June '07 Newsletter

by Gordy Slack

California healthcare has never been better. However, this is true only for those who have access to the state’s top medical specialists and the labs and equipment on which they rely. For the millions of Californians who live far from large medical centers, or are in prison, or on the streets, lack of access often means lack of good healthcare or none at all. A host of CITRIS telemedicine and remote access projects are attempting to correct this disparity.

“If it is too expensive or difficult to bring the patient to the specialist, we can increasingly bring the specialist to the patient,” says Ravi Nemana, Director of Healthcare@CITRIS, the newly created healthcare research center and Executive Director of CITRIS’s Services: Science, Management & Engineering program. For seven years Nemana was the lead technologist at the UC Davis Center of Health and Technology, where the fields of telemedicine and remote healthcare services took off in the early 1990s.

In those days, telemedicine simply meant a teleconferencing device connecting doctors in remote clinics and hospitals to specialists and information resources at the UC Davis Medical Center (UCDMC). The first institute to participate was a small hospital in Colusa County that nearly lost its obstetrics department when doctors were no longer comfortable practicing without the backup of specialists in emergency situations. Thomas Nesbitt, a physician and the Executive Associate Dean for Clinical and Administrative Affairs and Director of the Center of Health and Technology at UC Davis, linked a fetal-monitoring device in the Colusa hospital to UC Davis and then later added a tele-ultrasound, so that in difficult cases obstetricians could get real-time advice from on-call specialists in Davis. “That linkup gave the obstetricians the confidence to keep delivering babies in Colusa Country,” says Nesbitt, who was recently named the CITRIS Chief Scientist at UC Davis. “Thanks to that program, it is still possible to be born a native of Colusa.”

In the decade and a half since then, the technology of telemedicine and remote health care has come a long way. And Nesbitt, Nemana, and their colleagues have done much to address the disparity in access to medical expertise by making specialists and information available when and where they are needed: in remote parts of the state, at accident scenes, and in the homes of patients.

Videoconferencing has long been a staple of telemedicine, but what was originally a technology designed to allow bankers in Los Angeles and San Francisco to meet without traveling is now taking on a distinctly medical tint, says Nesbitt. High-resolution images zoom out to include the patient’s entire body, or zoom in to magnify a small part of it, permitting physicians at a distance to do comprehensive exams. Even though consulting off-site doctors may not be able to touch distant patients, the availability of real-time 3-D images enables them to recommend treatment for many conditions.

“It becomes unnecessary for a doctor to know what a joint feels like, say, if he or she can see inside of it and know exactly what is going on,” says Nesbitt.

In some cases, it is even possible to conduct surgery from afar with the use of robotic equipment that permits highly detailed operations conducted through a video display. “It does not matter whether that screen is three feet away from the patient or three hundred miles away, as long as someone is nearby to take over in the event of emergency,” says Nesbitt.

Nesbitt’s program at UCDMC provides telemedicine services to over 65 sites around the state, and that includes small hospitals, clinics, and even correctional facilities. Bringing prisoners to hospitals is expensive and time consuming. So is bringing medical specialists in to prisons; and frankly, says Nesbitt, many just are not willing to go. Allowing prison doctors to consult with specialists at Davis via digital video link and other monitoring devices is both more affordable for the state and time efficient, extending top healthcare services where they have not traditionally reached.

In addition to developing administrative systems and work-flow models to ease the passage of resources from big medical centers to patients in remote locations, CITRIS researchers are also developing a number of devices that will bring doctors, and data, and labs closer to the patients who need them, says Nemana.

UC Berkeley assistant professor of bioengineering Daniel Fletcher and his students, for example, are developing an inexpensive optical attachment for cell phones that will eventually allow for magnification up to 50x, a resolution sufficient for the examination of single red blood cells and potentially the identification of malaria-infected cells. Such a device would allow medical professionals and others who are far from any healthcare facility to send in data that could result in an inexpensive and nearly instant diagnosis.

Other optical cell phone fittings in the works will allow field practitioners, or paramedics, or parents for that matter, to photograph eardrums and take close-ups of lacerations or rashes that could help ER physicians triage cases before transport. Fletcher, whose students won support for the project in a CITRIS white paper competition earlier this year, imagines a time when such devices are common parts of a home medical kit. "Instead of bringing your child to the ER, you could snap a picture of his or her ear and send it instead. The doctors could tell you to come in, or, even better, save you the trip and simply prescribe an antibiotic," Fletcher says.

With the ability to send MRIs, CT scans, and even 3-D animated images of, say, a beating heart, along with real-time visual and sound data, “we are decoupling diagnosis and treatment,” says Nemana. “The patient can be in one place, the test can occur in another, and the diagnosis can be done in yet another. Then the treatment can be delivered wherever most appropriate. Often that is right where the patient already is,” he says.

“This will be especially appreciated by the baby boom generation, which wants to age at home and not in nursing homes or in the hospital,” says Nesbitt. When people can send in not only their heart rate, blood pressure, and oxygen readings, but also do on-site blood tests and gather biometric data on how conditions are responding to treatment, the quality of home care will improve a lot, he says, and the number of visits will be minimized.

The culture and practice of medicine are placing as great a limitation on the growth of telemedicine as technological challenges are, says Nesbitt, whose Davis program is forging new practices in the areas of patient confidentiality, billing for remote services, and coordinating on-call experts for the hundreds of tele-consultations that happen each month.

But the opportunities are easily worth the effort, says Nesbitt, on both the receiving and giving ends of digitally transmitted expertise. The technology not only gives underserved patients quick and efficient access to experts in arcane medical subspecialties, it also give those specialists access to patients who can fully exploit their training, putting such valuable doctors to the best possible use.

For more information:

The Center for Health and Technology: http://www.ucdmc.ucdavis.edu/cht/

Spotlight on Telemedicine: http://www.ucdavis.edu/spotlight/0407/telemedicine.html

Computerworld Honors UC Davis Telemedicine: http://www.cwhonors.org/viewCaseStudy.asp?NominationID=296

by Gordy Slack

The School of Engineering at UC Merced is taking a countercultural approach both to its IT needs and to teaching. By focusing on open source, both as a software infrastructure for the school and as a way to teach and learn engineering, the school is bucking one national trend and trying to create another.

“You would never buy a car without being able to look under the hood,” says Jeffrey Wright, Dean of Engineering and Director of CITRIS at UC Merced. “And you would never try to teach auto mechanics without being able to show your students under there, either.”

At the UC Merced School of Engineering, open source software—software developed in a free and accessible environment that is visible both to other engineers and end users—is not just a programming standard. It is a metaphor for the entire community, says Wright. “We are striving to cultivate an open source university, an open source culture. We do not want our students to be intimidated by software or hardware,” says Wright.

And perhaps the best expression of that is the University’s new CITRIS-supported Collaboratory, a computer teaching lab with an innovative and distinctly open source flavor. The Collaboratory opened for undergraduate engineering classes in the fall of 2006.

The affordability of an open source framework is no small thing for a brand new university that is building its computer labs and infrastructure from scratch. Because the software is free and safely adaptable, and because the Collaboratory’s systems are so efficient, says Wright, the new lab was built and runs on just a fraction of the budget of a typical lab its size.

The Collaboratory’s IT is designed to be both cost effective and operationally efficient because it is completely reliant on free and open source software (FOSS), commodity hardware, minimal administrative intervention, effortless remote access and interaction, and student-to-student and student-to-instructor interactivity. Furthermore, it has been designed entirely by its users. “The users own it,” says Wright.

Operationally, the Collaboratory consists of centrally-bootable mini-box servers at each of its sixty seats. The lab is free from upgrade-hungry private-domain software, and it can run on longer-lived, low-end technology that adds years onto the life of a system. Also, because it is open source, it is safely modifiable. When faculty members wants to add a function or do something new , they do not have to go out and buy a whole new system. “It comes in at about fifteen percent of the cost of running a typical teaching lab,” says Wright, “and less than fifteen percent of the energy consumption of a typical lab.”

“But open source at Merced is not just about inexpensive software,” Wright says. “There is also an educational pedagogy here that drives our classes. We are trying to get our students to think differently about information technology by placing an extremely strong emphasis on information and its management rather than on the technology.”

The lab’s functionality is designed by the faculty, another key advantage of open source, says Wright. “Whereas the traditional approach to developing such a facility is to approach vendors, who will happily say, ‘Here, this is what you need, because it’s what we’ve sold to others,’ the open source approach asks: ‘What functionality do we need to provide students the learning experience we wish them to have? Now let’s build it,’” says Wright.

For instance, faculty have developed within Collaboratory a component that allows individual student work sessions to be displayed on a central screen or on screens at multiple locations. The instructor or other students can interact with and control that session and work on documents together. If a student is having trouble with a problem, for example, the instructor can bring that student’s work on screen before the entire class and work through it with everyone.

Not all students, or the instructor for that matter, need to be physically present in the lab, says Wright. Because the lab is equipped with microphones, cameras, and speakers, the students can engage in a class sessions from outside the lab’s walls, and faculty can teach from anywhere.

This adaptability also helps the School of Engineering accomplish another of its CITRIS-supported objectives: forging collaborations with local community colleges and high schools to better prepare students at those institutions for programs like those at Merced.

“We are not just pushing courses out over the Internet, the way other programs might.” says Wright. “Rather, we have a course presence here at Merced and a course presence there on, say, the community college campus; our students and theirs can actually be interactively taking the same course at the same time.”

“We need to improve the eligibility of students coming into our program, and typical high schools and community colleges need better access to appropriate courses and subjects,” says Wright. Use of the Collaboratory can facilitate those goals and efforts are currently underway to install collaboratories in several regional high schools.

Though a part of the School of Engineering, the Collaboratory is not limited in use just to teaching budding computer scientists. The lab is open and available to all faculty at UC Merced for a wide variety of courses, even those unaccustomed to such technology. Several biology courses have used the Collaboratory, and faculty members are interested in using it for courses in history and psychology.

Another reflection of the program’s open source culture is its emphasis on getting students to develop real software solutions for real organizations that need it. One class, for example, is developing information management systems for a local battered women’s shelter in Merced as a part of the Schools Engineering Service Learning program. “The students work collaboratively with each other, their professors, and with the end users—the clients and administrators of the shelter—to make applications that address the shelter’s specific needs,” says Wright. For instance, the shelter needs a document organization and management system that supports low-income clients, and it would also like to develop an Internet-based counseling system for giving off-site support to shelter alumni.

Assistant professor Alberto Cerpa escorts his undergraduate students at Merced into real-world projects, too. In one course, after grounding them in basic open-source programming languages, Cerpa assigned his students to develop Merced-based Google-Maps-related projects that would contribute something to the community. One student obtained crime data from the Merced Police Department and made an application allowing people to search for available housing in the safest neighborhoods. Another student developed a map of all local gas stations that provided up-to-the-minute price information.

“Doing important and useful real-world work while learning computer science may draw a whole new kind of student into the field,” Wright says. By focusing on the content, and not just the programming itself, Merced aims to keep students interested and engaged.

For more information:

UC Merced School of Engineering: https://eng.ucmerced.edu/soe/