"M3"
"MALAYSIAN MEDICAL MATRIX"
An application of Distributed Medical Intelligence
Dave Warner MD Institute for Interventional Informatics San Diego CA. davew@well.comThis document is intended to provoke an optimised mindset for the development of a coherent technological policy and process which will guide the development of the next generation of intelligent telemedical communication systems for Malaysia. Optimal perception of what is both plausible and necessary requires vision; a new vision which aims to integrate the relevant features of emerging technologies with the well established need of providing quality medical services across space and time. Such a vision requires insight into both the technological and practical aspects of telemedicine. The conceptual basis for beginning the process of designing, implementing and refining the next generation of distributed telemedical systems is presented here. Web-based medical communication infrastructures are distinguished from historical telemedical processes yielding the next generation of the art: the Distributed Medical Collaborative Network.
Background: Telemedicine is the integration of telecommunications technologies, information technologies, human-machine interface technologies, and medical care technologies for the purpose of enhancing health care delivery across space and time. Telemedicine includes the transfer of medical information (graphic, video, voice, etc.) between distant locations with patients, physicians, other health care providers, and medical institutions. It includes using telecommunications to link health care specialists with clinics, hospitals, primary physicians and patients in distant locations for diagnosis, treatment, consultation, and continuing education.
In recent years the number of telemedicine applications has grown explosively. This is due to the acceptance that telemedicine can improve access to care, improve quality of care and reduce cost of care.
Improved access to care is possible because telemedical systems provides health care to previously under served or unserved areas. Access to care through use of telemedicine technologies enables rural communities to access information usually obtainable only in larger communities. Telemedicine allows access to specialty care thus can increases speed of diagnosis and treatment, providing immediate access to expert health care knowledge.
Improved quality of care comes from enhancing decision making through heretofore unavailable collaborative effort (referring physician, consulting physician and patient work together, simultaneously) Telemedicine can improve continuity of care by providing the primary care provider with the tools and knowledge to extend their service where they previously would have had to refer the patient to a specialised care provider. The utilisation of telemedical systems educates the referring physician so similar cases can be treated as well. Thus the fund of knowledge increases with use. It is also believed that telemedicine may improve patient involvement, knowledge and compliance, since the patient is an active part of the patient care team.
Reduced costs are realised when telemedical services help avoid expensive duplication of services, technologies and specialists. Telemedicine also provides a method for moving knowledge resources around to where they are needed most, this allows services to be provided without incurring the costs associated with travel (both money and time) for the specialist care provider and the patient. Telemedicine systems allow services to be provided in the locations where the costs of providing those services may be lower (rural centers vs. specialty care centers).
Currently the majority of telemedical systems are primarily of two main types; they are designed for remote diagnosis of some still image (radiological, dermatologic or pathologic) or they are simply video teleconferencing systems (talking heads) with minimal data exchange. The business issues of medical information systems such as Community Health Information Networks, Managed Care Information Systems and Hospital Information Systems mandate an infrastructure which is primarily to ensure the secured transfer of financial, administrative and clinical information throughout the corporate enterprise. The use of the communication network for remote knowledge access and/or patient care has not been designed into the system.
While the considerations in developing healthcare information systems mentioned above are important they seem to be incomplete. Their focus is on data transmission and the network technology not on the patient or the process of providing support to the care provider. There appears to be little effort to embed intelligent features into these systems. Systems should be designed to take advantage of developments of modern interface design, high speed communication systems, decision support technologies and computer facilitated communication techniques.
Distributed Medical Intelligence: A systems approach for developing an integrative healthcare information distribution infrastructure.
Distributed Medical Intelligence promotes the development of an integrative medical communication system which addresses the process of providing expert medical knowledge to the point of need. Distributed Medical Intelligence requires a systematic approach for developing a networked medical communication system which can effectively deliver medically relevant knowledge efficiently to a remote site. Such a system intelligently optimizes the flow of medical information between the persons seeking care and/or medical advice over the medical care network and the expert knowledge provider rendering the care and/or advice over that network. Distributed Medical Intelligence focuses on the process of communicating medical knowledge not the just the development a medical informatic infrastructure.
The Distributed Medical Intelligence system is divided into three main components. The Care-Portal, The Docking Station and The Bridge. These components are described below in an operational way. These operational descriptions help elucidate the discrete areas where improved technologies, as they become available, and methods of decision support, as they are refined, can be implemented. An intelligent medical communication system must be able to be refined at the component level without redesigning the entire system. That is to say that it must be designed to be scaleable, extensible, interoperable and modular at a fundamental level.
The Care Portal
The Care Portal is defined as any port of entry to the medical communication network which is utilised to seek care for a patient and/or knowledge for a remote care provider. The Care Portals will have the most variability in their design. The common feature of all Care Portals is that they are tele-linked to a medical communication infrastructure. A Care Portal may be a remote rural clinic, a mobile clinic in the inner city, a patient’s bedside monitor in the intensive care unit, a remote monitor in the home of an elderly patient, a health info kiosk in the mall.....i.e. anywhere a person can seek medical information or service from a source on the medical network. The Care Portals will have the most variety in the infrastructure of their communication systems. The Care Portals communication infrastructure will range from the "plain old telephone" through multiple megabit transmission systems like ATM. The Care Portals will also have a wide variety if input devices to aid in the acquisition of relevant information/data from the patient. Along with the patient’s history and physical data the Care Portals will include data from a host of diverse sensors such as cameras, microphones, bioelectric monitors, x-ray, and ultrasound machines. There may be a host of vital signs indicators and bio-chemical lab instruments to determine blood, urine and other body fluid compositions. Care Portals may also be utilised to educate patients and medical personnel at remote sites.
The Docking Station
The Docking Station is the site where the medical expert provides consulting services, education and collaborative input over the medical network. The Docking Stations will have a wide range of complexity in their interface options depending upon what kind of expertise is to be rendered. Most Docking Stations will have multiple viewing options where the expert can view and interact with a wide variety of information simultaneously. The Docking Stations will support a wide variety of data display devices including both visual and auditory. In their optimal design the Docking Station’s will support a spatialized array of data displays, both audio and visual, thus optimizing the interaction with multiple data sets simultaneously. The Docking Stations are designed to allow optimal interaction between the Care Portals, relevant databases, other experts in the healthcare team and the primary knowledge providers themselves.
The Bridge
The Bridge is an intelligent medical communication hub which optimizes the flow of information between the Care Portals and the Docking Stations. The bridge’s functions include facilitating connectivity, data tracking, accessing medical data bases and intelligently enriching the Care Portal’s information through proactive query so as to optimize the interaction between the Care Portal and the Docking Station. The Bridge is the intelligent electronic triage system which determines which Docking Station is appropriate to service a given Care Portal The Bridge is an intelligent consult manager. In the optimal configuration the Bridge will function to ensure that all the relevant information from the Care Portal is gathered, organised, filtered and presented to the Docking Station expert in a way which facilitates an efficient interaction. Along with optimizing the relevant information from the Care Portal, the Bridge will automatically also link the Docking Station to the most relevant medical databases and other medical experts which may be required during the consultative interaction.
When designing the communication infrastructure for Distributed Medical Intelligence there are several considerations to take into account. One of the most important considerations is the design of the interface. There are different classes of interfaces, human-computer, computer-computer, and computer-human. The interface is a key component and there are many opportunities to enhance the interface for Distributed Medical Intelligence both in the instrumentation and the design. Each class of interface presents an opportunity to embed more functionality into the system. For example, when designing the interface for a Care Portal, considerations should include some knowledge about the specific needs and knowledge level of the users which are most likely to use it. Thus, a Care Portal designed for a home health nurse in a mobile clinic will differ greatly from the Care Portals in a cardiac intensive care unit. The purpose of this communication infrastructure is ultimately for the purpose of communicating expert medical knowledge and it is that fact should which influence the overall design.
Other considerations include ensuring a flexible configuration, allowing for far-end-control of diagnostic devices and ensuring that there is an open architecture that allows for the adaptation of new devices without the redesign of the whole system.
The "Webification" of medicine: Application of web technologies to create an intelligent "medical communications matrix"
Interventional informatics, the use of information and communication technology to improve quality of life, can be greatly facilitated by utilising emerging the web technologies. Application of web technologies enable the creation of an intelligent "medical communications matrix" for use in healthcare, communication and education. As medical experts increase their use of on-line information systems, the need grows for Web-based infrastructures with which to make those on-line interactions more efficient, powerful, user friendly and intelligent. The Med-Wide-Web, a secure medical communication infrastructure utilising Web compliant interface and communication protocols, is a proposed cyber-spatial infrastructure which can be readily be deployed as a basic facility for doing medicine.
Towards a Dynamic Web-based Collaboratory System
To further augment the web-based telemedicine system requires the introduction of the Distributive and Collaborative Environment tools. Distributive and Collaborative Environments embed such systems into a networking mechanism for complex, time critical interactions across the Web between multiple users. Thus a Web-based medical collaboratory is one wherein a specific group of expert medical personnel, their support staffs, clinical/hospital resources and all related databases comprise the collaborative. The collaborative, then, is a networked collection/aggregate of expert knowledge and skill resources deployable as an entity, as needed.
What this means for Malaysia Traditionally telemedicine is considered to have a limited extensibility. However there exists a unique opportunity in Malaysia to develop a world class intelligent medical communication matrix. With the creation of the Multimedia Super Corridor (MSC), with it’s state of the art infrastructure, firm government backing, wide range of incentives and investments comes an opportunity to intelligently address the process of providing quality medical care to the greatest number possible within the reality of limited resources.
MALAYSIAN MEDICAL MATRIX " M3 " A national medical communication matrix designed to utilise the emerging world class information infrastructure of Malaysia to cost effectively distribute medical knowledge and expertise to any point of need independent of the geography. The Malaysian Medical Matrix "M3" is an intelligent medical communication system which enables the sharing of medical knowledge resources throughout Malaysia by interconnecting primary care providers to resources which they otherwise would not be able to utilize. M3’s innovative utilization of the emerging national communication infrastructure for distributing medical knowledge resources helps reverse the apparent loss of medical experts from the state systems by connecting them to all the systems. Thus via the M3 there no net loss of expertise
M3 is designed to meet the growing need for quality medical services by connecting medical experts so that they may distribute their services to a wider population. The M3 provides an interconnected communication infrastructure which will allow any point which can connect to the "med-web" to be part of the medical knowledge collective. Thus any site connected to the matrix will be able to utilise the knowledge resources of the whole matrix.
This method of collaborative health care is a new model for providing healthcare services utilizing a distributed collective of networked medical services. The architecture of the communication systems will allow the M3 to mediate connections between the most advanced high bandwidth systems and the low cost systems at remote sites. This way there is no exclusion.
Intelligent medical communication systems need to be thoughtfully defined and carefully implemented so that they meet the true needs of the community. The M3 has the designed capacity to adapt to the true and ever changing needs of the medical community. The M3 services are extensible in that they can be modified to meet emerging needs. The M3 has a scaleable systems design. This allows the M3 to have an intelligent deployment plan.
Finally it is important that the new medical communication system be economically viable. There must be realistic, cost effective and medically relevant implementation plan for the M3 to realise the maximal benefit from the system.
There is a critical deployment path that needs to be maintained in order to realise the vision of the M3.
The first step in the process is to identify and implement the necessary infrastructure. In the case of the M3 it is critical that a point of presence is established in the primary medical systems. It has been established that there at least 3 distinct systems of medical facilities.
The largest and most critical is the state system of 13 general hospitals and their affiliated clinics. This system is the "work horse" of the Malaysian medical services. There are two levels of connectivity that need to be addressed with in this system. It will be important to connect each regional hospital to its primary remote clinics within a given region. It will also be important to connect each of the general hospitals to each other. The net result of this connectivity will be the ability to share knowledge resources and medical expertise across the whole system.
The next medical system to be addressed is the private medical system. This system consists of large medical centers, small and medium size "urgent care" and outpatient clinics and private practices of individual physicians. This is a rapidly growing sector of the Malaysian medical service infrastructure and should be seen as both a consumer of knowledge services and provider of medical knowledge services.
The third system, the Malaysian medical universities, is a very valuable and mostly under-utilised sector of the Malaysian medical service system. This group can be looked at as a knowledge resource both for the state system and the private sectors of medical service . The three major medical universities can provide knowledge services in two main capacities, for remote diagnostic and consulting service and for the major source of content for continuing medical education.
Given that the three distinct systems all have common needs, i.e. the need to share medical knowledge, the next step in the implementation path is to intelligently connect them to the M3.
It must be understood that the initial roll-out applications that we will implement will have multiple functions. First the applications chosen will have an intrinsic medical value that is relevant to the actual needs of the systems. Secondly it should be understood that the "initial move" is to establish a presence in the medical service system at a very early stage of their emergence into the information age and to it at establish a fundamental level of core technology. The first point is obvious the second point is to establish market presence and to gather further intelligence which can be leveraged into future applications.
Based on initial "intelligence" the most robust applications which will help establish a presence are the following:
1 Remote diagnostic services for medical images in the areas of Radiology, Pathology and Dermatology.
Tele-radiology
Tele-pathology
Tele-dermatology
2 Continuing Medical Education. Distance medical education
The choice of these applications is not arbitrary. The "tele-consulting" features of the medical image diagnosis is a way to clearly demonstrate the utility of a distributed medical intelligence model. The model being that the distribution of "specialists" within any one of the three areas is not ubiquitous and therefore there will most likely be a need to gain assess to an available expert service. The distance medical education application provides a gateway to a large variety of medical experts. The exposure to the potential which this technology provides done in a non assuming way will provide a mechanism for "testing the waters" for other applications while at the same time providing some valuable(and billable) service via the M3. By taking this approach we can leverage the initial capital investment to be extended to other applications.
The extensible nature of the M3 architecture ensures that as an application is identified to be a marketable service then it can be implemented with minimal investment because the infrastructure is already in place and has been designed to be generic. Generic in the sense that every telemedical service for any application will need to utilise the communication infrastructure.