Secure Collaboration Technology for Rural Clinical Telemedicine

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Phase 1 Quarterly Report

January 1 - March 31, 1997

Task 1 Secure Collaborative Telemedicine Architecture

The primary focus of this effort is to develop a set of secure telemedicine services for use in customized telemedicine applications for healthcare providers in the treatment of their patients. This task will support the three telemedicine applications by providing secure access to healthcare information to authenticated healthcare providers, facilitating the authorized flow of healthcare information between healthcare providers and systems; and supporting secure teleconsultations by healthcare providers for the treatment of their patients.

A. Current Status:

The primary work thus far has been to evaluate devices and software that support secure telemedicine applications and to begin the design and initial development of elements of our system.

B. Work Accomplished During this Period:

The following milestone was reached during this reporting period:

• revision of security requirements for secure telemedicine services after review of the draft report of National Research Council's (NRC) Computer Science and Telecommunications Board's (CSTB) report entitled "Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure."

The remaining work included:

• installation of trial versions of public key cryptography facilities, such as certificate servers and directory servers;
• training on Schlumberger Smart Card systems; and
• design and prototype development of a vital sign server and remote viewer applets. At the HIMMS97 Conference, we demonstrated a remote viewer Java applet that displayed vital signs from a third-party CORBA-based vital signs server. However, these applets and services did not employ any security measures.

Task 2.1 Secure Telemedicine for Intensive Care Providers

The objective of this sub-task is to demonstrate the ability of secure, collaborative telemedicine applications to provide improved healthcare to patients at a hospital's Intensive Care Unit (ICU). By enabling specialists in intensive care medicine to have quick, yet secure, access to healthcare information, this application will allow the on-site ICU healthcare providers to consult with remote specialists and take timely steps in the treatment of patients.

A. Current Status:

We are currently working on the details for the scenario development.

B. Work Accomplished This Period:

The following work was completed in this reporting period:

• continuing work on the requirements gathering for the phased development and deployment of the scenario.

Task 2.2 Secure Telemedicine for Mid-level Providers

The objective of this subtask is to demonstrate the ability of secure, collaborative telemedicine applications to improve the delivery of healthcare through mid-level providers, such as Physician Assistants (PA) and Nurse Practitioners (NP). These applications will include teleconferencing, electronic patient record, and computer-aided diagnosis and treatment support systems, and will utilize an intuitive graphics/mouse interface.

A. Current Status:

This task began during this reporting period.

B. Work Accomplished This Period:

The following work was completed in this reporting period:

• initial requirements analysis for a secure telemedicine system for homecare patients, as a result of interviews with mid-level practitioners, through which we identified two distinct kinds of scenarios:
  • mid-level providers who practice under the direct supervision of a physician; and
  • an independent nursing practice that operates in collaboration with one or more physicians.
• interviews at one of the few independent nursing practices in West Virginia. We determined several types of transactions that can be enhanced by introducing health care informatics technologies. We will focus on translating these transactions into system requirements during the next quarter; and
• discussions with technical representatives from Mosby, Inc., who owns the ILIAD Diagnostic Expert System Knowledge Server. Based on these discussions, we are planning a wide area network interface between Artemis and ILIAD, called SAGE, to assist the mid-level providers. We propose the following dataflow model for the Artemis/ILIAD interface:
  • extract findings (signs, symptoms, labs) from the Artemis database;
  • translate the data from standard medical terms (e.g., BUN) to ILIAD codes;
  • transfer codes for a set of findings to the ILIAD Knowledge Server;
  • receive a set of differential diagnoses (DDx) from the ILIAD Knowledge Server;
  • translate disease codes to medical terms;
  • store DDx into the Artemis database; and
  • present the DDx via the user interface.

Task 2.3 Secure Telemedicine for Home Care Patients

The objective of this subtask is to demonstrate the ability of secure, collaborative telemedicine applications to improve the delivery of healthcare for home care patients through patient counseling information resources and support for near-time monitoring of patients with chronic ailments. Homecare patients with ready access to such information will be able to responsibly participate in the healthcare delivery process and its outcome. By enabling the patients to provide information about their conditions, this application will allow healthcare providers to take timely intervention in the treatment of their patients.

A. Current Status:

We are beginning the development of a first draft of software requirements for a home health care scenario.

B. Work Accomplished This Period:

The following work was completed in this reporting period:

• study of two important home care telemedicine projects at the Hays Medical Center in Hays, Kansas, and the Medical College of Georgia in Augusta, Georgia. We noted pointers for our project;
• visit to two home care agencies (the Wayne County Community Service Organization and the Wayne County Health Department) in the counties of West Virginia in which the project will be deployed, in order to ascertain their requirements and to understand the work processes involved in home health care;
• visit to Dr. Kilkenny of Valley Health Systems, which is collaborating from the clinical side, in order to determine the physician's view of home health care and to discover situations in which it may be advantageous for the physician to interact with a patient at home;
• contact with two companies (Protocol Systems, Inc., and Spacelabs Medical, Inc.) that manufacture patient monitoring equipment to see if they are interested in participating in this project. PSI has contributed one PropaqTM patient monitoring unit and will provide the software interface information needed to access their unit remotely; and
• decomposition of the software into nine modules.

Task 3.1 Evaluation/Assessment of the Impact of Collaborative Telemedicine Applications on Cost, Quality and Access to Care

The objective of this subtask is to assess the impact of telemedicine technology on cost, quality, and access to healthcare services in each of the three scenarios outlined in Task 2. We propose to develop three models that address different aspects of evaluation: 1) a multilayer model that provides an overall integrative framework for evaluation, 2) a presentation model for visualization of the impact of telemedicine on the healthcare enterprise at each layer of the proposed multilayer model, and 3) a cost model based on the selected scenarios.

A. Current Status:

We began the development of a multilevel evaluation based on the evaluation guidelines published by the Institute of Medicine (IOM).

B. Work Accomplished This Period:

The following work was completed in this reporting period:

• continued development of an evaluation plan for three scenarios (intensive care, mid-level providers, and home health care) to be deployed for telemedicine applications. During this period, we began an analysis of each scenario for baseline data collection for evaluation; and
• development of cost-related questions for querying the providers who are participating in the study, and raising of cost-related data gathering issues for health care. We developed the overall matrix of the four levels of cost evaluation (public/society, provider, payer, and patient) to be consistent with the IOM recommendations. The cost questions focus on provider and payer costs and are customized for the three scenarios.

Task 3.2 Security and Integrity of Electronic Patient Records

The objective of this subtask is to evaluate the technical and organizational approaches at the telemedicine application test sites to ensure the confidentiality and integrity of personally identifiable electronic health data while permitting legitimate transactions. Through formal assessments we plan to determine the effect of secure collaborative telemedicine applications on the healthcare organization's electronic patient record security policies.

A. Current Status:

We have begun to develop a detailed plan for evaluations, incorporating applicable recommendations from the National Research Council's Computer Science and Telecommunications Board (CSTB) report.

B. Work Accomplished This Period:

The following work was accomplished during this reporting period:

• review of security measures, based on recommendations in the CSTB draft report and our current understanding of security requirements for the telemedicine scenarios.

Task 4 Technical and Management Support Services and Infrastructure

The objectives of this task are to provide a highly-reliable, state-of-the-art, networked computing environment for CERC's staff to use in their development and testing activities; to provide systems and networking support for computers installed at other sites as part of Tasks 1-3; and also to provide administrative, accounting, and clerical support for the project.

A. Current Status:

Work in this task is progressing as scheduled.

B. Work Accomplished This Period:

The following work was accomplished during this reporting period:

• processing of additional Personnel Action forms to revise manpower loading on new project;
• establishment of internal project monitoring and tracking systems;
• completion of all paperwork (Statements of Work, proposal analyses) to establish proposed subcontracts with Valley Health Systems, and continued paperwork to set up the Los Alamos National Laboratory subcontract;
• distribution of technical reports and other information about the project upon request;
• processing of the necessary paperwork with the university telecommunications department in order to install new frame relay lines for the project's communications network;
• initiation of discussions and paperwork to establish computer hardware and software system maintenance agreements;
• continued installation of Windows NT workstations, two Windows NT servers, and Windows 95 notebooks; and
• normal maintenance of the existing computer hardware and software to support project activities.

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