Telemedicine on a Grand Scale: The Technology Strategy of the World‟s Largest Telemedicine Network Ron Riesenbach Vice President of Emerging Business Ontario Telemedicine Network

Overview 1. A quick overview of OTN 2. What OTN does 3. Impact of Telemedicine in Ontario 4. Q&A

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Ontario Telemedicine Network • One of North America’s largest and busiest videoconferencebased Telemedicine organization

• Serves all of Ontario: 416,000 sq miles, population 12.7M, 33 persons per sq km • Not for profit ≈ $28M budget in 08/09: ¾ Provincial, ¼ Federally funded • 15-20% of Ontarians live in rural and remote areas. • Most of the province’s north has no road systems

• Medical specialists are located in larger communities • Communities who need the service most, have the worst IP connectivity options

OTN Quick Facts • • • • • • • •

Videoconferencing Endpoints Participating Communities/Sites Clinical Programs/Specialties Patient Encounters 2009/10 Education/Admin Events 2009/10 Telehomecare Patients Emergency services sites Number of Employees

1,900 900+ 100+ 101,000

23,000 820+

20+ 180

Top 5 Therapeutic Areas of Care (Provincial) 2009/10

53%

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Webcasting

Teledermatology “Store-Forward”

Patient Site

Consultant Site

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OTN’s Telemedicine 4 “C” Pyramid

Clinical Customer Service

Collaboration Systems Connectivity

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What Does It Take To Support Clinical-Grade IP video-conferencing? Parameter

Description

Connectivity

Is the service available at all from a commercial provider?

Bandwidth

The maximum throughput supported on the circuit for sending and receiving

Packet Loss

The average number of packets that are dropped (not received by the end-point)

Latency

The delay between the transmission and reception of a „packet‟ if IP information

Jitter

The variation of Latency over time

Packet Order

The percentage of packets that arrive out-of-order

Availability

The percentage of time the circuit is operational and available for use

Security

Technology & methods used to maintain audio and video stream confidentiality

Service Level Agreement

Performance targets, provisioning time-frames, technical service access, commitments, reporting, incentives/punishments

Telemedicine Network

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Why the Public Internet is a Challenge for Clinical Videoconferencing 1. Videoconferencing through the public Internet is of

lower reliability than through private networks 2. There are no quality-of-service controls that can be

used on the public Internet. At times, a videoconference session will be good, at other times poor 3. Patient privacy and Security are more difficult to

ensure over the public internet than over private networks 4. Clinical videoconferencing service providers have

limited ability to monitor / control network-related technical quality issues on the public Internet

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Dynamic VPN Overlay • OTN has deployed 600 standard point-of-presence routers on top of the provincial network • These devices establish encrypted communications, basic Quality of Service (QoS) and the ability to monitor and control the service • The routers are centrally managed by OTN‟s 7/24 Service Desk • Membership contract and a technical Service Level Agreement (SLA) enforces standards and behaviors 18

OTN’s Telemedicine 4 “C” Pyramid

Clinical Customer Service

Collaboration Systems Connectivity

Not your Daughter‟s Webcam

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Clinical Videoconferencing Cart • Videoconferencing CODEC, Camera, Monitors • Medical grade • Microphone, speakers • Customized interfaces • High-resolution exam cameras

• Otolaryngoscope • Digital Stethoscopes

• Digital x-ray workstations

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Standards?

End-Point Eco-System

OTN’s Telemedicine 4 “C” Pyramid

Clinical Customer Service

Collaboration Systems Connectivity

Essential Service #1: Technical Service Desk • • • • • • • • • • •

1st Tier Technical Support 17 staff in two locations (Toronto & London, Ontario) 7am-7pm with after-hours on-call support Multipoint Bridge operations ITIL/ITSM v.3 Trained Incident Management Warranty management Asset tracking Communications Centre CODEC certification Session Monitoring

Service Monitoring and Control

Service Monitoring

Essential Customer Service #2: Referral Management & Scheduling • Centralized Scheduling Models 1. Fully Managed: Requests are expedited by call centre 2. Assisted: Event scheduling is shared between OTN and member 3. Self Scheduling: Events are self scheduled through a web tool

• Scheduling Call Centre – 25 schedulers across 10 sites

– 1-800 toll-free lines – VoIP-based call centre technology – 40-hours of telephone time/day – Constantly running inbound faxes: 1 ream (500 pages) of paper / day 30

Telemedicine Simplified

Referring Clinician

Consulting Clinician

Why Scheduling is a Bottleneck Complexity is a function of: – – – – –

Sites2 Nurses2 Studios2 VidSystems2 Specialists2

OTN‟s Centralized Model Linear growth: – – – – –

Sites Nurses Studios Vid Systems Specialists

Fully Managed Scheduling Process

Family Physician Central Scheduling Office

Video Consult TMC Patient Referring Side

Videoconference System

TMC Specialist Videoconference System Consulting Side

Studio Schedule Create ate & Manage Ev Events ventt View Other Studios/Days Training Documents, Reports Listing of Public V/C Events

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Separate Telemedicine Networks

Non-Scaleable Integration Model

Telemedicine Integration Network

OTN’s Telemedicine 4 “C” Pyramid

Clinical Customer Service

Collaboration Systems Connectivity

Example: Devon Island • Rocky desert in the Canadian North • The largest uninhabited island on Earth • Summer lasts just five weeks at an average temperature of only 2ºC • Extreme environment and remoteness has some of the characteristics of Mars 40

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Extreme Environment Telemedicine • • • • • • •

Tandberg Tactical V/C System CISCO 1711 Router AMD-2030 Dermascope AMD-2500 General Exam Camera AMD 2015 ENT/Otoscope AMD-2020 Direct Ophthalmoscope SonoSite 180 Ultrasound

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Real-Time Telemedicine Movie

Toronto, Ontario

Devon Island, N.W.T.

Telemedicine

4 “C” Pyramid

Patient Survey Results 2008/09 data

94%

would use telemedicine again.

97%

were satisfied with their telemedicine visit.

79%

said that telemedicine allowed them to see their healthcare provider sooner.

85%

agreed that telemedicine allows them to have more regular follow-up.

83%

agreed that telemedicine helps their providers work better as a team to care for them.

Avoided Travel in the North 50,000,000

45,912,636

45,000,000 40,000,000

36,494,370

35,000,000 30,000,000

32,237,562

25,000,000 20,000,000 15,000,000 10,000,000 5,000,000

14,944,489

12,051,205 8,871,796

18,839,887

12,635,185 10,043,273

0

2007/08

Avoided Travel in the North (kms) Pollutant Load Eliminated (kgs)

2008/09

2009/10

Estimated NHTG Cost Avoidance($)

Thank you Ron Riesenbach, VP Emerging Business [email protected]