Telemedicine & e-Healthin Taiwan
Heng-Shuen Chen, M.D. Ph.D.Dept. of Medical Informatics & Family Medicine,College of Medicine & Hospital
National Taiwan University
April 24, 2006 Internet2 Spring Meeting International Task ForcePanel Session Arlington, USA
Outline
Introduction
History and Development ofTelemedicine in Taiwan
Health Science Projects Relatedto National Research andEducation Network
Future Prospects
Introduction
Taiwan
Area: 36,000 km2
(near Netherlands)
Population:23 millions(near Australia)
second highestpopulation density inthe world (623/km2)after Bangladesh.
Taiwan’s BMW
Broadband NetworkDSL (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
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)
Internet in Taiwan
Taiwan NationalResearch & 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
TWAREN Topology(production network, 2003)
4 core nodes11 GPoPs20 G backbone
Eastern Broadband (10G)Chunghwa Telecom (10G)Chunghwa Telecom (5 G)
Core nodes
Dual circuits from two vendorsform the physical backbone
Taipei
NCU
NDHU
NCTU
NTHU
NCKU
NSYSU
NCNU
NCHU
SINICA NTU
Tainan
Taichung
CCU
Hsinchu
International Links from Taiwan
Hong KongHARNet
Amsterdam
AMSIX
622 Mbps 2.5 Gbps
SingaporeSingAREN
Tokyo-XP
LA
TaiwanTaiwan
2.5 Gbps
2.5 Gbps1.Mbps
155 Mbps
2.5GbpsLightpath
History and Developmentof Telemedicine in Taiwan
Why Telemedicine?
Geographic:75% mountainous area,several groups of isolated islets
Poor medical resources in rural area Physicians are reluctant to practice in
rural areaAfraid of being isolated Lacking opportunities for CME
Specific needs:Handicapped and ElderlyHome care(palliative medicine)
History of Telemedicine
1990 TANet (Taiwan Academic Network)
1994 NII (National InformationInfrastructure) Planning
1995 NII Kickoff (National HealthInsurance started)
1996 NII Pilot Telemedicine projects: Medical Distance Education
Teleconsultation
2000 HIN 2.0 (National Health InformationNetwork version 2) EMR
1995 NII Kick OffPilot Project of Distance Education
First Distance Education Lecture in Taiwan via ATM/DS-3 :NTU(College of Medicine), NTHU, NCTU
Three Stages of Telemedicine
Initiation Research Stage
(1994~1996)
Promotion Research Stage
(1997~1999)
Implementation Stage
(starts in 2000)
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
Distance EducationISDN Room-based 384K
Teleconsultation (DS1)Synchronous and Asynchronous
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
Multipoint VideoconferencePalliative Medicine Case Conference
VOD (CME in Family Medicine)
International TelemedicineVirtual Hospital Taiwan Mirror
International TelemedicineNTU-UIOWA Teleradiology
International TelemedicineNTU-UIOWA Teleradiology
Implementation Stage Integrate telemedicine to community health
information system e-Health
Network Clinic: Synchronous & Asynchronousteleconsultation
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
921 Earth Quake(1999 Sep. 21)Severe damage and destruction in Nan-Tou County
NTU Telemedicine 2000
NTU was responsible to reconstruct the healthsystem 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 andFamily Doctor System(CHGIFS, Lugu Township,Nantou)
Network Clinic & Telecare
Doctor’s EndDoctorDoctor’’s Ends End Patient’s EndPatientPatient’’s Ends End
Network ClinicsRemote Sites
本院
14
霧社
力行部落
萬豐部落
靜觀部落
合歡山
翠巒部落
Netwrok ClinicSynchronous Teleconsultation
Joint Network-Clinic CenterOnline Registration
3.Registation
4.Cancelling
2.InputData
1.Choose aDoctor
Joint Network-Clinic CenterElectronic Medical Records
1. Input Data
2. Upload
3. Confirmation
4. Printing
Continuing Medical EducationMultipoint Videoconference
Patient Distance Education
Nutritionist at NTUH Health Station atAboriginal Area
Medical e-Learning 2000~ Web-based e-Learning in Medical Education
Virtual Medical School
CHG-HIFDS Community Healthcare GroupHealth Information and Family Doctor System
300 CHGs with 2000 family doctors(15% in Taiwan)
CHG-HIFDSFamily Folder Subsystem
CHG-HIFDSElectronic Referral Subsystem
Canning of Chest Xray
With Mini PACS system
Medical Center Expert Diagnosis
CHG-HIFDSElectronic Referral Report
Health Science ProjectsRelated to National Researchand Education Network
TANet2/TAWREN Health ScienceRelated Projects & Activities
National DOH Telemedicine Projects:
Joint Network Clinic Asthma GRID SARS GRID Medical Problem Based eLearning (PBeL)
International multi-countryTeleconference & Forum Telemedicine and e-Health Medical Informatics (IP, H.323) Pancreatic Transplantation (DVTS)
Joint Network-Clinic ServiceNTUH-NCKU
Intranet
Internet
ISDN
台大醫學院405室
台大家醫遠距會診室
埔里基督教醫院&仁愛鄉衛生站
台大家醫6A討論室
台大醫學院101講堂
烏來鄉衛生所
成功大學聖馬爾定天主教醫
院
耕莘天主教醫院 阿里山鄉衛生所
Asthma Grid
Asthma Grid
Before After
In 2003Trans-Pacific links to Seattle and Chicago,each at 2.5 GbpsLinks between STTL & Chi: 622 Mbps & 1Gbpslightpath. From Chicago to Europe at 2.5 Gbps
Taiwan
Taipei
StarLightStarTap
CA*Net4
Abilene
VancouverEdmonton
CalgaryWinnipeg
MontrealHalifax
Toronto
STM-1
6 (2.5G
) 1 GbE
Taiwan’s connections to N. America at the time ofSARS epidemic
STM - 4
2.5 Gbps
Europe
SARS Grid
NCHC Access Grid node test the SARS Grid network links
Access Grid 1.2 PIG
SARS Virtual ClassroomNarrow Band Multivideo (I)
SARS Virtual ClassroomNarrow Band Multivideo (II)
SARS Virtual PatientProblem Based e-Learning
Medical ProblemReasoning
Characteristics Mentor and
Apprentice Problem-Based
Learning (PBL) Evidence-Based
Medicine
Basic DataChief Complain
HyposthesesGeneration
History,PhysicalExams
Observation,Hints
H2
History,PhysicalExams
H1
DecisionDecision
Diagnosis Diagnosis
Lab test,Image
Diagnosis
SARS Virtual Patient
Clinical Case Authoring
SARS Virtual Patient
Tracking & Evaluation in PBeL
International CollaborationIP Video Conference & Streaming
Four countries Videoconference(Speaker, Stanford U. Dr. Song)Quick Time or Real-video Streaming
2006 APAN DV10Medical Working Group Meeting
EzLMS e-Learning Platform
Future Prospects
Health Science NetworkProjects 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 CareServices, and Network ISP)
National Health Education Network & SuicidePrevention Network
Aging Population in Taiwan
2.94.3
6.88.8
9.9
14.3
19.7
0
5
10
15
20
1970 1980 1990 2000 2010 2020 2030
Rapidly Decreased Childbirth
----2015
13.3(1:7)9.51.189.562004
----2030
13.09.21,2310.062003
12.89.01,3411.022002
12.5(1:8)8.81,4011.652001
12.38.61,6813.762000
--6.81,7215.51990
--4.32,45241980
----7,04501951
CrudeBirthRate
AgingPopulation
TotalFertility
Rate
Old AgeDependency
RatioYear
14 25(1:4)
20 33(1:3)
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 emergencymedical services
NTU u-Hospital Project Objective:
To provide a mobile, personalized, andubiquitous care in realtime to achieve the bestquality of health service
Fundamental Elements Interdisciplinary teamwork telecommunication networks Healthcare services
Mobile Emergency Service NetworkMobile Home Healthcare NetworkMobile Ambulatory Healthcare Network
u-HospitalInterdisciplinary 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
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
Care CenterCompany
Ambulance
Community Hospital
Sensor area
Sensor Sensor
DTV
Family MemberWork Site Care Center
Ambulance
NTU u-Hospital System
Home Site
Family doctorof Clinic 1
I
23
Communityhealthcare group
Community Hospital
Homecarenurse
System Structure of u-Hospital
通訊端
服務端居家端Home
Security ServerNetwork Server
Internet CommunicationSystem
3GGPRSADSL
Wireless LAN
Home Application system
Communication module
Vital sign measurement andsensor End
Application system processing
Message transmit and receive module
Message receive serviceMessage transmit service
Data saving module
Internet base architecture
Data transfer engineXML
Vital signdatabase
InternetInternet
Vital sign query module
Alarm Service module
Heterogeneous data integration module
Vital sign data analysis
Online Analysis processing
Data Research analysis
InternetInternet
Application Interface module
Web-based Windows-based
Standard Data transfer module
HL 7 DICOM
Heterogeneous data transfer module
Care Center
Data Communication
Clinics service module
••• •••
醫療機構Hospital
Vital sign query
HIS integration module
HIS integration module
Data Integration Interface
行動看護Family Doctor
Data IntegrationInterface
Vital sign query
Mobile application systemmodule
Vital sign query
Emergency processing Module
支援服務中心
Emergency Inform
Data Integration Interface
Call Center module
Vital sign query
Data Integration Interface
Emergency Service
HL7 IE
Interface
Interface
Interface
Interface
DBDB----------------
----------------
----------------
ComponentRepository
InternetInternet
ExtranetExtranet
RISRISLISLISHISHIS
VPN
PDA(with GSMmodule)
PDA(with IEEE802.11 module)(with Web Browser)
PC
PC
WirelessOperatingNetwork
ExtendedModule
ExtendedModule
Interface
Interface
EMRSystemEMR
SystemInterface
Interface
Files
OtherSystems
Others HealthcareInstitution
PDA(with IEEE802.11 module)
(with Web Browser)
WebServerWeb
Server
Interface
Interface
Add-on ServicesAdd-on Services
Intranet
…
ClientLayer
Web ServiceLayer
App. ServiceLayer
IELayer
Electronic Medical Record (EMR)
From e-Hospital to u-HospitalAccess EMR via Mobile Devices and Desktop PC
Vehicle Computer Access EMR
Family Doctor & u-Hospital
Mobile Emergency Medical ServiceNetwork System Architecture
GPS
Internet(HTTP protocol)
PDAs( with MHEMS System)
GPRSModule
Vital Sign, ImagesPreliminary Data
Doctors
Treatment instruction(Prepare EHR)(Prepare Emergency Stuff)
MHEMSSystem
(Hospital Clients)
EIS
Ambulance Vehicles
Emergency Dept. ofHospitals
Doctors
Monitor
GIS
MHEMSSystem
(HA Server)
DSSRescue path
勤務指揮中心
EMTs
Dutyon fire
Terminologies:MHEMS: Mobile Mocile Hospital
Emergency Medical SystemDSS: Decision Support SystemGIS: Geographic Information SystemGPS: Global Positioning SystemEIS: Emergency Information System
(EMT Clients)
GPRSModule
AGPS System
Dispatch and MissionControl Center
Ambulance
Terminologies:MHEMS: Mobile HospitalEmergency Medical SystemDSS: Decision Support SystemGIS: Geographic InformationSystemGPS: Global Positioning SystemEIS: Emergency InformationSystem
Emergency Departmentof Hospital
Ambulance Dispatch andMission Control Center
The operator of Dispatch and Mission Control Centerdispatches Ambulances and monitor them by GIS.
Ambulance
GPS module
(GPRS)
Patient andEMT in theAmbulance
EMT PDA(GPRS/3G)
Message transfer inMobile Emergency Medical Service
Patientdata
4
5Vital signal& picture
Inform ETA &ambulance position
Emergency call
Ambulance
GPS
GPRS
PDAWinCE
2Read dutyinformation
Dispatch andMission control
CenterGIS
Dutyinformation
1Pre-calculateETA
Define districthospital andambulance
Inform hospital & readETA in period time
HIS
Hospital
Patienthistory
6Send Patient ID
Emergencytreatmentrecords
Show the patientinformation on the
order of ambulancesarriving
Message transfer flow establishes the work of MHEMS system
3
Emergencytreatmentsave to HIS
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, drugcompliance, appointment etc. )
Home TeleHealthGait Monitor & Fall Detection Measure gait:
Adidas Smart shoes: pressure sensors on shoes Smart floors: pressure sensors under floors
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)
Government u-HealthRelated Projects
DOHTeleCare Project
MOEAElderly U-Care Project
NHRIGeriatric Functional Index, Friability
NSC Intelligent living Technology
u-Health TAIWAN
EXPO for u-Health IndustryIEEE HealthCom 2007 ConferenceHL7 Asia-Pacific MeetingAPEC PACS Meeting
Wireless Hosp & Mobile Doctor
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, LongTerm Care with IDS(Integrated DeliverySystem)
Health Community Network
PatientHomeCallCenter
Family Folder
HealthInformation.BiosignalRecords
MedicalRecords
CA Security
e-Counsellinge-Rereferale-Appointmente-Health Education
Care giver
Healthy lifestyle
Self health management
Home safety
Emergency alam
Lifeline call
Tele-homecare
Coordinative
Comprehensive,
Continuous
u-Care Service
LifeCareHome
Care
Medical Care
National Health EducationNetwork http://health.edu.tw
Taiwan Suicide PreventionCenter http://www.tspc.doh.gov.tw
Thanksfor yourAttention