Establishment of E-Health Network for Disasters and Healthcare Improvement: Integrated Medical Information Technology Sy

1. Establishment of E-Health Network for Disasters and Healthcare Improvement: Integrated Medical Information Technology System Partner concept between Academies and Medical entities Yukako Yagi University of Pittsburgh Medical Center, Pittsburgh, PA, USA

2. Background: Why E-Health Network? In March 1, 2001, the Institute of Medicine (IOM) stated that: • “The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive. Health care today harms too frequently and routinely fails to deliver its potential benefits.” • The difficulty in maximizing the benefits of increased clinical and business knowledge and advanced diagnostic technologies comes from the basic problem of collecting, integrating and managing health information in various formats. Further, this data is stored in multiple physical locations that are often distant and hard to access when treating individual patients, especially those with critical medical needs. “use of information technology is key”

3. University of Pittsburgh Medical Center

4. Employees More than 35,000 Physicians More than 5,000 Hospitals 20 + Overseas hospitals Primary Service Area 29 western Pennsylvania counties UPMC Doctors' Offices More than 400 throughout the primary service area Rehabilitation Centers More than 65 hospital and outpatient facilities in the growing UPMC Rehabilitation Network Retirement and Long-term Care 8 skilled nursing units in hospitals12 freestanding facilities offering independent living, assisted living, and skilled nursing options UPMC has established Telemedicine Network through the system: Facts and Figures

5. Overview: Program Description • looking increasingly towards technology-assisted solutions to optimize how they manage and deliver health care. • Non-Civilian Medical Facilities (NCMF) and UPMC have created a partnership to collaborate on developing technology-assisted solutions to real-world medical problems The partnership is defined as the Integrated Medical Information Technology System (IMITS) Program.

6. Overview: Program Description • The IMITS program pioneers the application of state-of-the-art information management (IM) and information technology (IT) solutions, including advanced business and clinical decision support tools. This initiative brought together vast clinical and information technology expertise of both institutions and aids in the recognition and treatment of many types of medical conditions. In addition, the NCMS-UPMC partnership is providing new opportunities for enhancing expertise, evaluating solutions to technical dilemmas, and deploying strategies to address key medical issues.

7. IMITS Project • Congressional Special Interest Appropriation: • FY02: $8.5M - Establish initial project: Integrated Medical Information Technology System • FY04: $10.2M - Continue current projects & expand into Pacific Rim

8. Scope • The initial focus of the IMITS Program was on telemedicine and associated advanced technologies. The overall program objective is the design of new state-of-the-art clinical and business models supporting the delivery of fully electronic multi-media enabled electronic health records. The projects described below will be organized under the umbrella of the IMITS Program.

9. Scope: Multi-specialty Tele-consultation Project Situations: • There are many medical facilities in locations where specialty medical care is not readily available. • Patients often must travel significant distances and taking time off from work. • Resulting in: • Expense to both the patient and the enterprise • A delay in the diagnosis and treatment of the presenting medical condition Solutions

10. Scope: Multi-specialty Tele-consultation Project Solutions • Developing and refining computerized medical records, enhancing medical information retrieval and patient tracking, and creating clinical decision support rapidly increases the capability to provide high quality cost-effective medical care to non-civilian beneficiaries and civilians in even the most remote locations. • To design, build and test a multi-specialty teleconsultation system on a common technology platform. This system will provide widely available, flexible, clinically relevant services across multiple medical specialties on a secure, stable low cost technology platform utilizing asynchronous and synchronous communications. This will allow general clinicians and medical personnel access to remote expert advice, diagnosis and mentoring and in so doing contribute to providing a high-quality standard of care independent of location.

11. Scope The Multi-specialty Tele-consultation Demonstration Project was divided into the following areas: • Distributed Radiology Imaging Demonstration Project – The design and implementation of a distributed radiology imaging system utilizing the Stentor platform at a medical facility in Dayton, Ohio. The system was connected to UPMC linking the radiology departments for education and service opportunities. • Pathology Tele-consultation System Demonstration Project – The design and implementation of a telepathology system at a facility in Mississippi. The system is connected to UPMC linking the pathology departments for education and service opportunities. • Behavioral Health Tele-consultation System Demonstration Project - The design and implementation of a behavioral telehealth system at a facility in Texas. The system connects to UPMC linking the behavioral health resources for education and service opportunities. • Pediatric Cardiology Tele-consultation System Demonstration Project

12. Approach/Strategy • A high-level project work plan will be included in the individual scope of work documents. The main focus of the program will be on the implementation of tele-consultation applications. The tele-consultation implementation work plans have been developed based on a standard implementation methodology and are organized into seven major segments with corresponding activities as follows:

13. Approach/Strategy I. Project Set-Up Confirm project governance and organization structure. Confirm project roles and responsibilities. Confirm communication structures. Confirm methodology approach.

14. Approach/Strategy II. Analysis Conduct application education and training. Document functional and technical requirements. Assess hardware, interfaces and network. Document software requirements, conversion decisions, and data standard initiatives. Identify training needs and sites.

15. Approach/Strategy III. Design Complete system design. Develop conversion specifications and interface specifications. Identify data standards and file setups, customizations, and security requirements.

16. Approach/Strategy IV. Development Complete system build. Begin programming conversions, interfaces, and customizations. Develop new policies and procedures. Develop menus, forms, reports and screens.

17. Approach/Strategy V. Testing Define testing scope and approach. Identify testing team. Develop integrated and product specific test plans/scenarios. Conduct testing – system acceptance, unit, application, integration, stress, security and network/communications testing.

18. Approach/Strategy VI. Training Develop training plan and materials. Schedule and conduct user training.

19. Approach/Strategy VII. Conversion/Post-Live Support Develop go-live plan. Identify support team for go-live. Determine conversion downtime requirements and system freeze dates. Prepare contingency plans. Perform conversion. Identify post-live issues team. Initiate post-live support and transition.

20. FY 01-02 IMITS

21. FY 01-02 IMITS • Business Problem • Shortage of specialty physicians • NCMF high priority Radiology • Goal • Improve access to care and provide quality healthcare services to individuals regardless of location

22. FY 01-02 IMITS ProgramImplementation Overview • Extended period to move money and negotiate agreement • Pre-award implementation of Radiology project to meet NCMF requirements to replace legacy systems • Rigorous security requirements that necessitated adjustments to project timelines

23. IMITS ProgramDistributed Imaging • Dayton, OH • Installation of Stentor iSite COTS • UPMC customizations for NCMF’s workflow, global hub and spoke strategy • Replaces legacy PACs system • Establishes footprint for global NCMF image distribution infrastructure • Evaluation of provider acceptance and satisfaction

24. FY 01-02 IMITS ProjectsDistributed Imaging • Current Status • July 1, 2003 - Technical “go-live” • August 27, 2003 - Clinically live on private subnet • November 14, 2003 – Notified of impending final security accreditation • November 24, 2003 – Move from private subnet to live radiology network • January 20, 2004 – Clinical “go-live” • February 2004 – Begin UPMC customization • March 2004 – UPMC Radiologist wrapper installed • May 2004 – Clinician wrapper installed • June 2004 – ST&E for upgrade to iSite v3.2

25. IMITS ProgramTelepathology • Biloxi, MS • Installation of UPMC Static Telepathology (Mississippi, Florida, California) • Installation of dynamic telepathology for educational purposes (Mississippi, Florida, California) • R&D on whole slide imaging (Mississippi, Pittsburgh) • Progressive technology for imaging and storage of pathology specimens • Evaluation of provider acceptance and satisfaction

26. IMITS ProjectsTelepathology • Current Status • Feb 2003 – Version 1 Security Documents submitted for approval • July 2003 – Updates to Version 1 submitted • Sept 2003 – Version 2 Security Documents submitted for approval • Oct 2003 – Initial lab certification at DSI • Nov 2003 – Awaiting report of certification testing • Jan 2004 – Certification re-test • Feb 2004 – Awaiting IATO • April 2004 – IATO obtained • May 2004 – Awaiting CTO • June 2004 – CTO obtained • August 2004 – Final ST&E scheduled

27. IMITS ProjectsPediatric Tele-echocardiography • Current Status • Dec 2003 Installation equipment at all bases • Jan 2004 – Equipment installed • Mar 2004 – Awaiting ISDN re-install • May 2004 – Clinically live • Jun 2004 – Beta cases

28. IMITS ProgramPediatric Tele-echocardiography • Biloxi, MS • Implementation of Pediatric Tele-echo system modeled after Children’s Hospitals in Florida • Clinical implementation and support • Evaluation of parent and provider acceptance and satisfaction • No security requirements

29. IMITS ProgramEmergency Services • Emergency Communication Database • Demonstration project using international healthcare facility database in UPMC Command Center • NCMF identified additional required information in database • UPMC collecting data on health care facilities in South America • NCMF will evaluate via secure web access • Opportunity for future business relationship

30. FY 01-02 IMITS ProjectsEmergency Services • Expeditionary Medical Support (EMEDS) • NCMF forward deployed treatment facilities • Portable tents • Large IT footprint • Hard wired • Subcontract with MountainTop Technologies • Conduct needs assessment • Make recommendations for wireless solution

31. IMITS Program Discontinued Projects • Telemental Health • Internal NCMF issues • Change in leadership Wilford Hall Medical Center • Administrative changes in TRICARE • Teleradiation Oncology • Difficulty finding suitable site • IMRT requires specific equipment on linear accelerator

32. FY 04 IMITS (Sept, 2004) • $10.2M Congressional Appropriation • Congressional intent to expand into the Pacific Rim • Pacific Telehealth and Technology Hui • University of Hawaii • Expanded relationship with Wilford Hall Medical Center

33. FY 04 IMITS (Sept, 2004) Extracorporeal Membrane Oxygenation (ECMO) Platelet Gel Therapy Telepathology Simulation and Training Teleaudiology IMITS Telemental Health Evaluation Distributed Imaging and Workload Balancing Teleophthalmology Education

34. FY 04 IMITS ProjectsECMO • Extracorporeal Membrane Oxygenation • Invasive procedure for maintaining oxygenation of the blood when lungs and/or heart are failing • Requires specialized equipment and specially trained individuals

35. FY 04 IMITS ProjectsECMO • ECMO programs generally found in urban academic medical centers. • 145 ECMO centers in the world • 112 in the US • Only 2 NCMF in Texas • No centers located in the Pacific

36. FY 04 IMITS ProjectsECMO • Interest in establishing a regional ECMO Center for the Pacific in Honolulu • Senator Inouye • Non Civilian Medical Center • Kapiolani Women’s and Children’s Hospital • Pacific Telehealth and Technology Hui • University of Hawaii

37. FY 04 IMITS ProjectsECMO • FY 04 ECMO project is feasibility and planning study • Evaluation of existing resources • Requirements • Budget • Deliverable will be a plan for implementation of the center with the support of FY 05 appropriations sponsored by Senator Inouye

38. FY 04 IMITS Projects Distributed Imaging and Workload Balancing • NCMF experiencing a severe shortage of radiologist • 160 billets (FTE) as of July 1, 2004 only 60 filled • Need to maximize resources and distribute workload • Hub and spoke teleradiology model no longer useful • Symmetrical load balancing model more appropriate

39. Distributed Imaging and Workload Balancing • UPMC implemented distributed workload model one year ago • Shared worklist • Radiologists read films from facilities other than the one they are assigned to for the day • Same model implemented • Shared worklist • Appropriate cases for civilian readings

40. Distributed Imaging and Workload Balancing • Designated Non Civilian Medical Center • Scale up model developed for the hospital in OH • Attempt to keep readings within the US Gov

41. Distributed Imaging and Workload Balancing • IMITS 04 project scope • Assess the current workflow at NC Medical Center • Recommend changes based on UPMC workflow model • Implement a prototype system

42. Teleaudiology • Cochlear implants are utilized to improve hearing in severe to profound hearing loss • Once implanted the devices require monitoring and adjustment • This must now be done in person

43. Teleaudiology • UPMC and NCMF both have cochlear implant programs • Only one MTF that has a cochlear implant program • NCMF treats patients globally • Interested in developing a means to remotely access and adjust implants

44. Teleaudiology • FY 04 deliverables • Feasibility study • Vendor evaluation • Determine regulatory impact in civilian world • Plan for technology development • Pilot project

45. Teleophthalmology • Joint project with Type 2 diabetes • NCMF requested that retinal screening images captured for the diabetes project be stored in a DICOM archive • Consistent with newly released ATA guidelines “Telehealth Practice Recommendations for Diabetic Retinopathy”

46. Teleophthalmology • UPMC Radiology Informatics has done work with visible light images • Image archive for melanoma photographs • Customized viewer

47. Teleophthalmology • FY 04 IMITS Teleophthalmology Deliverables • Create DICOM object with associated metadata from acquired image • Transport the DICOM object form point of acquisition • Store image in a DICOM archive irrespective of vendor

48. Telemental Health • A major component of dealing with catastrophic events is Post Traumatic Stress Disorder • Victims of disasters • Critical incident stress management has been unsuccessful in management of PTSD • Cognitive Behavioral Therapy has been show to be successful

49. Telemental Health • FY 04 Project • Initial data collection and assimilation for analysis • Partnership with simulation center in San Diego

50. Telepathology • Three initiatives under this heading • Telepathology Needs Assessment Pacific Rim • Development of Whole Slide Imaging Capability • Incorporation of pathology images in enterprise image archive