Telemedicine & e-health in Taiwan

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1 April 24, 2006 Internet2 Spring Meeting International Task Force Panel Session Arlington, USA Telemedicine & e-health in Taiwan Heng-Shuen Chen, M.D. Ph.D. Dept. of Medical Informatics & Family Medicine, College of Medicine & Hospital National Taiwan University

2 Outline Introduction History and Development of Telemedicine in Taiwan Health Science Projects Related to National Research and Education Network Future Prospects

3 Introduction

4 Taiwan Area: 36,000 km 2 (near Netherlands) Population:23 millions (near Australia) second highest population density in the world (623/km 2 ) after Bangladesh.

5 Taiwan s BMW Broadband Network DSL (World s 2nd, 27.9/100 phone lines) Cable modem FTTH/FTTB (fiber to the home/building) 75% households Internet connected, 93% of them used broadband networks. Mobile & Wireless Network Mobile phone (World s Top, near 100%) Wireless LAN (WiFi, 90% Manufacture) WiMax

6 Internet in Taiwan Internet User Population 65% 42% of them wireless network user Top Ranking e-government Ranking (Brown University) Global Digital Living Index (Parks Associates) Internet usage (NOP World Culture Score Index) 12.6 hours on the computer/internet outside working time Taipei, Top Seven Intelligent Communities (Intelligent Community Forum, ICF)

7 Taiwan National Research & Education Networks TANet First Internet serve to educational & research institutions TANet2 Since 1998, Serve most education & research institutions The research network known to the international network Managed and operated by the NCHC TWAREN(TaiWan Advanced Research & Education Network) Since 2004, Serves higher educational & research institutions Three levels of services re-designed: Production, Research and Optical networks Three functions assigned: Computing center, Knowledge (data) center, Network operation center Since 2005, Backbone shared by TANet

8 TWAREN Topology (production network, 2003) NCTU NTHU NCHU NCNU CCU NCKU NSYSU NCU Hsinchu Taichung Tainan SINICA Taipei NTU NDHU 4 core nodes 11 GPoPs 20 G backbone Eastern Broadband (10G) Chunghwa Telecom (10G) Chunghwa Telecom (5 G) Core nodes Dual circuits from two vendors form the physical backbone

9 International Links from Taiwan Tokyo-XP 2.5 Gbps LA 2.5Gbps Lightpath 622 Mbps 1.Mbps Taiwan 2.5 Gbps 2.5 Gbps Hong Kong HARNet 155 Mbps Singapore SingAREN Amsterdam AMSIX

10 History and Development of Telemedicine in Taiwan

11 Why Telemedicine? Geographic:75% mountainous area, several groups of isolated islets Poor medical resources in rural area Physicians are reluctant to practice in rural area Afraid of being isolated Lacking opportunities for CME Specific needs: Handicapped and Elderly Home care(palliative medicine)

12 History of Telemedicine 1990 TANet (Taiwan Academic Network) 1994 NII (National Information Infrastructure) Planning 1995 NII Kickoff (National Health Insurance started) 1996 NII Pilot Telemedicine projects: Medical Distance Education Teleconsultation 2000 HIN 2.0 (National Health Information Network version 2) EMR

13 1995 NII Kick Off Pilot Project of Distance Education First Distance Education Lecture in Taiwan via ATM/DS-3 : NTU(College of Medicine), NTHU, NCTU

14 Three Stages of Telemedicine Initiation Research Stage (1994~1996) Promotion Research Stage (1997~1999) Implementation Stage (starts in 2000)

15 Initiation Research Stage Different bandwidth and network platform Distance education Pilot Project Broadband ATM DS3 videoconference Narrowband ISDN 128K desktop videoconference ISDN 384K room based videoconference Teleconsultation Pilot Project ATM DS1 teleconsultation ISDN 768K+768K teleconsultation

16 Distance Education ISDN Room-based 384K

17 Teleconsultation (DS1) Synchronous and Asynchronous

18 Promotion Research Stage Different specialties and applications Videoconference CME by videoconference: Family Medicine CME Course Broadcast to Community Hospital Multipoint Videoconference: Multi-center Palliative Medicine Case Conference Web-based Web-based Telemedicine System (EMR & PACS) Web-based Virtual Classroom & VOD Electronic Journal: Chinese Full-Text International Telemedicine: NGI/Internet2

19 Multipoint Videoconference Palliative Medicine Case Conference

20 VOD (CME in Family Medicine)

21 International Telemedicine Virtual Hospital Taiwan Mirror

22 International Telemedicine NTU-UIOWA Teleradiology

23 International Telemedicine NTU-UIOWA Teleradiology

24 Implementation Stage Integrate telemedicine to community health information system e-health Network Clinic: Synchronous & Asynchronous teleconsultation Telecare (Volunteer, School, Church) e-learning Continuing Medical Education (CME) Group Patient Distance Education VMS: Virtual Medical School e-records Family Folder system Electronic Health Records Electronic Referral System

25 921 Earth Quake(1999 Sep. 21) Severe damage and destruction in Nan-Tou County

26 NTU Telemedicine 2000 NTU was responsible to reconstruct the health system of Nantou County NTU-PCH(Puli Christian Hospital, Nantou) Telemedicine Project Joint Network-Clinic Service Center System (NTUH-NCKUH-TSGH) Community Health Group-Health Information and Family Doctor System(CHGIFS, Lugu Township, Nantou)

27 Network Clinic & Telecare Doctor s s End Patient s s End

28 Network Clinics Remote Sites 翠 巒 部 落

29 Netwrok Clinic Synchronous Teleconsultation

30 Joint Network-Clinic Center Online Registration 1.Choose a Doctor 3.Regi station 2.Input Data 4.Canc elling

31 Joint Network-Clinic Center Electronic Medical Records 1. Input Data 3. Confirmation 4. Printing 2. Upload

32 Continuing Medical Education Multipoint Videoconference

33 Patient Distance Education Nutritionist at NTUH Health Station at Aboriginal Area

34 Medical e-learning 2000~ Web-based e-learning in Medical Education

35 Virtual Medical School

36 CHG-HIFDS Community Healthcare Group Health Information and Family Doctor System 300 CHGs with 2000 family doctors(15% in Taiwan)

37 CHG-HIFDS Family Folder Subsystem

38 CHG-HIFDS Electronic Referral Subsystem Medical Center Expert Diagnosis Canning of Chest Xray With Mini PACS system

39 CHG-HIFDS Electronic Referral Report

40 Health Science Projects Related to National Research and Education Network

41 TANet2/TAWREN Health Science Related Projects & Activities National DOH Telemedicine Projects: Joint Network Clinic Asthma GRID SARS GRID Medical Problem Based elearning (PBeL) International multi-country Teleconference & Forum Telemedicine and e-health Medical Informatics (IP, H.323) Pancreatic Transplantation (DVTS)

42 Joint Network-Clinic Service NTUH-NCKU 台 大 醫 學 院 405 室 Intranet 台 大 家 醫 6A 討 論 室 台 大 家 醫 遠 距 會 診 室 台 大 醫 學 院 101 講 堂 埔 里 基 督 教 醫 院 & 仁 愛 鄉 衛 生 站 Internet 烏 來 鄉 衛 生 所 成 功 大 學 ISDN 聖 馬 爾 定 天 主 教 醫 院 耕 莘 天 主 教 醫 院 阿 里 山 鄉 衛 生 所

43 Asthma Grid

44 Asthma Grid Before After

45 Taiwan s connections to N. America at the time of SARS epidemic Taipei STM-16 (2.5G) 2.5 Gbps Vancouver Edmonton Calgary 1 GbE STM - 4 Abilene CA*Net4 Winnipeg Montreal StarTap Toronto StarLight Europe Halifax Taiwan In 2003 Trans-Pacific links to Seattle and Chicago, each at 2.5 Gbps Links between STTL & Chi: 622 Mbps & 1Gbps lightpath. From Chicago to Europe at 2.5 Gbps

46 SARS Grid NCHC Access Grid node test the SARS Grid network links

47 Access Grid 1.2 PIG

48 SARS Virtual Classroom Narrow Band Multivideo (I)

49 SARS Virtual Classroom Narrow Band Multivideo (II)

50 SARS Virtual Patient Problem Based e-learning Medical Problem Reasoning Characteristics Mentor and Apprentice H1 Basic Data Chief Complain Hypostheses Generation H2 Observation, Hints Problem-Based Learning (PBL) History, Physical Exams History, Physical Exams Evidence-Based Medicine Decision Decision Lab test, Image Diagnosis Diagnosis Diagnosis

51 SARS Virtual Patient Clinical Case Authoring

52 SARS Virtual Patient Tracking & Evaluation in PBeL

53 International Collaboration IP Video Conference & Streaming Four countries Videoconference(Speaker, Stanford U. Dr. Song) Quick Time or Real-video Streaming

54 2006 APAN DV10 Medical Working Group Meeting

55 EzLMS e-learning Platform

56 Future Prospects

57 Health Science Network Projects in Taiwan Ubiquitous Healthcare of Aging Society International Initiative for u-health Wireless Hospital Wireless LAN, VoIP, Messaging, Mobile EMR, Mobile Doctor Health Community Network Integrated with NHI Smart IC Card, HCA, EMR, Electronic Referral, Family Doctor Holistic Care, Long term Care (Institution, Homecare, Life Care Services, and Network ISP) National Health Education Network & Suicide Prevention Network

58 Aging Population in Taiwan

59 Rapidly Decreased Childbirth (1:7) , , (1:8) 8.8 1, , , , , Crude Birth Rate Aging Population Total Fertility Rate Old Age Dependency Ratio Year 14 25(1:4) 20 33(1:3)

60 Elderly Healthcare Problem Huge Healthcare Need: burden for families Biomedical support: chronic illness with complication, handicapped, terminal illness Psychosocial support: living alone, social isolation Emergency support: acute events Escalating Healthcare Expense: In Taiwan, 10% Elderly account for 25% of total health care expenses, 40% of emergency medical services

61 NTU u-hospital Project Objective: To provide a mobile, personalized, and ubiquitous care in realtime to achieve the best quality of health service Fundamental Elements Interdisciplinary teamwork telecommunication networks Healthcare services Mobile Emergency Service Network Mobile Home Healthcare Network Mobile Ambulatory Healthcare Network

62 u-hospital Interdisciplinary Teamwork National Taiwan University: College of Medicine: Medical Informatics, School of Nursing, School of Physical Therapy College of Public Health Institute of Health Organization Administration College of Electrical Engineering & Computer Science Department of Electrical Engineering, Department of Computer Science, Institute of Electronic Engineering University Hospital Department of Information Service, Department of Family Medicine, Department of Emergency Medicine, Branch Hospital with Nursing Home Other Collaborative Institutions and Organization National Taipei University of Technology Yu-Da College of Business Biomedical Engineering Center, Industry Technology Research Institute Cardinal Tien Hospital Taiwan Telecare Industry Alliance Taiwan Wireless Communication Strategic Alliance

63 u-hospital: Subprojects Mobile Computerized Health Records NTUH e-hospital Portal Mobile Electronic Medical Record (memr) Mobile Electronic Home Care Record (mehcr) Telecare System Mobile Emergency Medical Service Network Home Telehealth System Remote Activity Monitoring (Health Guard) Nurse s e-bag for Homecare Visit Gait Monitor & Fall Detection Health Management Medication Compliance & ADR Prevention ehealth Education: Weight reduction, suicide prevention

64 NTU u-hospital System 2 3 Sensor DTV Sensor Family doctor of Clinic 1 I Community Community Hospital Hospital Community healthcare group Sensor area Ambulance Home Site Ambulance Homecare nurse Family Company Member Work Site Care Center

65 System Structure of u-hospital Home 居 家 端 Vital sign measurement and sensor End Communication module Home Application system Internet Care 服 Center 務 端 Data saving module Web-based XML Windows-based Data Communication 通 訊 端 Data transfer engine Vital sign database Vital sign data analysis Alarm Service module Online Analysis processing Clinics service module Data Research analysis Heterogeneous data integration module Heterogeneous data transfer module Standard Data transfer module HL 7 DICOM Internet Hospital 醫 療 機 構 Vital sign query Data Integration Interface HIS integration module HIS integration module Emergency Service 支 援 服 務 中 心 Emergency processing Module Emergency Inform Data Integration Interface Call Center module Vital sign query Vital sign query Data Integration Interface Internet Communication System 3G GPRS ADSL Wireless LAN Message transmit and receive module Message transmit service Message receive service Internet base architecture Network Server Security Server Family Doctor 行 動 看 護 Mobile application system module

66 Electronic Medical Record (EMR) Intranet PDA (with GSMmodule) Extranet PC PDA Wireless Operating Network Internet Internet (with IEEE module) (with Web Browser) VPN PC Web Server PDA (with IEEE module) (with Web Browser) Interface Interface Add-on Add-on Services Services Component Repository EMR System DB DB Interface Interface Files HL7 IE Interface Interface Interface HIS LIS RIS Extended Module Other Systems Others Healthcare Institution Client Layer Web Service Layer App. Service Layer IE Layer

67 From e-hospital to u-hospital Access EMR via Mobile Devices and Desktop PC

68 Vehicle Computer Access EMR

69 Family Doctor & u-hospital

70 Mobile Emergency Medical Service Network System Architecture Duty on fire Rescue path DSS GPRS Module GPS GPRS Module Monitor MHEMS System (HA Server) Internet (HTTP protocol) AGPS System GIS EMTs PDAs ( with MHEMS System) (EMT Clients) Dispatch 勤 務 指 and 揮 中 Mission 心 Control Center Terminologies: MHEMS: Mobile Hospital Emergency Medical System Terminologies: DSS: Decision Support System MHEMS: Mobile Mocile Hospital GIS: Geographic Emergency Information Medical System DSS: System Decision Support System GIS: GPS: Geographic Global Positioning Information System GPS: EIS: Global Emergency Positioning Information System EIS: System Emergency Information System Doctors Doctors Treatment instruction Vital Sign, Images Preliminary Data MHEMS System (Hospital Clients) EIS (Prepare EHR) (Prepare Emergency Stuff) Ambulance Ambulance Vehicles Emergency Dept. Department of Hospitals of Hospital

71 Ambulance Dispatch and Mission Control Center The operator of Dispatch and Mission Control Center dispatches Ambulances and monitor them by GIS.

72 Ambulance GPS module (GPRS) Patient and EMT in the Ambulance EMT PDA (GPRS/3G)

73 Message transfer in Mobile Emergency Medical Service Emergency call Dispatch and Mission control Center GIS Pre-calculate ETA 1 Duty information Define district hospital and ambulance 2 Read duty information Inform ETA & ambulance position Patient data 3 Inform hospital & read ETA in period time 5 GPS 4 Vital signal & picture GPRS PDA WinCE Ambulance Send Patient ID 6 Hospital Show the patient information on the order of ambulances arriving Patient history HIS Emergency treatment records Emergency treatment save to HIS Message transfer flow establishes the work of MHEMS system

74 Functions of Home Telehealth Telecare Emergency call (life line) Location (indoor, outdoor) Alarm (remote monitoring of vital sign) Communication Interactive video (home setting, ambulatory) Society (Discussion Group) Management Electronic Records (home visit records of nurses, physicians and linked to HIS) Health management (Life style modification, periodic health exam, chronic disease surveillance, drug compliance, appointment etc. )

75 Home TeleHealth Gait Monitor & Fall Detection Measure gait: Adidas Smart shoes: pressure sensors on shoes Smart floors: pressure sensors under floors

76 Prospects of u-health Synchronize with current government policy National Health Information Infrastructure (NHII) e-taiwan II Project m-taiwan Project u-taiwan Project Collaborate with International Organizations IEEE/ITU-D/WHO Mobile e-health Initiative International Initiative for ubiquitous Healthcare Promote and Collaborate with Industry MOEA and Industry Alliances IEEE Healthcom International Conference Healthcom2006 (India), Healthcom2007(Taiwan)

77 Government u-health Related Projects DOH TeleCare Project MOEA Elderly U-Care Project NHRI Geriatric Functional Index, Friability NSC Intelligent living Technology

78 u-health TAIWAN EXPO for u-health Industry IEEE HealthCom 2007 Conference HL7 Asia-Pacific Meeting APEC PACS Meeting

79 Wireless Hosp & Mobile Doctor

80 Health Community Network Follow the planning NHII Apply techniques of the Internet and multimedia database Establish a community-based health information system Integrated Community Oriented Primary Healthcare, Public Health Service, Long Term Care with IDS(Integrated Delivery System)

81 Health Community Network e-counselling e-rereferal e-appointment e-health Education Medical Care Family Folder u-care Service Coordinative Comprehensive, Continuous Medical Records Health Information. Biosignal Records Emergency alam Home Patient Call Center Care giver Healthy lifestyle Lifeline call Tele-homecare Home Care Life Care Self health management Home safety CA Security

82 National Health Education Network

83 Taiwan Suicide Prevention Center

84 Thanks for your Attention

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