Technology Needs In Telemedicine

Rick CraftLead, Telemedicine Reference Architecture Project

Principal Member of the Technical StaffSandia National Labsrlcraft@sandia.gov

505-844-8873

Telemedicine’s Past and Immediate Future

First Wave Second Wave Third Wave

Timeframe

Emphasis

Scope

Nature

60’s-70’sEarly 90’sto present

Comingdecade

FeasibilityClinical

DevelopmentIndustrialization

Very limitedFringe

populationsMainstream

Care Delivery

Video links + Instrumentation + Informatics

Telemedicine is still young and evolving. Maturing it fully will require Telemedicine is still young and evolving. Maturing it fully will require visionvision and deliberate and deliberate attention to the technical foundationsattention to the technical foundations on which it rests. on which it rests.

Telemedicine Is About More Than Distance

Control

Status

ClinicalData

Stimuli

Observables

ClinicalDevice

Assessment

Plan

DoctorPatient

TraditionalEncounter

Control Status

ClinicalData

Stimuli

ObservablesPatientStation Clinical

Data

DoctorStation

Assessment

PlanOrder

PatientDoctor

Aide

Teleconsultation

Stimuli

Observables

SmartPatientStation

Control

Status DoctorStationAssessment

Plan

Assessment

PatientDoctor

AutomatedAssessment

Telemedicine Technology State of Affairs

• Systems are too expensive to enable wide-spread diffusion• Systems from independent vendors do not interoperate• What can be done “over the wire” falls far short of what can be

done in face-to-face encounters• Most systems are sold as turnkey capabilities that are not easily

customized to meet end user-specific needs• Reliance on COTS devices designed for traditional clinical

environments limits range of settings in which systems can be used

This Way ToThis Way To““Anywhere, Anytime”Anywhere, Anytime”

Ubiquity Capability Affordability

Key Telemedicine Technology Needs

• Less expensive

• Usable in more places by broader range of people

• Rich set of clinical capabilities

• Integration with EHRs

A New GenerationOf Devices Interoperability

Mechanisms forKnowledge Diffusion

• Vendor neutral station-to-station

• Plug-and-play devices

• Dynamic federation of distributed components

• Self-configuring

• Self-calibrating

• Education and training for non-traditional actors

• Tech-embedded, process-specific decision aides

• Intelligent devices

• Standardized user interfaces to allow portability of skills

Addressing healthcare delivery from a Addressing healthcare delivery from a systems perspectivesystems perspective

Greatest Need

Improving Healthcare Delivery Is A Systems Problem

• Healthcare systems are complex• Their performance (cost,

access, outcomes, etc.) is affected by many factors– Delivery system organization– Business and clinical

processes– External policies and

financing– Geography and demography– Technology

• Small perturbations can yield big changes– Finding the good ones and

avoiding the bad can be challenging

People

Knowledge

Geography

Laws & Policies Payers

Business Processes

Facilities

Clinical Processes

Resources

Tools

Diseases/Conditions

It Must Involve Both Optimization And Transformation

ReengineeringReengineering

Systems Thinking

Systems Thinking

Transformation of Care Delivery

Op

tim

iza

tio

n o

f C

are

De

live

ry Current CareCurrent Care

Delivery SystemDelivery System

Current CareCurrent Care Delivery SystemDelivery System

RedesignedRedesignedCare DeliveryCare Delivery

SystemSystem

RedesignedRedesignedCare DeliveryCare Delivery

SystemSystem

Fully OptimizedFully OptimizedVersion ofVersion of

Current DeliveryCurrent DeliverySystemSystem

Fully OptimizedFully OptimizedVersion ofVersion of

Current DeliveryCurrent DeliverySystemSystem

Fully Optimized,Fully Optimized,Redesigned CareRedesigned Care

Delivery StructuresDelivery StructuresAnd ProcessesAnd Processes

Fully Optimized,Fully Optimized,Redesigned CareRedesigned Care

Delivery StructuresDelivery StructuresAnd ProcessesAnd Processes

Qu

alit

yQ

ual

ity

This sentiment is echoed in the recent IOM/NAE report on the role of engineering in healthcare

Optimization Approaches Have Their Limits

Ford’s Woodhaven Stamping PlantPerformance Status Assessment

Total Overhead

Total Product MNT

Inventory Reduction

Ergonomics

Productivity/Yield

Hit-to-Hit

Training

Safety

Organizational Dev.

Material Utilization

Quality Systems

0 1 2 3 4 5 6 7 8 9 10

Initial Condition = 0World Class Performance = 10 1st Survey (4/90) 2nd Survey (11/91)

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aa bb

cc

AA BB

DD CC

Using Up Slack AmongIndependent Variables

From Systems Thinkingby Jamshid Gharajedaghi

From Systems Thinkingby Jamshid Gharajedaghi

Why Is This Important?

Courtesy of Kaiser Research and HealthTech

Age Distribution of the US Population

Source: 2000 US Census

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

50,000,000

under 5

5 to 14

15 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 to 84

85 and overAge (in deciles)

Po

pu

lati

on

Age groups where care burden is

greatest

Age groups where care burden is

greatest

Current workforce shortages pose

difficulty with care burden at this

level

Current workforce shortages pose

difficulty with care burden at this

level

2.5X

Population shift will increase care burden

Population shift will increase care burden

Big problems at this level !!

Big problems at this level !!

We have four choices:We have four choices:• Reduce demandReduce demand• Raise premiums / taxesRaise premiums / taxes• Limit benefitsLimit benefits• Extract more valueExtract more value

Clinical Trials

Healthcare SystemModeling and Analysis Engineering &

Informatics R&D

Requirements/Specsfor new devices & other components

Devices and other components for

clinical evaluation

Newcare delivery

concepts

New productsto market

Education methodsto be evaluated

Healthcare Education

Researchfindings

Proposedregulatory &

financialapproaches

Policy & Finance

Development

Newcaredeliveryconcepts

New education

methods

New policy & finance

environment

Requirementsfor new drugs

The National Healthcare Delivery Sciences Program

Mission:Mission:• Identify high-payoff care Identify high-payoff care

delivery conceptsdelivery concepts• Develop resources needed to Develop resources needed to

implement these conceptsimplement these concepts• Promulgate supporting policiesPromulgate supporting policies

Vision:Vision:A “science of healthcare delivery” as A “science of healthcare delivery” as advanced as our science of medicineadvanced as our science of medicine

Final Thoughts

• The medical establishment is not currently equipped to address this final problem – A partnership between medicine, engineering, law,

business, economics, social sciences, and other disciplines is required

• No entity currently owns the problem– Not NIH, NSF, DoD, DOE, nor any private concerns

• This work could be “birthed” at the local level and then “raised” at the national– Workshops / pilot initiatives would help provide insights

needed to engender a national dialog• If successfully cultivated, healthcare delivery science

will necessarily drive industry