Infopoverty - Milano, 17/4/08 Aziende Sanitarie Virtualiper i Popoli Migranti Aldo Franco Dragoni Lorenzo FalsettiNicola Tarquinio
TCP/IP-BASED TELECARDIOLOGYRESULTS – PITFALLS - PERSPECTIVES U.O. DI MEDICINA INTERNAOSPEDALE DI OSIMO Director: Dott. Prof. Francesco Pellegrini UNIVERSITA’ POLITECNICA DELLE MARCHE FACOLTA’ DI INGEGNERIA Prof. Aldo Franco Dragoni Pellegrini F, Falsetti L, Del Prete S, Filippi G, Tarquinio N, Rossini S, Di Stefano S, Ciotti G, Vaccarini I, Clavelli A and Aldo Franco Dragoni
A 5-years experience • A TCP/IP-based telemedicine system has been implemented all over our territory • Since then, it has been used to carry several kind of informations 1. Cardiological Consultation2. ECGs (first opinion/second opinion)3. Echocardiograms (second opinion)
Standard Protocols Standard Protocols In order to reduce errors, we Standardized : • EquipmentThe whole operations were based upon the same system • OperatorsA formation period of 2 months was required for the initial training of a standard equipe of 2 nurses. • ProceduresAll the procedures, from acquisition to report were made upon the same protocol
Man power Man Power • This system allowed to manage the work in our Hospital with a minimal equipe :1. Physicians : 3 trained physicians : Report, Quality control Case management Second-level examinations (when needed)2. Nurses : 2 trained nurses/point : Data collection Data transfer Small damages repair Every acquisition point was entirely managed by 2 Nurses. Resident physicians were excluded from protocols but could have access to the system and could ask for a second opinion on their exhamination
Standardization We applied the same protocols for- Inpatients - Admitted in our Unit - Admitted in the other Units- Outpatients - Territorial cardiology - Other Units Outpatients (Day Hospital) - Drug survelliance for psychiatric patients- Other Nations Services
Nonstandard Procedures Non-standard procedures were allowed only in a service based upon our servers but using another technology for a mission in the Philippines. The whole operation has been managed by University of Siena.
Endpoints Endpoints • Reduce reporting times • Increase number of reports • Standardize reporting • Increase productivity • Create a large repository of anamnestic data • Create a common database for instrumental findings
Outside Italy Emerging Countries • Despite the massive workload in our Zone we were asked to try to export our experience in foreign Countries • We were asked to install the same system in Kerkennah Island, near Sfax (Tunisia) • The place have been selected by locals who asked for a cardiology reporting system
Outside Italy Outside Italy • Another mission, managed by University of Siena but hosted in our systems, was installed in the Philippines
Outside Italy Outside Italy • Kerkennah system is a mirror of our actual territorial installations :- 2 tunisian nurses teached in our hospital- A client and a digitizer for cardiological informations • In our vision, this installation should have been a pilot project in order to extend our model of telecardiology outside Italy
Pitfalls Pitfalls • In Italy we are working with large volumes of data (about 11000 ECGs reported, with a mean of 500 ECG/digitizer/year). • Tunisian equipe didn’t send more than 150 tracings over a two-year period – an useless volume, counting the high cost sustained by our Hospital (Formation, Gear, Installation)
Pitfalls Pitfalls • Technology issuesa. Network incompatibility …fixedb. Software bugs …fixed c. Client Hardware errors …fixed • Manpower issuesa. On-site training and re-training …doneb. On-site quality control missions …done
Pitfalls Pitfalls • Still, this project, despite the hard work, is not growing as expected • The main reason is that local physicians have (mis)interpreted the presence centralized system as an exclusion from the diagnostic process • Thus, despite continous interventions, this project is not growing as expected
The Future Perspectives • Despite pitfalls, we are enlarging the networkby creating more acquisition points • In 2008 we will install two more stations, one in our territory and one in a foreign country • This project will evolve, in the next future, with another project – called “Miro” – which should solve many issues
The Future Perspectives • The actual system is, as already stated, a centralized system • Its main limit is that it depends on one or few centers • On the other side, a centralized telemedicine is easier to administer. Quality is easier to be controlled.
Actual Situation
Infopoverty - Milano, 17/4/08 doctors requesters
Infopoverty - Milano, 17/4/08 both the doctors and the requesters have to be authenticated
DIGITAL SIGNATURE: Smart Card Infopoverty - Milano, 17/4/08 RSA Key Pair Generation Certificate Request Sending CSR to CA Alias 1024 bit Sensitive Unextractable PKCS#10 CA Off-line Certificate Generation Storing in the Smart Card Sending X.509 To User OpenSSL X.509
Infopoverty - Milano, 17/4/08 ASINCHRONOUS BROKER-BASED ARCHITECTURE VIRTUAL COMMUNITY SOCIAL NETWORK • no complex dedicated hardware (PC-based clients) • data-transfer throught Internet (ADSL or Dial-Up modems) • costs independent on the number of installations. • independent on the particular field of medicine.
Differences
Infopoverty - Milano, 17/4/08 Problems Of Other Systems • Not easy-to-use • Specific applications and architectures • Dedicated hardware • Dedicated connections • Costs proportional to number of connected hosts • Lack of sustainable and stable services
Three Steps Convergence Step One Create Competent Professionals Create Trusted Centers Step One Complete Coding Enhance Compatibility Step Two Enlarge the Network Continuous Teaching Step Two Create Migration Tools Beta Testing Step Three Migrate DataInvolve local InstitutionsInvolve international institutions
Infopoverty - Milano, 17/4/08 HOSTING in the west world health records of migrating people we only needInternet connections
Infopoverty - Milano, 17/4/08 is for stable and reliable organizations
Infopoverty - Milano, 17/4/08 is for stable and reliable organizations
Infopoverty - Milano, 17/4/08 is for stable and reliable organizations
Infopoverty - Milano, 17/4/08 Conclusions • being data stored in a central server, a virtual health-care agency takes place that maintain clinical folders ofpatients wherever they’ll go all around the world • telereporting is an advantage especially for regions where there are few sanitary resources • flexible software architecture for telereporting activities based on TCP/IP. • data-transfer through Internet using digital certificates and timestamp. • creating communities for searching/offering medical opinions
THANKS FOR THE ATTENTION
Infopoverty - Milano, 17/4/08 workflow 1. an operator, through MIRO’s interface, inserts the patient's data and the information about the the diagnostic tuipe of the datum (for instance the ECG); the software will store all the data on the database of the central server. 2. any specialist is able, through the appropriate dotation HW/SW, to remotely consult their appropriate requests; he can choose the case he wants to report and eventually accesses the patient's clinical folder 3. eventually the specialist might be able to draw up the report in electronic format. 4. the report is made directly through the application interface. 5. eventually the operator close the event
Infopoverty - Milano, 17/4/08 Why Open Source? bringing good quality medical services to rural and remote areas mainly in developing regions with scarce resources • software development requires little or no initial investment • potential for evolution are generally easier with open source software • interoperability and standards compliance
Infopoverty - Milano, 17/4/08 clinical folder
Infopoverty - Milano, 17/4/08 SCHEMA E-R
Infopoverty - Milano, 17/4/08 timestamping
Infopoverty - Milano, 17/4/08 REQUESTER’s opening mask
Infopoverty - Milano, 17/4/08 DOCTOR’s operating mask
Infopoverty - Milano, 17/4/08 DOCTOR’s examination viewer
Infopoverty - Milano, 17/4/08 DOCTOR’s report mask
Infopoverty - Milano, 17/4/08 DOCTOR’s operating mask
Infopoverty - Milano, 17/4/08 REQUESTER’s viewing mask
