Establishing a Global Telehealth Service: Case Perspectives in Latin America
Orlando Vallone Junior National Telehealth Conference
University of Cincinnati, 20-21 March 2014
Disclosure
Specialty Telehealth Services, Inc.
- President and financial interest
Objectives Describe the evolution of Telehealth technology and
applications based on our experiences in the region
Share implementation lessons and operational tips when implementing distributed Telehealth networks
Describe educational uses and potential impact of a Latin American Regional Stroke Network
Demonstrate a live Telehealth system and Response Center operations
Topics
Our Background
Motivation and Opportunities
The Challenges
Implementation
Questions and Answers
System Demonstration
Development Timeline
2013 2006
Family member suffered stroke
2011
Government Contract
1990
Telestroke Network
Latin America
2005
Telehealth Solutions R & D
Telemedicine, Tele-education, Teletrauma,
and Teleradiology
TV Uplink Services - Brazil
Broadcasted to the U.S., Latin America, and Europe
2012
Brazilian Olympic
Team
Our Background Satellite and cable TV uplink services
provider and operator (Brazil, US, Latin America, Europe (1990 - 2005).
Implementation of Telehealth solutions
using wide-coverage satellite (Telemedicine, Tele-education, Teletrauma, and Teleradiology).
STS operates a Response Center in
Miami, FL USA (Teletrauma and Telestroke to US, LatAm, Europe).
Ultrasound Course Demonstration
Hospital Mario Covas – Santo André – SP – Brazil 2005
Teletrauma and Tele-education
Ryder Trauma Center – Miami, FL – USA 2006-2008
Demonstration of Remote and Main Hospital Installations
(Clinical Case Videoconference and Live HD Video Transmission)
1
Crystal Palace Training Center
London
STS Response Center - Miami
Brazilian Olympic Telemed System
Hospital into Trauma - Rio
Hospital Samaritano General - Rio
King’s College Hospital – London
Hospital ABBR General - Rio
London Olympic Venues
1
1
2
University of Miami Specialty Doctors
20 (Doctors+Physiotherapists ) (10 Smartphones + 10 Tablets)
2 2
2
VC + Phone E-mail+Telerad Cellular/WiFi
2 1
WSC 2012 – Latin American Telestroke Network
Motivation and Opportunities
Interest in applying international satellite and business experience to establish Telemedicine networks for tele-education, public health and disaster management uses
Family event of a stroke case in São Paulo 8 years ago Major DISABILITY Conjunction of favorable events in 2011/2012
‒ High level of broadband internet penetration ‒ Availability of standards-compliant imaging access ‒ Growth of Telestroke networks in the USA ‒ Technological developments
• ↑ Microprocessor speeds • ↓ Costs and stable tablets/PCs • ↑ Deployment of 4G/LTE cellular networks
Challenges, Implementations and Lessons Learned
CASE I – Teletrauma and Tele-education Equipment characteristics:
• Used mainly by the satellite and broadcasting industries, • Large satellite antennas and no broad band Internet, • High cost per systems and asymmetrical links (↑dowlink /↓uplink
rates), 1 channel HD video encoder ~ $50K/60K, • Emerging HD Video Conference Codecs (~2006/07),
Lessons:
• High cost to build one-way tele-education network with simultaneous teletrauma capabilities,
• Equipment required more training for doctors to become comfortable with technologies,
Challenges, Implementations and Lessons Learned
CASE II – Remote Clinics and Brazilian Olympic Telemed System Equipment characteristics:
• HD Videoconferencing hardware more common, • New software Codecs – lower costs, faster and scalable
deployments (highly dependent on servers and VC bridges) • Moderate cost per systems, growth in broad band Internet
availability - US and parts of Latin America - (mainly with the use of cable modems),
System requirements:
• 24-hour Telemed response for Brazilian Olympic Team • To provide response coordination and operations using WIFI and
LAN and very limited 3G/4G network • To provide imaging sharing capabilities among sites
Challenges, Implementations and Lessons Learned
CASE II – Remote Clinics and Brazilian Olympic Telemed System Lessons:
• Mandatory site survey and event pre-planning (reduce
connectivity problems, maps limitations),
• Constant Testing specially when operating multiple platforms (Hardware VC, Robots, Cellular/Satellite Phones, Tablets, and PC’s),
• This system can be scaled to provide concurrent emergency and
disaster support (additional uses may lower overall deployment costs),
Challenges, Implementations and Lessons Learned
CASE III – The Case for a Latin American Telestroke Network Competing Indices in Latin America and Brazil
• Brazil ranks extremely high in risk factors for stroke,
• Brazil highest TV viewership times Physical Inactivity Obesity, High BP, Diabetes Development of CVD,
• Brazil has very high cellular phone penetration over last 5-7 years (Surpassing Korea’s rates),
• Brazil has very high broadband internet penetration (16.8 Million subscribers 2011),
• Brazil had 129,000 stroke deaths and 11 years of disability (DALYs) lost per 1,000 population
TV Viewership Times From Instituto Brasileiro de Geografia e Estátistica (IBGE 2008) Panoramic Health Study in Brazil: (2013 estimate – Population ~ 200 Million) “Out of a total population of 189 million, 175 million people (92.4%) had a habit of watching TV, with 75.2 million of them (42.9%) watching TV for over 3 hours a day. 56.2 million (29.6%) declared using a computer or videogame with 28.8% of them using it for a duration of over 3 hours.” From Francine Kaufman MD, healthychildren.org: “Watching TV, surfing the internet, and playing video games don’t count as exercise. The time your child spends in front of a monitor should be kept to a limit. Some researchers recommend no more than 1 hour of screen time a day. The risk of obesity increases when your child watches more than 2 hours of TV per day.”
Brazil – Cellular Phone Penetration
0
50000
100000
150000
200000
250000
300000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
In T
hous
ands
Year
Cellular Phone Subscriptions in Brazil (~272 million Jan 2014)
Source: World Bank Data, 2012
Brazil – Broadband Penetration
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
In T
hous
ands
Year
Fixed Broadband Internet Subscribers in Brazil
Source: World Bank Data, 2012
The Opportunities
Brazil has the technological infrastructure to support new-age telehealth delivery (Mexico, Peru and Chile present similar trends)
• Brazil has very high cellular phone penetration with strong growth over last 5 years
(similar trends for most of Latin American Countries)
Our Challenges
How fast can we use these successful indices to our Telehealth advantage?
Can we reduce the burden of disability from stroke and implement telehealth with similar success?
Can we do it fast? (How many clicks away?)
Can these networks support good cases for Telestroke, Teletrauma, and Tele-Education?
Latin America Telestroke Network and Implementation
Start with smaller number of sites in areas of greatest positive health outcomes
Decide on adequate cost of on-site equipment
Shortest time to the implementation
Constant mandatory site survey and event pre-planning
Testing especially important when operating multiple platforms (VC, Robots, Phones, Tablets, and PCs).
Forms of Intervention Education (recognizing symptoms) and behavior modification (schools, media, cultural changes), Pre-hospital personnel training (EMS and Emergency Clinics) and mobile Telestroke,
Hospital-level response with Telestroke systems
− Training of Stroke Teams − Development of Primary and Comprehensive
Stroke Centers − Certification similar to that obtained in the US
Telestroke Network Components
Motivated Stroke Teams − Doctors, nurses, and protocols
Videoconferencing Collaboration System
Teleradiology Collaboration System Training
Why do we do it?
And Time is BRAIN!
Ref. National Geographic Magazine, Feb 2014
References De Bustos, Elisabeth M., Thierry Moulin, and Heinrich J. Audebert. "Barriers, Legal
Issues, Limitations and Ongoing Questions in Telemedicine Applied to Stroke."Cerebrovascular Diseases (2009): n. pag. Print.
De Bustos, Elisabeth M., Fabrice Vuillier, Didier Chavot, and Thierry Moulin.
"Telemedicine in Stroke: Organizing a Network - Rationale and Baseline Principles." Cerebrovascular Diseases (2009): n. pag. Print.
Massaro, Ayrton R. "Triagem Do AVC Isquêmico Agudo." Revista Da Sociedade De
Cardiologia Do Rio Grande Do Sul (2006): n. pag. Print. Schwamm, L. H., R. G. Holloway, P. Amarenco, H. J. Audebert, et Al, "A Review of
the Evidence for the Use of Telemedicine Within Stroke Systems of Care: A Scientific Statement From the American Heart Association/American Stroke Association." Stroke 40.7 (2009): 2616-634. Print.
References Schwamm, L. H., H. J. Audebert, P. Amarenco, N. R. Chumbler, and M. R. Frankel. et
Al, "Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement From the American Heart Association."Stroke 40.7 (2009): 2635-660. Print.
Silva, Gisele S., and Lee H. Schwamm. "Use of Telemedicine and Other Strategies to
Increase the Number of Patients That May Be Treated with Intravenous Thrombolysis." Current Neurology and Neuroscience Report (2012): n. pag. Print.
Pandian, J. D., P. Langhorne, and Linda D. Villiers. "Basic Stroke Services." Reading.World Stroke Academy. Web. <http://www.world-stroke-academy.org/pdf/WSA_basic_stroke_services_learning_module.pdf>.
"The Atlas of Heart Disease and Stroke." The CDC (2004): n. pag. The World Health
Organization. 2004. Web.
Thank You! Orlando Vallone Junior
www.stsmed.com
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