1. Using Technology in Urban Areas: Preparing for the Future April 26, 1999 Frank Ferrante Senior Manager Mitretek Systems, Inc. Presented to The Emerging Health Information Infrastructure Conference (HII99) Improving Health in a Digital World Sponsored by the Friends of the National Library of Medicine (FNLM) Washington, D.C.

2. 2 Agenda Technology: Changes and Trends Digital Healthcare Products Applications Current and Future Technologies Summary

3. 3 Technology: Changes Exponential Multimedia applications: Messaging, documents, desktop conferencing, image storage/retrieval, TV distribution ISDN 19501955196019651970197519801985199019952000 75 bps 300 bps 1200 bps Data Rates IBM's Token Ring 16 Mbps Ethernet (IEEE 802.3) 10 Mbps Direct Access Dial-Up Early Modem Access 100 Mbps 10 bps 100 bps 1 Kbps 10 Kbps 100 Kbps 1 Mbps 10 Mbps 1 Gbps 10 Gbps ATM/SONET Networks 1 Gbps+ 9.6 Kbps Modem Access IP Switching 1 Gbps Fast Ethernet 100 Mbps FDDI 100 Mbps X.25 56 Kbps ATM/SONET WDM Networks 100+ Gbps

4. 4 Technology: Internet Trends Internet consumer market to reach 43 million in 2000 from 30+ million households in 1998 {INTERNET2 reaching Gbps Rates) Source: The Age of Internet: Capitalization on the Data Opportunity, Information and Interactive Service Report, January 9, 1998

5. 5 Technology: Bandwidth Cost Trends Source: NGN - 1998 Conference Proceedings Legend: OC - Optical Carrier Rates (155 Mbps to 4.8 Gbps) WDM - Wavelength Division Multiplexing TDM - Time Division Multiplexing

6. 6 Technology: Digital Healthcare Products Digital Blood Pressure Monitor (Sphygmonometer) - less than 10 Kbits of data per second (required transmission rates) Digital Thermometer - less than 10 Kbits of data (required transmission rates) Digital Audio Stethoscope and integrated electrocardiogram - less than 10 Kbits of data (required transmission rates) Ultrasound, Angiograph, - 256 Kbytes (image size) Magnetic Resonance Image - 384 Kbytes (image size) Scanned X-Ray - 1.8 Mbytes (image size) Digital Radiolography - 6 Mbytes (image size) Mamogram - 24 Mbytes (image size) Compressed and full motion video (e.g., Nasopharyngoscope, Opthalmoscope, Proctoscope, Episcope, ENT Scope) - 384 Kb/s to 1.544 Mb/s (speed)

7. 7 Technology: Teleradiology Applications - Imaging 8 to 24 bits per pixel 512 to 4096 pixels

8. 8 Technology: Image Transmission Times Slow-Speed Services Medium-Speed Services (384 Kb/s - 45 Mb/s) Medical Images High-Speed Services (45 Mb/s - 4.8+ Gb/s) Medical/Scientific Visualization 29.1 min. 15.0 min. 1.1 sec. 325 ms 28.8 Kb/s (Modem) 56 Kb/s (Modem) 10 Mb/s (Ethernet) 45 Mb/s (T3) 155 Mb/s (ATM OC-3) 1.544 Kb/s (T1) 2048 x 2048x 12 bit image No compression Assumptions: Coaxial Modem Range 10.5 ms 4.8 Gb/s (ATM OC-96) 32.6 sec. 5.0 sec. 21 ms 2.4 Gb/s (ATM OC-48) Note: Service classes changing faster than ever

9. 9 Technology: ATM Collaborative Computing Live or stored video image transfer Desktop Video Teleconference Collaborative Work Board {Sample: discussing telemedical application} {Sample: tissue sample from patient}

10. 10 WDM Technology Pre-WDM: – On a single strand of fiber, a point-to-point backbone link would carry an OC-48 SONET signal at a single wavelength With WDM: –On a single strand of fiber, a point-to-point backbone link could carry multiple wavelengths (color bands) each wavelength capable of carrying an OC-48 SONET signal –Point-to-point throughput increases by a factor equal to number of wavelengths accommodated by the WDM equipment (4-8 in 1995) –Next development trend in WDM is true optical networking via optical cross connects where direct switching of optical signals rather than time slots are performed Technology trend towards direct IP over WDM (bypassing SONET equipment)

11. 11 Dense Wave Division Multiplexing (DWDM) Cost Savings Versus SONET Take advantage of DWDM bit-rate independence and lack of scaling capital expenditure as compared to SONET Source: NGN - 1998 Conference Proceedings

12. 12 Technology: Smart Cards Definition –Plastic card with embedded silicon chip, 1 to 8 kilobytes of memory, microprocessor, operating system in ROM (Read Only Memory). Capabilities –Typical 1- 8Kbytes storage memory –32kByte chips being developed –Price range now $2 to $25 per card (8Kb cards @$2) Medical Applications –Military experimenting in triage situations (Dog Tag replacements) –Insurance firms considering usage to reduce cost of accounting for medical future storage of patient records (assuming medical records policy changes takes place) Progress –Slow, with focus on billing/accounting –Expected to take off in near future if policy on records change Future –Could be useful in remote areas given inexpensive readers available (current readers cost $300 +) Reference: 3GI home page -http://www.3GI.com/

13. 13 Technology: Wireless Todays Services 0 Basic voice service 0 Fax / Paging (one-way, two-way) 0 Limited e-mail and internet access • 9.6 Kbps to 14.4 Kbps AUCAuthentication Center BSCBase Station Controller EIREquipment Identification Register HLRHome Location Register ISPInternet Service Provider MSCMobile Switching Center PSTNPublic Switched Telephone Network VLRVisitor Location Register Key: Base Station H.320 BSC VLR/HLR/ AUC/EIR MSC IP Network PSTN n X DS1 or DS-3 IP Gateway Corporate Intranet Video Server 3G Wireless Switch Air Interface: 3G CDMA Based 5 MHz RF Channels Future Future Services 0 Digital Voice and Data services 0 Fax / Paging (two-way) 0 Full High Speed E-mail / internet access • 28.8 Kbps to n x 1.5 Mbps

14. 14 Technology: Other Available Services Supporting Telemedical Applications Digital Subscriber Loop Services Cable Modems Frame Relay (predecessor for IP networks) Wireless services (cellular, satellite, other) Faster CPUs and memory storage explosion Future growth of digital record keeping acceptance

15. 15 Technology: Summary Technology is changing exponentially Internet services in urban areas represent a possible outreach approach to the public with high bandwidth offerings and ubiquity of the services Cost of bandwidth is dropping rapidly Telemedicine requires bandwidth which is now becoming more affordable and available in urban areas Urban areas are ripe for considering new technology applications as never before (e.g., wireless beyond the pager and cell phone explosion

16. 16 Technology: Recommendations Perform the cost-benefit tradeoff studies now to identify longer term applications of new technologies in telemedicine Due to the explosive nature of technology changes be flexible in buying into the new offerings (2 to 3 year contracts with options to change or get out; lease as much as possible, dont own your systems) Finally, encourage changes in insurance and legal restrictions to allow more telemedicine as facts prove their benefits.

17. 17 Contact Information Frank E. Ferrante Mitretek Systems, Inc. Senior Manager, Systems Engineering and Acquisition Center for Telecommunications and Advanced Technology 7525 Colshire Drive McLean, VA 22102-7400 Ferrante@Mitretek.orgTel: (703) 610-2905fax: (703) 610-2984