Grand Rounds on a Grand Scale

Doctors have long had a tradition of holding "grand rounds" to discuss patient cases and educate aspiring physicians.

The centuries-old practice certainly has its merits, but medical leaders in Arizona want to improve, update and broaden it to include a larger list of health care practitioners, such as nurses and social workers, regardless of their locations.

So the Arizona Telemedicine Program (ATP) drew on its extensive use of videoconferencing equipment to develop the Institute for Advanced Telemedicine and Telehealth, or the T-Health Institute, to facilitate a 21st-century way of teaching and collaborating across disciplines and professions.

This novel approach and use of technology put the T-Health Institute at the top of the Education & Academia category of the Computerworld Honors Program.

"Its specific mission is to use technology to permit interdisciplinary team training," explains Dr. Ronald Weinstein, co-founder and director of the ATP. "Now we're opening it up to a far broader range of participants and patients."

This initiative goes well beyond simply connecting two doctors through videoconferencing. It also enables individuals to meet in person in the newly built T-Health amphitheater. They can also meet remotely through finely tuned audiovisual equipment that can seamlessly segregate both in-person and remote meeting participants into smaller discussion groups.

Teams in Training

Project leaders say the goal is to create much-needed discussion and collaboration among professionals in multiple health care disciplines so that they can deliver the best care to patients.

"It's the effort to be inclusive," Weinstein says. "Medicine is quite closed and quite limited, but we're counting on telecommunications to bridge some of those communication gaps."

He's not the only one preaching this message. The prestigious National Academy of Science's Institute of Medicine (IOM) has advocated for more interprofessional training and has encouraged educators to develop more interdisciplinary curricula and incorporate interprofessional team training into their programs.

In a 2003 report, the IOM stated that "although the academic environments of the various health professions generally are not interdisciplinary, practice environments are increasingly so, posing a serious disconnect."

Page Break

One of the report's recommendations called for "developing and funding of regional demonstration learning centers, representing partnerships between practice and education."

Weinstein sees the T-Health Institute as one of the first such centers.

The institute is essentially a teleconferencing hub that enables students, professors and working professionals to participate in live meetings. Its technology also allows them to switch nearly instantly between different discussion groups as easily as they could if they were meeting in person and merely switching chairs.

Today, the facility has two panels of four screens (there are plans to add more). Two of the eight screens are focused on the two so-called hot seats in the auditorium, and the remaining screens are reserved for participants calling in from other sites.

Those participants might be calling from sites already in the ATP network or they might be invited from outside the network as guests.

Attendees can participate in a single large meeting, or they can be broken into groups -- one group of screens would be bordered by blue and the other by red to distinguish between the two meetings. Participants can be switched between the groups to shake up discussions.

This unique, flexible, agile setup directly supports the goal of providing interprofessional education. For example, participants in a meeting that involved medical students as well as nursing and pharmacy students could interact in various combinations so they could learn to work together and see the benefits of providing health care in a coordinated and collaborative manner, Weinstein explains.

"You just open up the world in terms of educational activity, research, case conferences," says Gail Barker, director of the T-Health Institute. "It breaks open any barriers to interprofessional education."

A New Way to Teach

The T-Health Institute is a division of the ATP, which Arizona lawmakers established in 1996 as a semi-autonomous entity. The ATP operates the Arizona Telemedicine Network, a statewide broadband health care telecommunications network that links 55 independent health care organizations in 71 communities.

Page Break

Through this network, telemedicine services are provided in 60 subspecialties, including internal medicine, surgery, psychiatry, radiology and pathology, by dozens of service providers. More than 600,000 patients have received services over the network.

Meanwhile, in 2004, as the IOM was pointing to communication gaps among health care professionals as a cause of significant problems, Arizona officials decided to create a new Phoenix branch for the state's medical school, the University of Arizona College of Medicine, in partnership with Arizona State University.

As part of that project, state leaders decided to build on the ATP's successes, and they identified the telemedicine program as an enabling technology for the educational program.

"We were selected by top leadership to think about how technology could make a difference," Weinstein says.

ATP leaders saw videoconferencing as a way to draw together students and professionals from the different health care disciplines in new ways.

"It's literally a new method of teaching medical students. It's a novel approach," says Jim Mauger, director of engineering at Audio Video Resources, a company hired to design and install the videoconferencing equipment for the T-Health Institute.

The T-Health Institute is on the campus of Arizona's new medical school in Phoenix. When it opened in 2006, every classroom on the campus was equipped with videoconferencing capabilities that tied back into a central control room, Mauger says. At that time, the T-Health amphitheater contained a standard teleconferencing setup, he explains.

From that base, Mauger says project leaders immediately started implementing the sophisticated technologies that are present today.

Because the ATP already had a statewide broadband health care telecommunications network in place, those implementing the infrastructure for the T-Health Institute could focus on getting the audio and video equipment needed for the job, says Michael Holcomb, the ATP's associate director for network architecture.

Broadcast Booth

The T-Health Institute uses a Tandberg 1500 videoconferencing system, and its video wall has 12 50-in. Toshiba P503DL DLP Datawall RPU Video Cubes. The video wall itself is controlled by a Jupiter Fusion 960 Display Wall Processor utilizing dual Intel Xeon processors. The Fusion 960 allows the wall to display fully movable and scalable images from multiple PC, video and network sources.

Page Break

A dedicated control room holds the audio and video switching equipment and Tandberg coder/decoders to connect the amphitheater to other telemedicine locations. The T-Health Institute's equipment is compatible with all standards-based equipment at other videoconferencing sites, Mauger says.

The amphitheater has 17 student desks with individual videocameras, microphones and headphones. There's also a free-standing Wharton Lectern with a Crestron control panel, which facilitators can use to control how participants are grouped on the video wall. Personal voice channels are clustered based on how the participants are grouped on the wall.

Although Weinstein was able to articulate this vision of interprofessional interaction -- that is, he could clearly lay out the user requirements -- implementing the technology to support it brought challenges, IT workers say.

Mauger says creating a videoconferencing system that linked multiple sites in one video wall wasn't the challenging part. The real challenge was developing the technology that allows facilitators to move participants into separate virtual groups and then seamlessly switch them around.

"The biggest challenges to making this work were the audio isolation among the separate conference participants as well as fast dynamics of switching video and moving participants to meetings," he explains.

To address those issues, Mauger says he customized the control system, a set of hardware and software tools from Crestron Electronics Inc. He also customized hardware from Extron Electronics, a maker of professional audiovisual systems integration products.

Mauger uses MediaMatrix from Peavey Electronics for audio processing.

"All this work took a couple of iterations, and we're still fine-tuning it," says Leela Doppalapudi, an ATP senior systems programmer and project manager for Phase 2 of the T-Health initiative.

Project leaders credited the team for having the expertise to get those components online. "It took all of our experience in videoconferencing to bring it all together and make it work," says Holcomb.

Page Break

He says his team also encountered other challenges -- ones that affect more typical IT projects, such as budget constraints, the need to get staffers in different cities to collaborate and the task of translating user requirements into actionable items. He notes that naming Doppalapudi as project manager in 2007 was instrumental in overcoming those challenges and getting the job done.

"It's necessary to have someone there on-site who understands [all the complex parts of the project]," Holcomb says. "Someone who is not just meeting with people every now and then, but someone who works with them on a daily basis."

Barker, who teaches in the College of Public Health at the University of Arizona and is a user of the system, led a trial-run training session at the T-Health amphitheater. She met with 13 people, including a clinical pharmacist, two family nurse practitioners, a senior business developer, two program coordinators, a diabetes program case manager and an A/V telemedicine specialist.

For that event, Barker says the biggest benefit was the time saved by having the facility in place; without the T-Health Institute, some participants would have had to make a four-hour round trip to attend in person.

Feedback from participants was positive, and there were no technical glitches during that first real test, Doppalapudi says.

Now the system is opening up to others in Arizona's health care and medical education communities. T-Health Institute officials say they see this as the first step toward a health care system that truly teaches its practitioners to work together across professional disciplines so that they can deliver the best, most efficient care possible.

"We think," Weinstein says, "that this is the only way you're going to create coordinated health care."