1. Telemedicine, Nephrology, and Renal Pathology Kim Solez, M.D. Kim.Solez@UAlberta.CA

2. A transition: Telemedicine, telehealth, e-health The primary care physician of the future is the patient (or parent) !

3. e-health Consumer-driven Telemedicine and Telehealth Provider-driven The public will tell us what they want in e-health. Providers no longer dictate but become partners with patient or parent.

4. Slide 4 Telemedicine - The Past, the Future In the past meant mainly phone based videoconferencing using phone lines or dedicated ISDN lines, largely impractical for developing countries. In the future, Internet based using such programs as Microsoft Netmeeting and ClassPoint, practical for developing countries. In the past meant mainly phone based videoconferencing using phone lines or dedicated ISDN lines, largely impractical for developing countries. In the future, Internet based using such programs as Microsoft Netmeeting and ClassPoint, practical for developing countries.

5. Slide 5 Telepathology - The Past, the Future In the past meant mainly real time robotic stage connection using dedicated ISDN lines, largely impractical for developing countries. In the future, Internet based using static images from inexpensive digital cameras, practical for developing countries. In the past meant mainly real time robotic stage connection using dedicated ISDN lines, largely impractical for developing countries. In the future, Internet based using static images from inexpensive digital cameras, practical for developing countries.

6. Slide 6 Internet technologies the ideal way to build consensus Three examples: ISN Disaster Relief Task Force ISN Consensus Conferences - COMGAN Banff conferences on allograft pathology Three examples: ISN Disaster Relief Task Force ISN Consensus Conferences - COMGAN Banff conferences on allograft pathology

7. Slide 7 Banff Classification Internationally agreed upon classification First developed in 1991, meetings every two years. Published in KI in 1993 and 1999. Employs lesion quantitation g,I,t,v,ah cg,ci,ct,cv,mm and standard diagnostic categories. Internationally agreed upon classification First developed in 1991, meetings every two years. Published in KI in 1993 and 1999. Employs lesion quantitation g,I,t,v,ah cg,ci,ct,cv,mm and standard diagnostic categories.

8. Slide 8 Banff Classification Inflammation does not equal rejection. Tubulitis suggests rejection, intimal arteritis diagnostic of rejection. Three histologic forms, tubulointerstitial, vascular, and transmural. Inflammation does not equal rejection. Tubulitis suggests rejection, intimal arteritis diagnostic of rejection. Three histologic forms, tubulointerstitial, vascular, and transmural.

9. Slide 9 Banff Classification Anyone can participate in the Banff meetings, on site or remotely. Next meeting April 21-28, 2001 Important breakthroughs expected in 2001. Chronic rejection classification. EM and C4D findings specific for chronic rejectiion, antibody mediated rejection. Donor biopsy classification. Anyone can participate in the Banff meetings, on site or remotely. Next meeting April 21-28, 2001 Important breakthroughs expected in 2001. Chronic rejection classification. EM and C4D findings specific for chronic rejectiion, antibody mediated rejection. Donor biopsy classification.

10. Slide 10 Communications for Banff Face to face meetings. Letters, faxes, phone calls. Expensive, cumbersome, slow. Since 1994 the Internet has been the main means of communication for this and other projects. Face to face meetings. Letters, faxes, phone calls. Expensive, cumbersome, slow. Since 1994 the Internet has been the main means of communication for this and other projects.

11. Slide 11 Origins of cyberNephrology In 1994 Michele Hales and I created the WWW page for ISN and RPS, and the NEPHROL discussion group. In 1995 we sent first renal biopsy images over the Internet and has the first international medical meeting that one could virtually attend via Internet and CD-ROM, and in 1996 created the first nephrology Internet teleconference (Edmonton-Milan) In 1994 Michele Hales and I created the WWW page for ISN and RPS, and the NEPHROL discussion group. In 1995 we sent first renal biopsy images over the Internet and has the first international medical meeting that one could virtually attend via Internet and CD-ROM, and in 1996 created the first nephrology Internet teleconference (Edmonton-Milan)

12. Slide 12 First Phase of NKF cyberNephrology 1997-2000 Many accomplishments Email discussion groups - NEPHROL, NEPHDEVEL, NEPHKIDS and progeny WWW sites - virtual attendance at meetings AJKD Forum http://www.ajkd.org Schrier Atlas http://www.kidneyatlas.org Renal-Tech computer donation project Internet videoconferencing, wireless connectivity, panoramas. WWW site http://www.cybernephrology.org

13. Support of ISN and NKF Programs. Furthering of new technologies. WWW sites: http://www.cybernephrology.org http://www.isn-online.org

14. Slide 14 Support of NKF Programs KEEP, RISE KEEP, RISE K/DOQI K/DOQI PARADE PARADE People like Us People like Us Spring Clinical Meeting, ASN Spring Clinical Meeting, ASN Publications Publications Donor Families, Donor Quilt Donor Families, Donor Quilt Transplant Games Transplant Games

15. Slide 15 Support of ISN Programs COMGAN COMGAN RENAL-TECH Computer Donation Project RENAL-TECH Computer Donation Project Video Legacy Project Video Legacy Project ISN Archive ISN Archive Sister Centers Program Sister Centers Program Teaching Resources Teaching Resources Discussion Groups Discussion Groups Assistance to National Societies Assistance to National Societies

16. Slide 16 Making Full Use of the Favorable Local Environment in Canada Canada is way ahead of the U.S. in the deployment and adoption of next-generation broadband services: The cross-Canada high- speed network backbone, CA*net3, is the world's first national optical research network. Canada is way ahead of the U.S. in the deployment and adoption of next-generation broadband services: The cross-Canada high- speed network backbone, CA*net3, is the world's first national optical research network. By the end of this year nearly 17% of Canadian on-line homes will have a broadband connection compared to 8.6% in the U.S. By the end of this year nearly 17% of Canadian on-line homes will have a broadband connection compared to 8.6% in the U.S. Living example of the success of wireless connectivity! From University of Alberta to College Plaza cyberNephrology complex. Living example of the success of wireless connectivity! From University of Alberta to College Plaza cyberNephrology complex.

17. Slide 17 New Operating Systems and Electronic Publishing Formats Palm computing platform Palm computing platform Macintosh OS 10 Macintosh OS 10 Linux Linux XML document presentation XML document presentation

18. Slide 18 Internet use becomes “mainstream” in 2000 - even in Africa! 1.Most health care workers using the Internet. 2.Access becoming faster, cheaper. 3.Computers themselves inexpensive. 4.No longer necessary to type. Voice recognition reaches 98% accuracy and still improving! Internet use becomes “mainstream” in 2000 - even in Africa! 1.Most health care workers using the Internet. 2.Access becoming faster, cheaper. 3.Computers themselves inexpensive. 4.No longer necessary to type. Voice recognition reaches 98% accuracy and still improving!

19. Slide 19 Internet Users Worldwide June 1999 - Nua Internet Surveys World Total 179.00 million World Total 179.00 million Africa 1.14 million Africa 1.14 million Asia/Pacific 26.97 million Asia/Pacific 26.97 million Europe 42.69 million Europe 42.69 million Middle East 0.88 million Middle East 0.88 million Canada and USA 102.03 million Canada and USA 102.03 million Latin America 5.29 million Latin America 5.29 million

20. Slide 20 The World is Changing - Now! September 26, 2001 New Hewlett Packard CEO Carly Fiorina said Tuesday that the world is now entering the "renaissance of the information age" -- a time when emerging technologies and an "always-on Internet" could transform human experience and entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." September 28, 2001 Major advance in quantum computing announced. September 26, 2001 New Hewlett Packard CEO Carly Fiorina said Tuesday that the world is now entering the "renaissance of the information age" -- a time when emerging technologies and an "always-on Internet" could transform human experience and entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." September 28, 2001 Major advance in quantum computing announced.

21. Slide 21 The World is Changing - Now!... continued November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor.

22. Slide 22 The World is Changing - Now! … continued - The “Digital Divide” November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. At a gathering of world leaders who adhere to "third way" politics, Clinton said one of the greatest domestic problems facing developed countries is the "digital divide" that gives those who have computers an enormous advantage over those who do not. At a gathering of world leaders who adhere to "third way" politics, Clinton said one of the greatest domestic problems facing developed countries is the "digital divide" that gives those who have computers an enormous advantage over those who do not.

23. Slide 23 The Internet in Europe, Asia, and Africa - including Kenya November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. Up until now there have been three main barriers to Internet use in Europe, Asia, and Africa: 1. Cost (Much higher than in North America and quite heterogeneous) 2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN) 3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture) Up until now there have been three main barriers to Internet use in Europe, Asia, and Africa: 1. Cost (Much higher than in North America and quite heterogeneous) 2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN) 3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture)

24. Slide 24 The Internet in Europe, Asia, and Africa - including Kenya - Solutions! November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. 1. Cost - Communications reform. Flat rate. 2. High speed Internet access DSL and cable modem coming, faster than ISDN and cheaper! 3. Language - Increasing success with non-English resources on the Internet. 1. Cost - Communications reform. Flat rate. 2. High speed Internet access DSL and cable modem coming, faster than ISDN and cheaper! 3. Language - Increasing success with non-English resources on the Internet.

25. Slide 25 Bandwidth considerations November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. The Internet in high bandwidth environments: Only 35% of human communication is words. With Internet video conferencing can capture gestures, body language, inflections of the voice, facial expression etc. plus share images, documents, software applications with "shared white board" or complete remote control of other computer! Requres 56 K modem or faster connection. Allows telemedicine/telepathology. The Internet in high bandwidth environments: Only 35% of human communication is words. With Internet video conferencing can capture gestures, body language, inflections of the voice, facial expression etc. plus share images, documents, software applications with "shared white board" or complete remote control of other computer! Requres 56 K modem or faster connection. Allows telemedicine/telepathology.

26. Slide 26 Bandwidth considerations November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. The Internet in low bandwidth situations: Web site educational content can be placed on CD-ROMs cheaply and easily so sites can be accessed without going to the World Wide Web. Email-based low bandwidth discussion has been enormously successful in nephrology and transplantation while WWW-based discussion has not. So potentially everyone has access to the Internet resources that have proven most valuable. The Internet in low bandwidth situations: Web site educational content can be placed on CD-ROMs cheaply and easily so sites can be accessed without going to the World Wide Web. Email-based low bandwidth discussion has been enormously successful in nephrology and transplantation while WWW-based discussion has not. So potentially everyone has access to the Internet resources that have proven most valuable.

27. Slide 27 Few Countries Out of Reach! November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. November 21, 1999 Clinton Calls for Widespread Internet Access - The New York Times FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their citizens have access to the Internet "as complete as telephone access," saying that would dramatically reduce the income gap between rich and poor. Almost all countries can benefit from Internet-based discussion. Email connectivity has reached almost everywhere. Very few exceptions: Countries lacking Internet access include only Afghanistan, Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara. Almost all countries can benefit from Internet-based discussion. Email connectivity has reached almost everywhere. Very few exceptions: Countries lacking Internet access include only Afghanistan, Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara.

28. Slide 28 "We strongly believe that better telecommunications will enhance our ability to deliver improved quality of life, electronic health and learning services to previously disadvantaged areas in the continent". President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998 "We strongly believe that better telecommunications will enhance our ability to deliver improved quality of life, electronic health and learning services to previously disadvantaged areas in the continent". President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998

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