Telemedicine: Networks in the Service of Healthcare

1. Telemedicine:Networks 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 / Privileging 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 Boston’s Logan Airport in 1968

10. 1971 Telemedicine to Alaska via satellite

11. So what’s new? 1994 1924

12. TELEMedicine: The Internet Broadband

13. University Corporation for Advanced Internet Development (UCAID)sponsoredInternet2 Program 1996

14. University Members 212 Members as of March 2008

15. 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/PIONIER (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)

16. 2003 www.nlr.net

17. Private non-profit nationwide optical Internet Service Provider Network research channels available No acceptable use policy (AUP) University based membership network organization Access for network management & research Non-restrictive AUP National LambdaRail Internet2 www.nlr.net www.internet2.edu

18. Networking Health: Prescriptions for the Internet A 2000 study by the:U.S. National Research CouncilComputer Science Technology Boardhttp://www.nap.edu/catalog/9750.html

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

20. 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

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

22. Common Network Speeds Line Type Speed Text Image 25x80 1024x768x24 (mbps) (msec) (msec) ADSL (down/up) 1.4 / 0.128 11.43 / 125. 13,428. / 146,875. T-1 - Cable 1.4 11.43 13,428. T-3 45. 0.36 418. Wi-Fi (802.11g) 54. 0.3 348. Ethernet (100 base-T)100. 0.16 188. OC-3 155. 0.1 121. OC-12 622. 0.026 30.2 Gig-E (1G) 1,000. 0.016 18.8 OC-48 2,500. 0.0064 7.5 OC-192 (10G) 10,000. 0.0016 1.9 mbps = mega bits per second msec = milliseconds

23. Best case storage requirements and transmission times for radiological images Digital chest film Mammography MRI study Echo-cardiogram study Via 100 mbps (100 base-T) Ethernet • 20 mbytes 2 sec. • 160 mbytes 16 sec. • 200 mbytes 20 sec. • 4,000 mbytes 400 sec. (6min. 40 sec.)

24. 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

25. 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

26. 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.

27. 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

28. 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 nation’s healthcare, health education, and health research systems in such areas as cost, quality, usability, efficacy and security.

29. A Comprehensive Tele-dermatology Program Oregon Health Sciences University, Portland, OR

30. University of Alaska at Anchorage, Anchorage, AK

31. Baby CareLink Beth Israel Deaconess Medical Center, Boston, MA

32. Video house calls for patients with special needs National Laboratory for the Study of Rural Telemedicine, University of Iowa, Iowa City, IA

33. Providing Healthcare to the Underserved Center-City: Tele-ophthalmology University of Southern California Advanced Biotechnical Consortium Drew University School of Medicine Los Angeles, CA

34. Tele-Radiology Most common form of telemedicine Fits workflow of radiology departments Reimbursable First to have clear standards for Telemedicine Imaging equipment Communications (DICOM)

35. 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

36. 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

37. 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

38. 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

39. SMS for Telemedicine • Appointment reminders • Monitoring chronic illnesses • asthma, diabetes, chronic heart failure • Health messages • Medication reminders • AIDS, elderly • Reporting laboratory test results • Surveillance reporting tool • SARS, avian flu, H1N1 flu • Emergency alerting tool • Personal Health Record (PHR) • Questions, consultation • Literature search

40. Medline® via SMS 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 carpal tunnel syndrome. At one year local steroid injection is as effective as surgical decompression for symptomatic relief. 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

41. 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

42. Lessons Learned - Patient’s 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

43. Lessons Learned - Provider’s 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

44. 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

45. 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 (EMR) Sensor technology m-Health

46. Changes likely to drive the future models telemedicine: Governmental & Cultural Consumer expectations of best practices and access to best specialists Next generation’s 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

47. FCC Rural Health Care Pilot Program - 2007 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 applicant’s 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

48. FCC National Broadband Plan - 2010 • Create appropriate incentives for e-care utilization • Modernize regulation to enable health IT adoption • Unlock the value of data • Ensure sufficient connectivity for health care delivery locations www.broadband.gov

49. 10.1: Create appropriate incentives for e-care utilization • HHS should identify e-care applications whose use could be immediately incented through outcomes-based reimbursement • When testing new payment models, HHS should explicitly include e-care applications and evaluate their impact on models • For nascent e-care applications, HHS should support further pilots and testing that review their suitability for reimbursement • As outcomes-based payment reform is developed, CMS should seek to proactively reimburse for e-care technologies under current payment models

50. Modernize regulation to enable health IT adoption • 10.2: Congress, states and the CMS should consider reducing regulatory barriers that inhibit adoption of health it solutions • Credentialing and privileging • State licensing requirements • E-prescribing • 10.3: The FCC and the FDA should clarify regulatory requirements and the approval process for converged communications and health care devices