Transcript Fundamentals of Telehealth

The Telemedicine Center
at East Carolina University
Division of Health Sciences
Salutes our Military abroad,
stateside, and in Eastern North
Carolina
The Telemedicine Center
ECU Telehealth Mission
Improve health care quality & access by appropriate
application of health information & communications
technologies and practices
in Eastern
Carolina
across our nation
Dr. Dawd Siraj with John Hopkins
University connecting to Ethiopia
and outreach to other nations
worldwide.
The Telemedicine Center
Current ECU telehealth
applications
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Teleconsultation/Specialist Referral Services
– patient accompanied by a presenter who’s at a clinical site
equipped with peripherals collaborates with a MD or other
consultant at a center of medical expertise
Distance learning and distance education
– lecturer or instructor who delivers presentation materials to
multiple locations for courses, grand rounds, or continuing
education, may need to support student/participant Q&A. May
be focused on adult health education/health literacy.
Multi-specialty health care collaboration
– subspecialists at multiple locations collaborating on single case
or groups of cases, e.g. tumor board, to discuss treatment
options; physician to physician collaboration
Patient interview/follow-up/compliance/education
– direct communication with a patient and/or care giver in situ
(e.g. home care) for following up on problems related to a
known diagnosis, ascertaining compliance with treatment
plans, and/or patient education
Meetings/Administrative
The Telemedicine Center
ECU Integrated Network
with Local Bridge Capability
IP T-1 1.5 Mbps
Microwave & IP 1.5 Mbps
NCREN - 180 sites
Internet2, Abilene, National
Lambda Rail
Distance Education/Learning
Distance Educ & Instructional
IP Video
384 kbps - 2 Mbps
REACH-TV - 27
sites
ECU Bridge
Direct / MCUs
Telemed & Distance Educ
ISDN
128 kbps – 1.5 Mbps
Telemed, Dist Ed, Consulting,
Mental Hea Dept,Disaster Relief
IP Video 384 kbps
NCIH - 186 sites
POTS 28.8 Kbps
Home Health
Distance Education
Telemedicine, Disaster Relief
The Telemedicine Center
ECU
Telemedicine
history
“Go ahead and tee off. Then I
want you to listen to this
wheezing”
The Telemedicine Center
ECU Telemedicine history
• First consults with State Prison in 1992 –
Consult # 00001: Vascular surgery
• Expansion of existing distance education
network to cover residency program and first
clinical rooms in rural hospitals -1994
Seventeen“17”
The Telemedicine Center
ECU Telemedicine history
• Established Advanced
Telemedicine Training
with more than 600
attendees representing
28 countries since 1997
• Awarded “Center of
Excellence” status by
University of North
Carolina General
Administration in 1999
The Telemedicine Center
ECU Telemedicine history
Research & development
• “Tele” diagnostic tools
• Physician work stations
• Technical interface
development for IP
technologies with video tools
• Development of requirements
for distribution of specialty care
• Telecommunications varieties,
wireless, cable, cell, radio, etc.
Dr. Bill Burke in the custom TM station
The Telemedicine Center
ECU Telemedicine history
• Research in Disaster Relief and Bioterrorism
Exercises since 1998
Flood waters consume Eastern
North Carolina homes and
businesses in 1999
Telemedicine Team transports
medical supplies and equipment
to shelter sites via helicopter
The Telemedicine Center
ECU Telemedicine history
Bioterrorism/refugee exercise in 2000
• US Military, the United
Nations, ECU and other
civilian organizations
worked together for the
first time in a refugee
management exercise at
Puu Paa, located on a
lava plain on the big
island of Hawaii
• ECU tested tele-medical
applications with “live”
link to NC physicians
The Telemedicine Center
Telemedicine
• Not a separate medical specialty.
• Products and services related to telemedicine are often part
of a larger investment by health care institutions in either
information technology or the delivery of clinical care.
• Even in the reimbursement fee structure, there is usually no
distinction made between services provided on site and
those provided through telemedicine and often no separate
coding required for billing of remote services. Presently, in
NC only Medicare/Medicaid services use a special
telemedicine modifier.
Telemedicine history
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Australian Royal Flying Doctor Service 1928
NASA 1960s
Nebraska Psychiatric Institute 1964
Logan International Airport Medical Station 1967
Alaska Applied Technology Satellite Biomedical
Demonstration 1971
STARPAHC 1972-1975
Memorial University of Newfoundland 1977
North-West Telemedicine Project 1984
NASA Space Bridge to Armenia 1988
The Telemedicine Center
Telemed Delivery
Mechanisms
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Point-to-point connections
– Hospitals and clinics that deliver services directly or contract
out specialty services to independent medical service
providers at ambulatory care sites may use private networks
or secured telecommunications or encrypted technologies
(e.g. radiology, pathology, interactive tele-consultations,
ICU monitoring services provided under contract, etc.)
Primary or specialty care to the home connections
– Connecting PCP, specialists and home health nurses
w/patients over single line phone-video systems for
interactive clinical consultations.
Home to monitoring center
– Links used for data collection of cardiac, pulmonary or fetal
monitoring, home care and related services that monitor
patients in the home.
Web-based e-health patient service sites
– Provide direct consumer outreach and services over the
Internet.
– Electronic medical records
Basic Telemedicine
Types
• Interactive (Synchronous)
-Two way video, real time
- high-bandwidth telecommunication
• Store and Forward (Asynchronous)
- Images, audio or video files stored and
transmitted, like e-mail, usually not real time
- lower bandwidth telecommunication
The Telemedicine Center
IP advantages
• IP already part of your existing network
• Can serve multiple applications
– Telemedicine
– Electronic medical record
– Internet interface – E-prescribing, medical info
– Personal workplace
– E-mail
– Other networked functions (databases, printing,
file sharing, etc.)
– Voice or other communication conferencing
The Telemedicine Center
IP challenges
• IP networks not designed/optimized for v/c
• IP video is bandwidth-intensive
– Cisco recommends video B/W + 20% for IP
• Technical issues:
– Congestion/packet loss
– Variable bit rate
– Security
– Firewall issues across networks
– Integrated vendors/port assignments
– Peripheral integration
– Directory services
The Telemedicine Center
Security
• Mandated with HIPAA regulations
• Circuit-switched N/W’s inherently secure
• Packet-switched (IP) more challenging, but several
solutions:
– Completely isolated (private) IP N/W
– Video encryption w/in codec
• Now interoperable across major H.323 platforms
– Virtual private N/W (VPN)
– Firewall
• Really only protects within your N/W
The Telemedicine Center
TM Reimbursement
from Traditional Payors
• Interactive (Synchronous)
-Two way video/audio, real time
- high-bandwidth telecommunication driven by
specialty
– Must meet HIPAA requirements
– Mode for all “lower 48”
Store and Forward (Asynchronous)
- Images, audio or video files stored and
transmitted (Radiology, Pathology, Ultra-Sound)
- Lower bandwidth telecommunication
- Exception is Alaska & Hawaii
The Telemedicine Center
Reimbursement
Fee for Services
Rural
Hospitals
Doctor’s
Office
Telemedicine
Specialized
Care Facility
Clinical Room in the Naval Hospital
Camp Lejeune, NC - 1996
Military Base
Hospitals
The Telemedicine Center
Revenue
Contracted Services
Correctional
Prisons
Short/Long
Term
Telemedicine
School/Child
Care Facility
Central Prison used 28 types of specialties
Travel/ Air
Cruise
The Telemedicine Center
Home /
Office
Sunbury – Happy, Inc.
AhoskieAhoskie
– Roanoke-Chowan
– Roanoke-Chowan
CNC/ACCESS-Jackson-Proposed
Ahoskie–Roanoke-Chowan Heart Center
Tillery-Community Ctr
EC Behavioral Health- LME
PORT – Rocky Mount-Proposed
Windsor– Bertie Memorial
Rocky Mount -Nash
Edenton – Chowan Hospital
Edgecombe Co. Proposed Spoke
Tarboro - Heritage
Bertie County Proposed Spoke
Raleigh – Central Prison
Tarboro-Heritage Heart
Nags Head - Outer Banks
Wilson - School for Deaf
PORT- Wilson-Proposed
Raleigh-Governor Morehead School for Blind
BSOM
UHS
Greenville –Health Steps 4 Units
Greenville –ECU Cardiology 2 Units
Greenville-ECU Psychiatry 2 Units
Morganton- School for Deaf
Belhaven - Pungo District Hospital
Taylorsville- Alexander Correctional
Maury – Maury Correctional
Goldsboro - Cherry Hospital
Goldsboro – Goldsboro Pediatrics
Faison - Goshen Medical Ctr
Kinston – Caswell Center
Clinton - HITC
Kenansville – Duplin General
Sites with Nurse Presenters
Sites with Trauma Rooms
Cardiology Network- 07-09
Psychiatry Network - 07-09
Avon - HealthEast Family Care
Lenoir County Proposed Spoke
RHA – Wilmington-Proposed
RHA –New Bern-Proposed
Jacksonville – Onslow
Hospital Site
Medical Center Site
School Infirmary Site
Correctional Sites 2009
REACH Network
Rural EAstern Carolina Health – Network
Telemedicine Clinical Sites
Top Current Clinical
Applications at ECU
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Dermatology
Pediatric Services
Cardiology Adult & Pediatric
Radiology
Mental Health/ Psyc
Rehab/ TBI Clinic/ EMG
OB/High Risk/ NCIU “Hello
Mommy”
• Neurology
• Endocrinology/ Diabetic
• Home Health Care
James Finley, MD Dept of Pathology with
tele-pathology unit to Outer Banks Hospital
The Telemedicine Center
Telecardiology network
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Initial 4 sites: (6 additional sites 2008)
– Heritage Hospital in eastern NC
– Ahoskie Heart Clinic in eastern NC
– Health Steps (Local Cardiac Rehabilitation Center)
– ECU Medical Pavilion, Department of Cardiology
• Use desktop videoconferencing
appliance to coordinate care for
Cardiac Heart Failure patients
between cardiologist and primary
care MD’s
• Collaboration with Pharmacist,
Nutritionist, and Psychologist
Dr. Mariavittoria Pitzalis connects from her office to outpatient clinic in
The Telemedicine
Center
regional Cardiology Rehabilitation
Center.
Tele – psych Network
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Initial 6 sites:
– Goldsboro Pediatric Services, Goldsboro, NC
– HAPPY, Inc, Sunbury NC
– Cherry Hospital, Goldsboro, NC
– TarHeel Services, Beulaville
– ECU Psychiatry Out Patient Clinic
– ECU Telemedicine Center
• Use desktop videoconferencing
and bridging to coordinate mental
health services for patients
between primary care MD’s, case
managers and other providers
• Collaboration with other
Psychiatrists, Pharmacist,
Psychologist, and other Team
Members to include primary
care giver with patient/family
Dr. Kaye McGinty, ECU child psychiatrist
Telemedicine
collaborates with psychiatrist atThe
Cherry
Hospital, Center
state psychiatric hospital
Traumatic brain injury
Dr. Jacinta McElligott &
Elsie Siebelink, TBI Nurse
• TBI Telemedicine Clinic established
in June 1998 on monthly basis
• Six (6) different sites
• Approximately 45 min-1 hr N/W
time/patent including both nurse &
physician
• Total of 156 patients seen
• No-show rate of 14% * compared to
38% no-show Rate in PCMH
Rehab Ctr **
•* including some cancelled clinics due to No physician or Network time during 1998-2000
** Percentages vary annually. This is average of collective years
The Telemedicine Center
ECU Teleconsultation Outcomes
• High patient satisfaction
• Patient convenience
– Reduced travel
– Less time away from work/school
– Quicker to see specialist
• Patient compliance
– e.g. better show rates for TH visits
– 7 - 10% general no-show rate for all TH as compared
to 35 – 42% No Show rate (TBI percentages)
• Continuity of care
– Referring MD in the loop
– Faster turnaround of consultant’s findings
The Telemedicine Center
System integration #*!
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Evaluate Need
Service Model (24/7)
Identify technology
Choose telecommunication
Participants
Design implementation
The Telemedicine Center
“Telemed” Clinical Tools?
• Patient/Spoke site
• Medical Specialty Driven
• Additional switch or inputs
for video sources
• Mobile capability
• Patient Room Camera Control
• Diagnostic tools?
The Telemedicine Center
Videoconferencing
endpoints
• “Hard” endpoints
– Dedicated
hardware/applianc
e
• “Soft” endpoints
– S/W and/or
peripheral on PC
– May include
hosting service
The Telemedicine Center
Hard endpoints (cont’d)
• Several form factors
– Desktop/executive
– Small room
– Large room
– Roll-about
• Tandberg Intern
• Polycom
Practitioner
• In-room or rack mounted
outside room
• Integrate with 3rd party
control systems and A/V
devices
The Telemedicine Center
Soft endpoints
• Numerous vendors, e.g.:
– Polycom
– Apple iChat AV
– Cisco
– AOL Video Messenger
– Sightspeed
– WebEx
• Improving quality
• Difficult to integrate TM
peripherals
• Share PC with other apps
• Limited interoperability
• Inexpensive
The Telemedicine Center
Technical Configuration
• Peripherals
– Otoscope
– Electronic stethoscope
– Hand held camera
– Pan/Zoom/Tilt camera
w/far-end control
Typical remote site
• Usually both TM
exam & conference
rooms
• Video instruments
– Otoscope (ear)
– Derm camera (skin)
– Ultrasound, other aux.
• Electronic
stethoscope
NEW ! Mobile desktop unit for clinic
connectivity
Legacy units (1994) continuing
with ECU Center
engineering support
The Telemedicine
New mobile Models
• Network/Power connectivity
• Video instruments
Interoperability?
• Electronic stethoscope
• Video switcher for Auxiliary
inputs including ultrasound
• HD codec, camera, and
display
• Stereo Microphone
• Increased Audio Frequency
range (up to 22kHz)
• UPS
The Telemedicine Center
Telemedicine suite
Four Tele-exam rooms
each equipped with:
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Engineer & MD entrances
EHR (Logician)
PC capability
Stethoscope capability
House phone
Remote control at sites
– PZT camera
– Recorders
– A/V devices
The Telemedicine Center
Current TH services
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Specialty tele-consultation
Engineering Consultants for NC State Mental Health Network
Re-installing/Expansion of NC Department of Corrections
HIV/AIDS case review c/ Ethiopia & Johns Hopkins
Cardiac Heart Failure Distributed Network
Tele-psychiatry Network
Neonatal Intensive Care Unit “Hello Mommy”
Telepathology
Distance learning, meetings, training
– Medical Missions for Children
– Telehealth project consultation
• UHS telehealth services
– Teleradiology (PACS)
– Tele-cineangiography (HeartLabs)
– Home care
– Disease management
The Telemedicine Center
ECU Telemedicine
Consultants
Current applications
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NC State Division of Mental Health
– Ten Main Points of Location across the State
– Network/Infrastructure Research Design
– Protocol Development for State Mental Health Telemedicine
Guidelines
– Training and Support to 38 additional connecting agencies
– Network Directory Development
– Business Hours On-line or Toll Free Support
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NC State Division of Mental Health
– Equipment Enhancement/Install Design
– Fourteen Sites Training and Support
– Clinical Services
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UHS/ ECU Medical Campus
– Emergency/ Trauma / ICU Design
– Audiology Services with patent Internet system
– Video Teaching with Medical Skills Simulation Lab
The Telemedicine Center
Future Telemed at ECU
Dental TH applications
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Specialty consultation
Primary dental care
– Mentoring -- “tele-attending”
– Screening/prevention
– Patient education
Pre/post-surgical follow-up
Interdisciplinary collaboration
Continuing Education/Training
Establishing Non-Traditional
points of care
– “Virtual” co-location in primary
care
– Extended care facilities
– Schools with Tele-Nurse station
– State facilities
The Telemedicine Center
Vision
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Available to everyone
Health care @ the point-of-convenience
Patient is informed & empowered
Telehealth/e-health applications assure patient
compliance, continuing education, ease of access into
health care system, healthy behaviors
Clinical data integrated w/ longitudinal EHR
Data available to patient (personal electronic medical
record) & authorized clinical providers
Data & transactions secure to greatest practical extent
System components (S/W & H/W) readily
interoperate w/o modification
The Telemedicine Center
Vision
Apply telehealth & IT
technologies, systems,
principles & practices to
enable the provision of
health care where it’s
needed, when it’s needed
Artist: Francisco Caceres
From MIT Technology Review (Mar. 2000)
The Telemedicine Center
Trends/Observations
• Multidisciplinary chronic disease mgt.
• Divergence from distance learning techs.
• Improving consumer infrastructure
– Broadband connectivity
– Home wireless
– High utilization of web & e-mail
– Consumer electronics
– Video messaging (SIP)/”soft” endpoints
• Health consumerism
• Diffusion of point-of-care technologies
The Telemedicine Center
Health consumerism
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Consumers attitudes toward healthcare (Arthur Anderson)
Health consumerism will drive additional telehealth applications and
use
Consumers evaluate physicians and medical centers via information
available on the web (Healthgrades)
Increased computer literacy and net usage
Physician/patient e-mail
– 93% of MD’s w/ access, 14% e-mail w/ patients (Baker, 2003)
– AMIA guidelines for physician/patient e-mail
Electronic personal health record (PHR) applications
– Internet-based systems
– Individual enters data & decides who can access their PHR
– PHR @ Kaiser Permanente NW, Beth Israel, VA, & U. Colo.
– COTS PHR applications/services (Cerner, GE Med. Sys.)
– Connecting for Health Initiative’s PHR Working Group (2003)
identifying standard elements of PHR systems
The Telemedicine Center
Connected health?
Health Information
Technology
Telehealth/
Telemedicine
• Specialty teleconsultation
• Telecare
• Remote monitoring
• Distance learning
• Multidisciplinary care
Common denominator is
the network
• Electronic Health Records
• Practice management systems
• Clinical decision support
• e-Prescriptions
• Alerts/reminders
• Digital imaging/PACS
Consumer Health
Informatics
• Personal Health Records
• Health web sites
• e-Visits
• e-Journals
• Virtual health/support
communities
The Telemedicine Center
Challenges
• Lack of physician
education, knowledge and
training
• Reimbursement
• Technical interoperability
• Lack of Directory of ‘Tele’Medical Services
• NO Integrated Med Record
• NO Integrated Pharmacy
services
• NO inter-pharmacy records
• NO easy assess center for TH
resources
• Telecommunication Costs
• Scheduling
• Slow or limited physician adoption
• Lack of patient education and
The Telemedicine Center
demand
In Closing
• Extensive experience in telehealth research, practice, &
policy
• Existing infrastructure (physical & personnel)
• ECU & institutional support for TeleHealth
• Myriad opportunities:
– Effects on access, convenience/efficiency, quality
– Innovation in health education
– Development of new clinical services and service
models (esp. consumer)
– Device & software development
The Telemedicine Center
Contact info
Gloria Jones
Assistant Director
Clinical Operations Manager
ECU Telemedicine Center
(252) 744-3855
[email protected]
http://www.ecu.edu/telemedicine
The Telemedicine Center