Technical Infrastructure
INNOVATIONS
The technical innovations of the proposed project are: the design,
implementation, and evaluation of a telemedicine-based approach for
improving access to care and for collecting data on health disparities
in underserved populations. This is a new telemedicine framework that
provides the functionality required for Urban Telemedicine. Equally
important, the proposed framework includes the high reliability and
performance that is required in order to operate a telemedicine system
in the proposed environment. The framework is scalable to multiple
sites (each with their own data models and schemas), and enables
researchers to incorporate culturally-sensitive surveys. The framework
is highly portable to multiple platforms, and is freely available to
other researchers so that they can test and validate the results
obtained in the proposed Urban Telemedicine environment in other urban
or rural settings.
The clinical research impact of the proposed project is that it will
provided a needed test-bed to test the hypothesis that such
telemedicine systems are needed to improve access to care. In the
course of implementation, the proposed system will also improve the
collection of health information from disadvantaged and poorly-studied
populations, and it will increase access to health information for
studies of disadvantaged populations. Longer-term, it will decrease the
cost of treating disadvantaged populations by identifying problems
earlier, and it will allow comparisons across populations in different
geographic locations and diverse environmental conditions. This may
lead to badly needed improvements in health outcomes in the target
populations.
TECHNICAL QUALIFICATIONS
Over the past few years the Research Informatics Core developed a
variety of telemedicine and teleinformatics capabilities, including
telemedicine data collection and display software, a
multi-institutional shared brain imaging database and documentation and
policies for interaction between collaborating locations. Core members
collaborated to publish numerous papers and invited presentations in
these areas, some of which are summarized here.
GENERAL TELEINFORMATICS
Research Informatics Core members have extensive experience in the
design and development of telemedicine systems. The scope of this
expertise encompasses the design and optimization of networks for
Teleradiology [Duerinckx, Valentino et al, 1996], the development of
Internet-based telemedicine systems [So, Li et al, 1996; Li, Valentino
et al 1996], the development of multimedia patient-records management
systems [Valentino, Huang et al, 1998], and the research and
development of advanced tele-monitoring for scanners and operating
rooms [Ratib et al, 2000; Farahani, Valentino et al, 1999].
Research and development has focused on the required teleinformatics
resources, including hierarchical storage servers for the distributed
archive and retrieval of medical imaging data [Huang, et al, 1998;
Valentino, Lufkin, et al, 2001; Valentino, Wei, Flowers, et al, 2002].
Recently a multi-tier storage infrastructure was implemented in Java
using JSP, J2EE, JDBC and mySQL for the internal relational database.
The underlying technology has been successfully used in a variety of
imaging research projects, and this technology will be used for the
storage and distribution activities within this project.
DATA MODELS AND SCHEMA INTERPRETATION
Recently, approaches were investigated for mapping data elements and
semantics from one database to a desired output file or other database.
As a result, a graphical data translation engine was designed and
developed that enables reading and writing from various data sources,
interpretation of the data elements, and translation of the attributes
from one data model to another [Valentino, 2003]. This approach enables
the use of graphical tools to quickly and easily select data elements,
specify how to interpret them, and map them to an output data source.
DATA PRESENTATION
The research team also has extensive experience in the design and
development of clinical workstations and presentation systems [Harreld,
Valentino, et al 1998; Valentino, Harreld, et al 1998]. Recently team
members designed and developed a portable framework in Java (the
jViewbox/Tk) for the presentation of brain imaging data [Valentino, Ma
et al, 2002]. The framework provides a comprehensive set of Java
classes and an easy-to-use application programmer interface and
programming model to simplify building imaging-intensive medical
applications. The jViewbox was evaluated on a variety of platforms and
optimized to provide excellent performance for very large data sets.
jViewbox was also used to build graphical user interfaces on mobile
devices and will be used to support the display and presentation of
data in this project.
PROTOTYPE TELEMEDICINE SYSTEM
Over the past year the new, Open Source Urban Telemedicine System (UTS)
was designed and implemented in a pediatric primary care setting. It
currently enables the integration and management of clinical and
research data through a centralized data center. Included are automated
business processes to secure data exchange, tools for data collection
and visualization, data screening, and a web based statistical analysis
environment. These automated web services operate in a secure
environment that extends across all departmental and organizational
boundaries providing an effective means for real-time web based
collaboration.
SOFTWARE ENGINEERING
The principals on this project have extensive software engineering
expertise. Team members have used software engineering procedures in
their research work for many years [Valentino, Taira, et al, 1994;
Valentino, 1996; Valentino, 1998], and have standardized software
development using widely available and portable software technologies.
This includes the use of Java and J2EE for toolkit and application
development, JDBC for database access, and MySQL for relational
database management. The team also developed a template to capture
Functional Requirements for infrastructure software, and used the
Unified Modeling Language to describe the functionality and "look and
feel" of application user interfaces [Valentino, Fiske, et al, 2001].
All newly developed software is routinely tested for reliability and
performance across a variety of operating systems to ensure the
portability and robustness of software development efforts.
OTHER KEY INFRASTRUCTURE
Lastly, as the reviewers are aware, there are a number of other key
infrastructure issues that cannot be described in detail in this
proposal. However, as described in a number of related publications
[Valentino et al, 1996; Li, Valentino et al, 1996; Valentino, Huang et
al, 1998], the research team has developed not only the software
resources, but also the procedures and strategies to address each
issue. For example, security is a concern from both technical and
policy standpoints. As described throughout this proposal, firewalls
and authorization access controls, as well as the policies and
procedures, have been implemented to ensure the security and
confidentiality of subject data and other resources.
RATIONALE FOR TELEMEDICINE AS A TOOL FOR ADDRESSING HEALTH DISPARITIES
As described in the introduction to this proposal, numerous factors
contribute to the significant health disparities that have persisted,
and in some cases worsened, over the past decade between urban
Caucasian populations and socially marginalized, economically
disadvantaged groups. However, due to a lack of relevant clinical data,
it is currently difficult to fully understand the extent of health
disparities and their underlying causes. Furthermore, the number of
sub-specialist physicians is decreasing nationwide. This is
particularly acute in the underserved communities where the worst
health disparities exist and sub-specialist expertise is perhaps most
needed.
Two significant barriers to reducing health disparities include the
difficulty of collecting, managing and sharing clinical research data
(leading to a lack of relevant clinical data), and the difficulty of
designing and developing the appropriate systems for evaluating new
approaches to care (leading to a lack of effective systems for
providing needed care). The focus of this research project is to design
a new telemedicine system that addresses critical needs of underserved
populations, and to develop an appropriate software framework that
improves access to care and improves data collection for patients in
underserved communities. The resulting software will be used to
evaluate the ability of the proposed telemedicine approaches to reduce
health disparities.
SOFTWARE DESIGN AND ARCHITECTUREA. Design
The open-source telemedicine software currently in use is highly
reliable, secure, easy to maintain and easy for other researchers to
adapt and extend as requirements change. Although some software exists
to manage electronic medical records, little such software exists for
imaging-based telemedicine. Over the past year, a number of design
criteria and key system components have been documented, developed and
tested. A flexible database schema design was proposed and developed
[Valentino, Lufkin, et al, 2001] to enable the management of multiple
data models. This will enable adaptation of the system to new clinics
and new healthcare systems as they are encountered. An object-oriented
design and development approach, which has been used on past projects,
will ensure that the software is scalable and reliable [Harreld, et al,
1998; Valentino, et al, 1998]. Lastly, the inclusion of appropriate
functionality will make the software easily configured for new health
disparities research studies, and will facilitate compliance with the
Healthcare Insurance Portability and Accountability Act (HIPAA).
B. Functionality
A number of features of the system have already been designed and
validated. As mentioned in Preliminary Results, a prototype system has
already been deployed to monitor Diabetic Retinopathy at several
community-based clinics in the South-Central Los Angeles area. Some of
the functionality of the system is briefly described here to indicate
the functionality that is included in the Pediatric Telemedicine
system.
Secure login screens authenticate all users and restrict access to the
appropriate medical records. Data Entry screens enable Physician
Assistants and Front Office staff to enter and validate patient
demographics either before the initial patient visit, or during the
patient examination, as required. Clinical Care and Research Data
Collection screens to will be implemented to collect clinical data for
telemedicine care as well as research data for specific clinical
research studies (with appropriate IRB approval).
The software is written in the Java language and Java Server Pages
(JSP). It uses the Apache Web Server and Tomcat JSP Server, and the
database uses MySQL. All of these components are free, open systems
that are widely available to the research community. The major system
components include: (a) the web-based, distributed and redundant
Telemedicine Server that includes a database and permanent archival of
clinical and research data collected; (b) the Exam Room Module that is
used by the PA to collect clinical and research data; (c) the Reception
Module that is used by the PA or Receptionist to register the patient
and collect basic demographic information; and (d) the Evaluation
Module that is used by the Specialist to review patient records and
determine how to care for the patient.
Critical clinical data is captured using the Exam Room module. As
illustrated in the Figure, as clinical data is captured, it is queued
on the local system, and then sent over a secure and encrypted
interface to the web-server. Only after the web-server confirms that
the data was accurately received and archived, then the local system
can delete that data.
The Reception and Evaluation modules run in a standard web-browser on
any desktop computer. This makes it inexpensive to implement and
maintain, and very convenient for the Specialist to access medical
records as needed. The web-server, of course, requires more computer
memory and significantly more disk space than the Reception and
Evaluation modules. The only module that requires special hardware is
the Exam Room module. If the exam images, then a PC image capture board
is required to digitize and store high-resolution images from an
imaging device such as a dermatology camera or otoscope. The use of
USB-based image capture devices was evaluated, but such devices were
too slow to capture high-resolution images in real-time. However, with
the development of the new USB 2.0 standard, it is expected that such
devices will be widely available within the next year.
