Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) project: technical implementation

Abstract

The Columbia University Informatics for Diabetes Education and Telemedicine IDEATel) project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goal of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine. The focal point of the intervention is the home telemedicine unit (HTU), which provides four functions: synchronous videoconferencing over standard telephone lines, electronic transmission for fingerstick glucose and blood pressure readings, secure Web-based messaging and clinical data review, and access to Web-based educational materials. The HTU must be usable by elderly patients with no prior computer experience. Providing these functions through the HTU requires tight integration of six components: the HTU itself, case management software, a clinical information system, Web-based educational material, data security, and networking and telecommunications. These six components were integrated through a variety of interfaces, providing a system that works well for patients and providers. With more than 400 HTUs installed, IDEATel has demonstrated the feasibility of large-scale home telemedicine.

Figure 1

Functional overview. The arrangement of the components relates roughly to their relationship. At the top level, the patients interact directly with the home telemedicine unit (HTU). Through the HTU, they access the case management system and Web resources. The clinical information system provides unique patient identifiers used by the other systems. It also provides the long-term repository for clinical data and supplemental data used by the case managers and physicians. The security and telecommunication components interact to support the function of all three layers.

Figure 2

Home telemedicine unit (HTU). The HTU is based on a conventional PC. It is installed with peripherals and a cart in the patient's home. The glucose meter is the SureStep (Lifescan, Milpitas, California). The blood pressure meter is supplied by A&D Medical (Milpitas, California).

Figure 3

Patient launch pad. To simplify operation of the home telemedicine unit (HTU), a customized mouse pad was developed. The buttons are programmable function keys that allow patients to answer video calls or electronically transmit glucose and blood pressure readings with a single push of a button. Pressing the “Web” button will dial the Internet service provider and connect to the project Web site. The patient can then enter a password to view results. The “Restart” button allows the user to either reboot or shut down the system entirely.

Figure 4

Summary of data access paths. Various users access project data on numerous systems. Encryption methods for each path are shown in Table 1▶. Back-end servers not accessed directly by users are not shown. See Table 1▶ for list of abbreviations.

Figure 5

Network architecture: overview of the telecommunication and network infrastructure for the project. Paths carrying only data are shown as solid lines. Paths carrying video or video and data are shown as dashed lines.

Figure 6

Data server interfaces. Multiple data interfaces integrate various project systems and tie the systems into the Columbia-Presbyterian Medical Center clinical information systems. Details are shown in Table 2▶.