Remote tele mentored-fast_methodology_e_geh13_2013_07_08

Telemedicine @ CRS4:REMOTE Project and

Tele-Mentored FAST methodology

Riccardo Triunfo – [email protected]

8th July 2013eGeH 2013

e-Government & e-Health

CRS4 / HEALTHCARE FLOWS GROUP

MEDICINE GOES DIGITAL

TELEMEDICINE PROJECTS

AGENDA

CRS4

CRS4: CENTER FOR RESEARCH, DEVELOPMENT AND ADVANCED STUDIES IN SARDINIA

‣ Interdisciplinary research center focused on computational sciences

‣ Located in the POLARIS Science and Technology Park (Pula, Sardinia,

Italy)

‣ Operational since 1992

‣ Scientific/industrial research, technological development and higher

education

‣ RTD staff of ~170 people

CRS4

STRENGHTS AND FOCUS

‣ Key strengths:‣ Infrastructure‣ Research and development in enabling

technologies‣ Direct experience in the application

context

‣ Primary focus is on‣ Energy & Environmental sciences‣ Information society‣ Biomedical sciences

‣ International and national collaboration‣ PON, EU FP7, Wellcome Trust, NIH, APL, …

‣ Technology transfer toward industry and regional structures‣ ENI, INPECO, IBM, NICE, GEXCEL,…

HEALTHCARE FLOWS GROUP

‣ Part of Data Fusion Sector

‣ More than ten year experience in research and development in ICT application for clinical practice, medicine and biology

‣ State of the art solutions to real medical needs

‣ Collaborations/direct involvments:‣ Hospitals‣ Enterprises‣ IHE‣ HL7 international‣ OpenEHR consortium‣ OME consortium

HEALTHCARE FLOWS GROUP

AGENDA





HEALTH ICT INVESTMENTS COMPARISON

7

% of expenditure in ICT on the total healthcare budget

HEALTH ICT INVESTMENTS

8

A really complex sector but few investments

% of expenditure in ICT on the total budget (PricewaterhouseCoopers Report)


AN AGEING POPULATION

9

• The % of popolation with more than 60 years is growing fast everywhere in the world

• We need health policies to ensure good quality of life to elderly people

*source United Nations, Population Ageing and Development 2012


DO WE HAVE A SILVER BULLET?


SAVINGS DUE TO THE USE OF HEALTH TECHNOLOGIES

11

• If 90% of USA hospitals will adopt HIT

– $77 Billion per year– $400 Billion per 15 year– 6% of global spending for

healthcare in USA


EFFECTIVENESS, NOT ONLY EFFICIENCY

12

• A recent study1 compared a group of hospitals in Texas that has adopted advanced HIT systems with a group that has not (measured by CITAT 2 index). It found that the first group:

–15% fewer deaths and

–16% fewer complications,

– lower costs.

1 Archives of Internal Medicine - 'Clinical Information Technologies and Inpatient Outcomes: A Multiple Hospital Study' – January 2009: 41 hospitals in Texas, 167.000 patients > 50 years old

2 Clinical Information Technology Assessment Tool: measures a hospital's level of automation based on physician interactions with the information system based on 4 subdomains: test results, notes and records, order entry, and decision support


NOW WHAT ARE INVESTMENTS FOR?

13


14


WE NEED A MOORE’S LAW FOR HEALTHCARE!

AGENDA




TELEMEDICINE

‣ Recognized at international and national level as an important tool to obtain:‣ Services of better quality and wellbeing for patients (home is

where you’re cared for)‣ Cost reduction, new care models‣ Positive contribution to industrial sector

‣ A big part of telemedicine projects is not able to evolve from pilot studies to tools used in real clinical contexts

‣ In Europe‣ Telemedicine is a key point of European Digital Agenda for e-

health, one of the 7 flagship

‣ In Italy‣ eGov 2012, telemedicine is among the prioritary sector with

booking centers, HER and e-prescription

TELEMEDICINE

REMOTE PROJECT RESOURCES AND ORGANIZATIONAL MODELS IN

TELE-ECHOCARDIOGRAPHY

‣ The main aim of the project is to enable remote real-time tele-consultations based on the transmission of medical images and direct collaboration of specialists.

‣ The project , partially funded by Sardinian Region, proposes a model to enable access to specialized care in remote areas using real-time telemedicine and low cost and open technologies

‣ The clinical focus in on operator dependent diagnostic methodologies, whose results may not be revealing when the exam is not performed by a specialist

‣ Project presented by CRS4 and Brotzu Hospital Paediatric Cardiology Structure, directed by Dr. Roberto Tumbarello

REMOTE PROJECT

‣ E-Health situation in Sardinia Region‣ 1.6 Milion people, 11 Public Health structures‣ Hub&spoke model promoted‣ Considerable investments (network, infrastructures) for the

creation of a regional HIS

Project name

Investment

Areas

SISaR 25M€ ADT, Scheduler, Emergency, Order Entry, Blood Banks, Pharmacy, Operating Theatres

MEDIR 10M€ GP and paediatrician network, EHT

SILUS 1.5M€ Laboratory

RTP 1.1M€ Cancer registry and teleconsultation

ANAGS 1.3M€ Federated Demographics DB

RTR NA Optical Fiber Networks

ORGANIZATIONAL CONTEXT: SARDINIA

REMOTE PROJECT

‣ Congenital heart diseases (CHDs) are the most common congenital disorders affecting 6 to 13 ‰ live-born infants and can be detected by echocardiography

‣ The diagnosis is complex, strongly operator dependent: even a expert cardiologist can’t perform this kind of examination, if not specifically trained

‣ Barriers rise to the access of specific exams, particularly in sparsely populated areas because of a lack of physician with a specific skill in the pathology

‣ In Sardinia there is a high incidence (double of international frequency), but only a tertiary center, Brotzu Hospital, with specialized expertise in the Paediatric Cardiology Structure directed by Dr. Roberto Tumbarello

CLINICAL CONTEXT: PAEDIATRIC CARDIOLOGY

REMOTE PROJECT

‣ Issue: high incidence of congenital hearth diseases / no false negatives‣ Resolution: virtual presence of specialists through telemedicine

applications

‣ Issue: operator dependent exam ‣ Resolution: direct interactions between the operator and the

specialist (real-time voice and video chats) enables correct exam execution.

‣ Issue: lack of specialists and devices in secondary healthcare structures‣ Resolution: the system allows better logistics, concentrating

specialists in tertiary hospitals, reducing shifts and reusing ultrasound devices heterogeneity and age (only a video output is needed)

‣ Issue: low investments in remote districts ‣ Resolution: COTS low cost devices and open source software.

MAIN ISSUES/RESOLUTIONS

REMOTE PROJECT

‣ The main objectives are:

‣ enable real-time consultations with direct interaction between clinicians involved

‣ reuse any diagnostic devices available in remote districts

‣ restrain the costs of additional material/software required

‣ lower the learning curve for the secondary care doctors

‣ facilitate teaching sessions via video conferences with many participants

OBJECTIVES

REMOTE PROJECT

STARTING FROM THE END

REMOTE PROJECT

Scheduling

BASIC FLOW

REMOTE PROJECT

Real-time teleconsultati

on Reporting

SCHEDULING

‣ Routine‣ scheduling system consistent with Sardinian regional scheduling

system‣ Emergency

‣ Access to consultation during availability periods‣ Emergency calls always available

REMOTE PROJECT

TELECONSULTATION START

‣ The specialist plans the teleconsultation with the requiring physician (via system scheduling or by phone for emergencies)

‣ The requiring physician starts teleconsultation in 3 simple steps (authentication, request and start)

‣ At this point only the specialist response is needed

REMOTE PROJECT

WAITING FOR THE SPECIALIST

‣ The specialist starts the system in his/her laptop‣ The specialist accepts teleconsultation in 3 simple steps

(authentication, request accepted and start)

REMOTE PROJECT

PROJECTION REQUESTECHO PARAMETER CORRECTIONPROBE POSITION CORRECTION

SCREENSHOT ACQUISITIONAUDIO FROM A CANALE DOPPLER

DURING TELECONSULTATION

‣ The physicians are connected by a audio/video channel‣ The specialist can see in real time the echograph output and the

examination scene recorded by a camera, and can guide who is performing the diagnostic test

REMOTE PROJECT

DEMOGRAPHIC DATAANAMNESISPREVIOUS EXAMINATIONS(ECG, etc)

STRUCTURED REPORTECHOCARDIOGRAPHY

AFTER TELECONSULTATION

‣ The specialist prepares the report for the examination‣ A structured report is used, to obtain uniformity and to automatically

analyze the data‣ The report can be exported in the most common formats (CDA

included) and integrated in Sardinian Region Ambulatory Care system

REMOTE PROJECT

SYSTEM ARCHITECTURE

GLOBAL VISION

EXPERIMENTATION

‣ The system was tested on 42 patients, performing the examination both in the traditional way and via teleconsultation

‣ The experimentation involved two specialist in Paediatric Cardiology, working directly or remotely according to an established rotation

‣ The protocol included specific steps and a pre-defined set of projection

‣ The structured report was fundamental to obtain comparable results

‣ The results for the global diagnosis were good, showing a complete match between the two diagnosis in the 97,6% of the cases

‣ The results obtained comparing the single voices of the report are satisfying and will be sent by the clinicians to American Hearth Association Congress

REMOTE CLINICAL TRIAL

RESULTS

‣ Clinical analysis:

‣ The results for the global diagnosis were good, showing a complete match between the two diagnosis in the

97,6% of the cases(The results obtained comparing the single voices of the report are satisfying and will be sent by the clinicians to American Hearth Association Congress)

‣ Economic analysis:‣ Potential savings avoiding unnecessary transport, examining the

patients via the tele-mentoring system

REMOTE RESULTS

Estimate obtained considering in retrospect the tranfers in 2012

‣ What is FAST? Focused Assessment with Sonography for Trauma (commonly abbreviated as FAST) is a rapid bedside ultrasound examination performed by radiologists, surgeons, emergency physicians and certain paramedics as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma.[1]

‣ Why telemedicine in FAST? Bedside ultrasound has become standard of care in emergency medicine in the hospital setting, and has been invaluable in the care of the trauma patient for many years. Deployment of ultrasound in prehospital care and emergency medical services (EMS) could potentially provide critical information about the traumatized patient but the emergency doctors have to be supported by radiologists.

‣ Where? There is an ongoing study at Burlo Garofolo hospital in Trieste and involves the Emergency and Radiology Departments. The study is coordinated by Dr. Floriana Zennaro.

EXTENDING THE PHILOSOPHY: FAST METHODOLOGY CASE STUDY

FAST USE CASE

FAST USE CASE: EXPERIMENTATION

‣ The system is currently under a clinical experimentation involving 80 incoming patients of emergency department

‣ Currently 15 patient has been examined

‣ The experimentation protocol includes 3 examinations per patient:‣ 1st : the emergency doctor is guided in FAST examination by a

radiologist using the system‣ 2nd: the same radiologist repeats the examination directly on the

patient‣ 3rd: a second radiologist repeats the examination directly on the

patient (Gold Standard)

‣ The protocol includes specific steps and a pre-defined set of projection

‣ The structured report is fundamental to obtain comparable results

FAST CLINICAL TRIAL

FUTURE DEVELOPMENTS

‣ Continuation of the research activities, to obtain real mobility and new interaction paradigms based on virtual reality

‣ Application in other clinical contexts with operator dependent diagnostic methods (FAST examination, haemodynamics,…)

‣ Connection of other centers, in Sardinia and in the rest of Italy (interest from Bologna, Trieste and Genoa)

‣ Software refactoring and release under opensource licence

‣ Industrialization and diffusion TELEMEDICINE@CRS4

QUESTION&ANSWER

THANKS TO ALL OF YOU FOR THE ATTENTION!

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Remote tele mentored-fast_methodology_e_geh13_2013_07_08