Data Integrity
• Selectable loss rate
• Security

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FCC Rural Health Care Pilot Program

• 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 for up to 85 percent of
  an applicants 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.gov www.usac.org
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University Corporation for Advanced Internet
Development (UCAID)sponsoredInternet2 Program

1996
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University Members 209 Members as of October 2007
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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/PIONIE
R (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)
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National LambdaRail (NLR) vs. Internet2
NewNet
www.nlr.net www.internet2.edu

• Non-profit nationwide optical ISP including
  optical switching
• Dense Wave Division Multiplexing (DWDM)
  technology
• 160 lambda (?) at 10 Gbps per fiber pair
• 1 Gbps Ethernet-like sub-lambda availability
• Cisco hardware
• Network research channels available
• No acceptable use policy (AUP)

• University based membership network
  organization
• DWDM techology
• 80 lambda at 10 Gbps per lambda
• Sub-lambda availability
• No vendor hardware preference, best of breed
• 100 Gbps interfaces
• Network access for management research
• Non-restrictive AUP

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Multicast
Unicast
Broadcast
Multicast
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IPv6 Necessary for greater security but not
sufficient

• IPv6 - 128 bit (3.438) address space vs.
• IPv4 - 32 bit (4.39) address space
• Less processing of packets within the network and
  easier security because IP address remains
  constant end to end
• Less need for firewalls or proxies

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The Network and Telemedicine
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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.

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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 nations healthcare, health education,
and health research systems in such areas as
cost, quality, usability, efficacy and security.
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A Comprehensive Tele-dermatology Program
Oregon Health Sciences University, Portland, OR
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University of Alaska at Anchorage, Anchorage, AK
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Baby CareLink
Beth Israel Deaconess Medical Center, Boston, MA
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Video house calls for patients with special
needs

• National Laboratory for the Study of Rural
  Telemedicine,
• University of Iowa, Iowa City, IA

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Providing Healthcare to the Underserved
Center-City
University of Southern California Advanced
Biotechnical Consortium Drew University School of
Medicine Los Angeles, CA
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Telemammography 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
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Radiation Oncology Treatment Planning/Care
Delivery Application

• Develop, implement, and evaluate NGI capabilities
  for radiation oncology treatment planning and
  care delivery.
• Application will provide diagnostic support,
  treatment planning, and remote verification of
  equipment from Cancer Center to a remote
  treatment facility.
• Focus on quality of service, security, privacy,
  and data integrity.

Johns Hopkins University Applied Physics
Laboratory, Laurel, MD Peninsula Regional
Medical Center, Salisbury, MD
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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
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Evidence Based Medicine SMS, Text Messaging
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
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
carpal tunnel syndrome. At one year local
steroid injection is as effective as surgical
decompression for symptomatic relief.
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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

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Lessons Learned - Patients 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

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Lessons Learned - Providers 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

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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

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Home (Consumer) TelemedicineThe 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.

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• 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
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• GUIDELINES Developing design guidelines that
  will provide vendors with the information needed
  to build interoperable sensors, home networks,
  health compute platforms, and health wellness
  services.
• CERTIFICATION LOGO Establishing a product
  certification program with a consumer
  recognizable logo signifying the promise of
  interoperability with other certified products.
• FDA EU REGULATIONS Collaborating with
  government regulatory agencies to provide methods
  for safely and effectively managing diverse
  vendor solutions.
• REIMBURSEMENT Working with leaders in the
  healthcare industries to develop new ways of
  addressing the costs of providing personal health
  systems.

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Telemedicine

• People
• Patients
• Providers
• Payers

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Telemedicine Resources

• American Telemedicine Association (ATA)
• www.atmeda.org
• Association of Telehealth Service Providers
  (ATSP)
• 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
• Telemedicine Information Exchange (TIE)
• tie.telehealth.org

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The only way to predict the future is to invent
it. Lister Hill Center National Center for
Biomedical Communications
http//www.nlm.nih.gov