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Telemedicine: Networks in the Service of Healthcare

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Security and medical data privacy. Nomadic computing. Network management ... Ensure medical data privacy and security. Kennedy Krieger Research Institute, ... – PowerPoint PPT presentation

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Title: Telemedicine: Networks in the Service of Healthcare


1
TelemedicineNetworks in the Service of
Healthcare
Michael J. Ackerman, Ph.D. Assistant
Director High Performance Computing and
Communications National Library of Medicine
2
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
3
TELEMedicine
4
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

5
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

6
Telemedicine
  • Signal processing
  • Physiologic samples
  • Electrocardiogram
  • Blood pressure
  • Heart or chest sounds
  • Image enhancement
  • X-ray, CT, MRI
  • Ultra-sound
  • Skin lesions
  • Patient visage

7
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
8
History of Telemedicine
  • Long undocumented history of providing
    information at a distance
  • U. Nebraska Psychiatry in the early 1960s
  • Massachusetts General Hospital project with
    Bostons Logan Airport in 1968

9
1971 Telemedicine to Alaska via satellite
10
So whats new?
1994
1924
11
TELEMedicine
The Internet
12
Networking Health Prescriptions for the
Internet
  • A 2000 study by theU.S. National Research
    CouncilComputer Science Technology Board
    http//www.nap.edu/catalog/9750.html

13
Commodity Internet vs. NGN
  • Current Internet
  • Passive, unintelligent
  • Best effort
  • Next Generation Network
  • Active, intelligent
  • Guaranteed effort
  • The difference
  • Quality of Service - QoS

14
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

15
QoS Features for Healthcare
  • Bandwidth reservation ( DCN )
  • Low latency
  • Low jitter
  • Variable priority
  • Data Integrity
  • Selectable loss rate
  • Security

16
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
17
University Corporation for Advanced Internet
Development (UCAID)sponsoredInternet2 Program

1996
18
University Members 212 Members as of March 2008
19
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20
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)
21
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

22
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.

23
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

24
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.
25
A Comprehensive Tele-dermatology Program
Oregon Health Sciences University, Portland, OR
26
University of Alaska at Anchorage, Anchorage, AK
27
Baby CareLink
Beth Israel Deaconess Medical Center, Boston, MA
28
Video house calls for patients with special
needs
  • National Laboratory for the Study of Rural
    Telemedicine,
  • University of Iowa, Iowa City, IA

29
Providing Healthcare to the Underserved
Center-City Tele-ophthalmology
University of Southern California Advanced
Biotechnical Consortium Drew University School of
Medicine Los Angeles, CA
30
Tele-Radiology
  • Most common form of telemedicine
  • Fits workflow of radiology departments
  • Reimbursable
  • First to have clear standards for Telemedicine
  • Imaging equipment
  • Communications (DICOM)

31
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
32
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
33
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
34
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

35
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

36
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

37
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

38
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

39
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
  • Sensor technology

40
Changes likely to drive the future models
telemedicine Governmental Cultural
  • Consumer expectations of best practices and
    access to best specialists
  • Next generations 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

41
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 to telcos for up to 85
    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
42
Sites included in RHCPP
43
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

44
Communications 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.
45
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.
  • Smart Car next?

46
  • 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
47
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48
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49
  • 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.

50
Teledoc
Robodoc
51
Telesurgery
Davinci robot
52
Telemedicine
  • People
  • Patients
  • Providers
  • Payers

53
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54
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

55
The only way to predict the future is to invent
it. Lister Hill Center National Center for
Biomedical Communications
http//www.nlm.nih.gov
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