Establishing a Global Telehealth Service: Case Perspectives in Latin America

Orlando Vallone Junior National Telehealth Conference

University of Cincinnati, 20-21 March 2014

Disclosure

Specialty Telehealth Services, Inc.

- President and financial interest

Objectives Describe the evolution of Telehealth technology and

applications based on our experiences in the region

Share implementation lessons and operational tips when implementing distributed Telehealth networks

Describe educational uses and potential impact of a Latin American Regional Stroke Network

Demonstrate a live Telehealth system and Response Center operations

Topics

Our Background

Motivation and Opportunities

The Challenges

Implementation

Questions and Answers

System Demonstration

Development Timeline

2013 2006

Family member suffered stroke

2011

Government Contract

1990

Telestroke Network

Latin America

2005

Telehealth Solutions R & D

Telemedicine, Tele-education, Teletrauma,

and Teleradiology

TV Uplink Services - Brazil

Broadcasted to the U.S., Latin America, and Europe

2012

Brazilian Olympic

Team

Our Background Satellite and cable TV uplink services

provider and operator (Brazil, US, Latin America, Europe (1990 - 2005).

Implementation of Telehealth solutions

using wide-coverage satellite (Telemedicine, Tele-education, Teletrauma, and Teleradiology).

STS operates a Response Center in

Miami, FL USA (Teletrauma and Telestroke to US, LatAm, Europe).

Ultrasound Course Demonstration

Hospital Mario Covas – Santo André – SP – Brazil 2005

Teletrauma and Tele-education

Ryder Trauma Center – Miami, FL – USA 2006-2008

Demonstration of Remote and Main Hospital Installations

(Clinical Case Videoconference and Live HD Video Transmission)

1

Crystal Palace Training Center

London

STS Response Center - Miami

Brazilian Olympic Telemed System

Hospital into Trauma - Rio

Hospital Samaritano General - Rio

King’s College Hospital – London

Hospital ABBR General - Rio

London Olympic Venues

1

1

2

University of Miami Specialty Doctors

20 (Doctors+Physiotherapists ) (10 Smartphones + 10 Tablets)

2 2

2

VC + Phone E-mail+Telerad Cellular/WiFi

2 1

WSC 2012 – Latin American Telestroke Network

Motivation and Opportunities

Interest in applying international satellite and business experience to establish Telemedicine networks for tele-education, public health and disaster management uses

Family event of a stroke case in São Paulo 8 years ago Major DISABILITY Conjunction of favorable events in 2011/2012

‒ High level of broadband internet penetration ‒ Availability of standards-compliant imaging access ‒ Growth of Telestroke networks in the USA ‒ Technological developments

• ↑ Microprocessor speeds • ↓ Costs and stable tablets/PCs • ↑ Deployment of 4G/LTE cellular networks

Challenges, Implementations and Lessons Learned

CASE I – Teletrauma and Tele-education Equipment characteristics:

• Used mainly by the satellite and broadcasting industries, • Large satellite antennas and no broad band Internet, • High cost per systems and asymmetrical links (↑dowlink /↓uplink

rates), 1 channel HD video encoder ~ $50K/60K, • Emerging HD Video Conference Codecs (~2006/07),

Lessons:

• High cost to build one-way tele-education network with simultaneous teletrauma capabilities,

• Equipment required more training for doctors to become comfortable with technologies,

Challenges, Implementations and Lessons Learned

CASE II – Remote Clinics and Brazilian Olympic Telemed System Equipment characteristics:

• HD Videoconferencing hardware more common, • New software Codecs – lower costs, faster and scalable

deployments (highly dependent on servers and VC bridges) • Moderate cost per systems, growth in broad band Internet

availability - US and parts of Latin America - (mainly with the use of cable modems),

System requirements:

• 24-hour Telemed response for Brazilian Olympic Team • To provide response coordination and operations using WIFI and

LAN and very limited 3G/4G network • To provide imaging sharing capabilities among sites

Challenges, Implementations and Lessons Learned

CASE II – Remote Clinics and Brazilian Olympic Telemed System Lessons:

• Mandatory site survey and event pre-planning (reduce

connectivity problems, maps limitations),

• Constant Testing specially when operating multiple platforms (Hardware VC, Robots, Cellular/Satellite Phones, Tablets, and PC’s),

• This system can be scaled to provide concurrent emergency and

disaster support (additional uses may lower overall deployment costs),

Challenges, Implementations and Lessons Learned

CASE III – The Case for a Latin American Telestroke Network Competing Indices in Latin America and Brazil

• Brazil ranks extremely high in risk factors for stroke,

• Brazil highest TV viewership times Physical Inactivity Obesity, High BP, Diabetes Development of CVD,

• Brazil has very high cellular phone penetration over last 5-7 years (Surpassing Korea’s rates),

• Brazil has very high broadband internet penetration (16.8 Million subscribers 2011),

• Brazil had 129,000 stroke deaths and 11 years of disability (DALYs) lost per 1,000 population

TV Viewership Times From Instituto Brasileiro de Geografia e Estátistica (IBGE 2008) Panoramic Health Study in Brazil: (2013 estimate – Population ~ 200 Million) “Out of a total population of 189 million, 175 million people (92.4%) had a habit of watching TV, with 75.2 million of them (42.9%) watching TV for over 3 hours a day. 56.2 million (29.6%) declared using a computer or videogame with 28.8% of them using it for a duration of over 3 hours.” From Francine Kaufman MD, healthychildren.org: “Watching TV, surfing the internet, and playing video games don’t count as exercise. The time your child spends in front of a monitor should be kept to a limit. Some researchers recommend no more than 1 hour of screen time a day. The risk of obesity increases when your child watches more than 2 hours of TV per day.”

Brazil – Cellular Phone Penetration

0

50000

100000

150000

200000

250000

300000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

In T

hous

ands

Year

Cellular Phone Subscriptions in Brazil (~272 million Jan 2014)

Source: World Bank Data, 2012

Brazil – Broadband Penetration

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

In T

hous

ands

Year

Fixed Broadband Internet Subscribers in Brazil

Source: World Bank Data, 2012

The Opportunities

Brazil has the technological infrastructure to support new-age telehealth delivery (Mexico, Peru and Chile present similar trends)

• Brazil has very high cellular phone penetration with strong growth over last 5 years

(similar trends for most of Latin American Countries)

Our Challenges

How fast can we use these successful indices to our Telehealth advantage?

Can we reduce the burden of disability from stroke and implement telehealth with similar success?

Can we do it fast? (How many clicks away?)

Can these networks support good cases for Telestroke, Teletrauma, and Tele-Education?

Latin America Telestroke Network and Implementation

Start with smaller number of sites in areas of greatest positive health outcomes

Decide on adequate cost of on-site equipment

Shortest time to the implementation

Constant mandatory site survey and event pre-planning

Testing especially important when operating multiple platforms (VC, Robots, Phones, Tablets, and PCs).

Forms of Intervention Education (recognizing symptoms) and behavior modification (schools, media, cultural changes), Pre-hospital personnel training (EMS and Emergency Clinics) and mobile Telestroke,

Hospital-level response with Telestroke systems

− Training of Stroke Teams − Development of Primary and Comprehensive

Stroke Centers − Certification similar to that obtained in the US

Telestroke Network Components

Motivated Stroke Teams − Doctors, nurses, and protocols

Videoconferencing Collaboration System

Teleradiology Collaboration System Training

Why do we do it?

And Time is BRAIN!

Ref. National Geographic Magazine, Feb 2014

References De Bustos, Elisabeth M., Thierry Moulin, and Heinrich J. Audebert. "Barriers, Legal

Issues, Limitations and Ongoing Questions in Telemedicine Applied to Stroke."Cerebrovascular Diseases (2009): n. pag. Print.

De Bustos, Elisabeth M., Fabrice Vuillier, Didier Chavot, and Thierry Moulin.

"Telemedicine in Stroke: Organizing a Network - Rationale and Baseline Principles." Cerebrovascular Diseases (2009): n. pag. Print.

Massaro, Ayrton R. "Triagem Do AVC Isquêmico Agudo." Revista Da Sociedade De

Cardiologia Do Rio Grande Do Sul (2006): n. pag. Print. Schwamm, L. H., R. G. Holloway, P. Amarenco, H. J. Audebert, et Al, "A Review of

the Evidence for the Use of Telemedicine Within Stroke Systems of Care: A Scientific Statement From the American Heart Association/American Stroke Association." Stroke 40.7 (2009): 2616-634. Print.

References Schwamm, L. H., H. J. Audebert, P. Amarenco, N. R. Chumbler, and M. R. Frankel. et

Al, "Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care: A Policy Statement From the American Heart Association."Stroke 40.7 (2009): 2635-660. Print.

Silva, Gisele S., and Lee H. Schwamm. "Use of Telemedicine and Other Strategies to

Increase the Number of Patients That May Be Treated with Intravenous Thrombolysis." Current Neurology and Neuroscience Report (2012): n. pag. Print.

Pandian, J. D., P. Langhorne, and Linda D. Villiers. "Basic Stroke Services." Reading.World Stroke Academy. Web. <http://www.world-stroke-academy.org/pdf/WSA_basic_stroke_services_learning_module.pdf>.

"The Atlas of Heart Disease and Stroke." The CDC (2004): n. pag. The World Health

Organization. 2004. Web.

Thank You! Orlando Vallone Junior

www.stsmed.com