TELEMEDICINETELEMEDICINEDIGITAL MULTIMEDIADIGITAL MULTIMEDIA

ARCHIVINGARCHIVINGandand

ELECTRONIC PATIENTELECTRONIC PATIENTRECORDRECORD

TELEMEDICINETELEMEDICINE Application of telecommunication technology to Application of telecommunication technology to

the practice of medicinethe practice of medicine Commonly used to define interactive medical Commonly used to define interactive medical

multimediamultimedia Better manage patients by having more complete Better manage patients by having more complete

informationinformation Dynamic imaging with full motion video/audioDynamic imaging with full motion video/audio

( interactive = real-time )( interactive = real-time )( store and forward = video E-mail )( store and forward = video E-mail )

HISTORY

Initial developments in late 1950’s:Initial developments in late 1950’s:– Dr. Cecil Wittson in Omaha, Nebraska Dr. Cecil Wittson in Omaha, Nebraska

developed an extensive telepsychiatry developed an extensive telepsychiatry programprogram

– Dr. Albert Jutras in Montreal, Quebec Dr. Albert Jutras in Montreal, Quebec developed an inter-facility teleradiology developed an inter-facility teleradiology programprogram

HISTORY

Subsequent programs in North Subsequent programs in North America established with federal America established with federal grants and most utilized satellite grants and most utilized satellite uplinksuplinks

By the late 1970’s, none could sustain By the late 1970’s, none could sustain themselvesthemselves

HISTORY

Reawakening of interest in the late Reawakening of interest in the late 1980’s:1980’s:– decreased cost of land-based decreased cost of land-based

telecommunicationstelecommunications

– ““CODECsCODECs””

– improved inexpensive computersimproved inexpensive computers

HISTORY

1989 - 3 interactive-video telemedicine 1989 - 3 interactive-video telemedicine programsprograms

1993 - 10 interactive-video program1993 - 10 interactive-video program 1994 - 20 programs1994 - 20 programs 1995 - almost 40 programs in various 1995 - almost 40 programs in various

stages of discussion/implementationstages of discussion/implementation

EUROPEAN COMMUNITYPROJECTS

AIMAIM / / EuriPACSEuriPACS SMZOSMZO - 400 -bed geriatric hospital, 1000- - 400 -bed geriatric hospital, 1000-

bed acute care hospital, geriatric center, and bed acute care hospital, geriatric center, and a nursing collegea nursing college

COVIRA COVIRA - integration of CT, MRI/MRA, - integration of CT, MRI/MRA, DSA, PET, and other modalitiesDSA, PET, and other modalities

FEST FEST - telemedicine integration framework - telemedicine integration framework

EUROPEAN COMMUNITYPROJECTS

GEHRGEHR - define requirements for a standard - define requirements for a standard health record architecturehealth record architecture

MILORD MILORD - integrated departmental - integrated departmental environment using object-oriented model to environment using object-oriented model to implement a true multimedia environmentimplement a true multimedia environment

SAMMIESAMMIE - software for an integrated - software for an integrated medical workstationmedical workstation

EUROPEAN COMMUNITYPROJECTS

SEISMEDSEISMED - guidance on security matters n - guidance on security matters n CEC DGXIII/F publication (ITSSEC) CEC DGXIII/F publication (ITSSEC)

DIOGENE IIDIOGENE II - distributed HIS integrated - distributed HIS integrated with PACS and RISwith PACS and RIS

RACE / TELEMEDRACE / TELEMED - working group - working group IMPHONE IMPHONE - investigation of hospital - investigation of hospital

communication needs and functionality communication needs and functionality needs in workstationneeds in workstation

PROJECTS WITHIN THE

UNITED STATES TEXAS TELEMEDICAL PROJECTTEXAS TELEMEDICAL PROJECT MAYO CLINICMAYO CLINIC KANSAS / OKLAHOMA / IOWA KANSAS / OKLAHOMA / IOWA MCGMCG MilitaryMilitary Over 20 interactive video project in Over 20 interactive video project in

telemedicinetelemedicine

MAJOR PROBLEMS FACING MAJOR PROBLEMS FACING TELEMEDICINETELEMEDICINE

– 1) Mistrust and miscommunication1) Mistrust and miscommunication

– 2) Lack of consistent reliable managerial 2) Lack of consistent reliable managerial plan plan

– 3) Lack of standards3) Lack of standards

– 4) Legal / confidentially issues4) Legal / confidentially issues

MAJOR PROBLEMS FACING TELEMEDICINE (cont.)

– 5) Reliance on vendor claims

– 6) Poorly selected or overpriced equipment

– 7) Continued reliance on federal and state grants

MAJOR OPPORTUNITIES WITH

TELEMEDICINE Clinical Consultations to provide access to Clinical Consultations to provide access to

cost effective Health Carecost effective Health Care Medical Education in a real time Medical Education in a real time

environmentenvironment AdministrationAdministration Financial with ability to drive down costsFinancial with ability to drive down costs

TELEMEDICINETELEMEDICINE

DIGITAL ARCHIVING DIGITAL ARCHIVING

ELECTRONIC PATIENT ELECTRONIC PATIENT RECORD RECORD

ECHTCHC OfficesTCHC Outreach ClinicsHospitals ServicedSavannah

Primary Impetus is to improve patient carePrimary Impetus is to improve patient care Early intervention = early diagnosis = shorter Early intervention = early diagnosis = shorter

hospital stayhospital stay Improve utilization of resources:Improve utilization of resources:

– Physician / technicianPhysician / technician

– always accessible studies within the system always accessible studies within the system which by definition are which by definition are diagnostic qualitydiagnostic quality

Initial thrust to transmit ECHOCARDIOGRAMS in a real-time interactive environment

Open platform / scaleable DICOM / HL-7 compatible Digital solution (becomes a link in a total

electronic patient record) “Off-the-shelf” solution

Cost savings– Neonatal transport savings

466 Neonatal transports via “Angel” 25% Approximate Cardiology referrals $2,500 Average cost / transport $292,000 Savings in Transport costs (ideal) $150-200k Increased revenue to referral

hospital

Cost savings– Physician Time

140 Average number of Remote echocardiograms / month 1995

70 Echocardiograms which could be performed with a telemedicine

application 2.33 Average number of

telemedicine episodes / day

Cost savings (cont.) 4.0 Hours of underutilized

physician time / day 150k Average Cardiologist salary 30% Benefits for physician $ 95 Value / hour physician time $ 380 Savings / day physician time $138,700 Cost savings / year in physician

time

COMMUNICATIONCOMMUNICATION– HOSPITAL NETWORK DESIGNHOSPITAL NETWORK DESIGN

Ethernet Ethernet 10 Mbits / sec10 Mbits / secFDDIFDDI 100 Mbits / sec100 Mbits / sec

COMMUNICATIONCOMMUNICATION– TELECOMMUNICATIONTELECOMMUNICATION

FIBEROPTIC CABLEFIBEROPTIC CABLE– T-3 / T-1T-3 / T-1– ATM / SONETATM / SONET

ISDNISDN

COMMUNICATIONCOMMUNICATION– TELECOMMUNICATIONTELECOMMUNICATION

64 K / 56 K64 K / 56 KTwisted pairsTwisted pairsCellularCellularSatellite ( SWAN )Satellite ( SWAN )

WORKSTATION DESIGNWORKSTATION DESIGN– Essential part of Essential part of IMACS / PACSIMACS / PACS

User friendly User friendly Well developed management toolsWell developed management toolsHigh performance with sustained High performance with sustained

through-put and speed through-put and speed

STORAGE MEDIASTORAGE MEDIA– Magnetic DiskMagnetic Disk

– JukeboxJukeboxCapacities in excess of 28 TbytesCapacities in excess of 28 Tbytes

– Magnetic Tape Magnetic Tape

STORAGE MEDIASTORAGE MEDIA– Optical DiskOptical Disk

WORM WORM MOMO

– Optical TapeOptical Tape

– CD-ROMCD-ROM

STORAGE AND COMMUNICATION

STANDARDS 1983 ACR-NEMA Digital Imaging And 1983 ACR-NEMA Digital Imaging And

Communications Standards CommitteeCommunications Standards Committee 1985 Standard 1.01985 Standard 1.0 1988 Standard 2.01988 Standard 2.0 1993 DICOM 3.0 ( ANSI ) 1993 DICOM 3.0 ( ANSI )

SPECIFIC ISSUES TO CARDIOLOGY

File formatFile format– Demographic dataDemographic data

– Administrative informationAdministrative information

– Video imageVideo imageconcurrent calibration information for concurrent calibration information for

measurement measurementraw dataraw data

SPECIFIC ISSUES TO CARDIOLOGY

Identify the “endusers”Identify the “endusers”– general hospital communitygeneral hospital community

rapid access to data via networkrapid access to data via networkeasy integration with all areas/ modalitieseasy integration with all areas/ modalities

– Clinical echocardiographerClinical echocardiographerrapid access to current and all prior rapid access to current and all prior

studiesstudies

SPECIFIC ISSUES TO CARDIOLOGY

Identify the “endusers” Identify the “endusers” ( cont)( cont)

– ResearcherResearcherstorage of as much quantitative and storage of as much quantitative and

uncompressed data as possibleuncompressed data as possible

STANDARDIZATION

Density and depth Density and depth – important implications for storage and important implications for storage and

transmissiontransmissione.g. “human eye” can discern only 60 e.g. “human eye” can discern only 60

levels of graylevels of gray

–hence, 6 bits ( 64 value) pixelshence, 6 bits ( 64 value) pixels

–8 bits for color8 bits for color

STANDARDIZATION

Size of screen to archiveSize of screen to archive– 512 x 512512 x 512

– 256 x 256256 x 256

– further “windowing “ to best utilize further “windowing “ to best utilize archive mediaarchive media

STANDARDIZATION

CompressionCompression– manageable levels of compressionmanageable levels of compression

““Gold Standard” is videotapeGold Standard” is videotaperatio 24:1ratio 24:1

a lack of clinically validated studies a lack of clinically validated studies existexist

– JPEG, MPEG, Wavelets, and othersJPEG, MPEG, Wavelets, and others

TECHNOLOGY CAVEATSTECHNOLOGY CAVEATS

Adaptability to changeAdaptability to change Open architectureOpen architecture ScaleabilityScaleability Ease of operationEase of operation Minimal maintenance requirementsMinimal maintenance requirements Technological Technological

compatibility/upgradeabilitycompatibility/upgradeability

ApplicationsApplications- matching technology - matching technology with specific demands of specialty with specific demands of specialty (consumer driven)(consumer driven)

ResearchResearch- specifically in areas of - specifically in areas of standardizationstandardization

Standards of care/outcome analysisStandards of care/outcome analysis- - evaluation of added value to communityevaluation of added value to community

ReimbursementReimbursement ImplementationImplementation ConfidentialityConfidentiality- software/hardware - software/hardware

protocolsprotocols Value/EconomicsValue/Economics- identify as a value - identify as a value

added serviceadded service

Educational valueEducational value- on-going educational value/CME/interactive educational value/CME/interactive surgical teachingsurgical teaching

Communication costsCommunication costs- flexibility of - flexibility of technology/new technologiestechnology/new technologies

Motivation for providers/patientsMotivation for providers/patients

MEDICAL EDUCATIONMEDICAL EDUCATION RESEARCHRESEARCH VIRTUAL HOSPITALVIRTUAL HOSPITAL VIRTUAL RESEARCH CONSORTIUMVIRTUAL RESEARCH CONSORTIUM

““CLINICAL TRIALSCLINICAL TRIALS MAGNET MAGNET ““