Telemedicine & e-Healthin Taiwan

Heng-Shuen Chen, M.D. Ph.D.Dept. of Medical Informatics & Family Medicine,College of Medicine & Hospital

National Taiwan University

April 24, 2006 Internet2 Spring Meeting International Task ForcePanel Session Arlington, USA

Outline

Introduction

History and Development ofTelemedicine in Taiwan

Health Science Projects Relatedto National Research andEducation Network

Future Prospects

Introduction

Taiwan

Area: 36,000 km2

(near Netherlands)

Population:23 millions(near Australia)

second highestpopulation density inthe world (623/km2)after Bangladesh.

Taiwan’s BMW

Broadband NetworkDSL (World’s 2nd, 27.9/100 phone lines) Cable modem FTTH/FTTB (fiber to the home/building) 75% households Internet connected,

93% of them used broadband networks. Mobile & Wireless Network

Mobile phone (World’s Top, near 100%)Wireless LAN (WiFi, 90% Manufacture)WiMax

Internet User Population 65% 42% of them wireless network user

Top Ranking e-Government Ranking (Brown University)

Global Digital Living Index (Parks Associates)

Internet usage (NOP World Culture Score Index) 12.6 hours on the computer/Internet outside

working time

Taipei, Top Seven Intelligent Communities(Intelligent Community Forum, ICF)

Internet in Taiwan

Taiwan NationalResearch & Education Networks TANet

First Internet serve to educational & research institutions TANet2

Since 1998, Serve most education & research institutions The research network known to the international network Managed and operated by the NCHC

TWAREN(TaiWan Advanced Research & Education Network) Since 2004, Serves higher educational & research institutions Three levels of services re-designed:

Production, Research and Optical networks Three functions assigned:

Computing center, Knowledge (data) center, Network operation center Since 2005, Backbone shared by TANet

TWAREN Topology(production network, 2003)

4 core nodes11 GPoPs20 G backbone

Eastern Broadband (10G)Chunghwa Telecom (10G)Chunghwa Telecom (5 G)

Core nodes

Dual circuits from two vendorsform the physical backbone

Taipei

NCU

NDHU

NCTU

NTHU

NCKU

NSYSU

NCNU

NCHU

SINICA NTU

Tainan

Taichung

CCU

Hsinchu

International Links from Taiwan

Hong KongHARNet

Amsterdam

AMSIX

622 Mbps 2.5 Gbps

SingaporeSingAREN

Tokyo-XP

LA

TaiwanTaiwan

2.5 Gbps

2.5 Gbps1.Mbps

155 Mbps

2.5GbpsLightpath

History and Developmentof Telemedicine in Taiwan

Why Telemedicine?

Geographic:75% mountainous area,several groups of isolated islets

Poor medical resources in rural area Physicians are reluctant to practice in

rural areaAfraid of being isolated Lacking opportunities for CME

Specific needs:Handicapped and ElderlyHome care(palliative medicine)

History of Telemedicine

1990 TANet (Taiwan Academic Network)

1994 NII (National InformationInfrastructure) Planning

1995 NII Kickoff (National HealthInsurance started)

1996 NII Pilot Telemedicine projects: Medical Distance Education

Teleconsultation

2000 HIN 2.0 (National Health InformationNetwork version 2) EMR

1995 NII Kick OffPilot Project of Distance Education

First Distance Education Lecture in Taiwan via ATM/DS-3 :NTU(College of Medicine), NTHU, NCTU

Three Stages of Telemedicine

Initiation Research Stage

(1994~1996)

Promotion Research Stage

(1997~1999)

Implementation Stage

(starts in 2000)

Initiation Research Stage

Different bandwidth and network platform Distance education Pilot Project

Broadband ATM DS3 videoconference Narrowband ISDN 128K desktop videoconference ISDN 384K room based videoconference

Teleconsultation Pilot Project ATM DS1 teleconsultation ISDN 768K+768K teleconsultation

Distance EducationISDN Room-based 384K

Teleconsultation (DS1)Synchronous and Asynchronous

Promotion Research Stage Different specialties and applications

Videoconference CME by videoconference: Family Medicine CME

Course Broadcast to Community Hospital Multipoint Videoconference: Multi-center Palliative

Medicine Case Conference Web-based

Web-based Telemedicine System (EMR & PACS) Web-based Virtual Classroom & VOD Electronic Journal: Chinese Full-Text

International Telemedicine: NGI/Internet2

Multipoint VideoconferencePalliative Medicine Case Conference

VOD (CME in Family Medicine)

International TelemedicineVirtual Hospital Taiwan Mirror

International TelemedicineNTU-UIOWA Teleradiology

International TelemedicineNTU-UIOWA Teleradiology

Implementation Stage Integrate telemedicine to community health

information system e-Health

Network Clinic: Synchronous & Asynchronousteleconsultation

Telecare (Volunteer, School, Church) e-Learning

Continuing Medical Education (CME) Group Patient Distance Education VMS: Virtual Medical School

e-Records Family Folder system Electronic Health Records Electronic Referral System

921 Earth Quake(1999 Sep. 21)Severe damage and destruction in Nan-Tou County

NTU Telemedicine 2000

NTU was responsible to reconstruct the healthsystem of Nantou County

NTU-PCH(Puli Christian Hospital, Nantou)Telemedicine Project

Joint Network-Clinic Service Center System(NTUH-NCKUH-TSGH)

Community Health Group-Health Information andFamily Doctor System(CHGIFS, Lugu Township,Nantou)

Network Clinic & Telecare

Doctor’s EndDoctorDoctor’’s Ends End Patient’s EndPatientPatient’’s Ends End

Network ClinicsRemote Sites

本院

14

霧社

力行部落

萬豐部落

靜觀部落

合歡山

翠巒部落

Netwrok ClinicSynchronous Teleconsultation

Joint Network-Clinic CenterOnline Registration

3.Registation

4.Cancelling

2.InputData

1.Choose aDoctor

Joint Network-Clinic CenterElectronic Medical Records

1. Input Data

2. Upload

3. Confirmation

4. Printing

Continuing Medical EducationMultipoint Videoconference

Patient Distance Education

Nutritionist at NTUH Health Station atAboriginal Area

Medical e-Learning 2000~ Web-based e-Learning in Medical Education

Virtual Medical School

CHG-HIFDS Community Healthcare GroupHealth Information and Family Doctor System

300 CHGs with 2000 family doctors(15% in Taiwan)

CHG-HIFDSFamily Folder Subsystem

CHG-HIFDSElectronic Referral Subsystem

Canning of Chest Xray

With Mini PACS system

Medical Center Expert Diagnosis

CHG-HIFDSElectronic Referral Report

Health Science ProjectsRelated to National Researchand Education Network

TANet2/TAWREN Health ScienceRelated Projects & Activities

National DOH Telemedicine Projects:

Joint Network Clinic Asthma GRID SARS GRID Medical Problem Based eLearning (PBeL)

International multi-countryTeleconference & Forum Telemedicine and e-Health Medical Informatics (IP, H.323) Pancreatic Transplantation (DVTS)

Joint Network-Clinic ServiceNTUH-NCKU

Intranet

Internet

ISDN

台大醫學院405室

台大家醫遠距會診室

埔里基督教醫院&仁愛鄉衛生站

台大家醫6A討論室

台大醫學院101講堂

烏來鄉衛生所

成功大學聖馬爾定天主教醫

院

耕莘天主教醫院 阿里山鄉衛生所

Asthma Grid

Asthma Grid

Before After

In 2003Trans-Pacific links to Seattle and Chicago,each at 2.5 GbpsLinks between STTL & Chi: 622 Mbps & 1Gbpslightpath. From Chicago to Europe at 2.5 Gbps

Taiwan

Taipei

StarLightStarTap

CA*Net4

Abilene

VancouverEdmonton

CalgaryWinnipeg

MontrealHalifax

Toronto

STM-1

6 (2.5G

) 1 GbE

Taiwan’s connections to N. America at the time ofSARS epidemic

STM - 4

2.5 Gbps

Europe

SARS Grid

NCHC Access Grid node test the SARS Grid network links

Access Grid 1.2 PIG

SARS Virtual ClassroomNarrow Band Multivideo (I)

SARS Virtual ClassroomNarrow Band Multivideo (II)

SARS Virtual PatientProblem Based e-Learning

Medical ProblemReasoning

Characteristics Mentor and

Apprentice Problem-Based

Learning (PBL) Evidence-Based

Medicine

Basic DataChief Complain

HyposthesesGeneration

History,PhysicalExams

Observation,Hints

H2

History,PhysicalExams

H1

DecisionDecision

Diagnosis Diagnosis

Lab test,Image

Diagnosis

SARS Virtual Patient

Clinical Case Authoring

SARS Virtual Patient

Tracking & Evaluation in PBeL

International CollaborationIP Video Conference & Streaming

Four countries Videoconference(Speaker, Stanford U. Dr. Song)Quick Time or Real-video Streaming

2006 APAN DV10Medical Working Group Meeting

EzLMS e-Learning Platform

Future Prospects

Health Science NetworkProjects in Taiwan

Ubiquitous Healthcare of Aging Society International Initiative for u-Health

Wireless Hospital Wireless LAN, VoIP, Messaging, Mobile EMR,

Mobile Doctor

Health Community Network Integrated with NHI Smart IC Card, HCA, EMR,

Electronic Referral, Family Doctor Holistic Care,Long term Care (Institution, Homecare, Life CareServices, and Network ISP)

National Health Education Network & SuicidePrevention Network

Aging Population in Taiwan

2.94.3

6.88.8

9.9

14.3

19.7

0

5

10

15

20

1970 1980 1990 2000 2010 2020 2030

Rapidly Decreased Childbirth

----2015

13.3(1:7)9.51.189.562004

----2030

13.09.21,2310.062003

12.89.01,3411.022002

12.5(1:8)8.81,4011.652001

12.38.61,6813.762000

--6.81,7215.51990

--4.32,45241980

----7,04501951

CrudeBirthRate

AgingPopulation

TotalFertility

Rate

Old AgeDependency

RatioYear

14 25(1:4)

20 33(1:3)

Elderly Healthcare Problem

Huge Healthcare Need: burden for families Biomedical support: chronic illness with

complication, handicapped, terminal illness Psychosocial support: living alone, social

isolation Emergency support: acute events

Escalating Healthcare Expense: In Taiwan, 10% Elderly account for 25% of

total health care expenses, 40% of emergencymedical services

NTU u-Hospital Project Objective:

To provide a mobile, personalized, andubiquitous care in realtime to achieve the bestquality of health service

Fundamental Elements Interdisciplinary teamwork telecommunication networks Healthcare services

Mobile Emergency Service NetworkMobile Home Healthcare NetworkMobile Ambulatory Healthcare Network

u-HospitalInterdisciplinary Teamwork National Taiwan University:

College of Medicine: Medical Informatics, School of Nursing, School of Physical Therapy

College of Public Health Institute of Health Organization Administration

College of Electrical Engineering & Computer Science Department of Electrical Engineering, Department of Computer Science,

Institute of Electronic Engineering University Hospital

Department of Information Service, Department of Family Medicine,Department of Emergency Medicine, Branch Hospital with Nursing Home

Other Collaborative Institutions and Organization National Taipei University of Technology Yu-Da College of Business Biomedical Engineering Center, Industry Technology Research Institute Cardinal Tien Hospital Taiwan Telecare Industry Alliance Taiwan Wireless Communication Strategic Alliance

u-Hospital: Subprojects

Mobile Computerized Health Records NTUH e-Hospital Portal Mobile Electronic Medical Record (mEMR) Mobile Electronic Home Care Record (mEHCR)

Telecare System Mobile Emergency Medical Service Network Home Telehealth System

Remote Activity Monitoring (Health Guard) Nurse’s e-Bag for Homecare Visit Gait Monitor & Fall Detection

Health Management Medication Compliance & ADR Prevention eHealth Education: Weight reduction, suicide prevention

Care CenterCompany

Ambulance

Community Hospital

Sensor area

Sensor Sensor

DTV

Family MemberWork Site Care Center

Ambulance

NTU u-Hospital System

Home Site

Family doctorof Clinic 1

I

23

Communityhealthcare group

Community Hospital

Homecarenurse

System Structure of u-Hospital

通訊端

服務端居家端Home

Security ServerNetwork Server

Internet CommunicationSystem

3GGPRSADSL

Wireless LAN

Home Application system

Communication module

Vital sign measurement andsensor End

Application system processing

Message transmit and receive module

Message receive serviceMessage transmit service

Data saving module

Internet base architecture

Data transfer engineXML

Vital signdatabase

InternetInternet

Vital sign query module

Alarm Service module

Heterogeneous data integration module

Vital sign data analysis

Online Analysis processing

Data Research analysis

InternetInternet

Application Interface module

Web-based Windows-based

Standard Data transfer module

HL 7 DICOM

Heterogeneous data transfer module

Care Center

Data Communication

Clinics service module

••• •••

醫療機構Hospital

Vital sign query

HIS integration module

HIS integration module

Data Integration Interface

行動看護Family Doctor

Data IntegrationInterface

Vital sign query

Mobile application systemmodule

Vital sign query

Emergency processing Module

支援服務中心

Emergency Inform

Data Integration Interface

Call Center module

Vital sign query

Data Integration Interface

Emergency Service

HL7 IE

Interface

Interface

Interface

Interface

DBDB----------------

----------------

----------------

ComponentRepository

InternetInternet

ExtranetExtranet

RISRISLISLISHISHIS

VPN

PDA(with GSMmodule)

PDA(with IEEE802.11 module)(with Web Browser)

PC

PC

WirelessOperatingNetwork

ExtendedModule

ExtendedModule

Interface

Interface

EMRSystemEMR

SystemInterface

Interface

Files

OtherSystems

Others HealthcareInstitution

PDA(with IEEE802.11 module)

(with Web Browser)

WebServerWeb

Server

Interface

Interface

Add-on ServicesAdd-on Services

Intranet

…

ClientLayer

Web ServiceLayer

App. ServiceLayer

IELayer

Electronic Medical Record (EMR)

From e-Hospital to u-HospitalAccess EMR via Mobile Devices and Desktop PC

Vehicle Computer Access EMR

Family Doctor & u-Hospital

Mobile Emergency Medical ServiceNetwork System Architecture

GPS

Internet(HTTP protocol)

PDAs( with MHEMS System)

GPRSModule

Vital Sign, ImagesPreliminary Data

Doctors

Treatment instruction(Prepare EHR)(Prepare Emergency Stuff)

MHEMSSystem

(Hospital Clients)

EIS

Ambulance Vehicles

Emergency Dept. ofHospitals

Doctors

Monitor

GIS

MHEMSSystem

(HA Server)

DSSRescue path

勤務指揮中心

EMTs

Dutyon fire

Terminologies:MHEMS: Mobile Mocile Hospital

Emergency Medical SystemDSS: Decision Support SystemGIS: Geographic Information SystemGPS: Global Positioning SystemEIS: Emergency Information System

(EMT Clients)

GPRSModule

AGPS System

Dispatch and MissionControl Center

Ambulance

Terminologies:MHEMS: Mobile HospitalEmergency Medical SystemDSS: Decision Support SystemGIS: Geographic InformationSystemGPS: Global Positioning SystemEIS: Emergency InformationSystem

Emergency Departmentof Hospital

Ambulance Dispatch andMission Control Center

The operator of Dispatch and Mission Control Centerdispatches Ambulances and monitor them by GIS.

Ambulance

GPS module

(GPRS)

Patient andEMT in theAmbulance

EMT PDA(GPRS/3G)

Message transfer inMobile Emergency Medical Service

Patientdata

4

5Vital signal& picture

Inform ETA &ambulance position

Emergency call

Ambulance

GPS

GPRS

PDAWinCE

2Read dutyinformation

Dispatch andMission control

CenterGIS

Dutyinformation

1Pre-calculateETA

Define districthospital andambulance

Inform hospital & readETA in period time

HIS

Hospital

Patienthistory

6Send Patient ID

Emergencytreatmentrecords

Show the patientinformation on the

order of ambulancesarriving

Message transfer flow establishes the work of MHEMS system

3

Emergencytreatmentsave to HIS

Functions of Home Telehealth

Telecare Emergency call (life line) Location (indoor, outdoor) Alarm (remote monitoring of vital sign)

Communication Interactive video (home setting, ambulatory) Society (Discussion Group)

Management Electronic Records (home visit records of nurses,

physicians and linked to HIS) Health management (Life style modification, periodic

health exam, chronic disease surveillance, drugcompliance, appointment etc. )

Home TeleHealthGait Monitor & Fall Detection Measure gait:

Adidas Smart shoes: pressure sensors on shoes Smart floors: pressure sensors under floors

Prospects of u-Health

Synchronize with current government policy National Health Information Infrastructure (NHII) e-Taiwan II Project m-Taiwan Project u-Taiwan Project

Collaborate with International Organizations IEEE/ITU-D/WHO Mobile e-Health Initiative International Initiative for ubiquitous Healthcare

Promote and Collaborate with Industry MOEA and Industry Alliances

IEEE Healthcom International Conference Healthcom2006 (India), Healthcom2007(Taiwan)

Government u-HealthRelated Projects

DOHTeleCare Project

MOEAElderly U-Care Project

NHRIGeriatric Functional Index, Friability

NSC Intelligent living Technology

u-Health TAIWAN

EXPO for u-Health IndustryIEEE HealthCom 2007 ConferenceHL7 Asia-Pacific MeetingAPEC PACS Meeting

Wireless Hosp & Mobile Doctor

Health Community Network

Follow the planning NHII Apply techniques of the Internet and

multimedia database Establish a community-based health

information system Integrated Community Oriented Primary

Healthcare, Public Health Service, LongTerm Care with IDS(Integrated DeliverySystem)

Health Community Network

PatientHomeCallCenter

Family Folder

HealthInformation.BiosignalRecords

MedicalRecords

CA Security

e-Counsellinge-Rereferale-Appointmente-Health Education

Care giver

Healthy lifestyle

Self health management

Home safety

Emergency alam

Lifeline call

Tele-homecare

Coordinative

Comprehensive,

Continuous

u-Care Service

LifeCareHome

Care

Medical Care

National Health EducationNetwork http://health.edu.tw

Taiwan Suicide PreventionCenter http://www.tspc.doh.gov.tw

Thanksfor yourAttention