1. eHealth HLST 2040 Prof. Sai Vemulakonda Lecture Oct.25,2012

2. Agenda Audit Trail Cloud Computing How to define tele-health and e-health? What is Canadian Experience? – Telehealth How does it work? Network, Equipment, Tech Advances, Internet – What are its key domains conceptually? By process, By intervention level, By client – How has it expanded? ↑ Teleconsultation, Established Subareas – Examples of subareas What are its challenges and trends? What are its benefits? What are its core principles?

3. Virtual private network (VPN) – A virtual private network (VPN) is a network that uses a public telecommunication infrastructure, such as the Internet, to provide remote offices or individual users with secure access to their organization's network. – A virtual private network can be contrasted with an expensive system of owned or leased lines that can only be used by one organization. The goal of a VPN is to provide the organization with the same capabilities, but at a much lower cost.

4. Cloud Computing Using the internet as a backbone Less or more use of hardware? Google Docs Bandwidth? Security?

5. Why We need Telehealth? Look at Nunavut – biggest bang for the buck Spanning three time zones, many rural areas and with travel by air being the only undesirable choice investment in Telehealth was an imperative. Problems -communication between sites and to the rest of Canada is limited by virtue of the need to use satellite links with their inherent bandwidth, satellite delay and cost problems. Source: Canadian Society of Telehealth. Telehealth - What the Future Holds: A White Paper produced by the Canadian Society of Telehealth.

6. Jane Doe is a 43 year old aboriginal woman who lives in Thatch Grove, a northern rural community. She has been noticing that her eye sight is not as good as it once was. She was considering having it checked but the nearest place to do so was too far away. Fortunately, she sees a notice in the local community centre announcing a mobile screening unit is due to visit her community and decides to take advantage of the opportunity to have her eyes checked. When the mobile unit visits the town, they are able to use the Province’s high speed broad band network through a connection at the local health unit to access the patient registry. Using the same connection they are able to check the registry to determine who in the local community needs a follow up exam. The care providers use a sophisticated camera to capture high resolution, three-dimensional retinal images of Jane’s eyes. These are then sent electronically via the broadband connection to eye specialists in the TeleOphthalmology Unit at the tertiary care hospital for interpretation. Upon review of the images, the eye specialist suspects that Jane might well be suffering from diabetic retinopathy. That information is relayed back to the care providers in the mobile screening unit and arrangements are made for Jane to be more rigorously assessed for possible diabetes using the videoconferencing system in the local health unit. This is an example of a multidisciplinary approach to chronic disease management which is adapted to the specific needs of the community at risk.

7. Traditional Settings for Telemedicine Space Ships at sea Military Rural settings like we saw in Nunavut New settings – Urban?

9. Definitions e-Health refers to the use of the Internet for the transmission of medical information. Telemedicine is the use of electronic communications and information technologies to provide clinical services to patients Telehealth. This term is often used to encompass a broader application of technologies are used to support healthcare services.

10. Social and Economic Context for eHealth Pg. 290 onwards Aging population New medical technologies Controlling administration and paper-based information costs Consumer informatics Pg. 288,289 “characteristics of the internet experience”

11. A little bit of history As early as 1950, a doctor was using CCTV to transmit images between the hospital and his home in Montreal Satellite Technology in 1960s and mid-1970s provided Telehealth with another boost and satellites were used in several pilot projects linking St John’s, Newfoundland, London Ontario, and Montreal Quebec to regions of northern Canada to test different telemedicine applications. Source: Canadian Society of Telehealth (Author). Telehealth - What the Future Holds: A White Paper produced by the Canadian Society of Telehealth.

12. Recent History In 2001, Canada Health Infoway 7 was created to foster and accelerate the development, deployment and adoption of electronic health records (EHR) across the country. Subsequently, eHealth Ontario was created in September 2008 out of a merger between the Ontario Ministry of Health's electronic health program and the Smart Systems for Health Agency (SSHA), with a mandate to create electronic health records for all patients in the province by 2015.

13. Ontario’s growth 1995-Ontario Network Infrastructure Program (ONIP) that saw several Telehealth projects started. 2002-CHIPP program - three major networks evolved – NORTHnet serving central and northern Ontario, Video Care serving the southwest part of the province and Care Connect based out of Ottawa for the eastern part Source:Canadian Society of Telehealth. Telehealth - What the Future Holds: A White Paper produced by the Canadian Society of Telehealth.

14. Prof. Sai Vemulakonda Telemedicine -1950-1980 From 1950 until the mid-1980's all telemedicine programs utilized analog technologies. The most common technology was closed circuit television (usually black and white) linked via a broadband telecommunications modality such as coaxial cable, microwave or satellite.

15. Prof. Sai Vemulakonda Modern Telehealth Era began in the late 1980's with the rapid advances in information and telecommunications technologies. computer processing was increasing digital storage was expanding compression technology was improving.

16. Technical equipment * Clinical Workstation - dedicated and/or PC based – interactive * Videoconferencing Systems – multimedia Audio Module – speakers, headphones, volume & base control Microphone Camera - lens, image sensor, pixels, resolution, illumination range, video Electrical specifications – central power switch, power requirement * Telecommunications link 56, ATM, ISDN, satellites, and networks (LAN) – Ethernet Connector panel – LAN, WAN, phone network; audio and video input and output ports; Image transfer – document and radiographic film digitizer output signal, power zoom * Peripheral Devices – otoscope, dermatoscope, stethoscope, ophthalmoscope, ultrasound device * Software - acquisition, compression, communication

18. E-health Internet-based healthcare delivery Information & education Services: professional, nonprofessional, business, consumers Commercial products E-health will eventually be used as an universal term for telemedicine and telehealth applications

19. Telehealth Telehealth: the use of information & communication technology to exchange health information and provide health care and wellness services Telecommunication infrastructure is a pre-requisite Telehealth solutions enable health service delivery channels: Tele-Consultations Videoconferencing stations, communication enabled medical devices Tele-Education Videoconferencing stations used for training/education Home Telehealth Active or passive monitoring of remote patients for pre/ post-op procedures, CDM etc. Tele-triage Centralized health call centers to offer first line delivery of service to clients as part of primary care and emergency response Source: Canadian Society of Telehealth

20. Telehealth Domains By Process Tele-care (patient care and support) Tele-consultation Tele-diagnosis Tele-learning, mentoring and training Tele-monitoring Tele-meeting (clinical, educational, admin) Tele-screening Tele-surgery

23. Expansion of Tele-Health Via “Teleconsultation” lens In the USA – the number of programs and their level of activity have been doubling yearly since 1994 – in 1997 at least 139 active programs in the US, doing over 40,000 non-teleradiology consultations in 35 specialties – about 75% of these were interactive-video mediated; 25% were store-and-forward – about 20% of all consultations are done in a prison setting – also in 1997 there were about 250,000 diagnostic teleradiology readings (PACS excluded) in the US

24. Telehealth in Canada In 2010 Canada Infoway reported 5,710 telehealth systems in at least 1,175 communities- and 187335 telehealth events Source: Elettra Ronchi OECD Senior Policy Analyst

26. Economic Benefits Canada Infoway has estimated that 1.2 million consultations could be reached within five to 10 years, with benefits to the health system valued at approximately $730 million, and an additional $440 million in cost avoidance for patients. Source(s): Canada Health Infoway (2011) Telehealth Benefits and Adoption Connecting People and Providers Across Canada 2010 ; CTF Pan-Canadian Telehealth Survey

27. Canadian Society of Telehealth The National Voice of Telehealth in Canada Affiliated with other e-health organizations (Collaboration Agreement with COACH) Leadership, Advocacy, Policy & Education Forum for exchange of ideas and knowledge

28. Benefits of Telehealth Increase access to health care services Improve quality of care Reduce health care costs

29. Telehealth Myths Build it and they will come All practitioners like it Training one person is all you need to do Broadband is everywhere One size fits all and it’s plug and play

30. Telehealth Myths If something goes wrong with a group of physicians, you will get another chance The government is here to help New equipment is always backward compatible Networks never fail It’s just wires and doctors

31. What are the issues? Telehealth should not be an additional silo of clinical information Telehealth should not be an isolated channel of service delivery

32. What are the issues? The core issue is the scope and complexity of telehealth integration: – Technology, bandwidth – Governance and policy – Law suites/liability – Service planning, delivery and compensation – Clinician workflow – Consumer participation and data privacy concerns

33. Nunavut We talked about Nunavut earlier Problems -communication between sites and to the rest of Canada is limited by virtue of the need to use satellite links with their inherent bandwidth, satellite delay and cost problems.

34. Prof. Sai Vemulakonda Many Flavours Teleradiology CBT Home health care Tele-EEG Tele-ECG Teleopthamology

36. Videos Home Telehealth Care Video Telestroke Equipment used for telemedicine encounter

37. Two Kinds of Telemedicine Consultations Real time Store and forward

38. The Ontario Telemedicine Network (OTN) one of the largest telemedicine networks in the world. Using two-way videoconferencing, OTN provides access to care for patients in every hospital and hundreds of other health care locations across the province. In addition to clinical care, we facilitate the delivery of distance education and meetings for health care professionals and patients. OTN is committed to improving access and quality of care. It’s about having the right provider in the right place at the right time.

39. OTN http://otn.ca/en/services/

41. OTN 2009 Patient Survey 94% of patients indicated they were satisfied with their telemedicine visit. 92% of patients would use telemedicine again. 66% of patients indicated they had saved money by using telemedicine versus travelling for care.

42. mHealth the practice of medicine and public health, supported by mobile like mobile phones, tablet computers and PDAs, for health services and information The mHealth field has emerged as a sub- segment of eHealth and Telehealth

43. mHealth Basics All devices are mini computers Palm Web OS, Windows CE,Symbian Use of apps or 3 rd party software LCD display Most of them do not have hard drive. Exception is an Ipod Mobile devices can be synchronized with PCs

44. mHealth benefits Care at the bedside Documentation at the point of need Wireless- so patient data is readily available

45. mHealth Challenges Limited documentation and impact evaluation- effects of integration Differential access to mobile technologies and capacity to maximize Integration Rapidly changing technologies and environment- Is the app up to date? Privacy, Theft concerns Patient training for proper use of PDA

46. PHR Characteristics (Drazen, 2011 ) There is currently no PHR that possesses all these characteristics (Drazen, 2011).

48. Summary Cloud computing Telehealth Telemedicine Mhealth