the telemedicine center the telemedicine center at east carolina university division of health...

The Telemedicine Center

The Telemedicine Center at East Carolina University

Division of Health Sciences

Salutes our Military abroad, stateside, and in Eastern North

Carolina


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


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


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


ECU Telemedicine

history“Go ahead and tee off. Then I want you to listen to this wheezing”


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”



• 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



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


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


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.


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


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


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


• 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


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


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


Reimbursement

Fee for Services

Telemedicine

Specialized Care Facility

Doctor’s Office

RuralHospitals

Military BaseHospitals

Clinical Room in the Naval Hospital

Camp Lejeune, NC - 1996


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


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


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.


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


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


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


System integration #*!

• Evaluate Need• Service Model (24/7)• Identify technology• Choose telecommunication• Participants• Design implementation


“Telemed” Clinical Tools?

• Patient/Spoke site• Medical Specialty Driven• Additional switch or inputs

for video sources• Mobile capability• Patient Room Camera Control• Diagnostic tools?


Videoconferencingendpoints

• “Hard” endpoints

– Dedicated hardware/appliance

• “Soft” endpoints– S/W and/or

peripheral on PC– May include

hosting service


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


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


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


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


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


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


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


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


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


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)


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


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


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


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


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


Contact info

Gloria Jones

Assistant Director

Clinical Operations Manager

ECU Telemedicine Center

(252) 744-3855

[email protected]

http://www.ecu.edu/telemedicine

mailto:[email protected]

the telemedicine center the telemedicine center at east carolina university division of health...

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