Networking Health Prescriptions for the Internet (2000) / Chapter Skim
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Appendix A: Site Visit Summaries
Appendix A: Site Visit Summaries
Pages 269-313
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Appendixes
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Ames Research Center, Mountain View, California; the Center for Health Sciences Communication at East Carolina University (ECU) , Greenville, North Carolina; the University of North Carolina (UNC)
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Huang and his colleagues at LRI demonstrated systems designed to share three different types of telemedical images: digital mammograms; cardiograms; and neurological images made by magnetic resonance imaging (MRI) and computerized tomography (CT)
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Participating physicians must be cross-licensed in the examination sites. Cardiology Teleconferencing Tony Chou, director of the catheterization labs, described a cardiology teleconferencing system linking UCSF and Stanford University.
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The HMO is not a single entity but, rather, an affiliation of two separate organizations: the Kaiser Foundation Health Plan, which handles administrative and management functions, and Permanente Medical Group, which consists of 12 separate groups of practitioners. Kaiser-Permanente has experimented with network-based telemedicine applications, particularly in teledermatology and teleradiology.
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The discussions during the site visit focused on both the institute's efforts to develop internal applications for use by care providers and on the efforts of KPOnline, a customer-focused system. Permanente Knowledge Connection Peter fuhn, executive director, described the activities of the Care Management Institute (CMI)
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The databases are linked together through the national office's intranet Web site, which makes the information searchable and reduces duplication of effort. In addition to linking care management information, the PKC provides a centralized outlet for other information resources of interest to care providers.
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Other benefits will accrue from improved knowledge management, which should succeed in educating care providers about new diagnostic approaches and new techniques. The Kaiser staff hope to make the link between successful patient-provider interactions and the PKC system evident, to demonstrate the system's ability to support corporate objectives.
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Eventually, the Kaiser staff would like to integrate KPOnline with the PKC so they can take the information gathered from patients through KPOnline and incorporate it into practice guidelines and, conversely, incorporate practice guidelines into chat rooms and e-mail discussions with patients. The goal is to help patients better understand health information, tailor it to them, connect them with providers, and to help them make sound, coordinated decisions regarding their care.
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At the time of the site visit, all of Kaiser-Permanente's care providers had e-mail accounts, but patients were not yet using them. The use of clinical e-mail raises several questions, as yet unanswered, regarding medical records.
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Security issues also need to be addressed. STANFORD CENTER FOR PROFESSIONAL DEVELOPMENT Committee members visited the Stanford Center for Professional Development on December 16, 1998, to meet with Andrew DiPaolo, its executive director, and members of his staff and learn more about the Stanford Online system.
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Stanford Online students see three things in their browser window: a relatively small video of the instructor giving the class; an index of topics covered by the lecture (topics can be selected as the student wishes) ; and PowerPoint slides or, alternatively, photos of projected slides or blackboards, coordinated with the audiovisual track.
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At present, Stanford Online is a technical implementation of current models of teaching; little thought has been given to changing the educational model to fit the technology. This approach has at least one advantage: it allows lecturers to deliver courses online without changing their form or structure.
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NASA AMES RESEARCH CENTER The committee visited NASA Ames Research Center on December 16, 1999. Committee members were hosted by Muriel Ross, then director of the Ames Center for Bioinformatics, and her team of biocomputing researchers.
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by the individual sites. Changes are made visible to all participants, and at the end of a manipulation, the centralized NASA computer sends an updated, full-resolution image back to each of the remote sites using multicast technologies.
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Telemedicine East Carolina University has two telemedicine suites an older one and a newer one with a total of eight rooms. Each room has a telephone, a personal computer for displaying electronic medical records, a display of the remote site, and a display of the consulting physician.
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At distant sites, ECU pays for all equipment and 3 years of line charges, taking this as a marketing and referral expense. Standard installation costs $150,000 per site, including remote camera control, two-way audio and video, and continuing medical education content.
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For instance, the hospital might get more cardiac referrals as an indirect result of a well-baby telemedicine program. Such benefits would be difficult to track, however.
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Remote sites use standard desktop computers (Pentium class) to transmit image files averaging 3 MB in size, a figure driven by technical limitations.
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Teleeducation East Carolina University has eight teleclassrooms on campus. The network was originally built to deliver distance education in engineering and is currently used for nursing classes.
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Grand rounds are seen as a loss leader designed to acclimate remote users to the equipment and style of interaction, in the hopes that they will later try clinical consultations at the remote sites. Scheduling is complex; ECU uses scheduling software developed in-house.
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The center at ECU also could become a means of providing services to more affluent clients who opt to pay for their own health care rather than relying on their health plan. Real-time treatment planning, with its increased bandwidth requirements, is seen as unlikely.
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A certification system would also have to be created for consultants, presenters, and, perhaps, for overall telemedicine programs. Security also would need to be improved.
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in Chapel Hill on February 3, 1999, featured two main activities: a visit to the computer graphics laboratory for demonstrations of telepresence systems with potential applications to medicine and a meeting to discuss Internetbased education programs in the School of Medicine. UNC's Computer Graphics Lab Guided by Henry Fuchs, the committee saw four demonstrations of computer graphics and virtual reality systems with potential applications to medicine: the Telepresent Office, augmented-reality ultrasound, widearea tracking/walking, and image-based rendering/depth extraction.
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Empirical observations suggest that it does not work very well in spite of apparently adequate bandwidth; there is not much emphasis, at present, on the efficient network transport of video and audio. Latency and time-stamping of different video streams are important, especially during the current transition from a two-dimensional to a threedimensional system.
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Educational Technologies John Loonsk, head of information systems for the School of Medicine and the Division of Medical Informatics in the Department of Biomedical Engineering, discussed the UNC approach to technology-based curriculum support. The goal is to create an Internet-based learning environment for medical education for both resident and nonresident students.
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The third component is an image repository a collection of medical images with some text descriptors and titles. Staff are trying to convert these into flat HTML format.
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Another constraint is security, especially for clinical data. The hospital uses audit trails to deter improper access to medical records.
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on February 10, 1999, consisted of a series of briefings on, and demonstrations of, a range of projects related to medical informatics and human-computer interfaces, a key factor in making the NGI more accessible to health care. Since the 1970s, UW has engaged in a series of computing, informatics, and Internet technology projects that have built upon one another.
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These data have implications for local universities; namely, they find it difficult to recruit top people for academic jobs, and there is limited practical value in 2-year academic programs, whose graduates fail to meet the employment criteria of much of local industry. The ARPANET was brought to the Pacific Northwest in 1979 by the UW Computer Science Department.
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Projects that were discussed in some detail at the site visit are summarized in the following subsections. They include the distributed radiology oncology network, the MINDSCAPE interface to a clinical data repository, the WWAMI network, medical projects at the Human Interface Technology laboratory, the gigaPOP, NGI projects, Biomedical Library programs, and the Digital Anatomist electronic repository of anatomical images and teaching programs.
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The system contains about 60 gigabytes of data, including clinical data (e.g., electronic medical records) , and offers links to library reference materials (e.g., drug databases, MEDLINE, laboratory tests reference data, and clinical guidelines)
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Funds from the Rural Health Policy Agency allowed the consortium to set up six telemedicine consultation sites in small communities. The local primary care physicians are also preceptors for medical students, and an average of one or two consultations, mainly specialty consultations, are held at each remote site every month.
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, they must get licensed in both states unless they are participating in telemedicine programs operated by the federal government (such as the Veterans Administration) , which are exempt from state licensure requirements.
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. The environment is based on photographs and equipment from Harborview Medical Center.
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This project is titled Patient-Centric Tools for Regional Collaborative Cancer Care Using the NGI. Brent Stewart outlined the project, in which a high-performance metropolitan area network is being designed to transmit clinical data, including radiology images (with a capacity to deliver eight simultaneous 10-MB image sets simultaneously, using a 622-Mb channel)
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make this transformation necessary. In addition to the WWAMI medical education program, the pharmacy, nursing, public health, and social work programs have distance education programs.
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They control access with user IDs and passwords and UW IDs and are increasingly making materials available through a proxy server. Access is also a problem, because not all materials are locally loaded, and network latency for materials stored at remote sites (NLM, journal publishers, etc.)
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of anatomical structures. It consists of a symbolic information database and a separate threedimensional image database accessed through a single server.
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; the Washington State Department of Public Health; and the Community Health Information Technology Alliance (CHITA) , working with a group called Agora.
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. Foundation for Health Care Quality Rick Rubin, president of the FHCQ, gave an overview of the foundation, a not-for-profit entity created in 1988 to meet the shared health information needs of the Seattle region.
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Other regional projects are aimed at exchanging data on pediatric immunizations, referrals, claims, and lab transactions. Community Health Information Technology Alliance Project with Agora Peter B
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tor nealtn care. He also WOUlCI consider tne formation ot a separate health information network as a means of avoiding some of the security concerns associated with the Internet.
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According to a preliminary evaluation, the pilot program improved the completion and timeliness of reports. The time required to send information to the local health office improved modestly (to less than 1 day)
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