The Telemedicine Center at East Carolina University Division of Health Sciences

1. The Telemedicine CenteratEast Carolina UniversityDivision of Health Sciences Salutes our Military abroad, stateside, and in Eastern North Carolina The Telemedicine Center

2. ECU Telehealth Mission Improve health care quality & accessby appropriate application of health information & communications technologies and practices in Eastern Carolina across our nation Dr. Dawd Siraj with John Hopkins University connecting to Ethiopia and outreach to other nations worldwide. The Telemedicine Center

3. 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 The Telemedicine Center

4. ECU Integrated Networkwith Local Bridge Capability IP T-1 1.5 Mbps Internet2, Abilene, National Lambda Rail Distance Educ & Instructional Microwave & IP 1.5 Mbps NCREN - 180 sites Distance Education/Learning IP Video 384 kbps - 2 Mbps REACH-TV - 27 sites Telemed & Distance Educ ECU Bridge Direct / MCUs ISDN 128 kbps – 1.5 Mbps Telemed, Dist Ed, Consulting, Mental Hea Dept,Disaster Relief IP Video 384 kbps NCIH - 186 sites Distance Education POTS 28.8 Kbps Home Health Telemedicine, Disaster Relief The Telemedicine Center

5. ECU Telemedicine history “Go ahead and tee off. Then I want you to listen to this wheezing” The Telemedicine Center

6. 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” The Telemedicine Center

7. ECU Telemedicine history • 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 The Telemedicine Center

8. ECU Telemedicine history 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 The Telemedicine Center

9. ECU Telemedicine history • Research in Disaster Relief and Bioterrorism Exercises since 1998 Telemedicine Team transports medical supplies and equipment to shelter sites via helicopter Flood waters consume Eastern North Carolina homes and businesses in 1999 The Telemedicine Center

10. 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 The Telemedicine Center

11. 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.

12. 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 The Telemedicine Center

13. 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

14. 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 The Telemedicine Center

15. 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 The Telemedicine Center

16. IP challenges • 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 The Telemedicine Center

17. 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 The Telemedicine Center

18. 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 The Telemedicine Center

19. Reimbursement Fee for Services Rural Hospitals Doctor’s Office Telemedicine Specialized Care Facility Military Base Hospitals Clinical Room in the Naval Hospital Camp Lejeune, NC - 1996 The Telemedicine Center

20. RevenueContracted Services Central Prison used 28 types of specialties Correctional Prisons Short/Long Term Telemedicine School/Child Care Facility Home / Office Travel/ Air Cruise The Telemedicine Center

21. Sunbury– Happy, Inc. Ahoskie – Roanoke-Chowan Ahoskie – Roanoke-Chowan CNC/ACCESS-Jackson-Proposed Ahoskie–Roanoke-Chowan Heart Center Tillery-Community Ctr EC Behavioral Health- LME PORT – Rocky Mount-Proposed Rocky Mount -Nash Windsor– Bertie Memorial Edenton – Chowan Hospital Edgecombe Co. Proposed Spoke Tarboro - Heritage Bertie County Proposed Spoke Tarboro-Heritage Heart Nags Head - Outer Banks Raleigh – Central Prison Wilson - School for Deaf PORT- Wilson-Proposed Greenville –Health Steps 4 Units Raleigh-Governor Morehead School for Blind BSOM UHS Greenville –ECU Cardiology 2 Units Belhaven - Pungo District Hospital Greenville-ECU Psychiatry 2 Units Morganton- School for Deaf Taylorsville- Alexander Correctional Maury – Maury Correctional Goldsboro - Cherry Hospital Avon - HealthEast Family Care Lenoir County Proposed Spoke Goldsboro – Goldsboro Pediatrics Kinston – Caswell Center RHA –New Bern-Proposed Faison - Goshen Medical Ctr Clinton - HITC Hospital Site Medical Center Site School Infirmary Site Correctional Sites 2009 Kenansville – Duplin General Jacksonville – Onslow Sites with Nurse Presenters Sites with Trauma Rooms Cardiology Network- 07-09 Psychiatry Network - 07-09 REACH Network Rural EAstern Carolina Health – Network Telemedicine Clinical Sites RHA – Wilmington-Proposed

22. 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 The Telemedicine Center

23. 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. The Telemedicine Center

24. 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 The Telemedicine Center

25. 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 The Telemedicine Center

26. 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 The Telemedicine Center

27. System integration #*! • Evaluate Need • Service Model (24/7) • Identify technology • Choose telecommunication • Participants • Design implementation The Telemedicine Center

28. “Telemed” Clinical Tools? • Patient/Spoke site • Medical Specialty Driven • Additional switch or inputs for video sources • Mobile capability • Patient Room Camera Control • Diagnostic tools? The Telemedicine Center

29. Videoconferencingendpoints • “Hard” endpoints • Dedicated hardware/appliance • “Soft” endpoints • S/W and/or peripheral on PC • May include hosting service The Telemedicine Center

30. 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 The Telemedicine Center

31. 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 The Telemedicine Center

32. Technical Configuration • Peripherals • Otoscope • Electronic stethoscope • Hand held camera • Pan/Zoom/Tilt camera w/far-end control

33. 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 The Telemedicine Center

34. 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 The Telemedicine Center

35. Telemedicine suite Four Tele-exam rooms each equipped with: • Engineer & MD entrances • EHR (Logician) • PC capability • Stethoscope capability • House phone • Remote control at sites • PZT camera • Recorders • A/V devices The Telemedicine Center

36. 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 The Telemedicine Center

37. 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 The Telemedicine Center

38. 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 The Telemedicine Center

39. 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 The Telemedicine Center

40. 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 Caceres From MIT Technology Review (Mar. 2000) The Telemedicine Center

41. 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 The Telemedicine Center

42. 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 The Telemedicine Center

43. Health Information • Technology • Electronic Health Records • Practice management systems • Clinical decision support • e-Prescriptions • Alerts/reminders • Digital imaging/PACS • Telehealth/ • Telemedicine • Specialty teleconsultation • Telecare • Remote monitoring • Distance learning • Multidisciplinary care • Consumer Health • Informatics • Personal Health Records • Health web sites • e-Visits • e-Journals • Virtual health/support communities Connected health? Common denominator is the network The Telemedicine Center

44. 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 The Telemedicine Center

45. 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 The Telemedicine Center

46. Contact info Gloria Jones Assistant Director Clinical Operations Manager ECU Telemedicine Center (252) 744-3855 jonesgl@ecu.edu http://www.ecu.edu/telemedicine The Telemedicine Center