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 ““