the telemedicine center the telemedicine center at east carolina university division of health...
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The Telemedicine Center
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 MissionImprove health care quality & access by appropriate application of health information & communications technologies and practices
across our nation
and outreach to other nations worldwide.
in Eastern Carolina
Dr. Dawd Siraj with John Hopkins University connecting to Ethiopia
The Telemedicine Center
Current ECU telehealthapplications
• 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 Networkwith Local Bridge
Capability
ECU BridgeECU BridgeDirect / MCUsDirect / MCUs
Microwave & IP 1.5 MbpsMicrowave & IP 1.5 MbpsNCREN - 180 sitesNCREN - 180 sitesDistance Education/LearningDistance Education/Learning
IP Video IP Video 384 kbps - 2 Mbps384 kbps - 2 Mbps
REACH-TV - 27 REACH-TV - 27 sites sites
Telemed & Distance EducTelemed & Distance Educ
IP Video 384 kbpsIP Video 384 kbpsNCIH - 186 sitesNCIH - 186 sites
Distance EducationDistance Education
IP T-1 1.5 MbpsIP T-1 1.5 MbpsInternet2, Abilene, National
Lambda RailDistance Educ & InstructionalDistance Educ & Instructional
ISDN ISDN 128 kbps – 1.5 Mbps 128 kbps – 1.5 Mbps Telemed, Dist Ed, Consulting, Telemed, Dist Ed, Consulting,
Mental Hea Dept,Disaster ReliefMental Hea Dept,Disaster Relief
POTS 28.8 KbpsPOTS 28.8 KbpsHome HealthHome Health
Telemedicine, Disaster ReliefTelemedicine, 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 historyBioterrorism/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
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.
The Telemedicine Center
Telemedicine history
• 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
Telemed Delivery Mechanisms
• 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
The Telemedicine Center
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 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
IP challenges
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 Reimbursementfrom 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
Telemedicine
Specialized Care Facility
Doctor’s Office
RuralHospitals
Military BaseHospitals
Clinical Room in the Naval Hospital
Camp Lejeune, NC - 1996
The Telemedicine Center
RevenueContracted Services
Central Prison used 28 types of specialties
Telemedicine
Short/Long Term
Correctional Prisons
Home / Office
School/ChildCare Facility
Travel/ Air
Cruise
Ahoskie – Roanoke-Chowan
Jacksonville – Onslow Kenansville – Duplin General
Tillery-Community Ctr
Rocky Mount -Nash
REACH NetworkRural EAstern Carolina Health – Network
Telemedicine Clinical Sites
Belhaven - Pungo District Hospital
Avon - HealthEast Family Care
Faison - Goshen Medical Ctr
Tarboro - Heritage
Hospital Site Medical Center Site School Infirmary Site Correctional Sites 2009
Nags Head - Outer Banks
Goldsboro – Goldsboro Pediatrics
Tarboro-Heritage Heart
Sites with Nurse Presenters Sites with Trauma Rooms Cardiology Network- 07-09 Psychiatry Network - 07-09
Kinston – Caswell Center
Sunbury – Happy, Inc.Ahoskie – Roanoke-Chowan
Ahoskie–Roanoke-Chowan Heart Center
Goldsboro - Cherry Hospital
Greenville –ECU Cardiology 2 Units
Greenville –Health Steps 4 Units
Raleigh – Central Prison
Taylorsville- Alexander Correctional
Morganton- School for Deaf
Edenton – Chowan HospitalWindsor– Bertie Memorial
Raleigh-Governor Morehead School for Blind
Wilson - School for Deaf
Greenville-ECU Psychiatry 2 Units
Lenoir County Proposed Spoke
Bertie County Proposed Spoke
Edgecombe Co. Proposed Spoke
BSOM UHS
EC Behavioral Health- LME
CNC/ACCESS-Jackson-Proposed
PORT- Wilson-Proposed
PORT – Rocky Mount-Proposed
RHA – Wilmington-Proposed
RHA –New Bern-ProposedClinton - HITC
Maury – Maury Correctional
The Telemedicine Center
Top Current Clinical Applications at ECU
• 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• 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 regional Cardiology Rehabilitation Center.
The Telemedicine Center
Tele – psych Network• 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 collaborates with psychiatrist at Cherry Hospital, state psychiatric hospital
The Telemedicine Center
Traumatic brain injury
• 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 **
Dr. Jacinta McElligott & Elsie Siebelink, TBI Nurse
•* 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 #*!
• 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
Videoconferencingendpoints
• “Hard” endpoints
– Dedicated hardware/appliance
• “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
Technical Configuration
• Peripherals– Otoscope– Electronic stethoscope– Hand held camera– Pan/Zoom/Tilt camera
w/far-end control
The Telemedicine Center
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 engineering support
The Telemedicine Center
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 roomseach equipped with:
• 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• 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• 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
• NC State Division of Mental Health– Equipment Enhancement/Install Design– Fourteen Sites Training and Support– Clinical Services
• 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• 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
• 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 CaceresFrom 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
• 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
Telehealth/Telemedicine
• Specialty teleconsultation• Telecare
• Remote monitoring• Distance learning
• Multidisciplinary care
Health InformationTechnology
• Electronic Health Records• Practice management systems
• Clinical decision support• e-Prescriptions
• Alerts/reminders• Digital imaging/PACS
Consumer HealthInformatics
• Personal Health Records• Health web sites
• e-Visits• e-Journals
• Virtual health/support communities
Connected health?
Common denominator isthe network
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
demand
The Telemedicine Center
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
http://www.ecu.edu/telemedicine