Colorado School of Public HealthGlobal Health Lecture Series

Wednesday, November 23, 2016

Francisco G. La Rosa, MDPathologist

Associate Professor, Department of Pathology, University of Colorado, Aurora Colorado 80045Francisco.LaRosa@ucdenver.edu

Past-President, “Asociación Iberoamericana de Telesalud y Telemedicina” (AITT)FLaRosa@teleiberoamerica.com

Honorary Professor, Universidad Nacional “Federico Villarreal” Lima, Peru

Colorado Coordinator Medical Missions to Peru (Christian Life Movement)medicalmissions.clmusa.org

"Telehealth and Telemedicine:A New Paradigm in Global Health"

Topics• United Nations Millennium Development Goals

• What is Information and Communications Technology (ICT)?

• The New Paradigm in Telecommunications

• The New Paradigm in Medicine

• The New Doctor-Patient Relationship

• What is Telehealth and Telemedicine? How do they work?

• Telehealth and Telemedicine Tools

• Types of Telemedicine

• Complexity of Telemedicine

• Development of an Operational Model: Rural Areas

• Real Problems of Telemedicine and Solutions

• Final Balance

• Our experience

United NationsMillennium Development Goals

What is Information Technology (IT)?

The term information technology was coined by the Harvard Business Review, in order to make a distinction between purpose-built machines designed to perform a limited scope of functions and general-purpose computing machines that could be programmed for various tasks.

Information technology (IT) is the use of any computers, storage, networking and other physical devices, infrastructure and processes to create, process, store, secure and exchange all forms of electronic data.

http://searchdatacenter.techtarget.com/definition/IT

Information and Communications Technology ICT?

ICT is an umbrella term that includes any communication device or application: radio, television, cellular phones, computer and network hardware and software, satellite systems and so on, as well as the various services and applications associated with them, such as videoconferencing and distance learning. ICTs are often spoken of in a particular context, such as ICTs in education, health care, or libraries. The term is somewhat more common outside of the United States.

http://searchcio.techtarget.com/definition/ICT-information-and-communications-technology-or-technologies

The New Paradigm in Telecommunications

The New Paradigm in Telecommunications

The New Paradigm in Medicine

We are also facing a new paradigm in the management of the Physician - Patient relationship, as a product of:

• Increase in the average life of the population• Shortage of medical staff and maldistribution• Lack of medical care in remote populations• Advances in technology• Demands for democratization of health care by

communities

The New Paradigm in Medicine

The New Paradigm in Medicine

Doctor Patient

The New Doctor – Patient Relationship

Information & CommunicationsTechnology

Information & CommunicationsTechnology

Doctor Patient

The New Doctor – Patient Relationship

What is Telehealth and Telemedicine?

Telehealth

- Long-distance medical care- Health education for patients and professionals- Public Health- Health administration- PREVENTION

“The use of Information and Communication Technology (ICT) to support health in remote

locations”

“The use of Information and Communication Technology (ICT) to support health in remote

locations”

Telemedicine

“The use of Information Technology to provide remote medical care”

“The use of Information Technology to provide remote medical care”

• A mother consults via Skype with her child's pediatrician

• A pregnant woman consults by telephone with her obstetrician

• A neurosurgeon practices remote surgery on the battlefield

• A medical teleconsultation from space

Examples of Telemedicine

Tele-ophthalmology

Dra. Giselle RicurInstituto Zaldivar

Argentina

Tele-radiologyAustralia

Tele-dermatology

Tele-cardiology

Tele-psychiatry

Tele-pediatrics

Tele-surgery

Ender's Game (film) 2103Da Vinci Robotic Surgery

Tele-nursing: The use of ICT in the provision of nursing services wherever a great physical distance exists between patient and nurses, or between nurses. It is part of telehealth and has many points of contact with other medical applications, such as tele-diagnosis, tele-consultations, tele-monitoring, etc.

Tele-nursing

• Appointments for telemedicine• Collects patient information• Assist doctors in teleconsultations• Virtual Triage• Prepare the patient for teleconsultations• Presents the patient in teleconsultations• Follows treatment protocols• Take the teleconsultation register• Guarantees the care of the equipment

HOW DO TELEHEALTH and TELEMEDICINE WORK?

Services are provided in three main ways:

1) Video-conferences and tele-robotic systems with real-time transmissions between health providers and patients (consultations and procedures), and between health providers and specialists (2nd opinions, inter-consultations and discussion of cases).

2) Remote patient monitoring, in which special electronic devices transmit patient health information to health care centers.

3) Store & forward: electronic transmissions of previously recorded data (i.e. videos, digital images) (teleradiology, telepathology, teledermatology, etc.) between patients and primary care providers and medical specialists.

Telehealth and Telemedicine Tools

• Internet • Email• FTP (File Transfer Protocol)• Remote Desktop• Instruments to capture

medical data• Teleconferences• Websites• Clouds

Origins of the Internet

INTERNET Speeds in the World

http://www.vox.com/a/internet-maps

INTERNET Speeds

INTERNET 2

Internet2 is a member-owned advanced technology community founded by the nation’s leading higher education institutions in 1996. It provides a collaborative environment where US research and education organizations can solve common technology challenges and develop innovative solutions in support of their educational, research and community service missions.

Internet2 operates the nation’s largest and fastest, coast-to-coast research and education network, with Internet2 Network Operations Center powered by Indiana University.

Internet 2 Speeds: 10 Gbps to 100 Gbps (1 Tbps)

Internet2 comprises:

• 317 U.S. institutions of higher education• 81 leading corporations• 64 affiliate and federal affiliate members• 43 regional and state education networks• More than 65 national research and education networking partners representing

over 100 countries

www.internet2.edu

INTERNET 2

http://www.internet2.edu/products-services/advanced-networking/

FTP

Instruments used to Capture Medical Information

Instruments of Capture of Medical Information

Teleconferences

Types of Telemedicine

PatientDoctor

Real Time (Synchronous)

Differed (Asynchronous)

Real Time (Synchronous) Requires wide band width (300 Kbps) One to one relationship (Medico / Patient) Higher cost Inefficient use of medical resources

Deferred (Asynchronous) Requires less bandwidth But efficient use of medical specialists Low cost Covers 80-90% of cases Does not cover emergencies

Types of Telemedicine

When the number of doctors and patients is low,The complexity is also low

PatientDoctor

Complexity?

Patients

Specialist doctors

But as the number of doctors and patients increases, the complexity grows exponentially

Complexity?

Patients

Triage Center(Nurse / Internist)

How to Manage Complexity?

Specialist doctors

• Redefine the operational model (structures, positions, roles, remunerations, relationships, etc.).

• Automatization of medical records

• Installing the right tools (applications - apps): scheduling and workflow management for teleconsultation.

• Installation of elements for data capture and clinical variables of the patient.

How to Manage Complexity?

DEVELOPMENT OF AN OPERATIONAL MODELFor Rural Areas

Asynchronous telemedicine, based on low-cost technologies, primarily aimed at rural areas of developing countries.

Based on the experience of several Latin American groups that have successfully applied in the last years models of telehealth and telemedicine in different rural areas in Venezuela, Ecuador, Peru and Bolivia.

LaptopPDA

Firewall

Web Server

Virtual Triage CenterSpecialist

Point of Consultation

Technical Infrastructure

Capture Devices

---------------------------------------- Specialists ----------------------------------------

Virtual Triage CenterGeneral Internist – Internal Medicine

Operative Model

Family PracticeFamily Practice Rural ClinicRural Clinic HospicesHospicesRural HospitalRural Hospital

• Dermatology• Traumatology • Internal Medicine• Neurology• Nephrology

• Dermatology• Traumatology • Internal Medicine• Neurology• Nephrology

• Infectious Diseases• Gynecology• Cardiology• Plastic Surgery

• Infectious Diseases• Gynecology• Cardiology• Plastic Surgery

• ENT• Pediatry• Hepatology• Odontology

• ENT• Pediatry• Hepatology• Odontology

• Ophthalmology• General Surgery• Gastroenterology• Pneumology• Rehabilitation

• Ophthalmology• General Surgery• Gastroenterology• Pneumology• Rehabilitation

• Deferred• Real TimeInternet

PATIENTSPATIENTS

• Deferred• Real TimeInternet

Problems of Telemedicine

The Real Problem in Telemedicine

• Technology represents only 10 to 20% of the total cost of implementing a telemedicine system:

Therefore, technology is not the problem

• Between 80 and 90% is related to people (organization, structure, training of qualified personnel, change management, process reengineering, continuous monitoring, etc.)

People are the real challenge

A high rate of failures in the implementation of telemedicine systems is mainly due to human factors:

• Recruitment• Resistance to change• The adaptation of the structures and processes of the organization

• Training Plan• Continuous monitoring• The rest is due to sustainability problems ($ $)

The Real Problem in Telemedicine

• CHANGE the PARADIGM: embrace telemedicine as routine• Set achievable goals• Define a correct implementation strategy• Select the ICT platform according to the needs• Define an owner or top manager• Establish a formal organization dedicated to the project• Select the right staff• Ensure project sustainability• Education, education, and more education ...

Telemedicine Solutions

• Adaptation to the new paradigm• Locate the right personnel• Connectivity and Broadband• Selection of a model adapted to the needs of

each medical service• Creating a Commitment for Telemedicine• Dynamic framework for new demands: not to

fear change

Telemedicine: Final Balance

Our Experience

TELEPATHOLOGY:

Practice of pathology at a distance by exchanging images and information through telecommunication, for diagnostic purposes, consultation, research or education.

Using a "Sony Handycam" HD video recorder with ad-hoc adapter (Martin Microscope) connected to TV-HD via HDMI

Uso of Cellular Phones

20x H & E section taken with Motorola RAZR cell phone

IF IgG 40x renal glomerulus taken with a cell phone "Motorola RAZR"

Scanning of histological slides - Aperio

Use of Digital SlidesIn Consultation and Teaching of Pathology

http://www.pathinformatics.com/spuc/archiveindex.html

Telemedicine in LatinAmerica

TelepathologyWorkshops

in Peru(1998)

Lima

Arequipa

First case of telepathology in Peru transmitted from Lima to Sterling, CO in 1998

Mobil Teleoncology

CUENCA

Ing. Carmen Lis Ugalde – BioinformaticsDr. Xavier León – Pathology ResidentDr. Jorge Ugalde – Head of the Pathology Service

Telepathology in Ecuador

Instituto del Cáncer SOLCACuenca, Ecuador

Mobile unit arriving to rural community

Interior ofMobil Unit

Examining Pap smears and sending images to the Central Laboratory in Cuenca

Central Laboratory in SOLCA Cuenca, EcuadorReceiving Papanicolaou Images from the Mobile Unit

Denver, Colorado USA

Cuenca, Ecuador

Teleconferences

Microscopic

Gross Examination

Founding Member Group of AITT ‐ Quito, February 11, 2011

1a. Jornada Iberoamericana de Telesalud y Telemedicina

Founding Member Group of AITT ‐ Quito, February 11, 2011

1a. Jornada Iberoamericana de Telesalud y Telemedicina

Grupo de Socios Fundadores de la AITT – Quito, 11 de Febrero 2011

www.teleiberoamerica.com

Asociación Iberoamericana de Telesalud y Telemedicina

Lima, Peru, October 16 – 18, 2014

I Congreso Iberoamericano de Telesalud y Telemedicina

I Congreso Iberoamericano de Telesalud y Telemedicina

Lima, Peru, October 16 – 18, 2014

revista.teleiberoamerica.com

revista.teleiberoamerica.com

http://revista.teleiberoamerica.com/numero-2/conferencias/videos/39.marciscano.html

http://revista.teleiberoamerica.com/numero-2/minisimposios/index.html

http://revista.teleiberoamerica.com/numero-2/minisimposios/14m.GonzalezRamosTeleoftalmologia.pdf

II Congreso Iberoamericano de Telesalud y Telemedicina

Sevilla, Spain, November 23 – 25, 2015

III Congreso Iberoamericano de Telesalud y Telemedicina

Bogota, Colombia ‐ October 4 – 6, 2017

www.Bogota2017.teleiberoamerica.com

Creation of Subsidiary Associations

ecuador.teleiberoamerica.com

peru.teleiberoamerica.com

colombia.teleiberoamerica.com

argentina.teleiberoamerica.com

www.seis.es

https://www.facebook.com/teleiberoamerica

https://twitter.com/AITTtelesalud

http://www.youtube.com/v/M4tXIgxCPZc

www.maniapure.org

Venezuela

Special Thanks

• Aníbal Carrera, Director General de Cronix, Quito, Ecuador• Dr. Marcial García Rojo, Telepatología, Hospital Jeréz de la Frontera,

España• Ivette Marciscano, RN, Tele-enfermería, Texas, EE.UU.• Dr. Mario Paredes, Consultor Telemedicina, Quito, Ecuador• Dr. Claudio Peláez, Consultor Telemedicina, Centro de Salud de

Olivenza, España• Giselle Ricur. Instituto Oftalmológico Zaldivar, Argentina• Dr. Tomás Sanabria y Ing. Morel Orta, Fundación Proyecto

Maniapure, Telesalud de Venezuela y TeleSalud International Inc.• Dr. Jorge Ugalde, SOLCA, Cuenca, Ecuador• Ing. Carmen Ugalde, SOLCA, Cuenca, Ecuador• Dr. Silvio Vega, Panama,

“Only a life lived for others is a life worthwhile”

“ Try not to become a man of success, but rather try to become a man of value ”

Albert Einstein