2013 remote@e telemed

Real-time telemedicine in paediatric cardiology

Riccardo Triunfo, Francesca Frexia, Francesco Cabras, Carlo Buttu, Valeria Lecca, Stefano Gessa, Sabrina Montis and Roberto Tumbarello

eTELEMED 2013 The Fifth International Conference on eHealth, Telemedicine, and Social Medicine

February 24 - March 1, 2013 - Nice, France

CRS4

HEALTHCARE FLOWS GROUP

REAL-TIME TELEMEDICINE APPLICATION

AGENDA

CRS4

CRS4: CENTER FOR RESEARCH, DEVELOPMENT AND ADVANCED STUDIES IN SARDINIA

‣ Interdisciplinary research center focused on computational sciences

‣ Located in the POLARIS Science and Technology Park (Pula, Sardinia, Italy)

‣ Operational since 1992

‣ Scientific/industrial research, technological development and higher education

‣ RTD staff of ~170 people

CRS4

STRENGHTS AND FOCUS

‣ Key strengths: ‣ Infrastructure ‣ Research and development in enabling technologies ‣ Direct experience in the application context

‣ Primary focus is on

‣ Energy & Environmental sciences ‣ Information society ‣ Biomedical sciences

‣ International and national collaboration ‣ PON, EU FP7, Wellcome Trust, NIH, APL, …

‣ Technology transfer toward industry and regional structures

‣ ENI, INPECO, IBM, NICE, GEXCEL,…

CRS4



AGENDA


‣ Part of Data Fusion Sector

‣ More than ten year experience in research and development in ICT application for clinical practice, medicine and biology

‣ State of the art solutions to real medical needs ‣ Collaborations/direct involvments:

‣ Hospitals ‣ Enterprises ‣ IHE ‣ HL7 international ‣ OpenEHR consortium ‣ OME consortium


Semantic and computable management of biomedical data

Clinical domain interconnection and traceability

Telemedicine and distributed medicine


MAIN RESEARCH TOPICS

CLINICAL DOMAIN INTERCONNECTION AND TRACEABILITY

‣ Hospital Information System has to communicate with many systems (LIS, RIS, CIS,…), different for structure and acquisition: connection one-to-one create a complexity scaling with the square on the systems’ number

‣ Precise control on information improves quality and security for the patients

‣ We design different paradigms, for moving from “information island” to smarter interconnection models, adopting international standards and guidelines like HL7 and IHE (eg: HL7 gateway, based on Mirth, working since 2009 in the biggest Sardinian hospital)


SEMANTIC AND COMPUTABLE MANAGEMENT OF BIOMEDICAL DATA

‣ The amount of data and information nowadays available is increasing at an high rate, making essential a robust data modeling

‣ Working on large volumes of data is intrinsically different than working on small datasets, standard computational tools will break

‣ Needs of semantic computable data models, robust in time and suitable for different kind of users (fomalism like openEHR, CDA,…)

‣ We study and realize data models to represent and manage biomedical data (eg: model for managing genetic data from a NIH large scale population study)


TELEMEDICINE

‣ Recognized at international and national level as an important tool to obtain: ‣ Services of better quality and wellbeing for patients (home is where you’re cared for) ‣ Cost reduction, new care models ‣ Positive contribution to industrial sector

‣ A big part of telemedicine projects is not able to evolve from pilot studies to tools used in real clinical contexts

‣ In Europe ‣ Telemedicine is a key point of European Digital Agenda for e-health, one of the 7 flagship

‣ In Italy ‣ eGov 2012, telemedicine is among the prioritary sector with booking centers, HER and e-prescription


TELEMEDICINE

‣ E-Health situation in Sardinia Region ‣ 1.6 Milion people, 11 Public Health structures ‣  Hub&spoke model promoted ‣  Considerable investments (network, infrastructures) for the creation of a regional HIS

Project name Investment Areas

SISaR 25M€ ADT, Scheduler, Emergency, Order Entry, Blood Banks, Pharmacy, Operating Theatres

MEDIR 10M€

GP and paediatrician network, EHT

SILUS 1.5M€ Laboratory

RTP 1.1M€ Cancer registry and teleconsultation

ANAGS 1.3M€ Federated Demographics DB

RTR NA Optical Fiber Networks


CRS4



AGENDA

REMOTE PROJECT RESOURCES AND ORGANIZATIONAL MODELS IN

TELE-ECHOCARDIOGRAPHY

REMOTE PROJECT

‣  The project , partially funded by Sardinian Region, proposes a model to enable access to specialized care in remote areas using real-time telemedicine and low cost and open technologies

‣ The clinical focus in on operator dependent diagnostic methodologies, whose results may not be revealing when the exam is not performed by a specialist

‣  Congenital heart diseases (CHDs) are the most common congenital disorders affecting 6 to 13 ‰ live-born infants and can be detected by echocardiography ‣  The diagnosis is complex, strongly operator dependent: even a expert cardiologist can’t perform this kind of examination, if not specifically trained

‣  Barriers rise to the access of specific exams, particularly in sparsely populated areas because of a lack of physician with a specific skill in the pathology

‣  In Sardinia there is a high incidence (double of international frequency), but only a tertiary center, Brotzu Hospital, with specialized expertise in the Paediatric Cardiology Structure directed by Dr. Roberto Tumbarello

CASE STUDY: PAEDIATRIC CARDIOLOGY

REMOTE PROJECT

‣ Issue: high incidence of congenital hearth diseases ‣ Resolution: virtual presence of specialists through telemedicine applications

‣ Issue: operator dependent exam ‣ Resolution: direct interactions between the operator and the specialist (real-time voice and video chats) enables correct exam execution.

‣ Issue: lack of specialists and devices in secondary healthcare structures ‣ Resolution: the system allows better logistics, concentrating specialists in tertiary hospitals, reducing shifts and reusing ultrasound devices heterogeneity and age (only a video output is needed)

‣ Issue: low investments in remote districts ‣ Resolution: COTS low cost devices and open source software.

MAIN ISSUES/RESOLUTIONS

REMOTE PROJECT

‣ The main objectives are:

‣ enable real-time consultations with direct interaction between clinicians involved

‣ reuse any diagnostic devices available in remote districts

‣ restrain the costs of additional material/software required

‣ lower the learning curve for the secondary care doctors

‣ facilitate teaching sessions via video conferences with many participants

OBJECTIVES

REMOTE PROJECT

STARTING FROM THE END

REMOTE PROJECT

Scheduling

BASIC FLOW

REMOTE PROJECT

Real-time teleconsultation

Reporting

SCHEDULING

‣ Routine ‣ scheduling system consistent with Sardinian regional scheduling system

‣ Emergency ‣ Access to consultation during availability periods ‣ Emergency calls always available

REMOTE PROJECT

TELECONSULTATION START

‣ The specialist plans the teleconsultation with the requiring physician (via system scheduling or by phone for emergencies) ‣ The requiring physician starts teleconsultation in 3 simple steps (authentication, request and start) ‣ At this point only the specialist response is needed

REMOTE PROJECT

WAITING FOR THE SPECIALIST

‣ The specialist starts the system in his/her laptop ‣ The specialist accepts teleconsultation in 3 simple steps (authentication, request accepted and start)

REMOTE PROJECT

PROJECTION REQUEST ECHO PARAMETER CORRECTION PROBE POSITION CORRECTION SCREENSHOT ACQUISITION AUDIO FROM A CANALE DOPPLER

DURING TELECONSULTATION

‣ The physicians are connected by a audio/video channel ‣ The specialist can see in real time the echograph output and the examination scene recorded by a camera, and can guide who is performing the diagnostic test

REMOTE PROJECT

DEMOGRAPHIC DATA ANAMNESIS PREVIOUS EXAMINATIONS(ECG, etc) STRUCTURED REPORT ECHOCARDIOGRAPHY

AFTER TELECONSULTATION

‣ The specialist prepares the report for the examination ‣ A structured report is used, to obtain uniformity and to automatically analyze the data ‣ The report can be exported in the most common formats (CDA included) and integrated in Sardinian Region Ambulatory Care system

REMOTE PROJECT

COMPLETE WORKFLOW

REMOTE PROJECT

ARCHITECTURE

GLOBAL VISION

ARCHITECTURE

CLINICAL UNITS

ARCHITECTURE

REQUIRING UNIT – BASE STATION

ARCHITECTURE

SPECIALISTIC UNIT – CONTROL STATION

ARCHITECTURE

CENTRAL CORE – DATA HUB

ARCHITECTURE

CONNECTIONS

ARCHITECTURE

TECHNOLOGY HIGHLIGHTS

‣ Main hardware and software technologies are state of the art but stable (eg. Voip, streaming protocols,…) ‣ Central role of COTS technologies and opensource software ‣ Easy porting to different architecture ‣ Attention to system scalability

OSX Windows Linux Android IOS

LANGUAGE PYTHON PYTHON PYTHON JAVA OBJECTIVE-C

AUTH OAUTH OAUTH OAUTH OAUTH OAUTH

API QT QT QT native native

GUI QT QT QT native native

VOIP PJSIP PJSIP PJSIP PJSIP PJSIP

AV GSTREAMER GSTREAMER GSTREAMER native native

BANDA INTERNET DATA HUB

APPLICATION SERVER VOIP HARDWARE

DECENTRALIZZAZIONE VOIP

STREAMINGS AND CONNECTIONS

‣ All the connections are encrypted via VPN channels ‣ 3 authentication levels (application, device, users) via standard streamline (OAUTH) ‣ User profiling, also according to the operational unit ‣ Secure https connection (via CA and certificates for single devices)

‣ Standard protocols used for streaming (MPEG4/H264 over RTP) ‣ SIP protocol for VOIP channel routing ‣ Audio/video transmission optimized to maintain synchronicity and low latency ‣ Controlled maximum bandwidth required for each single consultation (2.5 Mbps )

IN OUT

BASE STATION 500 kbps 2.5 Mbps

CONTROL STATION 2.5 Mbps 500 kbps

DATA HUB 500 kbps 500 kbps

TECHNOLOGY

EXPERIMENTATION

‣ The system was tested on 42 patients, performing the examination both in the traditional way and via teleconsultation

‣ The experimentation involved two specialist in Paediatric Cardiology, working directly or remotely according to an established rotation

‣ The protocol included specific steps and a pre-defined set of projection

‣ The structured report was fundamental to obtain comparable results

‣ The results for the global diagnosis were good, showing a complete match between the two diagnosis in the 97,6% of the cases

‣ The results obtained comparing the single voices of the report are satisfying and will be sent by the clinicians to American Hearth Association Congress

CLINICAL TRIAL

RESULTS

‣ Valid and appreciated teleconsultation system, low cost and opensource

‣ Application for consultation management and structured reporting

‣ Connection models dedicated to the different needs of the clinical units, with

heterogeneous diagnostic devices

‣ Organizational models for the clinical unit cooperation

‣ Opportunity for patient/clinician stress reduction and efficiency

‣ Successful clinical experimentation

‣ Streaming one-to-many for educational purposes

REMOTE PROJECT

FUTURE DEVELOPMENTS

‣  Continuation of the research activities, to obtain real mobility and new interaction paradigms based on virtual reality

‣ Application in other clinical contexts with operator dependent diagnostic methods (FAST examination, haemodynamics,…) ‣ Connection of other centers, in Sardinia and in the rest of Italy (interest from Bologna, Trieste and Genoa)

‣ Software refactoring and release under opensource licence

‣ Industrialization and diffusion

REMOTE PROJECT

CONCLUSIONS

‣ Technology is very important but must be an instrument

‣  User-inspired and user-driven approach

‣  Bottom-up development, but with a general point of view

‣  Attention to international standard and guidelines

‣  Attention to interoperability with existing systems

‣  Double perspective, research and real life experience

REMOTE PROJECT

CONTACTS

MORE INFORMATION

‣ Web sites

‣ www.telecap.it

‣ www.crs4.it

‣  e-mail addresses

‣ riccardo [email protected]

‣ [email protected]

‣ [email protected]

‣ 

THANKS TO

ACKNOWLEDGMENTS

QUESTION&ANSWER

THANKS TO ALL OF YOU FOR THE ATTENTION!

Documents

2013 remote@e telemed