Telemedicine Team

Secure Collaboration Technology for Rural Clinical Telemedicine

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Phase 1 Quarterly Report

April 1 - June 30, 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 requirements analysis, design, and initial development of elements of our system.

B. Work Accomplished During this Period:

During this reporting period, the major work included:

development of a reference implementation (software source code) of a vital sign server and a viewer application, and design of a CORBA server and remote viewer for vital signs (temperature, heart rate, invasive and non-invasive blood pressures, SPO2, and multi-lead EKG);
training on LinkTech's Medical Information Bus integration facilities;
development of prototypes of secure CORBA facilities using transformers and filters; and
development of a prototype of a smart card application. The patient's smart card was based on the G7/Eurocard format containing patient demographics and emergency clinical information. The health professional card provided role-specific access to information from the patient's card for administrators, physicians, and health care staff. We also designed a more extensive user interface for this application that will be evaluated in consultation with our healthcare partners.

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:

site visits to one of the participating hospital's intensive care units to determine equipment needed to provide real-time data to the intensivist's office from the Hewlett-Packard (HP) proprietary network in the hospital. Based on our findings, we ordered several pieces of HP equipment to conduct prototype experiments at CERC first: (1) a patient data server (which is a special programmable "box" that will allow the intensivist to access data from his office via ethernet), (2) a software development kit, (3) a patient monitoring system, (4) a communications controller, and (5) various sensors, cables, and other supplies. These pieces will be purchased from funding by a separate grant from HP.

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:

We are currently working on the details for the development of systems and system interfaces for mid-level providers.

B. Work Accomplished This Period:

The following work was completed in this reporting period:

discussions regarding the development of an expert systems interface, called SAGE, to assist the mid-level providers. This language mapping software will facilitate interfacing between the Artemis code and external processes. The Iliad Diagnostic Expert System will employ this communication protocol to support its inclusion as a wide area network instrument for diagnostic support in rural health clinics. We plan to incorporate Iliad's dermatologic images and expert analysis components into Artemis;
visit to the Crum Clinic in Crum, West Virginia. We obtained data pertaining to the clinic's operations, including information that will evolve into several patient use case scenarios. The resident physician's assistant was receptive to the idea of having access to healthcare-related Web pages and to diagnostic aids (such as Iliad);
collection of example patient data describing supra ventricular tachycardia, chronic obstructive pulmonary disease, diabetes mellitus/ketoacidosis, and sinus bradycardia for integration into Artemis for realistic user interface development and demonstration purposes; and
development of a Lisp software program to characterize electrocardiogram (EKG) waves by duration and amplitude, and then simulate example EKG data based on a database of values specific to various heart conditions (such as sinus bradycardia) and encoded as PQRST data. Simulated data was provided for integration into Artemis.

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 currently preparing detailed software specifications and design. We have yet to obtain commitment from a partner for the software's future deployment.B. Work Accomplished This Period:

The following work was completed in this reporting period:

hiring of a new software engineer to work on this task;
development of high-level specifications for five modules (enrollment, visit notes, visit scheduling, patient tracking and progress, and patient status);
design of a preliminary data base for home care;
development of a position paper for the project scope, presented for peer review at CERC;
discussions with the Wayne County Health Department regarding planning for their involvement in future deployment; and
submission of an abstract for a poster paper at the SCAMC Fall meeting. It was accepted.

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 are continuing 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:

interviews with the mid-level provider at the Crum Clinic in Crum, West Virginia, for developing the mid-level care scenario. Based on the work flow, we designed two experiments for this scenario -- one for measuring the EKG turnaround time and the other one for measuring the number and type of contacts with the supervising physician. The baseline data collection for these experiments was initiated; and
discussions with the chief financial officer and the persons responsible for patient accounting and general accounting at Valley Health Systems, as well as with the billing departments at the participating hospitals, for cost data gathering for each of the three proposed 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 various working groups.

B. Work Accomplished This Period:

The following work was accomplished during this reporting period:

review of security measures based on recommendations in National Research Council's Computer Science and Telecommunications Board (CSTB) report and the draft report by Internet Engineering Task Force's Site Security Handbook Working Group, in concert with our current understanding of the security requirements for the telemedicine scenarios; and
discussions with, and presentation of our own work to, members of an emerging healthcare information security consortium consisting of healthcare systems vendors, information security vendors, and healthcare organizations, with the objective of determining viable approaches to securing an organization's healthcare information.

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:

intensive review of costs and personnel salaries to prepare for the new university fiscal year;
continued work to establish subcontracts with Valley Health and Los Alamos National Laboratory;
distribution of information about the project upon request;
installation of the final Windows NT server and Windows 95 notebooks, and continued installation of Windows NT workstations; and
normal maintenance of the existing computer hardware and software to support project activities.