EU-US cooperation on eHealth

1. EU-US cooperation on eHealth Transatlantic Health Care Provision – a concrete example Laura Raimondo Senior Vice President, UPMC

2. UPMC at a glance • $10 billion in revenue • 20 hospitals operating over 4,200 licensed beds; 187,000 admissions per year • 4.6 million outpatient visits; 480,000 emergency visits per year • 1.6 million UPMC Health Plan members • 400 outpatient locations • 55,000 employees • 2,800 employed physicians • UPMC is closely affiliated with the University of Pittsburgh, which ranks fifth in National Institutes of Health Research Funding

3. UPMC and University of Pittsburgh Relationship NIH Funding NIH funding comparisons include affiliated hospitals/research institutes Based on FY 08 preliminary data

4. Global experience Our locations are world-wide and world-class. China Colombia Cyprus France Israel Ireland Italy Japan Kenya Korea Mexico Nigeria Pittsburgh Philippines Singapore Spain Turkey United Kingdom UPMC and University of Pittsburgh world-wide locations.

5. UPMC in Italy MANAGEMENT ACTIVITIES• ISMETT - Mediterranean Institute for Transplantation and High Specialization Therapies – is a 78-bed facility located in Palermo, Sicily. Managed and operated by UPMC from the very beginning, ISMETT is one of the leading organ transplant centers in Europe. ISMETT’s new infrastructure was opened in March 2004: 130,000 square feet over five levels, 14 ICU, 7 OR’s + Radiology (CT, MRI, Nuclear Medicine), Endoscopy, Interventional cardiology, Pathology, Laboratory. • Ri.MED Foundation – Based on UPMC’s success in managing ISMETT, the Italian Government has selected UPMC to be the qualified technical partner of the Foundation. The primary goals of the foundation are to enhance scientific culture with special reference to the role of biotechnology, to train scientific, technical and administrative staff with specific skills in biotechnology, and to create the Biomedical Research and Biotechnology Center (BRBC) in Carini, near Palermo.UPMC Italy will implement and manage the BRBC to be established in 2016. • UPMC San Pietro FBF -  The UPMC Center will offer cancer patients stereotactic radiosurgery, a radiation treatment that uses advanced treatment planning and sophisticated imaging technology to deliver precisely focused radiation to treat tumors and other abnormal masses or disorders. The UPMC Center will host the TrueBeam technology and will be the only one providing such an advanced technology in Central Italy, one of the few in the whole country. TRAINING ACTIVITIES • Simulation Center Renato Fiandaca - The center is hosted at ISMETT in cooperation with UPMC’s Peter M. Winter Institute for Simulation, Education and Research (WISER). The mission of the Center is to train health care providers, improve quality of care, reduce medical errors, and increase safety standards. RESEARCH PROJECTS UPMC Italy conducts and funds various projects in translational research, technological development and training in biotechnology and regenerative medicine. - Transplantation of human fetal liver cells for the treatment of chronic liver disease in patients on the waiting list for liver transplantation;- fetal skin progenitor cell transplantation for the treatment of acute and chronic skin lesions;

6. UPMC in Ireland • UPMC Beacon  is a 183-bed facility located in Dublin, Ireland. This state of the art facility opened in January 2007 and has been operated by UPMC since 2008; • UPMC Beacon Hospital is a full service hospital which combines the best in Irish and US health care. As the showcase site for General Electric in Europe, it has the latest Radiology systems, including MRI, CT scanner with cardiac capabilities, CT Sim, and PET/CT. It also features Digital Radiology suites with advanced Mammography, Nuclear Medicine, and Ultrasound, as well as Angiography suites and lab with advanced single-plane and bi-plane systems and Fluoroscopy; • UPMC Beacon Cancer Centre provides a comprehensive range of cancer services including Oncology Surgery, Chemotherapy, and Radiotherapy. The Radiotherapy includes intensity modulated radiation therapy (IMRT) and image guided radiation therapy and stereotactic radiosurgery. UPMC also operates a cancer center in Waterford, in the South East of Ireland - UPMC Whitfield Cancer Center ;

7. UPMC global investments in ICT IT Expenses (Capital & Operating in millions) WembleyStadium £ 800 million ($ 1.3 billion US)

8. Innovation at UPMC Center for Connected Medicine • Collaboration of industry leaders in health care, IT, communications, and application solutions to provide answers for all facets of the complex requirements for health care. Technology Development Center • Brings the health care expertise and the ability to marry innovative processes with cutting edge technology to produce commercial grade products.

9. Telemedicine: Why Now? • Scientific evidence emerging: • Evidence is emerging that outcomes at least remain unchanged between tele-visits and traditional visits • Early evidence suggests that outcomes, follow up and compliance are improved in telemedicine chronic disease management • Provider shortages (GPs and Specialists) • Costs are lower for a tele-visit • Funding for pilot cases and research • EU funding supporting the “Digital Agenda” • US is supporting $55 million annually in grants • Technology innovation, user adoption and affordability

10. Telemedicine at UPMC • Telepathology • Teledermatology • Teleconsults • Telewound care • TeleICU • Teleophthalmology • Telecardiology • Pre-/Post-surgical care • Telepsychiatry • Telestroke • Teleradiology • TeleMFM (Maternal Fetal Medicine) • TeleEndocrine • TeleTrauma • TelePediatrics • eVisits Teleradiology 16 Service Lines 19 Facilities

11. EU/US Telemedicine concrete experienceTELE – PATHOLOGY at ISMETT UPMC – ISMETT Project Starting: 1999 • Principal Players: • Technician responsible for the preparation of the samples and the transfer of the images • Doctor responsible for filling in the appropriate form indicating the clinical notes, the diagnostic hypothesis and the administrative personnel for the statistics • Main purposes: • Diagnostic: obtaining a “second opinion” • Scientific: set-up of a database of specialists • Educational: e – learning • Professional Development: the spread of skills/know-how

12. EU/US Telemedicine concrete experienceTELE – PATHOLOGY at ISMETT Tele pathology was vital to : • develop a transplantation program which became more and more sophisticated • Develop a pediatric transplantation program • Cure rare and difficult pathologies • Provide complex and highly specialized care all with 1 Pathologist Since 1999 ISMETT, with 70 beds (78 from 2011) of which 14 ICU beds, has performed 1250 (April 2012) transplantations with among the best European survival rates

13. Telepathology ISMETT - Cina • KingMed Diagnostics is the largest independent medical diagnostic laboratory in China. (250,000 anatomical pathology tests per year and growing). • KingMed has established 19 regional pathology labs around the country and is providing pathologic diagnosis & consultation services for about 9,000 hospitals nation-wide. • Using equipment that scans glass pathology slides, stores the images and transmits them electronically, KingMed will deliver second opinions on patient diagnoses from UPMC’s pathologists through a secure, Web-based telepathology portal. • The partnership will provide KingMed’s customers with access to UPMC’s broad pathology subspecialty expertise, which is not widely available in China • Next step: Continue to broaden and target marketing outreach

14. TELE - PATHOLOGY AvailableTechnologies A few significant fields of a hystological, cytological or bio technical sample are photographed and sent to a consultant as an attachment in an e-mail message – or via FTP technology • Tele-Pathology Statistics Through appropriate motorized microscopes the remote control of the movement of the instrument is carried out and simultaneously the microscope’s images are recorded by a camera and sent out. At the same time the case can be discussed in video conference between pathologists 2.Tele-Pathology Statistics Automatic execution of numerous photos with appropriate enlargement, which are put side by side until they cover the entire surface of the glass slide. All of the information on the glass slide is then transferred onto a file easily archived , catalogued and duplicated for consultation and/or quality control. 3.Digital Slides GE and UPMC new company to digitize pathology

15. Tele-ICUforpediatrics Transplant Surgery at Children’s Hospital of Pittsburgh: • International center for liver and small-bowel transplantation • 60 transplants a year (half are multi-visceral) • Survivals are best in the US • Liver Transplant Survival Rate: • 3-year survival - 95% (national average 89%) • Intestine Transplant Survival Rate: • 3-year survival - 74% (national average 65%)

16. Tele-ICU • Children’s Hospital of Pittsburgh of UPMC • Remote consultation for pediatric patients in critical care units located around the world is offered by Children’s hospital intensivists when complex critical care expertise is needed. The TeleICU coordination between UPMC Children’s Hospital and external locations via Bedside monitoring and Electronic health record; • Two critical care specialties have developed international programs: • Cardiac Intensive Care – Colombia • Post operative management of pediatric liver transplant patients – ISMETT, Italia • Locations • Colombia • Italy

17. Tele-ICU at ISMETT Tele-ICU started in November 2010 and was fully implemented in February 2011. It is mainly used in the Intensive Care Unit (ICU) for post-surgical liver transplant cases in pediatric patients; • 18 % of pediatric patients treated in the ICU (30% of total hospital stay was spent in ICU) • 95% days of ICU pediatric hospital stay covered by the tele-ICU service • Setting up a multi disciplinary team ISMETT- UPMC Children’s Hospital: • Interventionist (s) • Surgeon (s) • Pediatrician • Specialized nurse • Rounds every day at 3pm Italy time zone • Observable results: • Access to highly-specialized and specific competencies • Uniformity of protocols used and reduction of variance of care • Educational training function. We expect to improve our competencies • Cost savings :Ismett could not afford a diversified group of specialized physicians for only 9 pediatric beds

18. HOME – MONITORING Patientsconcerned Allpatientsresiding in Sicily, whoconsecutivelyunderwent a livertransplant at ISMETT and weredischargedstarting the 15th ofJuly 2011 through the 31th of March 2012  (TOT. 30 patients) ClinicalProtocols • recurrent clinical monitoring in the time of post-discharge (first 3 months or until the stabilization of clinical conditions) • Verify therapeutic compliance (immune soppresion, other drugs) • Verify compliance of surveillance scheme biohumural and instrumental post-transplant MainFunctionsof the Device • Periodical measuring of the vital parameters • Visual display of the calendar with the planned activities • Visual display of audio/visual reminders to encourage patients to follow their health protocol

19. HOME-MONITORING

20. What other Tele –Medicine programs at ISMETT? • We have already launched Tele-dermatology for pediatric patients (Children’s Hospital – Ismett) • We launched Teleradiology for pediatric neuroimaging (Children’s Hospital – Ismett) last January OUR GOAL IN PERSPECTIVE: TELE-Stroke program in Sicily • Very wide experience in UPMC and in the USA • High impact on costs savings and clinical outcome • Larger impact if surrounding hospitals do not have a stroke specialist and have never treated a patient with tPA Next programs: 1. Home monitoring for post surgical lung translanted patients and LVAD patients with Ismett-UPMC connection 2. Tele-ICU program with ISMETT as HUB and 7 Sicilian hospital satellites to support ICU management of organ collection

21. Stroke, tPA and Telemedicine • tPA saves $ 6074 and adds 0.75 quality • adjusted life year per use(1) • Telestroke is associated with increased • delivery of tPA(2) • (1): The Economic Case for New Stroke Thromobolytics; Stroke, October 2010 • (2): Telemedicine in Acute Stroke Management: Systematic Review; International • Journal of Technology Assessment in Health Care, 26:2 (2010)

22. Telemedicine Systems in US Schwamm et al. Stroke 2009

23. Telestroke v. SC Patients Treated with IV tPA – 90 day Outcomes

24. Waiting for you at2012 UPMC International Telemedicine Symposium For more information www.UPMC.com/Telemedicine