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Telemedicine and m-Health Michael J. Ackerman, Ph. D. 1 Assistant Director High Performance Computing Telemedicine and m-Health Michael J. Ackerman, Ph. D. 1 Assistant Director High Performance Computing and Communications National Library of Medicine

2 www. nlm. n. Ih. gov 2 www. nlm. n. Ih. gov

NLM Informatics Week at the Marine Biological Laboratory, Woods Hole, MA http: //hermes. mbl. NLM Informatics Week at the Marine Biological Laboratory, Woods Hole, MA http: //hermes. mbl. edu/education/courses/special_topics/med. html 3

Telemedicine The use of electronic communications and information technologies to provide or support clinical Telemedicine The use of electronic communications and information technologies to provide or support clinical health care at a distance Telehealth 4 The use of electronic communications and information technologies to provide or support clinical health care, patient and professional healthrelated education, public health and health administration at a distance

TELEMedicine: 5 TELEMedicine: 5

Telemedicine Using telecommunications and computers: • To exchange information to support medical decision making Telemedicine Using telecommunications and computers: • To exchange information to support medical decision making • For signal processing and image enhancement The arrangements for practicing medicine at a distance 6

Telemedicine Using telecommunications and computers to exchange information to support medical decision making • Telemedicine Using telecommunications and computers to exchange information to support medical decision making • • • 7 Medical Records – EMR and PHR Literature search Decision support Remote monitoring Consultation and Conferencing

Telemedicine • Signal processing – – Physiologic samples Electrocardiogram Blood pressure Heart or chest Telemedicine • Signal processing – – Physiologic samples Electrocardiogram Blood pressure Heart or chest sounds • Image enhancement – – 8 X-ray, CT, MRI Ultra-sound Skin lesions Patient visage

Telemedicine Arrangements to practice medicine at a distance • Network infrastructure • Licensure / Telemedicine Arrangements to practice medicine at a distance • Network infrastructure • Licensure / Credentialing / Privileging – CMS now accepts credentialing by proxy • Start-up Costs / Reimbursement / Long Term Financial Sustainability • Re-engineering Practice / Clinical Acceptance • Liability • Security HIPAA • Privacy 9 }

History of Telemedicine • Long undocumented history of providing information at a distance • History of Telemedicine • Long undocumented history of providing information at a distance • U. Nebraska: Psychiatry in the early 1960 s • Massachusetts General Hospital project with Boston’s Logan Airport in 1968 10

Dr. Kenneth T. Bird in the early days of Telemedicine (circa 1967) The delivery Dr. Kenneth T. Bird in the early days of Telemedicine (circa 1967) The delivery of medical care “without the usual patient-physician confrontation” Bird, 1967 11

“Doctor of the Future” ? ? - 1939 Fritz Kahn “Der Mensch gesund krank, “Doctor of the Future” ? ? - 1939 Fritz Kahn “Der Mensch gesund krank, Menschenkunde”, 1939

1971 Telemedicine to Alaska via satellite 13 1971 Telemedicine to Alaska via satellite 13

So what’s new? 1994 1924 14 So what’s new? 1994 1924 14

TELEMedicine: Broadband 15 The Internet TELEMedicine: Broadband 15 The Internet

University Corporation for Advanced Internet Development (UCAID) Internet 2 Program 16 221 University Members University Corporation for Advanced Internet Development (UCAID) Internet 2 Program 16 221 University Members

Europe Internet 2 International Partners ARNES (Slovenia) BELNET (Belgium) CARNET (Croatia) CESnet (Czech Republic) Europe Internet 2 International Partners ARNES (Slovenia) BELNET (Belgium) CARNET (Croatia) CESnet (Czech Republic) DANTE (Europe) DFN-Verein (Germany) FCCN (Portugal) GARR (Italy) GIP-RENATER (France) GRNET (Greece) HEAnet (Ireland) HUNGARNET (Hungary) NORDUnet (Nordic Countries) PSNC/PIONIER (Poland) Red. IRIS (Spain) RESTENA (Luxemburg) RIPN (Russia) SANET (Slovakia) Stichting SURF (Netherlands) SWITCH (Switzerland) TERENA (Europe) JISC, UKERNA (United Kingdom) Middle East ANKABUT (UAE) Israel-IUCC (Israel) MCIT [EUN, ENSTINET] (Egypt) Qatar Foundation (Qatar) 17 Americas CANARIE (Canada) CLARA (Latin America & Caribbean) CEDIA (Ecuador) CKLN (Caribbean) CNTI (Venezuela) CR 2 Net (Costa Rica) CUDI (Mexico) REUNA (Chile) RETINA (Argentina) RNP [FAPESP] (Brazil) SENACYT (Panama) Africa TENET (South Africa) AAU (Africa) Ubuntu. Net Alliance (Africa) Asia-Pacific AAIREP (Australia) APAN (Asia-Pacific) ANF (Korea) CERNET, CSTNET, NSFCNET (China) C-DAC, ERNET (India) JAIRC (Japan) JUCC (Hong Kong) MYREN/MDe. C (Malaysia) NECTEC / UNINET (Thailand) NREN (Nepal) PERN (Pakistan) REANNZ (New Zealand Sing. AREN (Singapore) TWAREN (Taiwan) Vina. REN (Vietnam)

Networking Health: Prescriptions for the Internet A 2000 study by the: U. S. National Networking Health: Prescriptions for the Internet A 2000 study by the: U. S. National Research Council Computer Science Technology Board 18 http: //www. nap. edu/catalog/9750. html

Commodity Internet vs. NGN • Current Internet - Passive, unintelligent - Best effort • Commodity Internet vs. NGN • Current Internet - Passive, unintelligent - Best effort • Next Generation Network - Active, intelligent - Guaranteed effort • The difference: - “Quality of Service” - Qo. S 19

The notion of End-to-End “Quality of Service” - Qo. S • Highly subjective − The notion of End-to-End “Quality of Service” - Qo. S • Highly subjective − − application-dependent user-dependent • Difficult to determine − − 20 often obscured by smart applications programming often obscured by network architecture like caching

Qo. S Features for Healthcare • Bandwidth reservation ( DCN ) • Low latency Qo. S Features for Healthcare • Bandwidth reservation ( DCN ) • Low latency • Low jitter • Variable priority 21 • Data Integrity • Selectable loss rate • Security

HIPAA - Security and Privacy • Security - assure data integrity, confidentiality and availability: HIPAA - Security and Privacy • Security - assure data integrity, confidentiality and availability: – Administrative policies – Physical safeguards – Technical services to protect data in storage For the Record: Protecting Electronic Health Information U. S. National Academy Press - 1997 http: //www. nap. edu/catalog/5595. html • Privacy - the claim of individuals, groups or institutions to determine for themselves when how and to what extent information about them is to be communicated - policy 22

IPv 6: Necessary but not sufficient • IPv 6: 128 bit address space - IPv 6: Necessary but not sufficient • IPv 6: 128 bit address space - 3. 4 x 1038 IPv 4: 32 bit address space - 4. 3 x 109 • Constant end-to-end IP address – Less processing of packets in network – Greater degree of interoperability between vendors – Easier security: Less need for firewalls or proxies http: //www. ipv 6. org/

The Problem: The US has enough health care resources and expertise but they are The Problem: The US has enough health care resources and expertise but they are poorly distributed • Some people have access to too much health care, some have access to too little • Sparsely populated and economically depressed areas lack full spectrum of health care • Generalists may be unwilling to practice in areas without specialty backup • Aging population has increasing health care needs with increased access difficulty • Increasingly ethnically diverse population 24

Some telemedicine facts… • Almost 50 different medical subspecialties have successfully used telemedicine. • Some telemedicine facts… • Almost 50 different medical subspecialties have successfully used telemedicine. • There approximately 200 active telemedicine networks in the United States, excluding radiology networks. • About half of these active networks are providing patient care services on a daily basis. 25

Global Benefits of Telemedicine • Potential reduction in health care costs • Keeping patients Global Benefits of Telemedicine • Potential reduction in health care costs • Keeping patients with their local provider retains the provider’s patient base • When patients leave the rural community for health care, their purchasing dollars go with them to the urban community 26

Healthcare and Next Generation Networking The U. S. National Library of Medicine is funding Healthcare and Next Generation Networking The U. S. National Library of Medicine is funding test-bed projects to demonstrate the use of Next Generation Networking (NGN) capabilities by the health community. These capabilities include: • • • Quality of Service Security and medical data privacy Nomadic computing Network management Infrastructure technology as a means for collaboration The demonstrations are designed to improve our understanding of the impact of NGN capabilities on the nation’s healthcare, health education, and health research systems in such areas as cost, quality, usability, 27 efficacy and security.

Mobile Telemedicine System – Brain • Optimizes Stroke Treatment Options in the “Golden Hour” Mobile Telemedicine System – Brain • Optimizes Stroke Treatment Options in the “Golden Hour” Attack • Initiates the Patient Record in the Ambulance • Enhances the Efficiency of the ER • Improves Patient Outcomes Intuitive Physician’s Interface • Adjustable image compression quality (medium JPEG compression) + • Adjustable image size (320 x 240 24 -bit images) + • About 5 kbps per analog cell phone line (4 phone lines) = Diagnostic quality slowscan video images at about 2. 5 seconds per image plus data and sound Northrop Grumman, Fairfax, VA University of Maryland in Baltimore, MD 1993 -1996

A Comprehensive Tele-dermatology Program Oregon Health Sciences University, Portland, OR 29 1993 - 1996 A Comprehensive Tele-dermatology Program Oregon Health Sciences University, Portland, OR 29 1993 - 1996

30 University of Alaska at Anchorage, AK 1997 - 2000 30 University of Alaska at Anchorage, AK 1997 - 2000

Baby Care. Link 31 Beth Israel Deaconess Medical Center, Boston, MA 1997 - 2000 Baby Care. Link 31 Beth Israel Deaconess Medical Center, Boston, MA 1997 - 2000

Tele-Radiology • Most common form of telemedicine • Fits workflow of radiology departments – Tele-Radiology • Most common form of telemedicine • Fits workflow of radiology departments – Reimbursable • First to have clear standards for Telemedicine - DICOM – Imaging format – Communications protocol 32

Tele-mammography for the Next Generation Internet, Phase II: The National Digital Mammography Archive • Tele-mammography for the Next Generation Internet, Phase II: The National Digital Mammography Archive • Provide a means to store and retrieve a complete clinical record, consisting of digital, mammographic images as well as radiology and pathology reports and related patient information in standard formats and using standard protocols • Multi-layered security • Input and retrieval from multiple locations University of Pennsylvania, Philadelphia, PA Y 12 National Security Complex in Oak Ridge, TN University of Chicago, IL University of North Carolina at Chapel Hill, NC University of Toronto, Canada 2001 - 2004 33

Tele-Pathology • Has great potential benefits – Fewer providers need to view images – Tele-Pathology • Has great potential benefits – Fewer providers need to view images – Reimbursable • Less common than radiology and more complicated – – 35 Color is important Resolution required is much greater Images take much more storage space Most PACS systems are controlled by Radiology Departments

Telemedicine Provides Emergency Surge Capacity • Disaster area lacks sufficient number of medical care Telemedicine Provides Emergency Surge Capacity • Disaster area lacks sufficient number of medical care specialists or providers • Hospital has capacity and equipment to care for patient, but patient needs a specialty consult not available at the facility • Extremely specialized medical expertise not typically available locally may be required – Pediatric Burn Surgeon – Infectious Diseases expert for a specific outbreak • Lack of exposure of health professionals • Coordination with Public Health 36

Hurricane Katrina: Ultra Low Bandwidth Communications • Only text messaging worked consistently – Situation Hurricane Katrina: Ultra Low Bandwidth Communications • Only text messaging worked consistently – Situation awareness and disaster relief information in 160 characters or less

SMS for Telemedicine • Appointment reminders • Monitoring chronic illnesses – asthma, diabetes, chronic SMS for Telemedicine • Appointment reminders • Monitoring chronic illnesses – asthma, diabetes, chronic heart failure • Health messages • Medication reminders – AIDS, elderly, diabetes • Reporting laboratory test results • Surveillance reporting tool – SARS, avian flu, H 1 N 1 flu • • 38 Emergency alerting tool Personal Health Record (PHR) Questions, consultation Literature search

Medline® via SMS Outbound SMS Search carpal tunnel syndrome surgery vs. steroid randomized control Medline® via SMS Outbound SMS Search carpal tunnel syndrome surgery vs. steroid randomized control trial 39 Lypen, D. Arthritis and Rheumatology, February 2005. “The bottom line”: Over the short Inbound SMS Surgical decompression vs. local steroid injection in carpal tunnel syndrome: A one year prospective randomized open controlled clinical trial term local steroid injection is better than surgical decompression for the symptomatic relief of carpal tunnel syndrome. At one year local steroid injection is as effective as surgical decompression for symptomatic relief.

Lessons Learned - Overview • Unanticipated social and economic barriers • Cost “savings” is Lessons Learned - Overview • Unanticipated social and economic barriers • Cost “savings” is based on how cost accounting is applied • Lack of equipment and communications standards • Patient demand, as a market force, will drive adoption of telemedicine • No business plan to support telemedicine after grant is completed • Healthcare system must adapt to benefit from the immediacy and quick turn-around afforded by telemedicine 40

Lessons Learned - Patient’s view • Acceptable to patient • Satisfied with encounters, perception Lessons Learned - Patient’s view • Acceptable to patient • Satisfied with encounters, perception of better quality of healthcare encounter • More personal responsibility for healthcare • Ploy by health care system to prevent referral to specialist 41

Lessons Learned - Provider’s view • Patient encounter were perceived as longer and more Lessons Learned - Provider’s view • Patient encounter were perceived as longer and more tedious but were actually shorter but more intense • Early provider involvement yields better provider utilization • Information sources made available to provider were under-used 42

Positive Trends • • • Better off-the-shelf lower cost equipment Higher Internet bandwidth to Positive Trends • • • Better off-the-shelf lower cost equipment Higher Internet bandwidth to the home High patient / family acceptance Applications that improve quality of care Integration of information systems within institutions and across health care institutions • Wireless technology 43

Changes likely to drive the future models of telemedicine • Reimbursement – Further expansion Changes likely to drive the future models of telemedicine • Reimbursement – Further expansion of Medicare – Home and workplace care • • • 44 Imaging devices Point of care lab tests Electronic Medical Record (EMR) Personal Health Record (PHR) Sensor technology • m-Health

Changes likely to drive the future models of telemedicine: Governmental & Cultural • Consumer Changes likely to drive the future models of telemedicine: Governmental & Cultural • Consumer expectations of best practices and access to best specialists • Younger generation’s acceptance of IT and telecommunication technology • Government efforts to increase IT and telecommunication technology – Disaster communication and education networks – FCC and Dept. Commerce grant programs – Meaningful Use 45

FCC National Broadband Plan - 2010 • Create appropriate incentives for e-care utilization – FCC National Broadband Plan - 2010 • Create appropriate incentives for e-care utilization – HHS, CMS • Modernize regulation to enable health IT adoption – Congress, FCC, FDA • Unlock the value of data – Congress, ONC • Ensure sufficient connectivity for health care delivery locations – Congress, FCC 46 www. broadband. gov

FCC Universal Service Fund Healthcare – Schools & Libraries • Facilitate the creation of FCC Universal Service Fund Healthcare – Schools & Libraries • Facilitate the creation of a nationwide broadband network dedicated to health care, connecting public and private non˗profit health care providers in rural and urban locations. • Rural Health Care (Pilot) Program Currently being revised

BTOP – Broadband Technologies Opportunity Program • U. S. UCAN – U. S. Unified BTOP – Broadband Technologies Opportunity Program • U. S. UCAN – U. S. Unified Community Anchor Network – Connect community anchor institutions (public libraries, schools, community colleges, research parks, public safety and health care institutions) with advanced broadband capabilities. – Enable these anchor institutions to serve their communities with telemedicine, distance learning and other life-changing applications.

Home (Consumer) Telemedicine: The Next Frontier • Technology is fostering consumer demand • Telemedicine Home (Consumer) Telemedicine: The Next Frontier • Technology is fostering consumer demand • Telemedicine – reimbursed • Consumer telemedicine – paid for by consumer • Consumer market is largely unregulated • Consumer product (Sony, Rubbermaid, Philips, Honeywell, Canon, Bosch, etc. ) and communications (Verizon, Sprint, Cisco, T-Mobile, AT&T, etc. ) companies have healthcare divisions • Consumer awareness is being raised by vendors (Microsoft, Google, etc. ) • “Smart Home” - reimbursed outside of U. S. • “Smart Car” next? 49 • m-Health

m-Health • The practice of medicine and public health, supported by mobile devices, such m-Health • The practice of medicine and public health, supported by mobile devices, such as smart phones and wireless connectivity, for health services and information. • The use of mobile devices to support health related monitoring and self help activities 50

and Mythical Journal of Medical Practice Management, 26(3): 191 -192, 2010 Journal of Medical and Mythical Journal of Medical Practice Management, 26(3): 191 -192, 2010 Journal of Medical Practice Management, 28(1): 72 -73, 2012 51

Pew Research Center: Mobile Health 2012 – November 8, 2012 • 52% of smartphone Pew Research Center: Mobile Health 2012 – November 8, 2012 • 52% of smartphone owners gather health information on their phones. • Latinos, African Americans, people between the ages of 18‐ 49, or people who hold a college degree are more likely to gather health information via smartphone. • 80% of cell phone owners say they send and receive text messages but only 9% say they receive health or medical text updates or alerts. • Women between the ages of 30 and 64 are more likely to have signed up for health text alerts. • 20% of smartphone owners have a health app. Exercise, diet and weight apps are the most popular. 52 http: //pewinternet. org/Reports/2012/Mobile‐Health. aspx

 • “A non-profit, open industry alliance of the finest healthcare and technology companies • “A non-profit, open industry alliance of the finest healthcare and technology companies in the world joining together in collaboration to improve the quality of personal healthcare” • “Our Mission is to establish an eco-system of interoperable personal telehealth solutions that empowers people and organizations to better manage their health and wellness” • “We believe that through the efforts of a collaborative industry organization, we can enable a personal health eco-system where many diverse vendors can combine their products into new value propositions with significant health benefits for people worldwide. ” 53 www. continuaalliance. org

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The Smart Home 56 The Smart Home 56

 • Sphygmomanometer – Blood pressure • Digestible RFID Pills NETWORK – Pulse • • Sphygmomanometer – Blood pressure • Digestible RFID Pills NETWORK – Pulse • Glucometer – Blood sugar • Bathroom Scale • Smart Band-Aids 57 - Chemistry – Weight – Water loss/gain

FDA or FCC? 58 FDA or FCC? 58

FCC m. Health Task Force – September 24, 2012 Goals: • FCC should continue FCC m. Health Task Force – September 24, 2012 Goals: • FCC should continue to play a leadership role in advancing mobile health adoption. • Federal agencies should increase collaboration to promote innovation, protect patient safety, and avoid regulatory duplication. • The FCC should build on existing programs and link programs when possible in order to expand broadband access for healthcare. • The FCC should continue efforts to increase capacity, reliability, interoperability, and RF safety of m. Health technologies. • Industry should support continued investment, innovation, and job creation in the growing mobile health sector. http: //www. itif. org/events/recommendations-mhealth-task-force 59

FCC m. Health Task Force – September 24, 2012 Barriers & Opportunities • Are FCC m. Health Task Force – September 24, 2012 Barriers & Opportunities • Are the most appropriate wireless technologies being used for the various medical use cases? • How is the high concentration of wireless devices impacting communication reliability? • Specific absorption rate testing • Patient (elderly & low-income) and provider (rural) access to broadband coverage • Patient safety, privacy and security • Reimbursement for cost reducing e‐Care services • ONC should include m. Health and other health IT services in Meaningful Use (MU) • Interstate licensing for physicians and nurses 60

FDA Draft Guidance for Medical Mobile Applications – July 21, 2011 • Mobile apps FDA Draft Guidance for Medical Mobile Applications – July 21, 2011 • Mobile apps that allow the remote use of medical devices by controlling, displaying, storing, analyzing, or transmitting patient-specific data. Example: remote display of bedside monitors, ECG waveforms, and medical images; the control of devices such as a blood pressure cuff or an insulin pump. • Software that transforms the mobile platform into a medical device by using attachments, display screens, or sensors, or by including functionalities similar to those of currently regulated medical devices. Example: apps that turn mobile devices into electronic stethoscopes, glucose meters, or sleep monitors. • Mobile apps that can be used to provide clinical decision support. Example: programs that help clinicians reach a diagnosis or perform a clinical calculation. 61 www. fda. gov/Medical. Devices/Device. Regulationand. Guidance/Guidance. Documents/ucm 263280. htm

ZEO™ personal sleep coach 62 ZEO™ personal sleep coach 62

Heart Monitor Cardionet ® Holter 63 Heart Monitor Cardionet ® Holter 63

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Digestible RFID Pills Proteus™ Biomedical 69 Digestible RFID Pills Proteus™ Biomedical 69

Teledoc Robodoc 70 Intouch Health ® Teledoc Robodoc 70 Intouch Health ®

Telesurgery Davinci® robot 71 Telesurgery Davinci® robot 71

The Health - Smart Car • Seat – Weight – Blood pressure – Breathing The Health - Smart Car • Seat – Weight – Blood pressure – Breathing rate • Steering Wheel – Pulse – EKG – Blood oxygen (PO 2) 72

Telemedicine People: • Patients • Providers • Payers 73 Telemedicine People: • Patients • Providers • Payers 73

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Telemedicine Resources • American Telemedicine Association (ATA) – www. atmeda. org • Office for Telemedicine Resources • American Telemedicine Association (ATA) – www. atmeda. org • Office for the Advancement of Telehealth, HRSA (OAT) – www. hrsa. gov/telehealth • Center for Telehealth & E-Health Law (CTe. L) – www. ctel. org 75

The only way to predict the future is to invent it. Lister Hill Center The only way to predict the future is to invent it. Lister Hill Center National Center for Biomedical Communications I wud b 2 anser ur ? ? http: //www. nlm. nih. gov 76