1. The Telemedicine Center The Telemedicine Center at East Carolina University Division of Health Sciences Salutes our Military abroad, stateside, and in Eastern North Carolina

2. The Telemedicine Center ECU Telehealth Mission Improve health care quality & access by appropriate application of health information & communications technologies and practices across our nation and outreach to other nations worldwide. in Eastern Carolina Dr. Dawd Siraj with John Hopkins University connecting to Ethiopia

3. The Telemedicine Center Current ECU telehealth applications Teleconsultation/Specialist Referral Services –patient accompanied by a presenter who’s at a clinical site equipped with peripherals collaborates with a MD or other consultant at a center of medical expertise Distance learning and distance education –lecturer or instructor who delivers presentation materials to multiple locations for courses, grand rounds, or continuing education, may need to support student/participant Q&A. May be focused on adult health education/health literacy. Multi-specialty health care collaboration –subspecialists at multiple locations collaborating on single case or groups of cases, e.g. tumor board, to discuss treatment options; physician to physician collaboration Patient interview/follow-up/compliance/education –direct communication with a patient and/or care giver in situ (e.g. home care) for following up on problems related to a known diagnosis, ascertaining compliance with treatment plans, and/or patient education Meetings/Administrative

4. The Telemedicine Center ECU Integrated Network with Local Bridge Capability ECU Bridge Direct / MCUs Microwave & IP 1.5 Mbps NCREN - 180 sites Distance Education/Learning IP Video 384 kbps - 2 Mbps REACH-TV - 27 sites Telemed & Distance Educ IP Video 384 kbps NCIH - 186 sites Distance Education IP T-1 1.5 Mbps Internet2, Abilene, National Lambda Rail Distance Educ & Instructional ISDN 128 kbps – 1.5 Mbps Telemed, Dist Ed, Consulting, Mental Hea Dept,Disaster Relief POTS 28.8 Kbps Home Health Telemedicine, Disaster Relief

5. The Telemedicine Center ECU Telemedicine history “Go ahead and tee off. Then I want you to listen to this wheezing”

6. The Telemedicine Center ECU Telemedicine history First consults with State Prison in 1992 – Consult # 00001: Vascular surgery Expansion of existing distance education network to cover residency program and first clinical rooms in rural hospitals -1994 Seventeen“17”

7. The Telemedicine Center ECU Telemedicine history Established Advanced Telemedicine Training with more than 600 attendees representing 28 countries since 1997 Awarded “Center of Excellence” status by University of North Carolina General Administration in 1999

8. The Telemedicine Center ECU Telemedicine history Research & development “Tele” diagnostic tools Physician work stations Technical interface development for IP technologies with video tools Development of requirements for distribution of specialty care Telecommunications varieties, wireless, cable, cell, radio, etc. Dr. Bill Burke in the custom TM station

9. The Telemedicine Center ECU Telemedicine history Research in Disaster Relief and Bioterrorism Exercises since 1998 Flood waters consume Eastern North Carolina homes and businesses in 1999 Telemedicine Team transports medical supplies and equipment to shelter sites via helicopter

10. The Telemedicine Center ECU Telemedicine history Bioterrorism/refugee exercise in 2000 US Military, the United Nations, ECU and other civilian organizations worked together for the first time in a refugee management exercise at Puu Paa, located on a lava plain on the big island of Hawaii ECU tested tele-medical applications with “live” link to NC physicians

11. Telemedicine Not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services. Presently, in NC only Medicare/Medicaid services use a special telemedicine modifier.

12. The Telemedicine Center Telemedicine history Australian Royal Flying Doctor Service 1928 NASA 1960s Nebraska Psychiatric Institute 1964 Logan International Airport Medical Station 1967 Alaska Applied Technology Satellite Biomedical Demonstration 1971 STARPAHC 1972-1975 Memorial University of Newfoundland 1977 North-West Telemedicine Project 1984 NASA Space Bridge to Armenia 1988

13. Telemed Delivery Mechanisms Point-to-point connections –Hospitals and clinics that deliver services directly or contract out specialty services to independent medical service providers at ambulatory care sites may use private networks or secured telecommunications or encrypted technologies (e.g. radiology, pathology, interactive tele-consultations, ICU monitoring services provided under contract, etc.) Primary or specialty care to the home connections –Connecting PCP, specialists and home health nurses w/patients over single line phone-video systems for interactive clinical consultations. Home to monitoring center –Links used for data collection of cardiac, pulmonary or fetal monitoring, home care and related services that monitor patients in the home. Web-based e-health patient service sites –Provide direct consumer outreach and services over the Internet. –Electronic medical records

14. The Telemedicine Center Basic Telemedicine Types Interactive ( Synchronous) -Two way video, real time - high-bandwidth telecommunication Store and Forward ( Asynchronous) - Images, audio or video files stored and transmitted, like e-mail, usually not real time - lower bandwidth telecommunication

15. The Telemedicine Center IP advantages IP already part of your existing network Can serve multiple applications –Telemedicine –Electronic medical record –Internet interface – E-prescribing, medical info –Personal workplace –E-mail –Other networked functions (databases, printing, file sharing, etc.) –Voice or other communication conferencing

16. The Telemedicine Center IP networks not designed/optimized for v/c IP video is bandwidth-intensive –Cisco recommends video B/W + 20% for IP Technical issues: –Congestion/packet loss –Variable bit rate –Security –Firewall issues across networks –Integrated vendors/port assignments –Peripheral integration –Directory services IP challenges

17. The Telemedicine Center Security Mandated with HIPAA regulations Circuit-switched N/W’s inherently secure Packet-switched (IP) more challenging, but several solutions: –Completely isolated (private) IP N/W –Video encryption w/in codec Now interoperable across major H.323 platforms –Virtual private N/W (VPN) –Firewall Really only protects within your N/W

18. The Telemedicine Center TM Reimbursement from Traditional Payors Interactive ( Synchronous) -Two way video/audio, real time - high-bandwidth telecommunication driven by specialty –Must meet HIPAA requirements –Mode for all “lower 48” Store and Forward ( Asynchronous) - Images, audio or video files stored and transmitted (Radiology, Pathology, Ultra-Sound) - Lower bandwidth telecommunication - Exception is Alaska & Hawaii

19. The Telemedicine Center Reimbursement Fee for Services Telemedicine Specialized Care Facility Doctor’s Office Rural Hospitals Military Base Hospitals Clinical Room in the Naval Hospital Camp Lejeune, NC - 1996

20. The Telemedicine Center Revenue Contracted Services Central Prison used 28 types of specialties Telemedicine Short/Long Term Correctional Prisons Home / Office School/Child Care Facility Travel/ Air Cruise

21. Ahoskie – Roanoke-Chowan Jacksonville – Onslow Kenansville – Duplin General Tillery- Community Ctr Rocky Mount - Nash REACH Network Rural EAstern Carolina Health – Network Telemedicine Clinical Sites Belhaven - Pungo District Hospital Avon - HealthEast Family Care Faison - Goshen Medical Ctr Tarboro - Heritage Hospital Site Medical Center Site School Infirmary Site Correctional Sites 2009 Nags Head - Outer Banks Goldsboro – Goldsboro Pediatrics Tarboro -Heritage Heart Sites with Nurse Presenters Sites with Trauma Rooms Cardiology Network- 07-09 Psychiatry Network - 07-09 Kinston – Caswell Center Sunbury – Happy, Inc. Ahoskie – Roanoke-Chowan Ahoskie –Roanoke-Chowan Heart Center Goldsboro - Cherry Hospital Greenville –ECU Cardiology 2 Units Greenville –Health Steps 4 Units Raleigh – Central Prison Taylorsville- Alexander Correctional Morganton- School for Deaf Edenton – Chowan Hospital Windsor – Bertie Memorial Raleigh- Governor Morehead School for Blind Wilson - School for Deaf Greenville-ECU Psychiatry 2 Units Lenoir County Proposed Spoke Bertie County Proposed Spoke Edgecombe Co. Proposed Spoke BSOM UHS EC Behavioral Health- LME CNC/ACCESS-Jackson-Proposed PORT- Wilson-Proposed PORT – Rocky Mount-Proposed RHA – Wilmington-Proposed RHA –New Bern-Proposed Clinton - HITC Maury – Maury Correctional

22. The Telemedicine Center Top Current Clinical Applications at ECU Dermatology Pediatric Services Cardiology Adult & Pediatric Radiology Mental Health/ Psyc Rehab/ TBI Clinic/ EMG OB/High Risk/ NCIU “Hello Mommy” Neurology Endocrinology/ Diabetic Home Health Care James Finley, MD Dept of Pathology with tele-pathology unit to Outer Banks Hospital

23. The Telemedicine Center Telecardiology network Initial 4 sites: (6 additional sites 2008) –Heritage Hospital in eastern NC –Ahoskie Heart Clinic in eastern NC –Health Steps (Local Cardiac Rehabilitation Center) –ECU Medical Pavilion, Department of Cardiology Use desktop videoconferencing appliance to coordinate care for Cardiac Heart Failure patients between cardiologist and primary care MD’s Collaboration with Pharmacist, Nutritionist, and Psychologist Dr. Mariavittoria Pitzalis connects from her office to outpatient clinic in regional Cardiology Rehabilitation Center.

24. The Telemedicine Center Tele – psych Network Initial 6 sites: –Goldsboro Pediatric Services, Goldsboro, NC –HAPPY, Inc, Sunbury NC –Cherry Hospital, Goldsboro, NC –TarHeel Services, Beulaville –ECU Psychiatry Out Patient Clinic –ECU Telemedicine Center Use desktop videoconferencing and bridging to coordinate mental health services for patients between primary care MD’s, case managers and other providers Collaboration with other Psychiatrists, Pharmacist, Psychologist, and other Team Members to include primary care giver with patient/family Dr. Kaye McGinty, ECU child psychiatrist collaborates with psychiatrist at Cherry Hospital, state psychiatric hospital

25. The Telemedicine Center Traumatic brain injury TBI Telemedicine Clinic established in June 1998 on monthly basis Six (6) different sites Approximately 45 min-1 hr N/W time/patent including both nurse & physician Total of 156 patients seen No-show rate of 14% * compared to 38% no-show Rate in PCMH Rehab Ctr ** Dr. Jacinta McElligott & Elsie Siebelink, TBI Nurse * including some cancelled clinics due to No physician or Network time during 1998-2000 ** Percentages vary annually. This is average of collective years

26. The Telemedicine Center ECU Teleconsultation Outcomes High patient satisfaction Patient convenience –Reduced travel –Less time away from work/school –Quicker to see specialist Patient compliance –e.g. better show rates for TH visits –7 - 10% general no-show rate for all TH as compared to 35 – 42% No Show rate (TBI percentages) Continuity of care –Referring MD in the loop –Faster turnaround of consultant’s findings

27. The Telemedicine Center System integration #*! Evaluate Need Service Model (24/7) Identify technology Choose telecommunication Participants Design implementation

28. The Telemedicine Center “Telemed” Clinical Tools? Patient/Spoke site Medical Specialty Driven Additional switch or inputs for video sources Mobile capability Patient Room Camera Control Diagnostic tools?

29. The Telemedicine Center Videoconferencing endpoints “ Hard” endpoints –Dedicated hardware/applianc e “Soft” endpoints –S/W and/or peripheral on PC –May include hosting service

30. The Telemedicine Center Hard endpoints (cont’d) Several form factors –Desktop/executive –Small room –Large room –Roll-about Tandberg Intern Polycom Practitioner In-room or rack mounted outside room Integrate with 3 rd party control systems and A/V devices

31. The Telemedicine Center Soft endpoints Numerous vendors, e.g.: –Polycom –Apple iChat AV –Cisco –AOL Video Messenger –Sightspeed –WebEx Improving quality Difficult to integrate TM peripherals Share PC with other apps Limited interoperability Inexpensive

32. Technical Configuration Peripherals –Otoscope –Electronic stethoscope –Hand held camera –Pan/Zoom/Tilt camera w/far-end control

33. The Telemedicine Center Typical remote site Usually both TM exam & conference rooms Video instruments –Otoscope (ear) –Derm camera (skin) –Ultrasound, other aux. Electronic stethoscope NEW ! Mobile desktop unit for clinic connectivity Legacy units (1994) continuing with ECU engineering support

34. The Telemedicine Center New mobile Models Network/Power connectivity Video instruments Interoperability? Electronic stethoscope Video switcher for Auxiliary inputs including ultrasound HD codec, camera, and display Stereo Microphone Increased Audio Frequency range (up to 22kHz) UPS

35. The Telemedicine Center Telemedicine suite Four Tele-exam rooms each equipped with: Engineer & MD entrances EHR (Logician) PC capability Stethoscope capability House phone Remote control at sites –PZT camera –Recorders –A/V devices

36. The Telemedicine Center Current TH services Specialty tele-consultation Engineering Consultants for NC State Mental Health Network Re-installing/Expansion of NC Department of Corrections HIV/AIDS case review c/ Ethiopia & Johns Hopkins Cardiac Heart Failure Distributed Network Tele-psychiatry Network Neonatal Intensive Care Unit “Hello Mommy” Telepathology Distance learning, meetings, training –Medical Missions for Children –Telehealth project consultation UHS telehealth services –Teleradiology (PACS) –Tele-cineangiography (HeartLabs) –Home care –Disease management

37. The Telemedicine Center ECU Telemedicine Consultants Current applications NC State Division of Mental Health –Ten Main Points of Location across the State –Network/Infrastructure Research Design –Protocol Development for State Mental Health Telemedicine Guidelines –Training and Support to 38 additional connecting agencies –Network Directory Development –Business Hours On-line or Toll Free Support NC State Division of Mental Health –Equipment Enhancement/Install Design –Fourteen Sites Training and Support –Clinical Services UHS/ ECU Medical Campus –Emergency/ Trauma / ICU Design –Audiology Services with patent Internet system –Video Teaching with Medical Skills Simulation Lab

38. The Telemedicine Center Future Telemed at ECU Dental TH applications Specialty consultation Primary dental care –Mentoring -- “tele-attending” –Screening/prevention –Patient education Pre/post-surgical follow-up Interdisciplinary collaboration Continuing Education/Training Establishing Non-Traditional points of care –“Virtual” co-location in primary care –Extended care facilities –Schools with Tele-Nurse station –State facilities

39. The Telemedicine Center Vision Available to everyone Health care @ the point-of-convenience Patient is informed & empowered Telehealth/e-health applications assure patient compliance, continuing education, ease of access into health care system, healthy behaviors Clinical data integrated w/ longitudinal EHR Data available to patient (personal electronic medical record) & authorized clinical providers Data & transactions secure to greatest practical extent System components (S/W & H/W) readily interoperate w/o modification

40. The Telemedicine Center Vision Apply telehealth & IT technologies, systems, principles & practices to enable the provision of health care where it’s needed, when it’s needed Artist: Francisco Caceres From MIT Technology Review (Mar. 2000)

41. The Telemedicine Center Trends/Observations Multidisciplinary chronic disease mgt. Divergence from distance learning techs. Improving consumer infrastructure –Broadband connectivity –Home wireless –High utilization of web & e-mail –Consumer electronics –Video messaging (SIP)/”soft” endpoints Health consumerism Diffusion of point-of-care technologies

42. The Telemedicine Center Health consumerism Consumers attitudes toward healthcare (Arthur Anderson) Health consumerism will drive additional telehealth applications and use Consumers evaluate physicians and medical centers via information available on the web (Healthgrades) Increased computer literacy and net usage Physician/patient e-mail –93% of MD’s w/ access, 14% e-mail w/ patients (Baker, 2003) –AMIA guidelines for physician/patient e-mail Electronic personal health record (PHR) applications –Internet-based systems –Individual enters data & decides who can access their PHR –PHR @ Kaiser Permanente NW, Beth Israel, VA, & U. Colo. –COTS PHR applications/services (Cerner, GE Med. Sys.) –Connecting for Health Initiative’s PHR Working Group (2003) identifying standard elements of PHR systems

43. The Telemedicine Center Telehealth/ Telemedicine Specialty teleconsultation Telecare Remote monitoring Distance learning Multidisciplinary care Health Information Technology Electronic Health Records Practice management systems Clinical decision support e-Prescriptions Alerts/reminders Digital imaging/PACS Consumer Health Informatics Personal Health Records Health web sites e-Visits e-Journals Virtual health/support communities Connected health? Common denominator is the network

44. The Telemedicine Center Challenges Lack of physician education, knowledge and training Reimbursement Technical interoperability Lack of Directory of ‘Tele’- Medical Services NO Integrated Med Record NO Integrated Pharmacy services NO inter-pharmacy records NO easy assess center for TH resources Telecommunication Costs Scheduling Slow or limited physician adoption Lack of patient education and demand

45. The Telemedicine Center In Closing Extensive experience in telehealth research, practice, & policy Existing infrastructure (physical & personnel) ECU & institutional support for TeleHealth Myriad opportunities: –Effects on access, convenience/efficiency, quality –Innovation in health education –Development of new clinical services and service models (esp. consumer) –Device & software development

46. The Telemedicine Center Contact info Gloria Jones Assistant Director Clinical Operations Manager ECU Telemedicine Center (252) 744-3855 jonesgl@ecu.edu http://www.ecu.edu/telemedicine