Telemedicine technology positioning
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The document discusses various applications and approaches in telemedicine. It defines telemedicine as the provision of healthcare services using information and communication technologies when the healthcare professional and patient are not in the same location. It describes different telemedicine technologies and applications including telesurgery, clinical kiosks, telepathology, mobile health monitoring, and remote intensive care units. It also discusses infrastructure requirements and case studies of telemedicine programs in places like Alaska, Mexico, and Denmark.
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Telemedicine technology positioning
- 1. Tendencias y enfoques en Telemedicina Healthcare Day - Caracas, February 19, 2009 Stefano SOLIANI Healthcare Solution Architect
- 5. Telemedicine Taxonomy http://www.citl.org/_pdf/CITL_Telehealth_Report.pdf Encounter taxonomy (time frame) Specialty based: Tele-radiology Tele-Pathology Tele-Psychiatry Tele-Cardiology Tele-Ophthalmology Tele-Dermatology Tele-Surgery Technology taxonomy Store & forward Real-time Collaborative Real-time Collaborative Tele-Monitoring Store & forward Real-time Collaborative Real-time Collaborative Tele-Treatment Store & forward Real-time Collaborative Real-time Collaborative Tele-Diagnosis Store & forward Real-time Collaborative Real-time Collaborative Tele-Consultation Non-Emergent setting Emergent setting Setting Intervention type
- 6. Hype Cycle for Telemedicine
- 7. Priority Matrix for Telemedicine
- 8. What Telemedicine solution ? Simple Solution complexity Complex Low Bandwidth requirements High VSAT Dial-up 2.5G GPRS/EDGE 3G UMTS/HSPA LTE E-UTRA DSL WiMAX E1 T3 Fiber 14.4K 128K 1M 2M 10M 100M 512K Telesurgery Clinical Kiosk Telepathology Mobile/Home Health monitoring Teleretinal imaging Teledermatology (store&fwd) Teledermatology [video] Remote ICU ECG monitoring Video visit E-visit Teleradiology [Outsourcing] Call Center Satellite potential span
- 26. Case studies
- 27. Seattle Children Hospital TM program Video
- 40. Recommendations
- 45. Language Interpretation Service Rapid access to Interpreter Pool Interpreter Medical-Grade Network Unified Communications Audio/Video Capable Triages call to audio only Interpreter 4b Establish Interpreter audio call Triages call to A/V Interpreter Establish Specialist video call 4a Call routed to appropriate Interpreter 3 Patient arrives – needs interpreter 1 Place call for Interpreter 2
Notes de l'éditeur
- Center for Information Technology Leadership Telehealth Taxonomy In order to form a conceptual framework of telehealth technologies on which to base the model, CITL set out to develop a telehealth taxonomy. It soon became apparent that consideration needed to be given to both the interaction of the provider* to the patient and to the technology that is in use in this field. Thus, CITL devised two telehealth taxonomies: an encounter taxonomy and a technology taxonomy. Encounter Taxonomy The field of telehealth is vast, with many different ways that telehealth equipment is being used to conduct these encounters and the individuals who are involved. From a review of the literature and interviews with experts in the field, three aspects of telehealth emerged to serve as the basis for the encounter taxonomy: the location of the patient, the setting in which it is used, and the timing in which the encounter is conducted. Location of Patient CITL first considered the location of the controlling medical authority (CMA)† with respect to the location of the patient. For the purposes of this report, the CMA is the provider who has ultimate responsibility for the patient’s care. For interactions in which the CMA is with the patient, or at the near side, we refer to this as a “consultation.” When the CMA is not with the patient, or at the far side of the communication, we refer to this as a “provider extension” relationship. Setting The second area CITL considered in our taxonomy was the setting in which care was provided, be it emergent or non-emergent. For the purposes of this report, an emergent encounter is a medical encounter that requires decisions on medical care to be made in a matter of minutes or hours, as opposed to days or weeks. A non-emergent encounter includes all other encounters in which decisions may be made over a longer timeframe. These two types of encounters cover the majority of patient visits to providers. Timing The last area CITL considered was the timeframe in which the communication of the encounter is transmitted. There are two timeframes in which a telehealth consultation can occur: store-and-forward and real time. A store-and-forward encounter collects data that is sent to a provider for evaluation at a later date, such as an email to transmit patient data and photographs to a consulting provider. A real-time encounter transmits information to be interpreted at that time, whether via a telephone call to review a patient’s case or via video conferencing. Based on these three aspects, CITL developed the following telehealth encounter taxonomy: 1. Consultation, emergent, real time The CMA is at the near, patient side caring for the patient in an emergency setting. The provider at the far side brings specialized knowledge to the care encounter. This scenario requires a dynamic telehealth network that is capable of supporting consultation on demand. 2. Consultation, non-emergent, real time The CMA is at the near side caring for the patient in a routine setting. The provider at the far side brings specialized knowledge to the care encounter. Ideally, this would occur on-demand but would typically require scheduling the consultation at a date and time when the far provider is available for the consultation. 3. Consultation, non-emergent, store-and-forward The CMA is at the near side caring for the patient in a routine setting. The two providers are not interacting in real time, but rather sending data, images, and messages for later interpretation and response. 4. Provider extension, emergent, real time The CMA is the provider at the far side caring for a patient in an emergency setting. Typically, the provider at the near side is an ancillary healthcare professional being directed to collect patient data, examine the patient, and treat the patient in real time. As with #1, this requires a dynamic telehealth network that is capable of supporting consultation on demand. 5. Provider extension, non-emergent, real time The CMA is the provider at the far side. Typically, the provider at the near side is an ancillary healthcare professional being directed to collect patient data, examine the patient, and treat the patient. This encounter is typically conducted during a pre-scheduled date and time. 6. Provider extension, non-emergent, store-and-forward The CMA is at the far side. Typically, the provider at the near side is an ancillary healthcare professional who has been trained to collect patient data, examine the patient, and treat the patient as previously established by the CMA. Data collected is transmitted to the CMA at a later date and time for analysis and interpretation. Technology Taxonomy CITL developed a taxonomy of telehealth technologies. In analyzing the breadth of what could be considered “telehealth,” i.e., the transmission of clinical data to be used at a distance from where it was collected, it became clear that there is a hierarchy of how information can be exchanged, as determined by available bandwidth. The critical issue is not overall network connectivity to each site, such as T-1, ATM, DSL, or cable, but instead is the minimum bandwidth needed per connection between the two end-points of the telehealth encounter, and whether it is technologically and financially feasible for the organizations involved. Bandwidth not only impacts how patient information may be moved, store-and-forward versus real time, but also the volume and the speed that the data may be moved. As such, bandwidth became the basis for CITL’s telehealth technology levels. Level 0 Level 0 is the traditional, non-computerized method of communication. Traditional postal mail is the classic example of the store-and-forward modality: we drop off our mail, the information travels to the recipient, and it is received at a later time, typically measured in days to weeks. The delay in transmission is accepted by users as a trade-off between lower cost for potentially large volumes of information that may be impractical or impossible to transmit in real time. In addition, this form of communication is only feasible in non-urgent situations where immediate attention is not required. The classic example of Level 0 real-time transmission of information is the telephone. When providers need to communicate urgently with a consultant, they merely pick up the telephone and have a discussion with the consultant in real time. While offering immediacy, the telephone is limited in the type of information that can be transmitted: describing radiologic studies or skin lesions is restrictive in its ability to clearly translate that data. The telephone is also limited in the volume of information that is practical to be communicated. For example, few healthcare providers would ever consider dictating a patient’s entire medical chart over the telephone. Level I The earliest attempt at applying IT to enable transmission of healthcare information is captured in CITL’s Level I. The store-and-forward modality is the common email system that most people use today. With constrained bandwidth, such as with dial-up, data transmission is limited to textual information. With time, as bandwidth capability has increased, so has the ability to email pictures and videos. The real-time corollary in Level I is the common facsimile (fax) system, ubiquitously in use today. While a fax system offers immediacy, there are ongoing costs involved, such as toner, paper, and maintenance, whereas once established, the marginal cost of faxes is minimal. Level II Most telehealth systems implemented within the past five to ten years fall into what CITL has termed Level II systems. The store-and-forward image system (Level IIa) is characterized by a web-based secure consultation system where providers upload patient information, high-resolution photographs, radiological images, laboratory data, and pathology slides to enable consultation by remote specialists. These systems require Integrated Services Digital Network (ISDN) or broadband level connections, although some remote sites have tolerated the slow image transmission associated with analogmodems over plain telephone lines. In Level IIa, the response from consultants is never immediate, but typically delayed by hours to days. The implicit trade-off in store-and-forward systems is that immediate, real-time interactions are sacrificed to enable high-resolution image content and more flexible use of network resources and provider-patient time. This trade-off in removing immediacy has made store-and-forward image systems poorly suited for any urgent, time-critical clinical interactions. The real-time modality in Level II is real-time video systems (Level IIb). The tradeoff here is that earlier real-time video systems sacrifice high-resolution still images for immediate visual interaction because of network bandwidth thresholds. This mode of transmission is optimal in encounters where face-to-face interaction may be necessary, as in the case of a neurological consultation or a psychological session. In non-emergent situations, because the patient-provider interaction is in real time, these teleconsults require scheduling and the use of space, such that patients may not receive a consultation earlier than an in-person specialist consultation. Level III Telehealth practitioners have increasingly recognized the limitations of store-andforward image systems and real-time video systems. With technology improvement, miniaturization of telehealth equipment, and falling technology costs, a hybrid system has evolved, which CITL has termed Level III. In its simplest form, hybrid technology combines the functionality of a store-and-forward image system with a real-time video system. A user of a hybrid system can choose to use it as a store-and-forward image system, as a real-time video system, or as a combination of the two on an encounterby-encounter basis. Modern hybrid telehealth systems are able to create a real-time channel of communication that is not only capable of transmitting video, but also high-resolution images, patient records, and other data traditionally associated with store-and-forward systems working in synergy. While hybrid systems may be installed in sites having only the limited network bandwidth needed to support Level IIa or IIb systems, the full potential of a hybrid system is realized when installed in sites with more plentiful bandwidth, where this synergistic data transmission capability can be fully utilized. Level IV Finally, some mature telehealth systems have developed into what CITL terms Level IV systems. These integrate the use of a hybrid telehealth system with an electronic medical records system (EMR). Early experiences suggest that this integration leads to additional synergistic effects in terms of the richness of patient data that can be shared. It is envisioned that a true Level IV telehealth system ceases to be seen separately from standard medical care, but instead is one more tool in the armament of a practicing clinician.
- Gartner's Hype Cycle model helps organizations understand the maturity of technologies and applications between initial commercialization and broad market acceptance. Every Hype Cycle includes five phases: Technology Trigger — A breakthrough, public demonstration, product launch or other event that generates significant press and industry interest. Peak of Inflated Expectations — During this phase of overenthusiasm and unrealistic projections, a flurry of well-publicized activity by technology leaders results in some successes, but more failures, as the technology is pushed to its limits. The only enterprises making money are conference organizers and magazine publishers. Trough of Disillusionment — Because the technology does not live up to its overinflated expectations, it rapidly becomes unfashionable. Media interest wanes, except for a few cautionary tales. Slope of Enlightenment — Focused experimentation and solid hard work by an increasingly diverse range of organizations lead to a true understanding of the technology's applicability, risks and benefits. Commercial, off-the-shelf methodologies and tools ease the development process. Plateau of Productivity — The real-world benefits of the technology are demonstrated and accepted. Tools and methodologies are increasingly stable as they enter their second and third generations. Growing numbers of organizations feel comfortable with the reduced level of risk; the rapid-growth phase of adoption begins. Approximately 20% of the technology's target audience has adopted or is adopting the technology as it enters the Plateau of Productivity. Publication Date: 25 June 2008/ID Number: G00157397
- Benefit Rating Definition Transformational Enables new ways of doing business across industries that will result in major shifts in industry dynamics High Enables new ways of performing horizontal or vertical processes that will result in significantly increased revenue or cost savings for an enterprise Moderate Provides incremental improvements to established processes that will result in increased revenue or cost savings for an enterprise Low Slightly improves processes (for example, improved user experience) that will be difficult to translate into increased revenue or cost savings
- VSAT: from narrow band to 4Mbps
- A Very Small Aperture Terminal ( VSAT ), is a two-way satellite ground station with a dish antenna that is smaller than 3 meters. Most VSAT antennas range from 75 cm to 1.2 m. Data rates typically range from narrowband[ vague ] up to 4 Mbit/s. VSATs access satellites in geosynchronous orbit to relay data from small remote earth stations (terminals) to other terminals (in mesh configurations) or master earth station "hubs" (in star configurations). VSATs are most commonly used to transmit narrowband data ( point of sale transactions such as credit card, polling or RFID data; or SCADA ), or broadband data (for the provision of Satellite Internet access to remote locations, VoIP or video). VSATs are also used for transportable, on-the-move (utilising phased array antennas) or mobile maritime communications. Usage The first commercial VSATs were C band (2 GHz) receive-only systems by Equatorial Communications using spread spectrum technology. More than 30,000 60 cm antenna systems were sold in the early 1980s. Equatorial later developed a C band (4/6 GHz) 2 way system using 1 m x 0.5 m antennas and sold about 10,000 units in 1984-85. In 1985, Schlumberger Oilfield Research co-developed the world's first Ku band (12-14 GHz ) VSATs with Hughes Aerospace to provide portable network connectivity for oil field drilling and exploration units. Ku Band VSATs make up the vast majority of sites in use today for data or telephony applications. The largest VSAT network (more than 12,000 sites) was deployed by Spacenet and MCI for the US Postal Service . Other large VSAT network users include Walgreens Pharmacy , Dollar General , Wal-Mart , CVS , Riteaid , Yum! Brands (Taco Bell, Pizza Hut, Long John Silver's and other Quick Service Restaurant chains), Intralot , GTECH and SGI for lottery terminals. VSATs are used by car dealerships affiliated with manufacturers such as Ford and General Motors for transmitting and receiving sales figures and orders, as well as for receiving internal communications, service bulletins, and interactive distance learning courses from manufacturers. The FordStar network, used by Ford and its local dealers, is an example of this. VSAT technology is also used for two-way satellite Internet providers such as HughesNet , StarBand and WildBlue in the United States; and ASTRA2Connect across Europe. These services are used across the world as a means of delivering broadband Internet access to locations which cannot get less expensive broadband connections such as ADSL or cable internet access; usually remote or rural locations. Nearly all VSAT systems are now based on IP , with a very broad spectrum of applications. As of December 2004, the total number of VSATs ordered stood at over 1 million, with nearly 650,000 in service. Annual VSAT service revenues were $3.88 billion (source: www.comsys.co.uk). Configurations Most VSAT networks are configured in one of these topologies : A star topology , using a central uplink site, such as a network operations center (NOC), to transport data back and forth to each VSAT terminal via satellite, A mesh topology , where each VSAT terminal relays data via satellite to another terminal by acting as a hub, minimizing the need for a centralized uplink site, A combination of both star and mesh topologies. Some VSAT networks are configured by having several centralized uplink sites (and VSAT terminals stemming from it) connected in a multi-star topology with each star (and each terminal in each star) connected to each other in a mesh topology. Others configured in only a single star topology sometimes will have each terminal connected to each other as well, resulting in each terminal acting as a central hub. These configurations are utilized to minimize the overall cost of the network, and to alleviate the amount of data that has to be relayed through a central uplink site (or sites) of a star or multi-star network. Technology VSAT was originally intended for sporadic store-and-forward data communications but has evolved into real-time internet services. VSAT uses existing satellite broadcasting technology with higher powered components and antennas manufactured with higher precision than conventional satellite television systems. The satellite antenna at the customer's location includes, in addition to the receiver, a relatively high-powered transmitter that sends a signal back to the originating satellite. A very small portion of a transponder is used for each VSAT return path channel. Each VSAT terminal is assigned a frequency for the return path which it shares with other VSAT terminals using a shared transmission scheme such as time division multiple access . [1] An innovative feature of VSAT is that the technology has evolved to the point that something that previously could only be done with large, high-powered transmitting satellite dishes can now be done with a much smaller and vastly lower-powered antenna at the customer's premises. In addition, several return-path channels can co-exist on a single satellite transponder, and each of these return-path channels is further subdivided using to serve multiple customers. In the system used by WildBlue , 31 different spot beams are used to serve the continental United States instead of the one beam used by conventional satellites. [2] Thus, the same Ka-band transponders and frequencies are used for different regions throughout the United States, effectively re-using the same bandwidth in different regions. The return path is transmitted from the customer's receiver in the L-band to a device called a low-noise block upconverter. There it is converted into the much higher frequency satellite transmission frequency, such as Ku-band and Ka-band , and amplified. Finally the signal is emitted to the dish antenna which focuses the signal into a beam that approximately covers the satellite with its beam. Because the transmission cannot be precise in these smaller dishes there is some effort to use frequencies for the uplink that are not used by adjacent satellites otherwise interference can occur to those other satellites. Another satellite communications innovation, also used by satellite trucks for video transmission, is that only a small portion of a single satellite transponder is used by each VSAT channel. Previously a single transponder was required for a single customer but now several customers can use one transponder for the return path. This is in addition to time-based subdivision. Pros and cons of VSAT networks Advantages Availability: VSAT services can be deployed anywhere having a clear view of the Clarke Belt Diversity: VSAT provides a wireless link completely independent of the local terrestrial/wireline infrastructure - especially important for backup or disaster recovery services Deployability: VSAT services can be deployed in hours or even minutes (with auto-acquisition antennas) Homogeneity: VSAT enables customers to get the same speeds and service level agreements at all locations across their entire network regardless of location Acceleration: Most modern VSAT systems use onboard acceleration of protocols such as TCP ("spoofing" of acknowledgement packets) and HTTP (pre-fetching of recognized HTTP objects); this delivers high-quality Internet performance regardless of latency (see below) Multicast: Most current VSAT systems use a broadcast download scheme (such as DVB-S ) which enables them to deliver the same content to tens or thousands of locations simultaneously at no additional cost Security: Corporate-grade VSAT networks are private layer-2 networks over the air Disadvantages Latency: Since they relay signals off a satellite in geosynchronous orbit 22,300 miles above the Earth, VSAT links are subject to a minimum latency of approximately 500 milliseconds round-trip. This makes them a poor choice for "chatty" protocols or applications such as online gaming Encryption: The acceleration schemes used by most VSAT systems rely upon the ability to see a packet's source/destination and contents; packets encrypted via VPN defeat this acceleration and perform slower than other network traffic Environmental concerns: VSATs are subject to signal attenuation due to weather (" Rain Fade "); the effect is typically far less than that experienced by one-way TV systems (such as DirecTV , DISH Network or British Sky Broadcasting ) that use smaller dishes, but is still a function of antenna size and transmitter power and frequency band Installation: VSAT services require an outdoor antenna installation with a clear view of the sky (southern sky if the location is in the northern hemisphere or northern sky if the location is in the southern hemisphere); this makes installation in skyscraper urban environments or locations where a customer does not have "roof rights" problematic Future applications Advances in technology have dramatically improved the price/performance equation of FSS (Fixed Service Satellite) over the past five years. New VSAT systems are coming online using technology that promise higher bandwidth rates for lower costs. FSS satellite systems currently in orbit have a huge capacity with a relatively low price structure. FSS satellite systems provide various applications for subscribers, including: phone conversations; fax; TV broadcast; high speed communication services; Internet access; video conferencing; Satellite News Gathering (SNG); Digital Audio Broadcasting (DAB) and others. These systems are applicable for providing various high-quality services because they create efficient communication systems, both for residential and business users. [ edit ] Constituent parts of a VSAT configuration Antenna Block upconverter (BUC) Low-noise block converter (LNB) Orthomode transducer (OMT) (IFL) (IDU) All the outdoor parts on the dish are collectively called the ODU (Outdoor Unit), i.e. OMT to split signal between BUC and LNB. The IDU is effectively a Modem, usually with ethernet port and 2 x F-connectors for the coax to BUC(Transmit) and from LNB (Receive). The Astra2Connect has an all-in-one OMT/BUC/LNA that looks like a QUAD LNB in shape and size which mounts on a regular TV sat mount. As a consequence it is only 500mW compared with the normal 2W, thus is poorer in rain.
- http://www.continuaalliance.org/home
- http://www.visicu.com/products/index.html ICU® Integrated Healthcare Solution for Critical Care The patented e ICU® Program allows hospitals to create a system-wide critical care program, built on a powerful technology infrastructure that improves quality, operating efficiency, and economic performance. View Diagram The e ICU Program is sold to hospital health systems that want to improve the quality of their intensive care unit (ICU) care. If you can understand how air traffic controllers and onboard technology for pilots keeps fliers safe, you'll be able to understand how an e ICU facility keeps patients safe. ICU patients require around-the-clock specialized care, however most ICUs don't have the specially trained physicians (intensivists) available to provide this. With an e ICU facility linked via telemedicine and computer monitors to their hospital ICU rooms they now can. An e ICU Program is staffed with an intensivist-led care team that can monitor and care for hundreds of patients much like air traffic controllers monitor hundreds of planes. In an airplane pilots also use on board sensors to identify problems and intervene to maintain a safe flight. Likewise, the e ICU care team uses software alerts to track patient vital trends and intervene earlier-before complications occur. Studies show that this type of care model can reduce ICU mortality by 25% and save costs. The keys are constant surveillance, providing the patient with immediate physician access and arming the physician with the patient information needed to make the right decisions, quickly. VISICU provides the hospital/healthcare system with the e CareManager™ technology system training and implementation which includes: Remote Care Tools Proprietary software System Architecture Care Delivery The hospital/health system provides the personnel to staff the e ICU center. A VISICU team works with the hospital/health system every step of the way, forging a lasting partnership for critical care excellence. Our e ICU Success Guide identifies the pitfalls and provides the blueprint for a successful program; following contract signing our clinical and technical implementation team will have you up and operational in 120 to 180 days. Following go-live, our clinical operations team will provide the necessary on-going support and our account managers and technicians will ensure timely response and customer satisfaction.
- TM for MedCom is part of a large effort to standardize on HC communication, saving money and time. They promoted effective data transfer between several actors of the health service, including stakeholders of the community-based social care system. This national network allows fast information flow in form of reliable data exchange of EDIFACT or XML-based messages among the respective software systems of the participating healthcare providers. Electronic data interchange (EDI) is used for the messaging process, including: • GP referrals to hospitals • GP prescriptions • GP requests for diagnostic tests • Test reports • Discharge letters to GPs • Notifications of discharges to community and home care services • Reimbursements. The focus of the economic assessment of this unique nationwide eHealth system has been on the direct impacts from improved message exchange. Benefits for citizens are derived from faster, more reliable and more efficient communication between healthcare and social care professionals. GPs’ benefits include costs savings on secretarial and clerical services in preparing and sending information to other healthcare services. Pharmacists can receive prescriptions directly and electronically from GPs, a faster and more reliable process than paper prescriptions transferred by hand.
- TeleHealth India: The Challenges Facing Teleconsultation via an eHealth Portal Case Study Authors Anonymous Application In 2001, an idea was conceived to support health systems in one state in India using ICTs. The project actually got underway in 2003 with creation of an e-health portal. Application Description The intention of the TeleHealth portal is to provide a single source of informational support on health in the state, serving everyone from individual citizens through primary health workers and medical professionals in tertiary care centres to health administrators. To date, the portal itself has been created, and it has developed and tested a teleconsultation application that links a primary health centre with the Mercy College Hospital in the state capital. In the primary health centre, the medical officer identifies non-emergency cases where there is some doubt that would normally cause her to refer the patient to Mercy College. Just after lunchtime, she fills a form located on the portal for each one of the patients. At mid-afternoon, the head of Medicine at the College Hospital accesses each case form, and provides expert comments online. These comments are accessed by the medical officer on the portal the following day, with guidance on how the case can be managed locally (or advice on further referral of the patient). Application areas under development include creation of: · an online resource centre for medical literature; · an online discussion forum for physicians located in rural primary health centres; and · an online discussion forum for medical specialists located in urban tertiary care centres. It is also intended to use the portal as a platform for initial and continuing medical education. Role of ICT The TeleHealth application is a Web-based portal hosted on a server PC. Alongside basic HTML, site pages are created using Java, ASP and SQL database. Application Drivers/Purpose The initial driver for the project came from staff in local medical academic institutions, seeking to find ways in which ICTs could be used to improve the delivery of health services. Stakeholders The core stakeholders are the health professionals within the state's health system, and the patients that they serve. As noted, the main originating stakeholders are a small group of medical specialists in a number of different academic institutions. Various health administrators need to be involved in progressing the system. Finally, there are funders within the state and central government, and technologists in government who have had an important influence on the project. Health and the Poor The teleconsultation module of the portal is intended to have a fairly direct impact, reaching out into poor communities. In the majority of cases referred through the teleconsultation module, the need for the patient to travel to the state capital is avoided. Previously they would have had to make that journey, at a direct cost of something like US$2 for travel of patient and relatives, plus the opportunity cost of income lost through having to travel instead of working. Impact: Costs and Benefits The development costs of the portal are unknown because this has occurred through the time given by the originating team or their students as a design exercise. The teleconsultation pilot cost around US$400 for each of the two PCs installed (one in the health centre, one in the College). Portal and server hosting costs are estimated at around US$200 per year. Only a very limited number of pilot teleconsultations have taken place, but it is estimated that the dial-up costs from the health centre are US20c per consultation, as compared to an estimated cost of US$10 per patient if they travel to the medical college for a referral. On one of the pilot days, there were eight referrals via the portal. One had to be rejected because the form was incomplete, one patient was referred to a gynaecologist, and six were able to be managed locally. Since the health centre medical officer had planned to refer all six to the college, that suggests a daily saving of nearly US$60. Even allowing for daily variations and uncertainties in the calculations, this suggests a financial payback period for each health centre installation of less than one month. However, as discussed below, the project has faced major difficulties which are hindering its full implementation. Evaluation: Failure or Success? The project is only at a pilot stage. It has succeeded as far as proof of concept is concerned, but cannot yet be evaluated since it has not been fully implemented. Enablers/Critical Success Factors Hybrid team . The successful piloting of this e-health application can be put down in part to the 'hybrid' nature of the team involved, drawing together skills from different areas including social science, medicine, and ICTs. In particular, the non-technical team members have taught themselves ICT skills so that they can understand both sides of the health-ICT divide. Constraints/Challenges Mindset and politics of technical staff . The main problems suffered by this project have come from the technical staff involved in the state government. They have always kept the technical and administrative controls for the portal to themselves. They have made it difficult to add new members to the portal discussion forums, forcing the project to make use of Yahoo groups instead of using the group feature within the portal. The portal's IP address has also been re-assigned at times - for six weeks it was used to declare the results of state high school examinations. One could attribute these problems to the traditional divide between 'techies' and mainstream health professionals. Indeed, this is the excuse used by the technocrats: that the non-technical project staff do not have the skills to manage the portal (despite the fact that these latter staff are running their own Web sites and online discussion groups). However, the underlying issues seem more likely to be political, from the simple desire of technical staff to retain power by retaining control, to their involvement with potentially competing projects. The politics of funding . Getting funding for the project has always been difficult, explaining the delays between conception of the project in 2001 and only really getting started in 2003. The project was begun with no funding, but the state government was interested. Funds were twice allocated for the project, but then transferred to other projects that had a higher political priority. As a result all progress had to be made from the project team's own resources. When a central funding award was finally made for the project, 95% of the money was assigned to an agency 2000km away, located in the constituency of a senior federal government minister. More politics . The state's own health department is keen on the portal to progress. However, there is animosity between the head of that department and the head of the main IT institution involved. This has hindered progress. Incentivising system use . A sister project to this pilot was developed to support the medical consultation process. Although the system has worked well in trials, and is being used for medical education, there has been no usage of the system by medical professionals despite it being available for more than one year. Those professionals are demanding first that a full-time staff member be appointed for the project, and second that they should be given some incentives to perform online consultations using the new system. Without these, they refuse to be involved with the system. Recommendations Creating hybrids . This project shows both the benefits and problems of the hybridisation necessary for an e-health project to succeed. The core project team has worked well in its combining of health and ICT competencies. Yet the divide between technical and non-technical staff has been a fundamental constraint to project progress. One lesson is that it is better to try to create hybrid individuals rather than hybrid teams for e-health projects: i.e. individuals who combine an understanding of health systems/services with an understanding of ICTs. One could try to create those individuals by training ICT staff in health matters. However, experience on the project suggests that it is much better to hybridise the other way: by taking existing health domain specialists and helping them to understand the technology. Patient-/health-centred design . In too many e-health projects, the application design is technology-driven. The technical staff take a very basic brief and then go off, design the architecture and develop the underlying software according to their own understanding, capabilities and interests. Training is then designed to make the health professionals understand, accept and adapt to the features the technologist has designed. This, of course, is the tail wagging the dog. A proper approach to design would start with the patient or the health professional and find out what they require. The approach would also be flexible, taking feedback from prototyping in order to redesign and create a more usable system. One key area this issue arises is in the question of security and privacy of health data. From a patient-centric perspective very strict protocols would be designed in, to avoid personal health data from being revealed. In the techno-centric approach used for some parts of the TeleHealth project, there was no real consideration of the need to protect data - patient details for teleconsultation were available on the portal. Avoid 'hard', software engineering approaches . As a follow-on from the previous point, e-health projects are sometimes developed using 'hard' software engineering approaches that have little consideration of actual information needs or of political realities. Instead, softer systems development methods are required that understand the political context for the e-health system, and which also develop that system on the basis of the true information needs of key health users. KISS: keep it simple, stupid . The software design needs to be such that system management and also system use are fairly simple processes that can readily be grasped by non-technical health professionals. Further Information n/a Case Details Case Editor : Richard Heeks. Author Data Sources/Role : Project Coordinator Role. Outcome : Too Early to Evaluate Region : South Asia. Start Date : 2001. Submission Date : January 2004.
- University of Miami Center on Aging Deploys Cisco Unified IP Phones to Assist Caregivers Video Phones Convert Homes into Workspaces for Alzheimer's Patient Care SAN JOSE, Calif. - January 8, 2008 - The University of Miami's Center on Aging today announced a pilot program that will help enable Alzheimer's patients' caregivers to reduce their stress, isolation, and likelihood of depression through video access to resources such as online support groups and care tips. The program, "A Computer Integrated System for Telephones", uses the Cisco® Unified IP Phone 7985G to help caregivers gain access to educational seminars and individual counseling sessions. With its video capabilities, caregivers use the phones to convert the home into a workspace for finding resources and obtaining quick solutions at the point of care. The Center on Aging selected Cisco Unified IP Phone 7985G because of the large, easy-to-read display area, buttons that caregivers can use to select different options, and the ease of displaying text based on caregivers' menu selections. Through the program, caregivers' homes are equipped with the Cisco Unified IP Phone 7985G, a broadband connection, and a Cisco 871 Integrated Services Router that connects them to the Center on Aging network and is capable of providing the quality of service (QoS) needed to send high-quality video over the Internet. Caregivers can also make and receive calls exactly as they would with any other phone. "We're working hard to develop innovative programs to help family members care for their relatives with Alzheimer's disease," says Sara Czaja, Ph.D., co-director of the Center on Aging. "The trend now is to keep patients in their homes instead of sending them to long-term care facilities. The primary caregiver is typically a family member, who becomes an extension of the medical system, using the home as the workspace. The Cisco video phones are a very valuable resource because even though family caregivers experience rewards while providing care, they also experience negative consequences, like stress, depression, and loneliness. These phones offer access to formal and informal support without caregivers having to leave their homes." The pilot study focuses on support for minority caregivers and currently includes three groups; African-American, Hispanic, and Haitian. Menus, resources, and counseling sessions are either in English, Spanish or Creole, depending upon need. In the future, this could be implemented in communities throughout the United States to help family members act as extensions of the medical system. "We're proud to see how the Center on Aging is using video with the Cisco Unified IP Phone 7985G," said Brian Dal Bello, director of marketing for Cisco's IP communications business unit. "With research expertise and outreach experience, the program is going to benefit a group of people that needs assistance and is often overlooked." The worldwide population is aging, which creates new challenges for the healthcare community. The University of Miami's Center on Aging uses research, education, and community outreach to find ways to prevent disability, increase independence, and help older people lead active and rewarding lives. Faculty conduct research on diseases such as Alzheimer's and also offer programs for the elderly and their caregivers.
- The province of Ontario in Canada has a population of approximately 12 million, most of it concentrated in the large cities of Toronto, Ottawa, and London near the U.S. border. Ontario's northern sector, on the other hand, is often referred to as a province within a province. The area is roughly the size of Texas and California combined, yet it is home to fewer than 1.5 million residents. In such a sparsely populated land, healthcare providers constantly battle shortages of health professionals, distance barriers, isolation, escalating health care costs, and the demands of serving the diverse needs of distinct populations. Of course, serving an isolated population is a challenge for medical professionals. It is impractical for every specialty to represent itself in such a ryet medical challenges in which time is a critical factor arise regularly. “ Thousands of people every year, spread out over a great distance, need access to medical care,” says Dr. Ed Brown, President and Chief Executive Officer of the Ontario Telemedicine Network (OTN). Brown noted that oncology, neurology, internal medicine and mental health care are among the specialties most often requested for patient referral. Three telemedicine networks had existed in Ontario since 1998, providing remote patient consultations with a specialist via video teleconferencing. While each successful in their own right, the three networks were not a complete solution due to compatibility problems between them that sometimes delayed care or required users to switch locations. The province needed a stable, secure, compatible solution that would serve both the isolated residents and the medical community. OTN, the result of a merger of the three Networks in 2006, filled that void. It uses videoconferencing and advanced information communication technologies to deliver clinical, educational and administrative services to more than 395 health care sites province-wide. It engages providers and institutions to provide the service, manages the technologies, fosters innovation through collaboration with its members and delivers telemedicine training. Medical telemedicine networks require the utmost performance since the information carried on them can literally mean life or death. Quality is equally important, since medical images or sounds require the highest resolution possible so doctors can quickly discern ailments and make accurate diagnosis. What is needed is a high-quality; reliable, compatible, far-reaching network able to serve a remote section of the country 24-hours a day.
- Tissue plasminogen activator (abbreviated tPA or PLAT ) is a protein involved in the breakdown of blood clots. Specifically, it is a serine protease ( EC 3.4.21.68 ) found on endothelial cells , the cells that line the blood vessels . As an enzyme , it catalyzes the conversion of plasminogen to plasmin , the major enzyme responsible for clot breakdown. Because it works on the clotting system , tPA is used in clinical medicine to treat stroke .
- Afghanistan might not be the first place you would expect to find some of the latest developments in the emerging field of telemedicine. But a project backed by Cisco and local telecommunications provider Roshan is helping to deliver medical care over computer networks. After 23 years of conflict and political turmoil, in Afghanistan there is an average of one doctor for approximately 5,300 people (compared to around 390 inhabitants per doctor for the United States), with some regions not having access to any doctors at all. To make matters worse, the roads throughout Afghanistan have been severely neglected and there are only 35 kilometers of functioning railways in the entire country, making access to medical care an extremely difficult challenge. Yet medical care is of paramount importance: Afghans have an average life expectancy of 44 years, one in four children die before the age of five and every 20 minutes a woman dies from birth-related complications. Telemedicine Helps to Provide Aid A partial cure to solving these issues could lie in part with telemedicine, which allows local health teams to call on the expertise of distant medical professionals and services. Using broadband technology, video consultation and digital image transfer, the Afghanistan telemedicine project aims to provide hospitals with real-time access to specialist diagnosis, treatment and training expertise from abroad. Cisco has teamed up with Roshan, the country's biggest telecommunications managed service provider, the Aga Khan University Hospital (AKUH) in Karachi, Pakistan, and the French Medical Institute for Children (FMIC) in Kabul, plus other technology suppliers in order to make the plan a reality. Roshan has taken the lead role in the project. Like Cisco, it has a highly developed and diverse program of corporate social responsibility, from soup kitchens to agricultural micro-credit projects. Cisco and Roshan are also collaborating on the provision of IT skills in Afghanistan, with Roshan providing USD$100,000 to sponsor 600 Cisco Networking Academy IT Essentials and CCNA graduates within the next three years. Year-Old Project Provides Critical Access to Experts The telemedicine project was officially launched in June 2007, connecting FMIC to the Aga Khan Hospital via a dedicated 2.048 Mbps E1 data link. There had already been a pilot launch February 2007, followed by an initial trial period in which approximately 60 to 80 scans and X-rays were being electronically transferred to the AKUH on a monthly basis for examination by specialists who could offer expert opinion on difficult cases. This innovative use of technology and telecommunications to enhance healthcare delivery will help underpin our efforts to meet the nation's other development challenges. Amirzai Sangin , Afghan Minister of Communications and Information Technology Access to experts is critical in a country where many vital medical centers outside the main cities lack even one specialized radiologist. The general lack of staff able to interpret scans and X-rays in the country was one of the reasons why the telemedicine project was first conceived; another was the ability to keep medical staff across Afghanistan up-to-date with the latest medical techniques. Now, thanks to the telemedicine project, a whole raft of continuing medical education (CME) seminars are planned, to help ensure the staff of FMIC is kept abreast of medical innovations and discoveries. Seminar participants can now watch, listen, and discuss them via 42-inch plasma screens at each location. Cisco is playing a central role in this part of the project, having donated a number of Cisco Unified Videoconferencing 3515 Multipoint Control Units , which work with Polycom VSX 5400 Presenter videotext units, allowing patients and physicians in Kabul to interact in real time with Karachi-based specialists. Linking up the entire country is the ambitious end goal of the project, and plans are already well advanced to make this a reality. One of the next steps will be to connect a remote rural hospital by the end of 2008. The hospital in question is a vitally important medical center which serves a population of 400,000 people. Despite this, it does not have a single qualified radiologist, so all scans and X-rays have to be analyzed by other, non-specialized medical staff. By joining the telemedicine network, this remote hospital's 100 X-rays per month will be made available for analysis by qualified radiologists from FMIC and, if necessary, by specialists at AKUH. Its staff will also benefit from CME seminars and a wider pool of medical knowledge from its links to Kabul and beyond. The advantages and benefits of this system are summed up by Amirzai Sangin, Afghan Minister of Communications and Information Technology: "Our Government is striving to improve the quality of life of our people and providing quality healthcare is one of our top priorities. "Telemedicine is the perfect marriage between the speed, convenience and cost-effectiveness of wireless and broadband technology." "This innovative use of technology and telecommunications to enhance healthcare delivery will help underpin our efforts to meet the nation's other development challenges."
- ABERDEEN, Scotland, January 30, 2008 - The Scottish Centre for Telehealth (SCT), Cisco,® and the National Health Service in Scotland today announce the launch of the world's first trial of Cisco's HealthPresence, an innovative patient care delivery concept using Cisco TelePresence technology. The trial is taking place at the Aberdeen Royal Infirmary in Scotland to assess the efficacy of Cisco HealthPresence, as well as patient and caregiver satisfaction, when the system is used in a safe, highly secure environment. Upon a successful outcome of this program, further trials may be planned in Scotland and around the world. Cisco HealthPresence combines state-of-the-art video, audio and call centre technology with medical information over a highly secure network to create a virtual face-to-face experience for patients and caregivers who may be miles apart. Cisco HealthPresence is a technical platform that interfaces with medical diagnostic equipment, such as stethoscopes and otoscopes, as well as a vital signs monitor that can measure blood pressure, temperature, pulse rate and pulse oximetry to capture the physiological condition of the patient. An attendant is available to operate the medical devices on behalf of the remotely located caregiver as well as to maintain the technology in good operating condition. Clinicians Dr Karyn Webster and Dr Fiona Mair from the Royal Aberdeen Infirmary, who have both used Cisco HealthPresence, commented that "HealthPresence is an asset to improve the quality of telephone advice and triage. Being able to visualise and have physiological parameters on a patient will improve patient care". The system was found to be easy to use, with the two doctors further commenting, "It is a straightforward setup … as easy as switching on a PC. As health professionals we are increasingly using technology and so are becoming very used to using this type of equipment". "In our efforts to provide better patient care and utilise our medical staff to the full, we have been collaborating with the Cisco Internet Business Solutions Group Healthcare team to find new solutions through innovative technology", says Gordon Peterkin, director of the Scottish Centre for Telehealth. "Solutions such as Cisco HealthPresence enable us to offer convenience for patients and service delivery efficiency for our doctors. We look forward to drawing upon the results from this pilot to optimise our regional and national healthcare delivery resources". "Shortages of healthcare practitioners and increasing costs, combined with aging populations, have put significant strains on health systems throughout the world. By using the network as a platform, Cisco has a key role to play in the delivery of safe, affordable and accessible healthcare", says Nick Augustinos, Global Healthcare Solutions director for the Cisco Internet Business Solutions Group. "Joining forces with NHS and SCT has enabled us, together, to consider bringing healthcare services to remote and rural areas where recruitment and retention of doctors and nurses is proving increasingly difficult". HealthPresence was developed by Cisco's Internet Business Solutions Group and prototyped at Cisco's Technology Centre; it is based on the Cisco TelePresence system, which was launched in October 2006. The lifelike experience of interacting using Cisco TelePresence resulted its deployment by 100 customers in more than 40 countries worldwide within its first year.
- ABERDEEN, Scotland, January 30, 2008 - The Scottish Centre for Telehealth (SCT), Cisco,® and the National Health Service in Scotland today announce the launch of the world's first trial of Cisco's HealthPresence, an innovative patient care delivery concept using Cisco TelePresence technology. The trial is taking place at the Aberdeen Royal Infirmary in Scotland to assess the efficacy of Cisco HealthPresence, as well as patient and caregiver satisfaction, when the system is used in a safe, highly secure environment. Upon a successful outcome of this program, further trials may be planned in Scotland and around the world. Cisco HealthPresence combines state-of-the-art video, audio and call centre technology with medical information over a highly secure network to create a virtual face-to-face experience for patients and caregivers who may be miles apart. Cisco HealthPresence is a technical platform that interfaces with medical diagnostic equipment, such as stethoscopes and otoscopes, as well as a vital signs monitor that can measure blood pressure, temperature, pulse rate and pulse oximetry to capture the physiological condition of the patient. An attendant is available to operate the medical devices on behalf of the remotely located caregiver as well as to maintain the technology in good operating condition. Clinicians Dr Karyn Webster and Dr Fiona Mair from the Royal Aberdeen Infirmary, who have both used Cisco HealthPresence, commented that "HealthPresence is an asset to improve the quality of telephone advice and triage. Being able to visualise and have physiological parameters on a patient will improve patient care". The system was found to be easy to use, with the two doctors further commenting, "It is a straightforward setup … as easy as switching on a PC. As health professionals we are increasingly using technology and so are becoming very used to using this type of equipment". "In our efforts to provide better patient care and utilise our medical staff to the full, we have been collaborating with the Cisco Internet Business Solutions Group Healthcare team to find new solutions through innovative technology", says Gordon Peterkin, director of the Scottish Centre for Telehealth. "Solutions such as Cisco HealthPresence enable us to offer convenience for patients and service delivery efficiency for our doctors. We look forward to drawing upon the results from this pilot to optimise our regional and national healthcare delivery resources". "Shortages of healthcare practitioners and increasing costs, combined with aging populations, have put significant strains on health systems throughout the world. By using the network as a platform, Cisco has a key role to play in the delivery of safe, affordable and accessible healthcare", says Nick Augustinos, Global Healthcare Solutions director for the Cisco Internet Business Solutions Group. "Joining forces with NHS and SCT has enabled us, together, to consider bringing healthcare services to remote and rural areas where recruitment and retention of doctors and nurses is proving increasingly difficult". HealthPresence was developed by Cisco's Internet Business Solutions Group and prototyped at Cisco's Technology Centre; it is based on the Cisco TelePresence system, which was launched in October 2006. The lifelike experience of interacting using Cisco TelePresence resulted its deployment by 100 customers in more than 40 countries worldwide within its first year.
- From “ U.S. Healthcare Transformation and the Role of Health Information Technology (HIT) “, IBSG Recommendations A comprehensive approach to HIT-enabled healthcare reform includes strategies and networked IT solutions that address three opportunity areas: The interoperable exchange of health information . This is where much of the industry and policy focus has been during the past 8-10 years. Enabling technologies include a national health information network, interoperable electronic health records (EHRs) and technologies that monitor a patient’s health status remotely (from home or work) Effective collaboration among healthcare workers . The ability for people and teams to find each other quickly and communicate effectively improves patient care cycle times, reduces the risk of avoidable errors or sub-optimal care, and increases the efficiency of scare professionals. Enabling technologies include messaging (email, instant messaging, converged voice and text messaging); work spaces (Web 2.0 technologies such as wikis); location technologies (directories, location services and RFID tracking); and, conferencing technologies (phone, video, presence, and application sharing) Delivery of healthcare services to patients using networked HIT . Enabling technologies include a variety of telemedicine services. Examples are secure messaging between providers and patients; on-line radiology consultations; and, direct patient care via high quality video (presence) including dermatology, primary care and mental health services. Policy Recommendations1 (US) Adoption Incentives. The Department of Health and Human Services (HHS) should implement, or seek authorization from Congress as necessary, to implement financial and other incentives for the adoption of standards based solutions. Incentives should include broad-based approaches such as pay-for-value, as well as targeted approaches that include grants directed at small, safety net, and financially challenged providers. Workforce Needs and Impacts. The Departments of Labor and Commerce, in concert with HHS, should identify and quantify deficiencies in healthcare workforce knowledge and skills that must be addressed to secure maximum benefit from HIT. The effects of HIT on the use of labor and the upward mobility of workers in the healthcare system should also be considered. Based on these findings, these Departments should create a plan to meet workforce needs and better estimate the financial impact of workforce changes that occur as a result of HIT adoption. Public Awareness. HHS should develop and execute a public awareness campaign that helps educate consumers, providers, and other interested constituencies of the benefits of using interoperable HIT. HHS should implement the campaign in conjunction with the Department of Commerce and other government and private-sector organizations. Data Standards. HHS should ensure broad acceptance, effective implementation, and ongoing maintenance of a complete set of interoperable, non-overlapping data standards. Such standards should assure that data in one part of the health system is, when authorized, available and meaningful across the complete range of clinical, administrative, payment system, public health, and research settings. Standard Product Identifiers and Vocabulary. Standardizing data at the point of its creation will greatly accelerate the creation of an interoperable healthcare information network. HHS should work with manufacturers of drugs, devices, and test kits to achieve standardized identifiers and vocabulary in labels and packaging, and in all data outputs of devices and test kits. Federal Privacy Standard. Congress should authorize the Secretary of HHS to develop a uniform federal health information privacy standard for the nation, based on HIPAA and extending HIPAA as appropriate. The federal privacy standard should pre-empt state privacy laws in order to anticipate and enable interoperability across the nation. Consumer Protections. Patients should be protected from the consequences of unauthorized access to or release of their personal health information. Therefore, HHS should study and recommend to Congress actions to prohibit discrimination based on data obtained in that way. Coordinated Care Across the Continuum. Legislation is needed to recognize and support voluntary, collaborative “care systems” among different health service organizations. Such voluntary collaboration can improve care management and team-based care. The collaboratives would share care plans and HIT such as electronic health records, case management tools, clinical decision support and repositories for quality and cost analysis, as well as care pathways built into clinical systems. Collaboration and social networking technologies can support efficient, effective communication. Legislation should remove anti-trust barriers to cross-organizational collaboration and support quality based reimbursement for the entire collaborative team. Medicare regulations should be revised to expand the definition of “point-of-care” to include “e-consults,” “teleconsults,” and telemedicine in all its variations. Patient-physician Relationships and the use of HIT . Medicare reimbursement should cover ongoing communication and health management by providers for patients without requiring in-person patient visits. Specifically, the Medicare program should recognize and reimburse for the Patient-Centered Medical Home care model with sufficient reimbursement to support HIT investments. Medicare reimbursement should also recognize remote consultations between primary care providers and patients, supported by technologies such as secure messaging.
- Let me take a few moments to describe a typical patient encounter. There are a number of patient encounters within the continuum of care that language interpretative services are needed. Some examples include the Admissions Department, Emergency Department, patient & family consultation room, or within ancillary departments such as radiology, hematology and don’t forget -- patient rooms. In all cases, the patient and or family arrive and require language interpretation services as shown in step 1. Next, the clinician places a call to a healthcare provided phone number also known as a pilot number. The number dialed can be a generic pilot number that allows the clinician to select the language from a prioritized list or the clinician can spell the language using the phones touch tone key pad. Another method that can be used is to allow the clinician to use speed dials on the endpoint to “direct dial” a pilot number specific to the language they require. A flexible web interface allows for yet another contact method for those clinicians that have access to a PC. Through the use of a web interface the clinician selects a language and callback number. In all cases, the call is placed as shown in step 2 and the clinician specifies the desired language. The call is accepted by the IP Contact Center, namely UCCX. UCCX locates an agent that is most appropriate for the language interpretation using a number of metrics. The primary selection metric is that of language, but within the script process which locates the “most appropriate” translator, additional metrics can be used such as gender, skill level and so on. For those deployments that are shared between hospitals, the selection of an in-house translator is favored over that of a translator located at a collaborating external healthcare provider. I’ll discuss those details later in this presentation. The important note here is that UCCX is extremely flexible in implementing a selection process that meets the business needs of the healthcare provider. Once the “most appropriate” language interpretation agent is identified, UCCX redirects the call to the agent as shown in step 3. If the agent has identified themselves to the UCCX system as being “Ready”, but has erroneously stepped away from their desk, or is unable to accept the call for some reason, UCCX redirects the call to another available agent. If both calling endpoint and the receiving endpoint are H.264 video enabled endpoints, the call is established with two way video as indicated in step 4a. If however the calling side for example is not video enabled, any agent may accept the in a typical audio only call also shown. The video between the two endpoints uses the H.264 video codec, also commonly known as MPEG4. This video based codec provides very good video quality at the lowest possible bit rates. Because of the high video quality and high frame rates, the video can be used with deaf and hearing impaired patients through the use of sign language. In most cases, to provide optimum audio quality, the G.722 wideband audio Codec is used. This codec provides ultra high fidelity and clarity to the audio portion of the call, thus enabling the interpreter with the ability to provide language interpretive services to patients that may not be able to speak with clarity in their native language. Call flow and call routing: Clinician locates Collaborative Care – interpretation Service endpoint. Clinician places call to pilot number of interpretation service or specific language pilot number. Call is answered by UCCX, and script is started to collect caller requirements. IPCC directs call to interpretation agent most suited to need. Talking points Increase staff efficiencies by streamlining the patient communication process; Gain economies of scale by providing interpretation services through the means of pooling trained medical language interpreters; Reduce medical errors by effective listening and communication between the patient and caregiver; Address unique language or communication disabilities which are non-native; Increase patient satisfaction with care provided in a native language; C3 facilitates hearing impaired patient encounters Reduces organizations risk when using non-medically trained resources for interpretation services; and Reduce impacts on patient care and clinician productivity when using clinicians as interpreters rather than patient care. Ease access to interpreters with unique skill sets that may otherwise be hard to get