Telemedicine

1. Telemedicine Steven D. Johnson, M.D., M.S. President Voyageur Radiology

2. The World is FlatThomas Friedman How advancing technologies and changing market dynamics are creating new services, products and more importantly a platform and virtual culture to allow innovation.

3. Innovation and disruption The development of new technologies may arise from existing technologies in one field applied to a new field or the convergence of several technologies to create a new technology.

4. Magnetic resonance imaging Magnetic resonance of nuclei discovered in the 1950s Explosive growth in the study of Molecular structure in chemistry and biochemistry In the 1970s Paul Lauterbur discovered how to spatially localize magnetic resonance signal New field of medical imaging born

5. Overview Telemedicine defined Current state of art of telemedicine Current technologies Barriers to service Future directions

6. Telemedicine “The use of telecommunications and information technologies in order to provide clinical health care at a distance.”

7. Early Adaptors African villagers used smoke signals to warn people to stay away from villages infected with serious diseases. Australians used two-way radio’s in the early 1900’s to communicate to flying medical services.

8. Communications Technology Similarly the advent of the Internet age and personal computers has redefined Society in the 21st century. Information is now freely available to remote regions with social networking including oral and video communications transmitted across the globe and often independent of international borders.

9. How Internet has changed Modern Medicine • History of data communications • How data comminications impact remote medicine • How mobile networks are impacting remote medicine

10. History of data communications • ISDN • Provides a data communication channel across existing copper telephone lines at a rate of 144 kbit/s, • By 1990, due to a world wide effort, National ISDN 1 (NI-1) was made compatible with existing proprietary equipments for telecommunication services.

11. History of data commincations • T1 • Provides a data communication channel across existing or new copper telephone lines at a rate of 1.54Mbps. • By 1980s T1 was industry standard for communications for businesses and governement entities.

12. History of data communications • DSL • Provides a data communication channel across existing or new copper telephone lines at a rate of 512kb-12mbs. • First developed in 1989, ADSL has become an industry standard for many communications for homes, and businesses.

13. History of data communications • Broadband (Cable/Satilite) • Provides a data communication channel across existing cable lines or satiltes at a rate of 512kb-30mbs. • First developed in late 1990's, Cable/Satlite has become an industry standard for many communications for homes, and small businesses.

14. History of data communications • National LambdaRail • Established in 2009 • 12,000 miles fiber optics • 1.6 Tbits/s aggregate • 99.99% high availablity • Transcontinental • Over 280 research Universities and Laboratories • Private non Corporate funded

15. History of data communications • Wireless (Wifi, Bluetooth, 1G-4G) • Provides a data communication channel across airwaves at a rate of 128kb-54mbs. • First implimented in the late 1980's, Wireless has become the industry standard for personal communications. • Wifi has become the industry standard for home, business, and governement entities. • Mobile Smartphones now offer 4G with data rates of 3-10mbs in remote areas (Hotspots).

16. Summary of bandwidth ISDN 128kb/s T1 1.44mb/s DSL 512kb-12mb/s Cable/Satellite 512kb-30mb/s LambdaRail 1.6Tb/s Wireless 128kb-54mb/s

17. Communications and Medicine The ability to provide medical services to ever growing numbers of people, in wider and more remote locations, with greater knowledge based sophistication of services is one of the challenges of our Era.

18. Teleradiology

19. Teleradiology Teleradiology is greater than 50% of all telemedicine “Store and forward” telemedicine “CLOUD” Distributed client/ server applications Data in server, local or cloud work list can route data to appropriate reading radiologist, distributed model

20. Teleradiologycontinued Complex Work rule driven software Data transmitted twice Thin client data viewing technology Viewing software resides on servers Remote PC monitor systems view via internet The image data on the server where the viewing software also resides

21. Process continues Transmission of image to server for storage and routing out to interpreting network radiologists. Radiologist interpretation transmitted back to facility and primary care provider for treatment decision

22. Distributed Data in Tech Support Upgrades Add software $

23. Thin Client Technology “Zero footprint client” “Streaming Video”

24. Ramifications of technology Tech support upgrades DATA IN

25. Ramifications of technology cont. • No remote read site Software to support all Thin client data packet viewing • Lower Cost • Faster movement of data and interpretations

26. Mobile X-ray Equipment

27. Ultrasound Minuaturized Traditional

28. Mobile Diagnostic Imaging Services Digital Radiology Ultrasound Cardiac Echo Electrocardiogram(EKG) Location Care facilities of any type Now possible due to increasing sophistication of technologies and data transfer bandwidths

29. Service Provided

30. Current State of the Art of Telemedicine Technology communication platforms Patient service requirements Medical service provider level of training and knowledge Geographic locations of all the above

31. VIDEO CLASSROOM

32. TELE-SOMETHING Through a technology called telepresence, it creates the illusion that students miles apart are in the same classroom. Interactive television isn't new. Schools have been doing distance learning for years. But the Ojibwe language telepresence classroom at Deer River High School goes well beyond a simple TV monitor and a camera. At a pair of long desks, teacher Gerald White and eight high school students recently recited Ojibwe phrases. They faced three huge, high-definition screens at the front of the room. In an identical classroom 25 miles away in Remer, Minn., a classmate was in a room with the same furniture, tan walls and carpet. She also recited Ojibwe phrases, giving the impression that they were all a few feet from each other. White is the only Ojibwe language teacher within the seven districts that comprise the Itasca Area Schools Collaborative. He said telepresence technology makes him a more effective teacher.

33. Webcam

34. TELEMEDICINE MD-PATIENTINTERACTIVE SYSTEM TELEPUPPET

35. Telecommunicationscontinues Video conference Mobile device monitoring data transfer communication

36. Telepathology • The practice of pathology at a distance • Telecommunications technology used to facilitate image-rich pathology data. • Systems: • Static image • Real time • Virtual slide systems • Digital slide scanners

37. Telepathology

38. Telepathology cont. Frozen section specimens Primary histopathology diagnosis Subspecialty pathology expert diagnosis

39. Teledermatology Using audio, visual, and data communication exchange medical information about skin and skin conditions to provide diagnosis, consultation, and treatment. Digital images Video conferencing Teledermoscopy Mobile teledermatology

40. Teledermatology equipment

41. Teleopthamology

42. Current Services Teleradiology Telepathology Teledermatology Emergency Medicine EICU Telenursing Telepharmacy

43. Internet Interactive Services • Patient and healthcare provider, how it works • Log On • Pay • Give History (text or email returned in 30 minutes) • Get treatment Plan • Get prescription • Phone interaction possible • Provider Level Nurse 24/7 or Physician M-F 8-8 • weekends, holidays 9-5

44. List of Diseasesnurse support Acne Bladder infection Breast Infection Burn & sunburn Cold cough and allergy Deer tick bite Ear pain Flu Lice

45. Doctor on line M-F 8-8 weekend/holidays 9-5 Cough, cold & Flu Sinus, ear & eye infections Headaches Bronchitis Acne skin conditions Stomach ache Allergies Urinary tract infections Register and choose a M.D. Webcam, chat or phone, videoconferencing Internet or telephone Home or office no appointment Compliments traditional healthcare

46. Current Services cont. • Telerehabilitation • Neuropsychology • Speech-language pathology • Occupation therapy • Physical therapy • Telecardiology • Telepyschiatry • Teledentistry • Teleaudiology

47. The Internet Age New designs of service : On Line Technology capabilities on line? Skype: Voice over Internet provider Webcam video transmission ( real time) Any formatted digitized data ( Images) Streaming Video ( view data before all is sent)

48. Visions of the future The environment of telemedicine is moving from its infancy to being a more mature and important component of medical service. The instrumental components that have allowed the initiation of telemedicine will inevitably expand and become more sophisticated. The continued technological, organizational, and political components that will foster telemedicine will be complex and likely evolving over time. To understand, anticipate, or envisioning of the future requires a look at where we have been and where we are today.

49. EXAMPLES Phone from home, call the Doctor , get the receptionist, get appointment, still sick, maybe call back from Nurse, time delay of hours? Poor efficiency Lacks timely service

50. Ipad