Transcript AIDS/HIV -TELEMEDICINE

AIDS/HIV
-TELEMEDICINE
Athina Stravodimou
Supervisor: Dr.Ernest L Carter MD PhD
I. Overview
II. Marketing
III. Workflow
IV. Medical Peripherals
V. Telecommunications
VI. Financials
OVERVIEW
• The current medical system provides medical
services to patients who visit hospitals. However,
medical services can be provided at or close to the
home of the patient using fully equipped mobile
telemedicine systems. Such a system can identify
the disease at an early stage, improve quality of
life and prognosis through early diagnosis and
treatment, and reduce the costs of medical
service. Furthermore, the unit can provide mass
screenings of the population, as well as full medical
service to remote areas.
Estimated number of people living with
HIV/AIDS
In 2001 and during the first quarter of 2002, UNAIDS and WHO worked closely with
national governments and research institutions to recalculate current estimates on people
living with HIV/AIDS. These calculations are based on the previously published estimates
for 1997 and 1999 and recent trends in HIV/AIDS surveillance in various populations. A
methodology developed in collaboration with an international group of experts was used
to calculate the new estimates on prevalence and incidence of HIV and AIDS deaths,
as well as the number of children infected through mother-to-child transmission of HIV.
Different approaches were used to estimate HIV prevalence in countries with low-level,
concentrated or generalized epidemics. The current estimates do not claim to be an exact
count of infections. Rather, they use a methodology that has thus far proved accurate in
producing estimates which give a good indication of the magnitude of the epidemic in
individual countries. However, these estimates are constantly being revised as countries
improve their surveillance systems and collect more information.
MARKETING
Aids sufferers have tripled in
Greece over the last decade
• The number of Aids sufferers has tripled in Greece over the last
decade, while Greece currently holds fifth position in Europe
concerning the ratio of AIDS sufferers and population after being in
eighth place six years ago.
• The revelation was made by the president of the Special Infectious
Diseases Control Center, who said the total number of deaths and
patients approached 5.000 people in the last decade, 70 of whom are
children.
• He expressed fears that AIDS sufferers are more than initially
estimated in Greece, adding that all cases have not been declared to
enable an overall picture of the problem to be created.
• It appears that the age bracket having the greatest disk is that
between 25-35 and concerns both homosexual and bisexual men.
Assessment of the epidemiological
situation ( 2002)
Through December 2001, a cumulative total of
5,859 HIV seropositive persons, 2,254 AIDS
cases and 1,299 deaths from AIDS have been
reported at national level. Among newly
reported HIV cases during 2000-2001 period,
26,94 % are men who have sex with other men
(MSM),17,78 % heterosexuals and 2,98% IDUs.
The route of transmission is yet to be
determined in 51,86% of cases.
GREECE
Population pyramid, 2001
Indicators
Year
Eastimate
Source
Total population (thousands)
2001
10.623
UNPOP
Population aged 15-49 (thousands)
2001
5.269
UNPOP
0.3
UNPOP
60
UNPOP
0.6
UNPOP
WHO
Annual population growth
% of Urban population
Average aAnnual Growth Rate of Urban
Population
1995-2000
2000
1995-2000
% of Government Budget Spent on Health Care
1998
9.3
Total Adult Literacy Rate
1997
97
UNESCO
Adult Male Literacy Rate
1997
98
UNESCO
Adult Female Literacy Rate
1997
95
UNESCO
Crude Birth Rate (births per 1000 pop.)
1995-2000
9
UNPOP
Crude Beath Rate (deaths per 1000 pop.)
1995-2000
10
UNPOP
Material mortality Rate (per 100,000 live
births)
1995
2
WHO
Life Expectancy at Birth
1995-2000
78
UNPOP
Total Fertility Rate
1995-2000
1.3
UNPOP
Infant Mortality Rate (per 1,000 live bitrhs )
1995-2000
7
UNPOP
Physicians rate/100.000/year:392
WHO 1995
In Greece the subtype A in individuals not having
traveled abroad is not documented. An average of
subtype B genetic divergence of 15% is noted.
There are findings that demonstrate the
presence of at least two genetic subtypes of HIV1 in Greece- subtype A and subtype B. The
predominant subtype is subtype B.
Estimated number of adults and children
living with HIV/AIDS in Greece, end
of 2001
Adults and children
8800
Adults (15-49)
(%) 0.2
Women (15-49)
Children (0-15)
8800
1800
<100
Adult rate
Newly reported HIV positive persons
During the year 2001, 427 new HIV positive cases were
reported. Among them 319 (74,7%) are males and 104
(24,4%) are females. The gender is not reported for 4
cases.
Among them 60 cases were immediately reported as AIDS
cases . The route of transmission was reported as
"undetermined" in 49,4% of cases. Men who have sex with
men are 29% and heterosexual men and women are 18%.
In 2 cases the transmission mode is through blood
transfusion. Both patients had received this transfusion
abroad at past . The majority of cases at time of
report ranges between 25-44 years old .
Newly reported HIV positive cases, by
gender in Greece from 1/1/2001 to
31/12/2001
Gender
Total
N
%
Males
319
74.7
Females
104
24.4
Unknown
4
0.9
427
100
Total
Newly reported HIV positive cases, by
transmission group and gender reported in
Greece from 1/1/2001 to 31/12/2001
Transmission groupt
Total
Males Females
%
%
%
Homo/bisexual males
29
38.9
Injecting Drug Users (IDUs)
2.8
2.8
1.9
0
0
0
Transfusion recipients
0.5
0
1.9
Heterosexual
18
9.1
46.2
Mother to child
0.2
0
1
Undetermined
49.4
49.2
49
Total
100
100
100
Haemophiliacs/Coagulation Disorder
Transmission category
Overall, sexual transmission accounts for the vast majority
of reported HIV cases. Out of them 39,4% are men who
have sex with other men (MSM) while 15,7% are men and
women who have been infected through heterosexual
contact.
Among 918 cases infected through heterosexual contact,
the majority are women. Heterosexual contact is the
transmission mode which women account for the majority
of the cases. 39.3% of cases are about persons that lived
or originate from countries where transmission through
heterosexual contact is frequent, 27,2% had sexual
contact with HIV positive person of unknown way of
transmission,10,3% had sexual contact with a bisexual man
and 9,6% had multiple sexual partners.
Newly diagnosed AIDS cases
During year 2001, 72 new AIDS cases were reported in
Greece. Among them 54 (75)% are males and 18 (25%)
females. Men who have sex with other men account for
43,1% of newly reported cases while heterosexuals (males
and females) account for 33,3%. No new hemophiliac case
was reported.
One blood transfusion recipient and one mother to child
transmission case progressed to AIDS. Most of cases
are aged within 30-44 years old, while one new pediatric
AIDS case was reported.
System of care
community hospital
expert
home health care
PCP
System of care
Athens
N.Aigaio
Kiklades: Syros Hospital
Dodekanisa: Rodos Hospital
Crete
Xania Hospital
S. Aigaio
Samos
PCP
Paros
Mikonos
Leros
kos
Lesvos
Population
Athens
Aigaio
Crete
2.664.776
508.807
601.131
Number of physicians
Athens
Aigaio
Crete
3589
102
194
WORKFLOW
WORKFLOW
General approach to the HIV-infected patient
in o remote area without HIV specialist
Follow-up
Treatment at home ( self-infusion system )
Someone is greatest risk for
AIDS/HIV if he/she:
a. Has unprotected sex with multiple partners
b. Has unprotected sex with someone who is HIVc.
d.
e.
f.
g.
positive
Has another sexual transmitted disease (syphilis,
herpes, chlamydia, gonnorrhea, bacterial vaginosis)
Share needles during intravenous drug use
Is a person with hemophilia who received blood
products between 1977 and April 1985-the date
standard testing for HIV began
Received a blood transfusion or blood products before
1985
Newborns or nursing infants whose mothers have
tested positive for HIV
High risk person goes to the primary care physician (PCP)
Clinical exam by the doctor
Registration form
doctor gives the data to the clerck
clerk writes the data to the computer
Doctor writes order for baseline laboratory studies
Patient does this laboratory exams
Clerk writes the results in the computer and alerts the nurse
Nurse writes order for PCP consult
PCP reviews the results
PCP writes order for HIV specialist consult
Remote area
Clerk
notifies the technician
notifies the HIV specialist for consult
Administrator schedules time for consult with technician and HIV specialist
Consult occurs:
1.
2.
3.
4.
5.
technician arrives at bedside
turns on and make all peripherals ready for study
opens electronic record
enters patient data
establish telecommunication linkage
a. set up videoconferencing
b. set up the links
c. make sure they work
d. establish data to transfer
6. PCP arrives at bedside
7. start telecommunication
8. technician ask to position the peripherals in the location, by the
HIV specialist
9. all data is transferred to HIV specialist
10. end telemedicine encounter
Remote area
diagnosis
HIV specialist reviews and generates consults
treatment
not serious
Diagnosis
need to be transferred (emergency situation)
Consult is sent to remote PCP via e-mail
Medical history
• HIV serology with dates of positive and negative tests
• Transmission category
• HIV related history: CD4 cell counts, viral load, HIV-associated
•
•
•
•
complications
Medical care: history of care and source, prior PPD, prior Paps,
vaccination:Pneumovax, tetanus, influenza, HBV,HAV
Past medical history: cardiovascular risks(HAART candidates)obesity, hypertension,smoking, family history, and blood lipids
Targeted history: TB exposure/risk, prior chicken pox or
shringles, STDs, hepatitis A, B or C, gynecologic history,
substance abuse
Medications: HIV meds and adherence;OTC drugs, alternative
therapy
•
•
•
•
•
•
•
•
•
•
•
Physical Examination
Vital signs
Temperature
Weight
Eyes
Oropharynx
Lymph nodes
Lungs
Hepatosplenomegaly
Pelvic examination : external genitalia/perineum,
speculum and bimanual pelvic examination
Neurologic
Skin
Clinical Exam
•
•
•
•
•
Chief complaint
History of present illness
Allergies
Family history
Social history (tobacco, drug and alcohol use,sexual activity
and preferences, travel history)
• Current medications
• Gynecological, obstetrical and contraceptive history
• Vaccination history (pneumococcal vaccine, tetanus toxoid,
influenza )
Laboratory test-baseline
• Total BilirubinComplete Blood Count: Hematocrit
•
•
•
•
•
•
•
•
•
•
Serum Chemistries
Sodium
Potassium
Chloride
Bicarbonate
Blood Urea Nitrogen
Other Chemistries
SGOT (AST)
SGPT (ALT)
Alkaline Phosphate
Platelet count
Leucocyte count:Neutrophils
Bands
Lymphocytes
Monocytes
Eosinophilis
Laboratory test-baseline
•
•
•
•
•
•
CD4 cell count
HIV viral load
HIV serology
Chemistry profile with
liver and renal
function test
Toxoplasma serology
(IgG)
VDRL
•
•
•
•
•
•
Anti-Hepatitis C virus
Anti-Hepatitis B core
PPD
Pap smear for female
patient
Chest x-ray
C.traxomatis and
N.gonorrheae urinary
test
Diagnosis of HIV
Is based on detecting serum antibodies to
HIV
ELISA
If it is positive
WESTERN BLOT
If it is positive
Repeated once to protect against laboratory error
Reasons for False Positive Results
• Presence of high levels of HIV antibodies in non-
infected babies born to infected mothers
• Presence of HIV antibodies in recipients of HIV-1
trial vaccines
• Technical errors
• Reduced specificity of assays
• Hypergammaglobulinemia/Antibodies reactive to
cellular
components
Reasons for False Negative Results
• Unavailability of antibodies due to the formation
of antigen-antibody complexes
• Infection by HIV-1 subtype O or HIV-2
• Reduced sensitivity assays
• Technical errors
Reasons for Indeterminate Results
Probable True Positive (HIV Infection)
• Seroconverting
• HIV-2 infection
• Technical errors
Reasons for Indeterminate Results
Probable True Negative (No HIV Infection)
• Uninfected babies with maternal antibody
• Recipients of HIV-1 trial vaccines
• Recipients of influenza and hepatitis B virus vaccines
• Persons with non-HIV acute viral infections
• Congenital bleeding disorders
• Alcoholic hepatitis and other chronic liver diseases
• Hematologic malignancies, lymphomas
• Positive RPR test
• Technical errors
• Antibodies reactive to cellular components as in
- multiparous women
- polytransfused patients
- patients on chronic hemodialysis
- patients with autoimmune disease
Routine follow up
Routine follow up
• The routine follow up is timed according to the patient’s clinical
situation and treatment program.
 Patients receiving antiretroviral therapy: Patients newly placed
on antiretroviral therapy should initialy be seen within 2 weeks
and then every 2 to 6 weeks, whereas patients stable on
established therapies may be seen every 6 to 12 weeks.
 Patients not receiving antiretroviral therapy: Patients who are
HIV (+) with early asymptomatic disease ( CD4>500/mm3) who
decline antiretroviral therapy should be seen every 3 to 4
months.
Routine follow up
Patient turn on the computer
Writes his personal data ( name and password)
Enters in his own wed page
Writes his life style data
Writes his clinical data
Ask his physician any question
HIV specialist reviews the data every day
He follows up his patient progression and informs them for any changes
Home kit collection
A phlebotomist venous sample kit
Follow up and HIV testing using home
collection
Home collection kit (HCK) is send to the HIV patients
All of them are numbered and linked
Each of 3 specimens is identified with a unique bar code
Each patient has his own bar code
He is asked to follow the instructions and make the test
The test is send by mail to the laboratory
After the sample analysis the clerk inserts the results to the computer
Physician is informed for the results by his computer
He informs his patients
Treatment at home
Treatment at home – self infusion
system
Self infusion systems are infusion pumps that
plug into a phone jack to allow a medical
professional to monitor and troubleshoot the
pump via telecommunications
Treatment at home – self
infusion system
Technician installs the computer and the machine in the patients home
Home care nursing and a parmacist programs the pump according to the
treatment plan
Nurse instructs the patient how to use the pump
Show him details about calling for help
Patient is ready to use the pump
Complications
• Bacterial infections: MAC
TB
Salmonellosis
Bacillary angiomatosis
• Viral infections: CMV
•
•
•
Viral Hepatitis
HSV
HPV
PML
Fungal infections: Candidiasis
Cryptococcal meningitis
Parasitic infections: PCP
Toxoplasmosis
Cryptococcal Meningitis
Cancers: Kaposi sarcoma
NHL
Video teleconference
Store and forward
History and physical exam
MRI and x-ray
Computer based patient data
Clinical protocol / workflow
Lab exams
MEDICAL PERIPHERALS
Medical peripherals
Remote area
VTC-microphone
Digital camera
Dermoscope
X-ray
x-ray scanner
Paper scanner
fax
Consultant
VTC- microphone
pC
screen with high resolution
fax
Home
home care tel
pc
AMD-2500p General Examination Camera - PAL video format
Specifications
• Dimensions: 2.2"W x 3.7"D x 2.9"H
• Weight: .5 lbs.
• Magnification: Auto-zoom from 1-50x.
• Polarization: Push-button
• Zoom: Push-button
• Pixels: 410,000 from a 1/4" CCD
• Horizontal Resolution: Greater than 430 lines
• Signal to Noise Ratio: Greater than 48dB
• Output Signal: Composite and S-Video
• Output Format: NTSC
• Integrated Freeze-frame: Push-button
• Color Adjustments: Auto white balance
• ACC: Full iris control
• Lighting: Fluorescent
• Operating Temperature Range: 0 degree C - 40 degree C
• Operating Humidity: Less than 90%
• Power Consumption: 5W
• Voltage Range: 110/220 VAC 10%, 50/60 Hz, or 12VDC
• Lens: General purpose lens close focus, 50x polarized lens, and optional
•
200x polarized contact lens
List Price : $5,490.00
AMD-8200 Vital Signs Monitor (BP, Pulse, Sp02, Body Temp )
Specifications
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dimensions: 6.5"(16.5 cm) H x 8.6"(21.8 cm) W x 5.0"(12.7 cm) L
Weight: 6 lbs. (2.8 kg)
Data Output: RS-232
Blood Pressure Accuracy: Meets or exceeds SP10-1992 AAMI
standards
Cuff Pressure Range: 0-300 mmHg
Pressure Preset Levels: 120,140,160,200,240 or 280 mmHg
Systolic Determination: Max: 250 mmHg; Min: 60 mmHg
Diastolic Determination: Max: 160 mmHg; Min 30 mmHg
Pulse Rate Determination: Max: 200 bpm; Min: 40 bpm
Temperature Accuracy: Meets or exceeds ASTM E112-86 standards
Temperature Determination: Normal and Monitor Mode, Max: 108.0 deg.
F (42.2 deg. C); Min: 84.0 deg. F (28.9 deg. C)
Power Requirements: N. American version: 120 VAC, 60 Hz.
International version: 220-240 VAC, 50-60 Hz
Internal Battery: Lead Acid, with external recharger
Safety Standards: IEC 60601-2-30, UL 2601-1, CAN/CSA C22.2
No.601.1
Conformity: CE
List Price : $2,995.00
AMD-9300 Weight-Tel Transtelephonic Digital Weight Scale
w/embedded modem
Specifications
• Dimensions: 2.05" (5.2cm) H x 12.25" (31.1cm) W x 12.01"
•
•
•
•
•
•
•
•
(30.5cm) D
Weight: Approximately 5.96 lbs. (2.7kg)
Measurement Device: Load Cell
Measurement Range: 0.1 lbs. (50g) to 300 lbs. (136kg)
Display: Liquid crystal, character height: 1" (2.5cm)
Operating environment: 10° to 35°C at less than 85% relative
humidity
Power: One DC-9V Alkaline battery, auto power off
Telephone Connection: RJ-11
List Price : $636.00
X-ray
X-ray scanner
Home care monitoring
TELECOMMUNICATIONS
ISDN line
CONSULTANT
REMOTE
Multimedia electronic record/
software
Multimedia electronic record/
software
FILE
FILE
ISDN line
File : -patient data
text
image
- lab test
text
image
- physical exam video
FINANCIALS
GOAL
Profit 10% per year
Remote area
Equipment
Office supplies
Assistant salary
Telephone line
Regular mail
Rent
Home
Equipment
Telephone line
pc
Expert
Telephone line
Equipment
Office supplies
Computer
software/hardware
Assistant salary
Technician salary
Regular mail
OUTCOME
INCUME
Payment of the patient
Network sales service