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11.04.23 teleneurofeedback © EEG-TRAIN 1

TELE-NEUROFEEDBACKWITH SPECIAL APPLICATION OF REAL-TIME-NORM-TRAINING

Doerte Klein, EEG-TRAIN EEG-Biofeedback Trainingszentrum Hannoverwww.eegbiofeedback.de [email protected]

SAN – Congress Sevilla May 2008

Tele-Neurofeedback Background:

The special need for professional Neurotraining in face of limited professionals calls for distance training.

There are demands for Tele-communication and Tele-training also concerning Neurofeedback

Tele-Neurofeedback/Tele-medicine is not a “new” technique – it is the application of an existing method within a new frame – insofar existing standards have to be transmitted (i.e. privacy, data protection)

Methods:

„No Tele-Medicine without data protection“ - Luecke, 2008, „partnership for the heart“

The Z-Score-Real-Time Neurofeedback-option will be introduced as scientifical

controlled method to train distance patients with neurofeedback -

A local co-therapist will be introduced, the frequency of supervision has to be set

according to individual needs.

Part of the Tele-Approach is an individual contact to the professional trainer/therapist in a setting,

appropriate to the individual circumstances: fractionated treatment in practice or home visits.

Results:

Experiences with Tele-norm-training/neurofeedback proved the efficiency and effectivity of

neurofeedback-training also in this setting, independently of group of / intensity of symptom.

Basic technical settings are important to reflect. 11.04.23 teleneurofeedback © EEG-TRAIN 2

Tele-communication in Health-Systems has a long history


The Radio Doctor 1924 Fischer 2008


The portable electrocardiograph – 1925Fischer 2008


The Tele-Surgeon 1931 Fischer 2008


HistoryTradition of telephone diagnosis since 18971922 forecast of Th. Edison „radio has no future“1925 the portable Electrocardiograph1931 the Tele-SurgeonSince the 70th in the US: direct Patient-Computer-Interaction and remote systems1972-75 STARPHAC (Space Technology Applied to Rural Papago Advanced Health Care) – NASA – medical care for astronauts in the orbit, Bashshur, 19802008 – Telemedicine as reality, still to be integrated – Tele-Neurofeedback to be established


Scepticism on the future of Telemedicine

Depletion of communication & Encouragement of social isolation – „…computer-mediated communication … offers nothing to psychoanalytic practice,

except to erode the therapeutic alliance“ (Curtis, 2000)

Lack of personal contact & Deprivation of medical cultur – „Cybermedicine …retards development of physician compassion and patient trust…

encourages morally inappropriate patient-physician relationships“ (Bauer 2004)

“There is no reason for anyone to have a computer in their home” – James Olson, CEO, digital equipment corporation (DEC) – 1978 (s. Collura)

“Home neurofeedback training will never be practical” – Anonymous clinician - 2002 (s. Collura, Remote Neurotherapy)


Actual state in health system

Congress „TeleHealth 2008“ integrated in CeBit, Hanover, march 2008Questions: - Role of IT* in health care in the future ? - can IT in Health care contribute to cost reduction ?Topics: integration of hardware-solutions into existing clinic and practice it-systems and improvement of medical care and documentation of medical datas with electronic patient records (EPR)

* IT - Information Technology 11.04.23 teleneurofeedback © EEG-TRAIN 9

Actual state in health system - 2Examples of research in Tele-Monitoring – s. Luecke 2008

Charité/Berlin: cardiovascular monitoring imbedded in emergency system, criterias for data security/privacy

Claim: No Telemedicine without Data protection

Criterias of requirement: - „techno“- education and written informed consent

- limited use of datas - only for this special purpose - trustfulness - access to datas only by authorized persons

- authenticity - authorized person clearly to be assigned - integrity - undistortability of collected, stored, transmitted or processed datas - availability - datas are available exactly when needed - validity - datas must be valid - traceability – origin and author of processing should be reproducable at any time

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Charité - 2Data-Protection – methods: Access control - education and code only for authorized persons

Access control - allowance of necessary access rights per login and password

Input control - processing only by registered persons

User control - access to datas only by authorized persons, no access to public internet, remote access only by own network

Transmission control – where will which datas be sent to ? Transport control – prevention of reading, changing, or deleating of datas on

their transport way (coding, VPN, private net)

Organisation control - control of all methods by data security officials, ongoing education, patient/therapist confidentiality (written)


Charité - 3

Examples of legal basics: (Medical) professional code of conduct: confidentialityCriminal code: authorization to inform third party on therapeutical datasEU privacy policy: a priori control by internal security administratorSocial security code: agreement/compliance of patientNational Data Protaction Act: no access to personal datasFederal Data Protraction Act…



Example best practise: MEDGATE – Telediagnostic and Teletherapy in Swiss Center for Telemedicine: since 1999, 150 physicians, up to 1.600 contacts/dayTeleconsultation: 80 % of calling patientsTelediagnostics – Telebiometrie – Telecare: Teleadvice, Teletherapy (prescription per fax)Realconsultation: 20 % of patients


Medgate - 2

Role of method of communication in therapeutic information transmission

text telephone F2F


Classical assumption:„i have to see my patient...“

Amount of information transmitted

text sound video F2F

Pre

fere

nce

l ow

hig

h

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What we say and what we do(Schliemann et al, 2002)

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Example for Tele-Diagnostik;

Levine SR et al.: Telemedicine for acute stroke: When virtual is as good as reality. Neurology. 2007Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) was started in February 2003. Twelve community hospitals with no or very limited stroke thrombolysis experience and two stroke centers were connected via a network providing online neurologic examination and transfer of neuroradiologic scans. CONCLUSIONS: Mortality rates and functional outcomes for telemedicine-linked community hospitals and stroke centers were similar and comparable to the results from randomized trials.


Terms IT – Information Technology – general termTelematic = Telecommunication + InformaticsTelearchitecture – serves with appropriate designsE-Health – art term of applicationTelemedicine - applicationQuality Management – general necessitySustainability – claim Best practice – scientifical claimTelemonitoring – practise of distance monitoringAAL – Ambient Assisted Living – systemic aspect


Definition E-Health/Tele-Medicine

Eysenbach (2001) ... not only a technical development but also...a (special) way of thinking, attitude and obligation to networking and global thinking to improve medical care... by use of information and communication technology.Convergence internet and medicine can create something NEW – with chances and risks for all acteurs in health systems.


Definition Telemedicine

Def. in application: „telemedicine is the use of information and telecommunication technologies to provide and support healthcare when distance sepearates the participants (M.J.Field 1996, s. Oeser 1998, 9)Def. in structure: TM consists of sender – remote data transfer - receiver; transfer individual-related or anonymous; datas as „classical“ information (text, sound, picture) or as information to control machines (e.g.telesurgery – online and realtime)Def. Oeser: TM… technique providing provision of medical information and services independently of their actual physical existence for the patients sake. Telemedicine is the delivery of care to patients anywhere in the world by combining communications technology with medical expertise. Telemedicine is an emerging field that could have a revolutionary impact on the delivery of medical care. .. The goal is to improve access to high-quality medical care at afordable cost. ..challenge for policy makers, healthcare organizations, and providers…Goldberg, 1995, s. Oeser, 2001


Why Tele-Neurofeedback ?

Quality control and cost management in several aspectsOvercome geographical, time barriers (Collura, Remote Neurotherapy)- NFB-Therapist Network not jet compact enough - Distance training without distance driving (time)Create a natural extension of clinical practice (Collura)Multi-tele-modules simulates F2F situationCollura: There is no fundamental reason we cannot get neurofeedback into homes, schools, offices. • Telemedicine is the future of medicine. • Teleneurofeedback is the future of neurofeedback.


Why Remote Z-Score Training ?

Quality management: Corresponds to qualitative assessement proceduresSecurity to not training dysfunctional optionsT.F.Collura, 2007: Integrates QEEG analysis with training in real time – protocol automatically and dynamically adapts to what is most needed – consistend with established QEEG-based procedures with demonstrated efficacy (slide 35)Control for protocols by setting of age & session numbers


Special treatment settings of Tele-Neurofeedback

Intake - AssessementDecision on possibility of tele-trainingTreatment planningLocal co-trainerEquipment for client should be a remote systemTreatment settingsTele settingsEvaluation


Intake

Inicial setting: personal contact in clinic or home visitDecision: ongoing F2F-setting or remote setting? Co-trainer: client/patient or third person ? Fractionated therapy in clinic and/or remote sessions?Treatment contracts:

- consent of voluntary desicion for tele-neurofeedback (client) - own responsability for risks (client) - privacy, data security/protection, and professionality (therapist)


Assessement

Procedure as in clinicAnamnestic datas, different ass. Datas (Testreports, medical results & reports…)QuestionairesTestsEEG-Assessements – Morphology, (Mini)QEEGSymptom- and localisation approach


Decision about Tele-Training Intellectual understandingComputer skillsTechnical understandingManual, technical abilitiesResponsabilitiescomplianceSW & HW easy to useAbility to spent a certain amount of money (renting, purchasing equipment, technical training)


Equipment

Remote option in software ensures user controlOptions for purchasing the equipment:

- client keeps the e. (periods of ongoing training) - client-group shares the equipment - selling the e. second hand with therapists help


Options „in-office“- and TeletrainingBest: - initially 1-2 weeks (at least 2 days) compact training in-office

- 2-3 sessions per day - technical training - Teletraining 1/week, home sessions 2-3/week

Optional: - decision for Tele-NFB during ongoing therapy - fractionated therapy (patient lives at a certain distance) - fractionated rental teletraining

No clinic visits in case of patient in vegetative state


Short report on „ultimate“ Tele-Neurofeedback

Patients in „vegetative state“ (or „state of minimal consciousness“?), living at home Initial assessement (Mini-Q) – analyse by an expert („astonishing much thalamo-cortical activity“)Q-EEG after 4 months training – clinical analysis Dr. R. ThatcherCritical Question: is Neurofeedback possible? Is there a feedback ? Neurofeedback Test-Session (two dolphins with water sound)If Feedback works – fractionated home visits ?Or: Tele-Neurofeedback – 4 channel z-score-dll ? (first remote 4-channel z-score system?)

Appropriate briefing and/or education local co-therapist (physiotherapist – visits patient 5x/week)Co-therapist conducts symptom tracking over internetAppropriate professionel supervised sessions by tele-contacts, initially 2 x /weekHome visits therapist 1/month (300 km)


Report - 2Results so far Facial expression – improvement – relaxationEye contact 50 % ↑Constipation 50 % ↑Circadian rhythm 50 % ↑Pain – no results(s. eegexpert.com – symptom tracking, s. verbal reports from wife and co-therapist)„ultimate-plus“ could be: remote training with Mini-Q device


Treatment planning

First fractionated sequence of sessions in clinicImportant for client: trust in methodImportant for therapist: trust in client, in procedures = his own strategy for ongoing treatment, in protocol decisionsEnsures professionality and quality standardsDecision according to assessement outcomeAdaptation of decisions according to treatment progressNo change in treatment strategy without tele-supervision


Local Co-Trainer

If necessaryParents, relatives, friendsother therapists (i.e. physiotherapist, ergo-therapist, logotherapist, medical or psychological collegues)Suffient and necessary amount of coaching, educationOngoing support


Equipment for client/patient

aquisition of equipmentRenting – purchasing„remote“-system important to prevent malpractice


Treatment settings - Tele-Neurofeedback

Installation of software & equipmentInstallation of VPN (Virtual Private Network - a secured „tunnel“ in the internet)

Installation of remote service software (i.e. teamviewer, Real VNC – Real Virtuel Network Computing)

Important: local pc professional – settings for internet security, minimum computer experience


Treatment settings - 2

SW-HW Installation: help and support should be an important part – experience of different basic knowledge with clients/patients!

Keeps compliance, motivation Remote Option in SW: Packed NFP protocols easy to transfer back & forth

- blank by clinician- With sessions by client/patient


Treatment settings – 2a

Continuum in treatment conditions: clinic remote telephone support support / protocols by email VPN-remote training (plus audio-video contact

or plus telephone)

Shift in treatment setting: less time per client/patient, more patient to be treated, cost reducing for patient/health system


Treatment settings – 2b

Clients: = patients = schools = artists, musicians = sportsmen


Treatment settings – 3

VPN – Virtual private network (private = separated from internet and exclusively to be used by partners)

Uses „tunnel-technique“ within internetSystem as VPN-rooter with i.e.) windows server 2003/ 2008 operating systemConnection of therapist pc and client pc to VPNConnection therapist pc and client pc via remote service sw (Real VNC, Teamviewer etc.) Note: connection over VPN stops other internet connection


VPN Client - Connecting with VPNWindows XP

Client - Connecting with VPN Windows Vista

- Start- System control- Network connection- (top left) setup of new network – next- option „create connection with network on computer“ – next- choose VPN connection – next- name - i.e. „EEG“ - next- webadress teleneurofedback.dnsalias.net– next- finish

- Start- System control -classical view- Network- and Opening Center – next- (left) setup of connection or network - next- establish connection with computer – next- no, establish a new connection - next- domain: teleneurofeedback.dnsalias.net- name: test – next- username client- password test – next- define location – home/private


Remote service – configuration - 1

i.e. Real VNC (Virtual Network Computing) For client: serverFor therapist: viewerThe following settings will stop the Firewall completely for the VPN network


Remote service – configuration - 2

For ClientWindows XP

For ClientWindows Vista

Important: VNC connection only over secured VPN netStartSystem controlSecurity centerManagement of security settings for Windows FirewallExpandedMark VPN connection „EEG“SettingsAddDescription „VNC“Name or IP adress (…) localhostExtern port-#: 5900Intern port-#: 5900 Confirm all windows with OK or close

StartSystem controlSecurity centerTop left: Windows FirewallTop left: start or stop Windows FirewallTop: expandedRemove mark with network connection „EEG“Confirm all windows with OK or close


Tele-Session

Replay z-score sessionDemonstration setting for first tele-neurofeedback Demonstration of Tele-Managing


Evaluation

Ongoing evaluation with z-score trainingFractionated start – middle – endEEG-datas (QEEG), questionaires (online-tracking), achievement criterias, ratings parents, teachers, …Another fractionated clinic sessionsEvaluating end of treatmentWhat do with the equipment ?


Further solutions of remote NFB

„Walk-in-lab“


Literature * Allen, A.: When the ship.com comes in. Editor's note. Telemed Today, 7, 6 (1999) S. 7. * Bauer, J. C.: Consumerism redefined ... the e-health imperative. Mich Health Hosp., 36, 4 (2000) S. 42. * Braecklein, M., Lücke, S.: Datenschutz im Telemonitoring: Erfahrungen aus dem Projekt “Partnership for the Heart”, Talk TeleHealth, Cebit, Hannover 2008 * Collura, Thomas F: Targeting Strategies for EEG Biofeedback Using Normative Databases, 2007, http://www.brainm.com/kb/entry/229/ - Remote Neurotherapy, http://www.brainm.com/kb/entry/229/ - Remote Flowchart, http://www.brainm.com/kb/entry/229/ * Collura, Terri and Thomas F., The realities of remote neurofeedback http://www.brainm.com/kb/entry/229/ * Currell R et al.: Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Nurs Times. 2001 Aug 30-Sep 5;97(35):35. PMID 11957594. * De Las Cuevas C et al.: Randomized clinical trial of telepsychiatry through videoconference versus face-to-face conventional psychiatric

treatment. Telemed J E Health. 2006 Jun;12(3):341-50. PMID 16796502 * Della Mea, V.: What is e-health (2): The Death of Telemedicine? Editorial. Journal of Medical Internet Research 2001; 3(2): e22.

http://www.jmir.org/2001/2/e22/ * Eysenbach, G.: What is e-health? J Med Internet Res 2001; 3 (2): e20 http://www.jmir.org/2001/2/e20/. * Ferguson, T.: Consumer health informatics. Healthc Forum J 38, 1 (1995) S. 28. * Ferguson, T.: From patients to end users. BMJ, 324 (2002), S. 555 * Fischer, A.: Doc around the clock – Telediagnostik und Teletherapie im Schweizer Zentrum für Telemedizin – Möglichkeiten, Notwendigkeiten und

Grenzen, Talk on TeleHealth, CeBit, Hannover 2008 * Goldstein, D.: The e-healthcare cybertsunami. Manag Care Q 8, 3 (2000) S. 9. * Haas, Peter/ Meier, Andreas/ Sauerburger, Heinz: eHealth. Praxis der Wirtschaftsinformatik. HMD 251. dpunkt.Verlag. ISBN 3-89864-383-2 * Hankins, J.: The Internet. Adm Radiol., 10, 8 (1991) S. 69. * IBM (Schweiz): Wege zur personalisierten Medizin in der Schweiz [2] * Kraft, D.: Telematik im Gesundheitswesen, DuD-Fachbeiträge, Deutscher Universitäts-Verlag 2003, ISBN 3824421666 * Jäckel, A. (Hrsg.): Telemedizinführer Deutschland, Jahrbuch der Telemedizin 2007, 8. Ausgabe, Bad Nauheim 2006, ISBN 3-937948-05-8 * Jähn, K. u. Nagel, E. (Hrsg.): e-Health (2004)


Literature – 2 * Levine SR et al.: Telemedicine for acute stroke: When virtual is as good as reality. Neurology. 2007 Aug 28;69(9):819-20. PMID 17724282 * PricewaterhouseCoopers (PWC): Pharma 2005. Marketing to the Individual, 1999. * Oeser, R.: Projektmanagement aus Auftraggebersicht zur Umsetzung telemedizinischer Konzepte. Diplomarbeit TU-Wien (1999) Download * Oeser, R.: Technologienabhängige Systembetrachtungsmethode zur Umsetzung telemedizinischer Konzepte, Diss., Wien 2001 * O'Reilly R et al.: Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatr

Serv. 2007 Jun;58(6):836-43. PMID 17535945 * Ruskin PE et al.: Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. Am J

Psychiatry. 2004 Aug;161(8):1471-6. PMID 15285975 * Schuman, S. H.; H. B. Curry; M. L. Braunstein; R. Schneeweiss; G. C. Jebaily; H. M. Glazer; J. R. Cahn; W. H. Crigler: A computer -

administered interview on life events: improving patient-doctor communication. J Fam Pract 2, 4 (1975) S. 263. * Slack, W. V.; D. Porter; J. Witschi; M. Sullivan; R. Buxbaum; F. J. Stare: Dietary interviewing by computer. An experimental approach to

counseling. J Am Diet Assoc 69, 5 (1976) S. 514. * Slack, W. V.; L. J. Van Cura: Patient reaction to computer-based medical interviewing. Comput Biomed Res 1, 5 (1968) S. 527. * Slack, W.: Cybermedicine: How Computing Empowrs Doctors and Patients for Better Health Care. Jossey-Bass, San Francisco 1997. * Szecsey A et al.: Telemedizinische Konsile in der Gerontopsychiatrie: Ein Pilotprojekt. NeuroGeriatrie 2004; 1 (1): 32-34.

Zusammenfassung * Telemedicine in Gerontopsychiatry. European J Medical Research 7 Suppl, I, 7th Int Conf on the Med Aspects of Telemed - Integration of

Health, Telematics into Med Pract, Regensburg, Sept 2002, p 84, Szecsey A, Koch HJ * Singh SP et al.: Accuracy of telepsychiatric assessment of new routine outpatient referrals. BMC Psychiatry. 2007 Oct 5;7(1):55 [Epub

ahead of print]. PMID 17919329 * Schwab S et al.: Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007 Aug 28;69(9):898-903.

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