Secure Collaboration Technology for Rural Clinical Telemedicine

Funded by the National Library of Medicine

Principal Investigator: Dr. Ramana Reddy, Director, CERC
Co-Principal Investigator: Dr. V. "Juggy" Jagannathan, CERC

Technical Point of Contact: Ravi Raman

| Summary | Team | Technical Reports | NLM's 8 Oct. 1996 Press Release

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Project Summary

Telemedicine has captured the interest of the medical community, the government, and the public as a cost-effective means of improving access to quality healthcare. In rural areas, where specialized medical care may be unavailable, telemedicine can have an especially large impact on the quality and speed of patient care. But, while many people acknowledge the practical advantages of telemedicine, not everyone is at ease with the transmission of confidential patient data over electronic networks.

Addressing this concern, our team of computer system developers, medical practitioners and products companies, and other experts will utilize the cutting edge in data security to show that secure telemedicine is viable over public networks. In addition, we will show that its adoption as an integral part of an overall healthcare plan can result in cost savings and improved access to quality healthcare for rural populations.

Through a competitively-won contract from the National Library of Medicine (NLM), we will achieve our objectives through three primary tasks:

developing open, standards-based, secure, collaborative telemedicine services for use in customized telemedicine applications,
field testing these services in three representative, rural healthcare scenarios in which telemedicine shows great potential for reducing cost and improving access to quality healthcare, and
evaluating the effect of the services in a set of rural West Virginia healthcare facilities.

Additionally, we will develop the software components to be reusable and will make them widely available so vendors and healthcare organizations can create their own customized versions.

Issues

Working prototypes of numerous telemedicine systems already exist. While some of these systems show considerable promise, all are far from realizing their full potential until several fundamental barriers are overcome. In developing the next generation of telemedicine applications, we will address these barriers by:

assuring the security, privacy, and integrity of medical information stored in computers and during communication over public networks,
ensuring usability by seamlessly integrating telemedicine applications into the "workflow" of healthcare providers and into the enterprise's overall support system,
ensuring interoperability by providing a standards-based, open architecture to enable the creation of plug-and-play component-based solutions that can access information from legacy systems, and
demonstrating cost-effectiveness measures by ensuring scalability and migrating research prototypes into real-world operational environments.

Characteristics of the System's Architecture

For this project, we will develop a set of secure telemedicine services for use in customized applications for healthcare providers. Our goal is to develop mechanisms that can support a wide range of security policies and procedures and provide for a secure telemedicine healthcare framework.

Using the open systems approach and emphasizing the reuse of technologies already developed under previous projects as well as those available commercially, we are developing a Secure Collaborative Telemedicine Architecture (SCTA). The overall philosophy is best described as "plug-and-play."

To accomplish this, we will develop a telemedicine system "backplane" (a software system) into which a variety of modules can be "plugged," by embracing the object-oriented approach and using the industry standard protocol known as CORBA (Common Object Request Broker Architecture), which is presently supported by over 600 vendors world-wide. Our architecture will be flexible to accommodate other standards, such as Object Linking and Embedding (OLE) by Microsoft.

The backplane will provide as its core capabilities:

a security infrastructure that supports authentication and the secure transmission of private and confidential patient information, utilizing high-bandwidth communications and secure communications technologies (encryption, authentication, non-repudiation, certification authorities, and smart cards,
transparent and easy access to distributed patient information through a distributed virtual master patient index,
a secure workflow in the context of patient treatment, using common patient record models, and
a secure consultation service with voice, video, and shared applications for patient information and treatment.

Other services that we will plug into this backplane to provide custom support features to specific providers include:

real-time or near real-time access to information gathered by instruments monitoring a patient, and
seamless access to clinical decision support systems and on-line knowledge repositories, such as MedLine.

Application Scenarios

In order to successfully assess and evaluate the results of employing telemedicine, it is necessary that we demonstrate its utility in real-world scenarios. We therefore chose three application areas particularly suitable for the practice of clinical telemedicine. For each scenario, the clinical telemedicine tools and applications will be integrated and customized to meet the specific needs of the roles of healthcare providers at the pilot sites.

Remote access to Intensive Care Unit electronic patient data

We will demonstrate secure, collaborative telemedicine applications that will provide improved healthcare to patients at a hospital's Intensive Care Unit (ICU). Intensivists at a clinic will be able to confer with healthcare providers at a remote hospital's ICU in the treatment of their patients, as well as to remotely and securely review ICU patient information and monitor data from selected bedside devices.

Secure telemedicine for mid-level providers

We will demonstrate secure, collaborative telemedicine applications to improve the delivery of healthcare through mid-level providers, such as Physician Assistants (Pass) and Nurse Practitioners (NPs). These applications will include teleconferencing, electronic patient record, and computer-aided diagnosis and treatment support systems; and will utilize an intuitive graphics/mouse interface. Physicians will be able to supervise mid-level providers in remote rural clinics, review patient information, and approve diagnosis and treatment decisions. Mid-level providers will be able to employ a computer-aided diagnosis support facility to assist them in the diagnosis and treatment of their patients. The on-demand integration of selected portions of the patient's medical data with an up-to-date medical information knowledge base will reduce healthcare provider data entry without compromising patient confidentiality.

Secure telemedicine for home care patients

This telemedicine application will enable home care patients to access patient counseling information sources and will also allow near-time monitoring for patients with chronic ailments. For example, diabetic patients could provide periodic updates of their daily medical logs (blood sugar, weight, medication, well-being) and benefit from early intervention, such as changes in drug dosage, diet, or further check-ups. Home care patients with ready access to such information will be able to responsibly participate in the healthcare delivery process and its outcome.

Evaluations

Studies of the healthcare organizations, healthcare providers, and patients for each telemedicine scenario will provide insight into the effect of these secure telemedicine applications. Our evaluation effort consists of two components:

assessing the impact of secure collaborative telemedicine applications on cost, quality, and access to care. We will incorporate the recommendations from the National Research Council's Computer Science and Telecommunications Board into our risk assessment process, and
assessing the security, confidentiality, and integrity of electronic patient records. We will determine the "before and after" effects of the telemedicine applications.

Previous Technical Experience

Several of the team members previously collaborated to develop a multimedia patient record system, known as ARTEMIS, through separate funding by NLM and the Defense Advanced Research Projects Agency. ARTEMIS was the first application that enabled healthcare providers to access distributed clinical patient records over an intranet utilizing the World Wide Web. The system is currently undergoing field trials and evaluations at a set of VHS clinics and at Cabell Huntington and St. Mary's Hospitals. We will reuse the technologies developed for ARTEMIS during this project.

Telemedicine Team

Project Team | Advisory Board

Telemedicine Project Team

The Concurrent Engineering Research Center is an interdisciplinary research unit of West Virginia University. CERC's primary business is the research, development, and demonstration of computer and communication technologies to enable collaboration in different domains. Over the last eight years, CERC developed software technology for the Defense Advanced Research Projects Agency (DARPA) and has been applying collaboration technology in the medical informatics arena in the last three years under both DARPA and the National Library of Medicine's (NLM's) High Performance Computing and Communications (HPCC) Initiative. CERC developed the ARTEMIS multimedia patient record system.

Its director, Professor Ramana Reddy, is the Principal Investigator of this project and has managed over $50M in sponsored research from both the Federal Government and industry.

Associate Professor V. ("Juggy") Jagannathan, Co-Principal Investigator, is renowned for his work on object-oriented programming, and distributed artificial intelligence and, more recently, for his contribution to starting the CORBAMed special interest group to bring a standards based approach to healthcare information systems.
Valley Health Systems, Inc., is a private, non-profit corporation based in Huntington, West Virginia, that operates an integrated network of 15 community health centers and public health programs in southern West Virginia. It serves mainly rural or physician-short areas in seven counties in West Virginia as well as some counties in Ohio and Kentucky.

Three VHS clinics are connected via a frame-relay communications network, and are similarly connected to CERC and St. Mary's Hospital. VHS recently received a grant of $50K from the Bell Atlantic Corporation to improve its computing and counications infrastructure based on the success of the separately-funded ARTEMIS project, for which VHS is a field site. VHS is also a field site for this project.

One of the Co-Principal Investigators of this proposal, Bruce Merkin, M.D., is the former Medical Director of VHS and is now a rural, general, internal medicine specialist.

Another Co-Principal Investigator, Dr. Michael Kilkenny, M.D. is the Medical Director of VHS.
Cabell Huntington Hospital is a 300-bed tertiary care medical center with teaching and research affiliation with the Marshall University School of Medicine. Serving 29 counties in the tri-state area of southern West Virginia, Ohio, and Kentucky, CHH provides emergency and trauma services. Its health care providers are participating in the telemedicine application for intensive care providers.
St. Mary's Hospital is a not-for-profit, teaching hospital serving southern West Virginia, southeastern Ohio, and Kentucky. Health care providers at St. Mary's are participating in the telemedicine application for intensive care providers.
The Huntington Internal Medicine Group is a group practice of physicians associated with St. Mary's Hospital. An intensivist from this group will work with CERC in the development and testing of the intensivist scenario experiment.
The Marshall University School of Medicine, at one of the two major universities in West Virginia, emphasizes primary care and the training of medical students in rural areas of West Virginia. An intensivist from the school will work with CERC in the development and testing of the intensivist scenario application.
Alderson-Broaddus College is a four-year college with a nationally recognized program for training mid-level healthcare providers, and has targeted telemedicine as an important new area for emphasis. The Claude Worthington Benedum Foundation of Pittsburgh (a major regional charitable foundation) recently awarded Alderson-Broaddus $250K for five projects in the Physician's Assistant program, including telemedicine and distance learning. Alderson-Broadus will provide consultation in the design and testing of telemedicine applications for mid-level providers.
West Virginia Primary Care Association, Inc., represents the more than 70 non-profit community health centers in West Virginia. Their mission is to strengthen access to primary care through a network of health services, providing community awareness and identifying areas of unmet need. Home care providers will work with CERC researchers and VHS physicians to define and deploy the home care scenario application.
Wayne County Community Service Organization, Inc., operates and finances social and public welfare programs for the benefit of disadvantaged populations of Wayne County. Home care providers will work with CERC researchers and VHS physicians to define and deploy the home care scenario application.
Los Alamos National Laboratory is a US Department of Energy laboratory that is actively pursuing telemedicine. The goal of LANL's Telemed project is to develop an open standards-based radiology repository. LANL is assisting CERC in the development, customization and integration of diagnostic support services for the telemedicine application for mid-level providers.
Applied Medical Informatics, Inc., is a company specializing in customized expert systems and diagnosis and treatment decision support tools, such as Iliad, which is in use in many medical schools; and Medical HouseCall and Pediatric HouseCall, which provide information about disease symptoms, medical procedures, and drug interactions to healthcare consumers. AMI is the recipient of a $2 million grant from the National Institute of Standards and Technology to provide a medical knowledge server based on Iliad's expert system capabilities enabling real-time diagnosis, treatment, and alerts. AMI will donate software that will be integrated into the ARTEMIS system.
Protocol Systems, Inc., is a manufacturer of patient monitoring instruments and systems. Protocol's portable Propaq monitors and Acuity central monitoring systems provide cost-effective care for monitoring patients in a continuous manner. Protocol will donate hardware that will be integrated into the ARTEMIS system.

Telemedicine Advisory Board

Senator John D. Rockefeller, West Virginia (Chair)
Dr. Thomas Bender, M.D., Executive Director of the International Union for Circumpolar Health, Anchorage, Alaska
Mr. Denis Bone, President, Bell Atlantic West Virginia
Dr. Neil Bucklew, Ph.D., former President of West Virginia University; Professor of Management and Chairman of Informatics Taskforce at WVU's College of Business and Economics
Dr. Michael DeBakey, M.D., Chancellor Emeritus, Baylor College of Medicine and Director, DeBakey Heart Center
Mr. J. Thomas Jones, Executive Director/CEO, St. Mary's Hospital, Huntington, West Virginia
Dr. Michael Kilkenny, M.D., Medical Director, Valley Health Systems, Inc.
Dr. Raman Mitra, M.D., Ph.D., Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
Judge Dan O'Hanlon, Judge of the West Virginia Sixth Judicial Circuit
Mr. A. Michael Perry, President/CEO Bank One, Huntington, West Virginia
Dr. Niels Rossing, Professor of Medicine, National University of Denmark, Copenhagen, Denmark; former head of the European Health Telematics program
Dr. Jay Sanders, M.D., Eminent Scholar Chair of Telemedicine, Medical College of Georgia

Mr. Steve Shattls, CEO of Valley Health Systems, Inc., and Dr. Ramana Reddy, Director of CERC and Professor of Computer Science at West Virginia University, will serve as ex-officio members of the panel.

This initial group will be augmented with members of other healthcare professions.

Related Technical Reports

ARTEMIS: A Collaborative Framework for Health Care (CERC-TR-TM-93-005), Nov. 1993

Viewfoil Presentations

Secure Collaboration Technology for Rural Clinical Telemedicine, December 1996.

Progress Reports

ARTEMIS Team

Health Care Advisory Board

Valley Health Systems, Inc.

CEO: Steve Shattls

Health Care Providers (users of ARTEMIS)

Dr. M. Kilkenny, M.D., Family Practice, Medical Director for Valley
Dr. Bruce Merkin, M.D., Internal Medicine
Dr. Herb Myers, D. O., Ob/Gyn
Dr. DeRosa, D.O., Ob/Gyn
Dr. Richards, M.D., Family Practice
Colleen Rager, Nurse Practitioner