What is Telemedicine?

1. PMP4 Telemedicine Solution for Trinidad and TobagoPresented ByDr. Paul Antonio PereiraOn Behalf of Card Guard, Israel And Life Watch, Chicago

2. What is Telemedicine? “ The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities”. WHO(2002)

3. What is Telemedicine? • Patient and doctor are located in different places • Patients can be examined, treated and monitored • Patient’s data (text, voice, images or even video) can be sent from a remote location and medical advice offered from a speciality Centre.

4. Need for Telemedicine • “Emergency Medical Care is designed to overcome the factors most commonly implicated in preventable mortality, such as delays in seeking care, access to health facility and provision of adequate care at the facility.” WHO (2002)

5. Need for Telemedicine • “Emergency Medical Care is designed to overcome the factors most commonly implicated in preventable mortality, such as delays in seeking care, access to health facility and provision of adequate care at the facility.” WHO (2002)

6. Need for Telemedicine Telemedicine ensures delivery of • right medical advice • at the right place • at the right time

7. Need for Telemedicine • Non availability of facilities locally • Limited availability of appropriate skills / technology locally • Travel or commute distances

8. Advantages of TM • Makes expertise available - anywhere • Early institution of appropriate treatment • need for transfers • Effective utilization of transports • Saves costs to patient , provider, system

9. TYPES • On the Basis of Time frame – • Store & forward. • Home Care • Real-time. • Surgery Wards • Ambulatory

10. Applications • Tm can be utilized in all Clinical applications - medical, surgical, diagnostic • Emergency care • Disaster management • Homecare • Rehabilitation

11. Entities involved in Telemedicine • Telemedicine Platform. • Telemedicine Software. • Clinical Devices. • Communication Media.

13. Telemedicine Platform • Desktop PC • Laptop • Palmtop / PDA (System in a Suitcase) + • Clinical Devices • Videoconferencing Equipment

14. Clinical Devices • Digital ECG • Electronic Stethoscope • High Resolution Camera • Tele-pathology Microscope • Trinocular Tube • X-Ray Digitizer • FHR, PFT, etc • Digital Camera Contd.

15. Telemedicine Software • Acquisition, • Storage and display, and • Transmission of patient related information • PMP4 software

16. Media of Connectivity Terrestrial Connectivity • PSTN / POTS • ISDN • VSAT • LAN / WAN Mobile Connectivity • GSM (Global System of Mobile Communication) • GPRS (General Packet Radio Services) • 3G Cell phone with serial / USB Interface to connect PC • CDMA

17. Transmitted Data • Text – History, examination, blood reports etc . • Audio –(MP3 format ) (heart sounds, murmurs, voice, etc ) • Still images – (JPEG, TIF, GIF Format) ECG, X-Rays, Ultrasound, CT scan, MRI etc. • Video – (MPEG2 Format) Operative procedures, Echocardiograms, Angiograms , Teleconsultation

18. Objectives of TM • Enable the medical experts to take control of a remote medical emergency when required • The telemedicine system and sub-system especially at the remote location should be designed for use by non-medical but trained personnel • The remote telemedicine system should be designed for easy portability • The telemedicine solution should be cost effective requiring minimal training, installation and maintenance • The telemedicine equipment used should use a optimum bandwidth for data communication

19. A Model for TM TeleMedicine Specialty Center TM Consulting Centre Remote Site

20. Usage Scenario The patient is examined and the data is embedded in an encrypted message and sent to the referring site's server Diagnosis is sent back and if required a phone or video conference is used The specialist opinion

21. CONCLUSION • TM is for real and real-time TM interventions are practical • Potential to reduce costs and save lives

22. Telemedicine is a concept, a tool. Its use is limited only by your imagination.

23. The PMP4 technology: State-of-the-art monitoring solution • Customized IT infrastructure with periodic updates • Increased efficiencies of professional EMS staff • Electronically measured and tracked patient vital signs enroute • Increased efficiencies of professional home healthcare staff • Decreased costs associated with visiting RNs

24. Products and Services Card Guard’s wireless healthcare system, the PMP4, provides the tools required for • Screening, • Monitoring, and • Management of general consumer health, • Disease Management, • Wellness and Fitness.

25. The PMP4 wireless medical monitors measure and transmit medical data to handheld devices, which can be uploaded to a dedicated Web-Based Medical Centre that physicians and patients may access by using a browser.

26. The PMP4 suite of portable and wireless based devices include: • 1 and 12- lead ECG event monitor, • Spirometer, • Pulse Oximeter, • Weight Scale, • Blood Pressure monitors and • Blood glucose monitor. Card Guard devices are also land-line telemedicine products for the telehealth market, including 1 to 12-lead ECG recorders, Spirometers, Fetal Maternal Monitors, and telemedicine software packages.

27. Project Objectives The PMP4 telemedicine project is intended to improve the level of health care and health services in Trinidad and Tobago by • Improving the chest pain center services nationwide via the implementation of telemedicine. • Improving the health services available in the hospitals by increasing the number of hospital beds available at any one time through the use of telemedicine and home care monitoring. • Providing a more efficient health care system by bringing the data to the doctors wherever they may be.

28. Modules • #1 The Construction of a Telemetric Center. • #2 Trauma Centers utilizing 12 lead ECG’s • #3 Surgery Wards with wireless continuous monitoring. • #4 Home Care for hospitalized patients in order to free up hospital beds.

29. Modules Cont’d • #5 Emergency Wards with ECG and other vital sign reports. • #6 Ambulatory facilities. • #7 The GP’s practices. • #8 The private home patient. • #9 The Rural Mobile Clinic. • #10 The expansion of regional services

30. Feedback for Modules AS WE REVIEW THE MODULES: • What are some of the Doctors expectations for the day to day operations • How would you anticipate the information flow to occur for each module.

31. Module #1 Telemetric Center. Turn Key Call Center Setup - Full Service Facility The center will be set up from the onset to receive and transmit data and reports from any of the telemetric devices utilized. All the key software and functions available in the center will be functional and ready in a plug and play mode for any of the devices.

32. Module # 1 Telemetric Center Follow me everywhere data delivery. • The data received will be processed by the telemetric center technicians and will be available to the physician on duty wherever he is. The center’s capabilities of following the physicians enables it to be efficient and reliable in terms of 24/7 telemetric care. 99.99% uptime with fail over redundancy. • The fail over redundancy support provided by the Boca Raton or Chicago centers enable a full service FDA and medical board approved center operated at the highest standards of medical care according to the US medical regulations. Several aspects of the Center would be carefully detailed including: • Location Identification. • Facilities Turnkey • Technician Training • Management Training • Fail Over and Redundancy • Inventory • IT Infrastructure – Procurement, installation and training. • Hardware • Software • PMP4 application training

33. Module #2 Trauma Centers Rollout Services in Health Clinics Nationwide. The installation of 12 lead ECG’s in every health center nationwide to handle cardio. In addition to the Cardio services the Health centers would also be able to record and transmit any of the menus of services listed such as: • Diagnostic 12-lead ECG • Professional blood pressure monitor • Blood glucose meter • Spirometer • Pulse Oximeter • SelfCheck Weight Scale

34. Module #3 Surgery Wards • The installation of wireless systems for ECG and other vital signs on all the surgery patient wards in every hospital nationwide for remote patient monitoring. • Patient monitor device will be available to present continuous patient vital signs measurements. This presentation will be available at the nurse station and will be available on line for the telemetric center.

35. Module #4 Home Care for hospitalized patients • The setting up of a system to allow for telemedicine home care in order to free up hospital beds nationwide. For every hospital. • For the home monitoring several solutions will be provided. These options are designed to facilitate the patient capabilities whether it is utilizing a cell phone, PDA, computer or a basic land line. All of then send the data (test) to the same PMP4 web center application: • Using one of the fix line ECG devices. The patient does his tests and sends it via his land line directly to the call center. • Using one of the wireless ECG devices. Then the patient needs to use a PDA, mobile phone or PC to send his tests to the telemetric center. • Utilizing the home Healthcare device called Amber (a join venture with Visonic, Israeli company) which all the devices: SelfCheck ECG, weight and easy2check (Gluco and BP 2in1 device), will send the data using this device via the home regular land line, directly to the PMP4 web center. This makes the solution seamless and extremely easy to use. This home Healthcare device also serves also as a call button with many additional features like fall detector etc'.

36. Module #5 Emergency Wards • Rollout 12 lead ECG in Emergency wards nationwide. This would allow for remote cardiologist experts to be available OUTSIDE the emergency centers and the system would have the capacity to do both remote and use internally as a stand alone application. • Patient monitor device will be available as well to present continuous patient vital signs measurements. This presentation will be available at the nurse station and will be available on line for the telemetric center.

37. Module #6 Ambulatory facilities. • Rollout 12 lead ECG in Ambulances nationwide. The 12 lead CG 7000DX-BT will send the signals to the telemetric center and simultaneous forward to remote receiving emergency ward at hospital and will be able to work as it continues monitoring on PC/laptop screen as well, which gives an excellent solution for this module and ambulance services. • Patient monitor device will be available as well to present continuous patient vital signs measurements. This presentation will be available at the nurse station and will be available on line for the telemetric center.

38. Module #7 The GP’s • The private practice doctors will have the option to utilize the PMP4 Telemetric center • Connected via the web. • Doctors without internet access can transmit the 12 lead ECG readings via a cell phone or land line phone to the PMP4 telemetric centric and receive the readings via their fax. • Can provide home care solutions also. • Setting up each doctor’s office with device and event recording for each patient from Doctors office. Doctor sends it to the center and receives the report back rather than sending the patient to another clinic to do ECG. Some expert doctors can also have the option of implementing the stand alone solution for their own use.

39. Module #8 The private home patient. • The supply of service to private sector patients for home consumption. These devices would be purchased or leased under contract by the private sector patients and used in their home for personal consumption. Any of CG devices are available for this service.

40. Module # 9 The Rural Mobile Clinic. • Establish mobile/ambulatory clinics to service the remote regions of country. These mobile units would go into the remote regions where no health centers currently exist and provide health service from the mobile units. • The perfect solution for this utilizing the GP model. The mobile stations can use any of the devices available, using laptop, sending tests to the call center as needed for expert's analysis.

41. “GP” Model • In this model a GP (General Practitioner) or a “smart” technician / nurse do all the tests on the patient using his PDA or Laptop and send the tests data to a call center, where experts can view and analyze, almost in a real time, the tests and send their reply back to the GP. The GP then can print a summary report with all tests results and recommendations to the patient. • All data is saved in patient history for future need both in the laptop and at the call center. The system enables the GP to connect to a remote server, view relevant data according to the user permissions and download/upload relevant data. • The medical data recorded by a PMP4 monitor includes the test results, patient’s personal data, physicians/Expert’s notes and diagnoses, etc. • The system provides administrator tools to add users to the system, setting user permissions, link between users (patients, physicians, GPs, Experts, etc.). • The PMP4 Web Center provides privacy and data protection of patient information, ability for interaction between physicians and patients anywhere, anytime and between GPs and Experts.

42. Module # 10 The regional services expansion • The supply of all the telemedicine services for the entire Caribbean region from every public hospital and private clinic and doctor’s practice in all the 23 Caribbean countries with the central call center being hosted in Trinidad. This would be a step by step approach targeting one island at a time.

43. TURN KEY SOLUTION • CG will allocate senior project managers (a local recruit will be trained as a project Manager (PM), which will be trained in Israel with all our devices and solutions). This PM also will be responsible for the center build up. He will work "hand in hand" with CG Israel and with the customer according to a detail work plan that will be presented (see also the R&R table). The customer (Trinidad government) will also have to assign a PM – at least one - for this project as well. • Card Guard will come and implement the entire solution according to US FDA standards and regulations including: • Site selection, • Setup installation, • Training, • Monitoring, • Testing. Card Guard has all the prerequisite knowledge with their subsidiary company Life Watch regarding full turn key solutions. Once this project starts CG will take all necessary steps in conjunction with LW complying on all US FDA standards and regulations, which are already supported by our operations.

44. Key Facts • Each working station will support 15 transmissions per hour. • Shift Manager - will be required per 10 seats / 150 transmissions. • Technician training approx 5 to 7 days. • 24/7 failover support to Boca Raton office. • EMR or Electronic medical records and history can be developed. • The center will potentially ramp up to 1200 reports per day in year one.

45. Site Visits • Experts from Israel will come and make site visits at all the hospital facilities and meet with the key doctors and experts.

46. Public Trauma Centers Public Hospitals Public / Private GP’s Regional Clients Caribbean Islands Patients Monitoring 24/7 On Ward Service Agreement 12 Lead ECG Service Agreement Multiple Service Agreements Contracts Regional Services Agreement SPV – PMP4 Telemetric Centre Mount Hope Medical Complex Regional Services Distribution Agreement Regional Services Distribution Company Card Guard Chicago Consulting Agreement and Support Agreement Distribution, Support and services agreement Medical Distribution Company Master Distribution Agreement Card Guard Israel License, Know How, Start up Mgmt and IP agreement Equipment Sales Service Support Owners Rep

47. Predictors of Success • “Support From the Top” – Administrative support • Internal funding AND grant funding • Assignment of staff necessary to implement and operate the program • Multiple goals that meet the organization’s mission • Is a team approach being used? • Clinical • Financial • Administrative/Operational • Technical

48. More Predictors of Success • Responsible, conservative implementation (or expansion) time line • Operational documentation and training (technical & operational) • [For Remote Sites] Select a partner who has Staying Power • Is it well supported? • Do you have an existing relationship? • Are they strong in the specialties you need?

49. Defining Success • Satisfaction • Patients • Physicians • Community • Economic Benefits • Reimbursement • Grants …. Ongoing Funding sources • New referrals and/or markets • Clinical Outcomes • Public & Market Position/Presence

50. Evidence for effectiveness • Satisfaction • patient satisfaction • physician satisfaction • Clinical Outcomes • Cost effectiveness