Telemedicine
Telemedicine The exchange health information at a distance to facilitate clinical care using telecommunication technology
Applications of TelemedicineTelepathologyTeledermatology TeleradiologyTelesurgeryTeleHomecare
Use of information, communications, measurement and monitoring technologies to evaluate health status and deliver healthcare from a distance to patient care at home
Telemedicine vs. TeleHomecare
Telemedicine Associated with sophisticated, expensive, and high-tech tools of institutionalized medicineRemote care delivered by physicians
TeleHomecareAssociated with the usual routine care provided in home health visit by nursesFocused on the care of chronically ill patients
Telemedicine vs. TeleHomecare
TeleHealth = Telemedicine + TeleHomecare
TELEMEDICINE
*Telecare = TeleHomecare
E-health
Definition"the combined use of electronic communication and information technology in the health sector for clinical, educational and administrative purposes, both at the local site and at a distance“ (Mitchell, 1999).
E-health Considered an equivalent of E-commerce in the healthcare industry Embraces a broader context and seems more appropriate Seems more useful in attracting investorsTelemedicine has become an obsolete term
TeleHomecare System
Provider Station Patient Station
Communication Link
System Architecture
Home #1
Visiting nurse
HospitalGP
Specialist
Distributed Distributed Medical Medical
Information Information SystemSystem Control
Centre
Home #2
Home #4
Home #3
Wide area network
Local area network
Physiological Sensors 11 22 33 44 55 66
Technologies InvolvedSensors and Assistive devices
To monitor health related parameters To provide appropriate therapy and support
Home communications network To enable communications between the physically distributed components within the home Local processor unit which link between the home and the appropriate care providers
System intelligenceMixture of both human experience and computerized artificial analysis and decision makingFiltering information to sort out the relevant information from the ‘noise’
Sensors for TeleHomecarePhysiological
ECG: Pulse rate and variabilitySpirometer: Respiration rate, peak flow, inhale/exhale ratioSphygmomanometer: Blood pressureThermometer: Basal temperatureGalvanic skin response: SweatingColorimeter: Pallor, throat inflammationStethoscope: Heart and breathing sounds
LifestylePassive infra-red: Client mobility / securityAccelerometer: Fall and tremorInductive badge: Room occupancy I.R. smart badge: Person identification & location
EnvironmentalThermometer: Room temperatureMicrophone: Noise-pollutionCoil clamp: Power consumption / appliance usageI.R. smoke alarm: Fire detector
Home Monitoring DeviceFlexible Sensor Connectivity
Blood sugarBlood sugar
Blood pressureBlood pressure
ThermometerThermometer
StethoscopeStethoscope
ECGECG
Pulse O2Pulse O2
CameraCamera
Digital ScaleDigital Scale
309
Home Monitoring Devices
The Hospital Without WallsAA telehomecaretelehomecaresystem system incorporating incorporating vital signs vital signs monitoringmonitoring
Monitoring Device
Controlled by PC in homeControlled by PC in home4 sensors (8,000 bits/sec) 4 sensors (8,000 bits/sec)
3-axis accelerometers: fall detectionHeart rate monitor“Panic button”2-lead ECG
TwoTwo--way transmission way transmission 2.4 GHz ISM band2.4 GHz ISM band
UltraUltra--low power low power -- up to 2 weeks battery lifeup to 2 weeks battery life100m range100m range
Radio System
100100mm
Diversity Diversity antennaantenna
Radio base Radio base stationstation
ModemModem
Fixed sensorsFixed sensors
Blood pressureBlood pressure
Pulse oximetryPulse oximetry
Heart monitorHeart monitor
Body area network
Body Area Network
Real time vital signs display
TeleHomecare Integrated with EMR
Vital sign data from the TeleHomecare unit
TeleHomecare Integrated with EMR
Driving Forces
Cost EffectiveCost EffectiveTechnologyTechnology Healthcare Cost Healthcare Cost
IncreaseIncrease
Increased Increased AcuityAcuity
Aging Aging PopulationPopulation
Patients Move Patients Move Toward SelfToward Self--CareCare
Managed CareManaged CareCapitated PaymentsCapitated Payments
TeleHomecare Services
First-generation systems Anxiety reduction among elderly and high-risk patientsPersonal alarm systems and emergency response telephones
Second-generation systemsContinuously monitor variables sensitive to changes in functional health status and generate alarms without the intervention of the patientIntegrated with evolving "smart home" technology for home automation, security and environmental control
Third-generation systems Attempt to deal with issues of loneliness and quality of life ofpatients by creating a virtual community of clients, carers, healthcare providers and other community services
Suitability of TeleHomecareUK report (1998)
15% of home visits could be replaced with telecare
Gann D, Tang P, Curry R. Feasibility study: technologies for telecare in the home. SPRU, December 1998.
US report (1999)46% of all activities carried out by on-site nursing could be replaced by telenursing
Allen A, Doolittle GC, Boysen CD, et al. An analysis of the suitability of home health visits for telemedicine. J Telemed Telecare 1999; 5: 90-96
Uses and Outcomes
UsesCongestive Heart FailureCOPDDiabetesCancerAsthmaHigh risk pregnancyHospiceMental HealthPost surgical
OutcomesImprove access to careIncreases quality of lifeEarly detection/interventionCost effective
• Decreases ED visits• Decreases hospital
readmissionsPatient empowermentPatient satisfaction
Outcomes of the Kaiser Permanente TeleHomecare Project
OBJECTIVETo evaluate the quality, use, patient satisfaction, and cost savings from the use of remote video technology
PARTICIPANTSCongestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care
INTERVENTIONControl groups: home visits and telephone contactIntervention group: + consultation using remote video system
Reimbursement system
Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000
Became effective Oct. 1, 2001 Eliminate important limitations to TeleHealth reimbursement, mandated under the Balanced Budget Act of 1997
Fee-sharing requirementsExpands eligible geographic areas, services, and types of presenters
Reimbursement system
Fee sharing: EliminationBBA: A distant specialist split his/her fee with the referring siteNew Law: Originating site($20), specialist (full payment)
Eligible Presenters : At the originating siteEliminates the requirement that a physician or eligible practitioner must present a patient
Eligible Geographic areas: Expansion From the designated health professional shortage areas To a county not included in a Metropolitan Statistical Area
Reimbursement system
Eligible Services: ExpansionThe listed specific CPT codes that are to be eligible Included codes are professional consultations, office visits, and office psychiatry
Store-and-Forward Interactive Consult (BBA)Demonstration projects in Hawaii and Alaska will be eligible for reimbursement
Telehomecare Health ServicesHome health agencies may adopt TeleHealth technologies but these technologies will neither be recognized nor reimbursed Home health agencies can spend prospective payment dollars on TeleHealth
Other Third Party Payer PoliciesMedicaid
20 states’ programs cover telemedicine servicesArkansas, California, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Montana, Nebraska, North Carolina, North Dakota, Oklahoma, South Dakota, Texas, Utah, Virginia, and West Virginia
Coverage: idiosyncraticsome states only covering teleradiology, while others cover the full range of services.
Private Health insuranceThree States prohibit insurers from discriminating between regular medical and telemedicine servicesBlue Cross/Blue Shield provided at least some telemedicine coverage in 11 of the states
Issues: Reimbursement system
TelemedicineGeographic Location: Urban underserved areas are not eligible for Medicare telemedicine payments Services: Exclude speech, physical, and occupational therapy and nutritional counseling from coverageSettings: Nursing homes are not eligible for payment
TeleHomecareLack of incentive: Savings from reduced hospitalizations accrue to the payers, not the home health agencyProductivity gains for home health agencies outweigh the investment required for agencies such as process changes and staff training
Characteristics of Ideal TeleHomecare System
ATA Technology SIG White Paper (2000)Modularity: “Plug-and-Play”Intuitive interface Based on standardIntegrated w/ EMR: Distributed: geographically independent access to patient information Bandwidth independent: store-and-forwardSecure: security, safety
Key Technologies for Smart TeleHomecare
Distributed Computing:Frameworks for interoperability and plug-and-play devices,Standards for terminology and device interaction, andHome-based networks that allow distributed medical devices to function as virtual systems.
Intelligent Processing:Knowledge assimilation algorithms that collate data from separate devices into care decision matrices,Artificial intelligence, neural network, and fuzzy logic algorithms for making care decisions,Information reduction technology for avoiding physician and patient information overload, and
Information Surety:Authentication and access control: biometric algorithmsOwner-aware sensors,Surety mechanisms for protecting data integrity and reliability
Key Technologies for Smart TeleHomecare
Devices and Sensors:Wearable devices: non-invasive, self-calibrating, and low-power sensors,Body LANs that use low-power telemetry to unite data from autonomous sensors worn on the body, and Processing algorithms that filter data prior to storage and transmission.
EPR and Data Repositories:Distributed EPR repositories and knowledge databases that can besecurely accessed, andTemporary EPR and knowledge databases that reside in the home.
Standards:information architectures, security, plug-and-play hardware, communication, messaging, storage, nomenclature, diagnostic protocols and procedures, and device descriptions.
Telemedicine Reference Architecture (TRA)
Telemedicine Reference Architecture (TRA) Object-oriented device architecture for secure, plug-and-play telemedicineused to build prototypical hardware and software
Key idea The interfaces between components are standardized The mechanisms needed to support plug-and-play and distributed operation are built into system elementsPossible to create a range of telemedicine devices from a common set of building blocks.
Seven Service Areas of TRAUser Interface Medical Devices Patient Records
application-level interfaces for storing and retrieving patient-encounter data
Communications Service Area communication with other devices and the services
Protocols Service Area The programs or scripts accomplish specific medical objectives E.g.> measure BP, store the reading, and tell the user interface to display the reading
Backplane mechanisms that tie the other six areas togetherincludes the "middleware" (e.g. CORBA, DCOM, RMI)
Seven Service Areas of TRA
Patients Record Server
Personal Status Monitor
Patients Station
Smart Home
“Wires” houses and automates certain routine functions of daily livingAll appliances can be redesigned
To improve the quality of life To Reduce the healthcare threats
Falls and accidentsExposure to pathogens and allergens
Not yet embraced the provision of health services
Smart Home for TeleHomecare
Current Features Thermostat, humidifierFloor sensor/alarms to prevent fallsAudio/video reminders for medicationsBlankets that alerts patients/caregiver about wound care needsRefrigerators for food ordering and expiration date reminders
Future Examples“Wearable research”: bio-monitors in clothing and jewelry that gather personal details on the wearers' body chemistry
Future Home Layout
Home LAN
Fully Distributed Network of Healthcare Information Resources
*T/R
*T/R: Transmitter/Receiver
LivingRoom
Patient vital signs monitor with wrist display
Air-born agent sensor
Flexible Communications
Electronic medical
records and knowledge database
Health education, diagnosis and treatment
Set-top box
Television
Electronic Patient Record
Repositories
Data ProcessingAlgorithms
High-Performance Computers
KnowledgeDatabases
RF Link
T/R
Hospitals T/R
Web Resources
TIE (Telemedicine Information Exchange)http://tie.telemed.org/
ATA (American Telemedicine Association)maybe useful for the members
OAT (Office of Advanced Technology)http://www.telehealth.hrsa.gov
Sandia http://www.sandia.gov/CIS/6200/Telemedicine/
E-disease management
Significance & NeedsPatients with chronic diseases
account for a great portion of mortality, healthcare utilization, and costs in the United States (Bringewatt, 1998).
70% of healthcare costs 80% of mortality.
Needs Most consumers lack the information needed to effectively managetheir chronic conditions. During the physician office visit, over two-thirds of patients did not receive information about medications or their conditions (Cyberatlas, 1999). Lack of information would
adversely affects ability and motivation of patients on self-managementresult in poor compliance
DefinitionsDisease management
“A set of coordinated healthcare interventions and communicationsfor populations with conditions in which patient self-care efforts are significant (Disease Management Association of America, 2003)." target groups of disease management
Diabetes, congestive heart failure, asthma, HIV, and cancer patients.
E-disease management system Internet based disease management systemCentral component: Improving the self-management
through connecting patients with caregivers, information, and decision-support systems using the internet technology (Demeris and Eysenbach, 2001).
PurposeNot to replace traditional disease management, but to enhance it using internet technology
E-healthRelationship between Telemedicine, E-disease management, E-health
E-disease Management
Telemedicine
E-Health
Traditional Healthcare Services
Web-based Healthcare Service
E-disease management vs. Telemedicine
E-disease Management Telemedicine
Medical Profession-focusedTechnology-orientedStandalone Service
Consumer-focusedService-orientedIntegrated with Traditional Healthcare Services
Potentials
Improve chronic disease management through the provision of essential functionalities:
providing ease and accuracy of data entryenhancing communication between patients and their caregiversensuring access to relevant informationdelivering decision support for both patients and caregivers
Potential Benefits of E-disease Management
Potential Benefits Components of Disease Management
Ease and accuracy of data entry to aid patient monitoring
Patient risk screeningPopulation screening
Improved patient communication with care givers
Team-base careAlternate encounter
Improved patients’ access to disease-specific information
Patient empowermentOutreach/case management
Improved access to patient tracking and decision-support tools at the point-of-care
Support of guideline/protocolDecision support at the point of care,
Empirical EvidencePacifiCare Health Systems and Health Hero Network, Inc: CHF
A small and inexpensive device called the Health BuddyCollect information regarding their weight, medication compliance, clinical symptoms, and functional indictors each morningReduced half of admissions and 73 percent of emergency room visits, and resulted in an average savings per patient of $5,271 and a 200 percent return on investment for PacifiCare.
Highmark Blue Cross Blue Shield and CorSolutions, Inc.CHF patients using the application so called Cardiac SolutionsA nurse was assigned to each enrolled patient in order to facilitate a strong interpersonal relationship. After a six-month pilot program
1) hospital admissions declined by 60 percent2) 58 percent of patients were taking their medications at an optimal level3) satisfaction rates with the program were very high among physicians (75%) and members (90%).
CIGNA HealthCare and American Healthways, Inc. (1997)disease management program for its 87,000 members with diabetesintegrate CIGNA’s systems with American Healthways’ diabetes management applicationIn 1998, hospital admissions were reduced by 6 percent.
Tufts Managed Care Review, 2001
ModelsExtended model:
integrated with pre-existing disease management servicesenhance current disease-management systems through the addition of new functionalities
Standalone model subscription-based program establish self-containing service systems
Models & ViabilityViability:
to successfully enroll patients, their physicians must first be motivatedphysician referral is the most significant factor for patient participation
Revenue-generation model independent from the healthcare reimbursement contract between the E-disease management system and a healthcare organization Patients with chronic disease are less likely to pay the subscription fee additional benefit: not great
overlapped with traditional healthcare services or disease-management servicesHealthcare organizations are not likely to buy financial impact of E-disease management services is hard to measure, especially in short-term scale.
Clinical Appropriateness Recommendations of E-disease Mx
Information on self-management and patient education and management recommendations for physiciansKnowledgebase of the recommendations should be valid and maintained to have consistency with up to date medical knowledge(LeGrow, 2001).
Local adaptation of the knowledgebaseavailability of services
e.g. a system recommends a CT scan, but CT scan is not available to the hospital
preference in disease management policiesdesignated clinical review committee responsible for
examination of the clinical validity local adaptability of knowledgebase and recommendations
Evidence on Cost-effectiveness
Only few empirical studies Performance of E-disease management
Few small scale studiesCost-effectiveness
To persuade policy makers, payers, and healthcare organizations and professionals to adopt E-disease management
Key factors of success and failure
Reimbursement
UsabilityUsability
The most important factor affecting the success of projectsFrequently ignored by designers and evaluators
Important usability considerations ease of use
Chronic patients: usually old and unfamiliar with ITSimple to use, minimum training required
considerations on functional limitations of usersReduced sensory, cognitive or motor capability (Telecommunications Industry Association, 2003).
Example Well@Home and Health Buddy: allow users to input data without using a keyboard.
Privacy and ConfidentialityUbiquitous issue in the health care sector
Health Insurance Portability and Accountability Act (HIPAA)
Security measures to meet the requirements of HIPAA (LeGrow, 2001)
Communication between patients and their caregivers (occurring) behind the firewall of the applicationAdoption of username and password systemTracking (system) for all edits, look-ups, and usage of patients’informationPoint-to-point security, such as a network encryption method
E-health care systems can attract patients only when they ensure patient privacy and confidentiality.
Patient and Provider Acceptance
Diffusion of an innovation depends on Attitudes of users
Potential impacts should be carefully examined to facilitate the acceptance of users: patients, caregivers, family members, providersto avoid potential resistance and conflicts among usersregarding their financial, socio-cultural, and legal aspectsExample
need to guarantee 24-hour accessibility to the system's help desk and a reasonable response time.
How to facilitate widespread adoption of E-disease management
1) the system should be integrated with traditional disease management services for better performance and viability
2) clinical appropriateness of knowledgebase should be ensured
3) financial incentives for E-disease management services should be built into the healthcare reimbursement systems
4) Technology employed in E-disease management should be user-friendly for their potential users with functional disadvantages
5) Appropriate security measures should be in place to protect privacy and confidentiality of patients
6) Potential impacts of the E-disease management system should be carefully examined, and the system designed to minimize users’ resistance and enhance acceptability.
Information Security &Public Key InfrastructureDr. Paul J. Hu
Accounting and Information Systems University of Utah
January 16, 2003
Sample Online Transactions
Confidentiality/Privacy: Information sent is not
intercepted and read by an unauthorized third party
Authentication and data integrity: Kate is in fact the sender of the order; and the
message has not been altered during transmission
Message & Credit Card Information
Kate Air FluffSend one pound of pop corn
Information Security: Example
Bob’s messageTo Alice: “Will
You marry me?”Hash
Message Digest ofBob’s Message
EncryptMessage
Text
EncryptMessageDigest
Send Both to Alice
Information Security: Example
New MessageDigest Derived
from Bob’s Message
HashBob’s
Message
Receive Bob’sMessage and
Message digest
DecryptBob’s
MessageDigest
DecryptBob’s
Message
MessageDigest asReceivedfrom Bob
Compare
“Will you murderMe?”
Not From Bob?
Message DigestsNot the Same!!+
IS: Fundamental Requirements
Confidentiality: Information is revealed only to the intended receiver, not to unauthorized partiesIntegrity or data integrity: The intended receiver can verify whether a message has been modified (altered) during transmissionAuthentication: The intended receiver can verify the origin of a message (i.e., identity of the sender)Non-repudiation: The intended receiver can prevent a message sender from falsely denying sending the message at a later timeAvailability and legitimate use: Specified users and their legitimate access to or use of information must be provided and preserved
Non-Electronic Security Mechanism
Notarized signatureCertified or registered mail
Non-repudiation
Indelible inkHologram on credit card
Integrity
Sealed letterOpaque envelopeInvisible ink
Confidentiality
Locks and keysMaster key systemCheckpoint guard
Access Control
Photo identification card Knowledge of mother’s maiden name
Authentication
Non-Electronic Mechanism ExamplesSecurity Service
Internet Security Issues
User name and password or other kind of access control mechanisms
Digital certificatesand other technologies used to authenticate identity
Digital signature
SolutionDoes a user have permission to access a specific computer or collection of information?
Is the user truly who he or she purports to be?
Did the person sending a message actually send it? Can receiver be sure that the message has not been changed?
Authorization
Authentication
Integrity
Business ConcernProblem
Internet Security Issues
Public-private key encryption algorithms
Log, audit, systems management policies and procedures
Firewalls
Solution
Is my conversation (or business transaction) private? Is anyone eavesdropping or spying?
Is anyone stealing from me?
Can someone enter my internal information systems and/or networks and access private information or destroy/alter information?
Business Concern
Privacy
Fraud/theft
Sabotage
Problem
A General Process
Plaintext Ciphertext Plaintext
Encryption Decryption
Classification of Cryptography
Symmetric or Secret-key technologySubstitutionTranspositionSubstitution + Transposition (e.g., DES)Character stuffingOthers
Asymmetric, public-key or dual-key technology (e.g., RSA, DSA, PGP, etc.)Symmetric + asymmetric (e.g., digital envelop)
Symmetric Technology
Key
Plaintext PlaintextEncrypt Decrypt
System A System B
Common Symmetric Algorithms
Algorithm Key Size (bits) Block Size (bits) Example Applications
DES 56 64 Kerberos, PEM, SNMPv2Triple DES 112 64 PEMIDEA 128 64 PGP
SKIJACK 80 64 Clipper
DES = Data Encryption StandardIDEA = International Data Encryption AlgorithmPEM = Privacy Enhanced MailSNMPv2 = Simple Network Management Protocol, version 2PGP = Pretty Good Privacy
Symmetric Technology: Substitution
Simple mono-alphabetical substitution: Each character in P is replaced by a corresponding character in C (e.g., Caesar Cipher and ROT 13)Simple mono-code substitution: Each character in P is replaced by a group of characters (code) in C Homophonic substitution: Each character in P is replaced by one of several pre-determined characters in CPolygram substitution: Each group of characters in P is replaced by a corresponding group in C Poly-alphabetical substitution: P is encrypted with several simple mono-alphabetical substitution
Symmetric Cryptography
Symmetric cryptography has been widely used since early 1970sSymmetric techniques involves one and only one key; that is, the same key is used for encryption and decryptionThe key is kept secret from everybody except the sender and intended receiver(s)A symmetric algorithm may operate as a block cipher (e.g., 64-bit) or stream cipher
Analysis of Symmetric Technology
Strengths: Relatively low processing costs, as measured
by processing time and computing resource requirements Straight-forward key management
WeaknessesDifficulty in key distributionDoes not support spontaneous transactionsPotential use of multiple keys and needs for
frequent key changes
Key size (bits) Number ofAlternative Keys
Time Required at 1Encryption/µs
Time Required at 106
Encryptions/µs
232 = 4.3 ´ 109 231
Exhaustive Key Search:Average Time Requirements
32 µs = 35.8 minutes 2.15 milliseconds
56 256 = 7.2 ´ 1016
2128 = 3.4 ´ 1038
255
2127 µs = 5.4 ´ 1024 years
µs = 1,142 years 10.01 hours
128 5.4 ´ 1018 years
Asymmetric Cryptography
Use a key pair (i.e., public key and private key): one for encryption and the other for decryptionOne key is kept secret (i.e., private key) and the other key (i.e., public key) can be placed in the public domain One key offsets the other keyGiven one key, cannot derive the other keyFundamental assumption: The key owner is the ONLY person has access to the private key
Public-key Cryptography:Essential Foundations
Two fundamental theorems: 1. Given one key, we cannot derive the other key2. One key cancels the other key; thus, we can
use one key for encryption and use the other for decryption that is, Public (Private (P)) = P, and
Private (Public (P)) = P
PGP Encryption: Plaintext
PGP Encryption: Ciphertext
Digital Signature
A digital signature is a data entity derived from a message and often is transmitted together the message, plain or encryptedA digital signature can be used to
Ascertain message (data) integrity, data origin (sender’s) authentication, or bothProvide non-repudiation services
Require a “sign” operation at the sending end and a “verify” operation on the receiving end
Digital Signature: Sign and Verify
Plaintext
Sign
Sender’s Private Key
Signature
Verify
Sender’s Public Key
Plaintext
Originator Transmitted Message Recipient
Digital Signatures
Message
Digitally sign the message
using sender’sprivate key
+
Recipient UsesSender’s Public
Key to Decrypt or Verify the Digital
Signature
Sender’sPublic Key
Digital Signature
Message+ RecipientSender’s
Private Key
Message
Sent by John
Digital Signature with Hash FunctionsOriginator
Message
Encrypt
Signature
Sender’sPrivate
Key
Digest
Hash Function Message
Signature
Message
Decrypt
Expected Digest
Sender’s Public
KeyActual Digest
Hash Function
TransmittedMessage
Recipient
If these are the same, the signature is then verified
Public Key Infrastructure (PKI)A method of encryption and authentication that uses keys to convert encrypted information into a readable format plus identify the author
Uses a string of numbers (keys) to encrypt documents to protect against unauthorized access and decrypts for authorized users
A 3rd party (a certificate authority) manages the creation and use of key pairs and digital certificates for each user.Digital certificate : public key and a private key
Public key is used to code document.Private key is used to decrypt and must be kept secure.
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