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Establishment of EHealth Network for Disasters and Healthcare Improvement: Integrated Medical Inform

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Title: Establishment of EHealth Network for Disasters and Healthcare Improvement: Integrated Medical Inform


1
Establishment of E-Health Network for Disasters
and Healthcare Improvement Integrated Medical
Information Technology System Partner concept
between Academies and Medical entities Yukako
Yagi University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
2
Background Why E-Health Network?
  • In March 1, 2001, the Institute of Medicine (IOM)
    stated that
  • The American health care delivery system is in
    need of fundamental change. Many patients,
    doctors, nurses, and health care leaders are
    concerned that the care delivered is not,
    essentially, the care we should receive. Health
    care today harms too frequently and routinely
    fails to deliver its potential benefits.
  • The difficulty in maximizing the benefits of
    increased clinical and business knowledge and
    advanced diagnostic technologies comes from the
    basic problem of collecting, integrating and
    managing health information in various formats.
    Further, this data is stored in multiple physical
    locations that are often distant and hard to
    access when treating individual patients,
    especially those with critical medical needs.
  • use of information technology is key

3
University of Pittsburgh Medical Center
4
UPMC has established Telemedicine Network through
the system
Facts and Figures
5
Overview Program Description
  • looking increasingly towards technology-assisted
    solutions to optimize how they manage and deliver
    health care.
  • Non-Civilian Medical Facilities (NCMF) and UPMC
    have created a partnership to collaborate on
    developing technology-assisted solutions to
    real-world medical problems
  • The partnership is defined as the Integrated
    Medical Information Technology System (IMITS)
    Program.

6
Overview Program Description
  • The IMITS program pioneers the application of
    state-of-the-art information management (IM) and
    information technology (IT) solutions, including
    advanced business and clinical decision support
    tools. This initiative brought together vast
    clinical and information technology expertise of
    both institutions and aids in the recognition and
    treatment of many types of medical conditions.
    In addition, the NCMS-UPMC partnership is
    providing new opportunities for enhancing
    expertise, evaluating solutions to technical
    dilemmas, and deploying strategies to address key
    medical issues.

7
IMITS Project
  • Congressional Special Interest Appropriation
  • FY02 8.5M - Establish initial project
    Integrated Medical Information Technology System
  • FY04 10.2M - Continue current projects
    expand into Pacific Rim

8
Scope
  • The initial focus of the IMITS Program was on
    telemedicine and associated advanced
    technologies. The overall program objective is
    the design of new state-of-the-art clinical and
    business models supporting the delivery of fully
    electronic multi-media enabled electronic health
    records. The projects described below will be
    organized under the umbrella of the IMITS Program.

9
Scope Multi-specialty Tele-consultation Project
  • Situations
  • There are many medical facilities in locations
    where specialty medical care is not readily
    available.
  • Patients often must travel significant distances
    and taking time off from work.
  • Resulting in
  • Expense to both the patient and the enterprise
  • A delay in the diagnosis and treatment of the
    presenting medical condition

Solutions
10
Scope Multi-specialty Tele-consultation Project
Solutions
  • Developing and refining computerized medical
    records, enhancing medical information retrieval
    and patient tracking, and creating clinical
    decision support rapidly increases the capability
    to provide high quality cost-effective medical
    care to non-civilian beneficiaries and civilians
    in even the most remote locations.
  • To design, build and test a multi-specialty
    teleconsultation system on a common technology
    platform. This system will provide widely
    available, flexible, clinically relevant services
    across multiple medical specialties on a secure,
    stable low cost technology platform utilizing
    asynchronous and synchronous communications.
    This will allow general clinicians and medical
    personnel access to remote expert advice,
    diagnosis and mentoring and in so doing
    contribute to providing a high-quality standard
    of care independent of location.

11
Scope
  • The Multi-specialty Tele-consultation
    Demonstration Project was divided into the
    following areas
  • Distributed Radiology Imaging Demonstration
    Project The design and implementation of a
    distributed radiology imaging system utilizing
    the Stentor platform at a medical facility in
    Dayton, Ohio. The system was connected to UPMC
    linking the radiology departments for education
    and service opportunities.
  • Pathology Tele-consultation System Demonstration
    Project The design and implementation of a
    telepathology system at a facility in
    Mississippi. The system is connected to UPMC
    linking the pathology departments for education
    and service opportunities.
  • Behavioral Health Tele-consultation System
    Demonstration Project - The design and
    implementation of a behavioral telehealth system
    at a facility in Texas. The system connects to
    UPMC linking the behavioral health resources for
    education and service opportunities.
  • Pediatric Cardiology Tele-consultation System
    Demonstration Project

12
Approach/Strategy
  • A high-level project work plan will be included
    in the individual scope of work documents. The
    main focus of the program will be on the
    implementation of tele-consultation applications.
    The tele-consultation implementation work plans
    have been developed based on a standard
    implementation methodology and are organized into
    seven major segments with corresponding
    activities as follows

13
Approach/Strategy
I. Project Set-Up Confirm project governance and
organization structure. Confirm project roles and
responsibilities. Confirm communication
structures. Confirm methodology approach.
14
Approach/Strategy
II. Analysis Conduct application education and
training. Document functional and technical
requirements. Assess hardware, interfaces and
network. Document software requirements,
conversion decisions, and data standard
initiatives. Identify training needs and sites.
15
Approach/Strategy
III. Design Complete system design. Develop
conversion specifications and interface
specifications. Identify data standards and file
setups, customizations, and security requirements.
16
Approach/Strategy
IV. Development Complete system build. Begin
programming conversions, interfaces, and
customizations. Develop new policies and
procedures. Develop menus, forms, reports and
screens.
17
Approach/Strategy
V. Testing Define testing scope and
approach. Identify testing team. Develop
integrated and product specific test
plans/scenarios. Conduct testing system
acceptance, unit, application, integration,
stress, security and network/communications
testing.
18
Approach/Strategy
VI. Training Develop training plan and
materials. Schedule and conduct user training.
19
Approach/Strategy
VII. Conversion/Post-Live Support Develop
go-live plan. Identify support team for
go-live. Determine conversion downtime
requirements and system freeze dates. Prepare
contingency plans. Perform conversion. Identify
post-live issues team. Initiate post-live support
and transition.
20
FY 01-02 IMITS
21
FY 01-02 IMITS
  • Business Problem
  • Shortage of specialty physicians
  • NCMF high priority Radiology
  • Goal
  • Improve access to care and provide quality
    healthcare services to individuals regardless of
    location

22
FY 01-02 IMITS Program Implementation Overview
  • Extended period to move money and negotiate
    agreement
  • Pre-award implementation of Radiology project to
    meet NCMF requirements to replace legacy systems
  • Rigorous security requirements that necessitated
    adjustments to project timelines

23
IMITS Program Distributed Imaging
  • Dayton, OH
  • Installation of Stentor iSite COTS
  • UPMC customizations for NCMFs workflow, global
    hub and spoke strategy
  • Replaces legacy PACs system
  • Establishes footprint for global NCMF image
    distribution infrastructure
  • Evaluation of provider acceptance and satisfaction

24
FY 01-02 IMITS Projects Distributed Imaging
  • Current Status
  • July 1, 2003 - Technical go-live
  • August 27, 2003 - Clinically live on private
    subnet
  • November 14, 2003 Notified of impending final
    security accreditation
  • November 24, 2003 Move from private subnet to
    live radiology network
  • January 20, 2004 Clinical go-live
  • February 2004 Begin UPMC customization
  • March 2004 UPMC Radiologist wrapper installed
  • May 2004 Clinician wrapper installed
  • June 2004 STE for upgrade to iSite v3.2

25
IMITS Program Telepathology
  • Biloxi, MS
  • Installation of UPMC Static Telepathology
    (Mississippi, Florida, California)
  • Installation of dynamic telepathology for
    educational purposes (Mississippi, Florida,
    California)
  • RD on whole slide imaging (Mississippi,
    Pittsburgh)
  • Progressive technology for imaging and storage of
    pathology specimens
  • Evaluation of provider acceptance and satisfaction

26
IMITS Projects Telepathology
  • Current Status
  • Feb 2003 Version 1 Security Documents submitted
    for approval
  • July 2003 Updates to Version 1 submitted
  • Sept 2003 Version 2 Security Documents
    submitted for approval
  • Oct 2003 Initial lab certification at DSI
  • Nov 2003 Awaiting report of certification
    testing
  • Jan 2004 Certification re-test
  • Feb 2004 Awaiting IATO
  • April 2004 IATO obtained
  • May 2004 Awaiting CTO
  • June 2004 CTO obtained
  • August 2004 Final STE scheduled

27
IMITS Projects Pediatric Tele-echocardiography
  • Current Status
  • Dec 2003 Installation equipment at all bases
  • Jan 2004 Equipment installed
  • Mar 2004 Awaiting ISDN re-install
  • May 2004 Clinically live
  • Jun 2004 Beta cases

28
IMITS Program Pediatric Tele-echocardiography
  • Biloxi, MS
  • Implementation of Pediatric Tele-echo system
    modeled after Childrens Hospitals in Florida
  • Clinical implementation and support
  • Evaluation of parent and provider acceptance and
    satisfaction
  • No security requirements

29
IMITS Program Emergency Services
  • Emergency Communication Database
  • Demonstration project using international
    healthcare facility database in UPMC Command
    Center
  • NCMF identified additional required information
    in database
  • UPMC collecting data on health care facilities in
    South America
  • NCMF will evaluate via secure web access
  • Opportunity for future business relationship

30
FY 01-02 IMITS Projects Emergency Services
  • Expeditionary Medical Support (EMEDS)
  • NCMF forward deployed treatment facilities
  • Portable tents
  • Large IT footprint
  • Hard wired
  • Subcontract with MountainTop Technologies
  • Conduct needs assessment
  • Make recommendations for wireless solution

31
IMITS Program Discontinued Projects
  • Telemental Health
  • Internal NCMF issues
  • Change in leadership Wilford Hall Medical Center
  • Administrative changes in TRICARE
  • Teleradiation Oncology
  • Difficulty finding suitable site
  • IMRT requires specific equipment on linear
    accelerator

32
FY 04 IMITS (Sept, 2004)
  • 10.2M Congressional Appropriation
  • Congressional intent to expand into the Pacific
    Rim
  • Pacific Telehealth and Technology Hui
  • University of Hawaii
  • Expanded relationship with Wilford Hall Medical
    Center

33
FY 04 IMITS (Sept, 2004)
Extracorporeal Membrane Oxygenation (ECMO)
Platelet Gel Therapy
Telepathology
Simulation and Training
Teleaudiology
IMITS
Telemental Health
Evaluation
Distributed Imaging and Workload Balancing
Teleophthalmology
Education
34
FY 04 IMITS Projects ECMO
  • Extracorporeal Membrane Oxygenation
  • Invasive procedure for maintaining oxygenation of
    the blood when lungs and/or heart are failing
  • Requires specialized equipment and specially
    trained individuals

35
FY 04 IMITS Projects ECMO
  • ECMO programs generally found in urban academic
    medical centers.
  • 145 ECMO centers in the world
  • 112 in the US
  • Only 2 NCMF in Texas
  • No centers located in the Pacific

36
FY 04 IMITS Projects ECMO
  • Interest in establishing a regional ECMO Center
    for the Pacific in Honolulu
  • Senator Inouye
  • Non Civilian Medical Center
  • Kapiolani Womens and Childrens Hospital
  • Pacific Telehealth and Technology Hui
  • University of Hawaii

37
FY 04 IMITS Projects ECMO
  • FY 04 ECMO project is feasibility and planning
    study
  • Evaluation of existing resources
  • Requirements
  • Budget
  • Deliverable will be a plan for implementation of
    the center with the support of FY 05
    appropriations sponsored by Senator Inouye

38
FY 04 IMITS Projects Distributed Imaging and
Workload Balancing
  • NCMF experiencing a severe shortage of
    radiologist
  • 160 billets (FTE) as of July 1, 2004 only 60
    filled
  • Need to maximize resources and distribute
    workload
  • Hub and spoke teleradiology model no longer
    useful
  • Symmetrical load balancing model more appropriate

39
Distributed Imaging and Workload Balancing
  • UPMC implemented distributed workload model one
    year ago
  • Shared worklist
  • Radiologists read films from facilities other
    than the one they are assigned to for the day
  • Same model implemented
  • Shared worklist
  • Appropriate cases for civilian readings

40
Distributed Imaging and Workload Balancing
  • Designated Non Civilian Medical Center
  • Scale up model developed for the hospital in OH
  • Attempt to keep readings within the US Gov

41
Distributed Imaging and Workload Balancing
  • IMITS 04 project scope
  • Assess the current workflow at NC Medical Center
  • Recommend changes based on UPMC workflow model
  • Implement a prototype system

42
Teleaudiology
  • Cochlear implants are utilized to improve hearing
    in severe to profound hearing loss
  • Once implanted the devices require monitoring and
    adjustment
  • This must now be done in person

43
Teleaudiology
  • UPMC and NCMF both have cochlear implant programs
  • Only one MTF that has a cochlear implant program
  • NCMF treats patients globally
  • Interested in developing a means to remotely
    access and adjust implants

44
Teleaudiology
  • FY 04 deliverables
  • Feasibility study
  • Vendor evaluation
  • Determine regulatory impact in civilian world
  • Plan for technology development
  • Pilot project

45
Teleophthalmology
  • Joint project with Type 2 diabetes
  • NCMF requested that retinal screening images
    captured for the diabetes project be stored in a
    DICOM archive
  • Consistent with newly released ATA guidelines
    Telehealth Practice Recommendations for Diabetic
    Retinopathy

46
Teleophthalmology
  • UPMC Radiology Informatics has done work with
    visible light images
  • Image archive for melanoma photographs
  • Customized viewer

47
Teleophthalmology
  • FY 04 IMITS Teleophthalmology Deliverables
  • Create DICOM object with associated metadata from
    acquired image
  • Transport the DICOM object form point of
    acquisition
  • Store image in a DICOM archive irrespective of
    vendor

48
Telemental Health
  • A major component of dealing with catastrophic
    events is Post Traumatic Stress Disorder
  • Victims of disasters
  • Critical incident stress management has been
    unsuccessful in management of PTSD
  • Cognitive Behavioral Therapy has been show to be
    successful

49
Telemental Health
  • FY 04 Project
  • Initial data collection and assimilation for
    analysis
  • Partnership with simulation center in San Diego

50
Telepathology
  • Three initiatives under this heading
  • Telepathology Needs Assessment Pacific Rim
  • Development of Whole Slide Imaging Capability
  • Incorporation of pathology images in enterprise
    image archive

51
Telepathology Pacific Rim Needs Assessment
  • Telepathology needs of the Pacific Rim differ
    from CONUS
  • Static vs. dynamic
  • Multiple time zone changes, international date
    line
  • Staffing at MTFs
  • FY 04 Deliverables
  • Needs assessment and feasibility study for
    telepathology in the Pacific Rim

52
Telepathology Whole Slide Imaging
  • Technologies that allow rapid and automatic
    imaging of entire slides at high resolution,
    storage of the image and display
  • Equipment developed but technology has not been
    integrated into clinical practice
  • FY 04 project
  • Development and implementation of a fully
    integrated WSI clinical application at UPMC

53
Telepathology Image Archive
  • Native telepathology images are not in DICOM
    format
  • File size for WSI is rather large
  • FY 04 project
  • Leverage work done to date at UPMC with visible
    light images for melanoma and ophthalmology to
    integrate pathology images into a DICOM archive

54
Simulation and Training
  • Three initiatives under this heading
  • Wilford Hall Simulation Center
  • University of Hawaii Simulation Center
  • UPMC Nursing Injury Prevention Program
  • All projects will involve WISER

55
Simulation and Training Wilford Hall Simulation
Center
  • Wilford Hall has simulation capabilities
    distributed in various departments throughout the
    MTF
  • Wants to consolidate existing capabilities and
    build a Simulation Center
  • FY 04 deliverable
  • Assessment of current capabilities and
    recommendations for an integrated simulation
    center

56
Simulation and Training UH Simulation Center
  • University of Hawaii will be opening a new
    Medical School Building in 2005
  • One floor dedicated to advanced simulation and
    training
  • UH interested in WISER applications
  • FY 04 deliverable
  • Development of a collaborative partnership and
    implementation of a WISER pilot at UH

57
Simulation and Training UPMC Nursing Injury
Prevention
  • Work related injuries are a significant issue for
    nursing
  • Simulated situations can assist with assessment
    and prevention of injuries
  • FY 04 project
  • UPMC Nursing in collaboration with WISER will
    develop and implement a work related injury
    prevention simulation

58
Platelet Gel Therapy
  • Wound healing therapy
  • Creation of platelet rich plasma that enhances
    wound healing and decreases healing time
  • Applicability to non-healing diabetic ulcers
  • FDA approved
  • Not reimbursed by Medicare or private insurers

59
Platelet Gel Therapy
  • Additional studies needed to validate efficacy
  • FY 04 project
  • Planning and development of multi-center clinical
    trial comparing platelet gel therapy to standard
    wound care treatments
  • Literature review
  • Protocol development
  • Vendor negotiations
  • IRB approvals

60
Education
  • Three initiatives under this heading
  • Nursing Leadership training
  • Nursing Magnet Program
  • Type 2 Diabetes Education in Italy

61
Education Nursing Leadership
  • UPMC and the NCMF have similar objectives for
    leadership training
  • UPMC has established the Beckwith Leadership
    Institute
  • FY 04 project
  • Review Joint Leadership Core Curriculum to
    determine synergies between NCMF and UPMC
  • Make recommendations for joint curriculum
    development

62
Education Type 2 Diabetes Italy
  • Incidence of type 2 diabetes increasing in Italy
  • Need Diabetes Self Management Tools
  • Partner with the hospital in Italy and
    Mediterranean Institute for Transplantation and
    Advanced Specialized Therapies (UPMC)
  • FY 04 project
  • Initiate an on-line diabetes education program
    for type 2 diabetes

63
Evaluation
  • Leadership from Center for Biomedical Informatics
  • Conduct rigorous and professional evaluation of
    the IMITS projects
  • User acceptance
  • Technology integration

64
Evaluation
  • Oversight of all evaluation activity
  • Protocol development
  • Protection of humans subjects
  • IRB approvals
  • Federal and state regulations

65
Conclusions
  • 1. The civilian counterparts, particularly in
    developing countries are interested in
    implementing information technology that
    eliminates inefficiencies, increases utilization
    and improves quality of care, while also lowering
    administration costs. Given the limited manpower
    and resources facing the military non-civilian
    and private sectors, improved information
    technology and management will be the foundation
    for quality health care.

66
Conclusions
  • 2. University of Pittsburgh Medical Center has
    also some other partnership models and close
    cooperation with Italy, Czech Republic, Brazil
    and China and is looking forward to cooperate
    with Arab Region as well
  • 3. One of these models of partnership between
    the university and medical entities can be
    applied in case of Arab nations region.

67
Background
  • The IOM committee believes the development and
    application of information systems is essential
    to enhance quality and improve efficiency.
    Information technology must play a central role
    in the redesign of the healthcare system if a
    substantial improvement in quality is to be
    achieved over the coming decade.
  • These problems are even more acute when applied
    to a military service population for a number of
    reasons. First, service men and women and their
    families are among the most mobile members of our
    society. Second, due to their exposure to
    diseases and environmental factors in a multitude
    of geographic locations, they are subject to a
    wider variety of difficult-to-diagnose medical
    conditions. Complicating this is the likelihood
    that relevant medical data is stored in
    incompatible health information systems increases
    with the time spent deployed outside CONUS. In
    addition, the drawdown in military forces and the
    closure of medical treatment centers in the 1990s
    has resulted in a reduction in funding and
    staffing for medical care applied against a
    stable but aging population of beneficiaries.
  • Like its civilian counterparts, the Air Force is
    interested in implementing information technology
    that eliminates inefficiencies, increases
    utilization and improves quality of care, while
    also lowering administration costs. Given the
    limited manpower and resources facing the
    military and private sectors, improved
    information technology and management will be the
    foundation for quality health care.
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