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									Using Technology in Urban Areas:
    Preparing for the Future
                            April 26, 1999




                          Frank Ferrante
                            Senior Manager
                         Mitretek Systems, Inc.




                             Presented to
    The Emerging Health Information Infrastructure Conference (HII99)
                  Improving Health in a Digital World
   Sponsored by the Friends of the National Library of Medicine (FNLM)
                           Washington, D.C.
Agenda

   Technology: Changes and Trends
   Digital Healthcare Products
   Applications
   Current and Future Technologies
   Summary




                                      2
Technology:
Changes Exponential
             Multimedia applications:
             Messaging, documents, desktop
             conferencing, image storage/retrieval,                   ATM/SONET
             TV distribution                                         WDM Networks
Data Rates                                                             100+ Gbps

100+ Gbps
                                                                ATM/SONET
 10 Gbps
                                                                 Networks
                                                                  1 Gbps+
                                                                              IP Switching
  1 Gbps                                                     FDDI
                                                                                 1 Gbps
                                                           100 Mbps
100 Mbps                                                                Fast Ethernet
                                                Ethernet                  100 Mbps
 10 Mbps                                      (IEEE 802.3)
                                                              IBM's Token Ring
                                                10 Mbps
                                                                  16 Mbps
  1 Mbps
                                                     • ISDN
 100 Kbps                      Early Modem   X.25
                               Access      56 Kbps
 10 Kbps                       1200 bps
                  Dial-Up                         Modem Access
  1 Kbps          300 bps                           9.6 Kbps

 100 bps     Direct Access
                75 bps
  10 bps
        1950     1955   1960   1965   1970   1975   1980   1985   1990   1995   2000



                                                                                             3
Technology:
Internet Trends
 Internet consumer market to reach 43 million in 2000 from 30+
  million households in 1998 {INTERNET2 reaching Gbps Rates)

                                 $5,000
                                 $4,500
   Internet Market in Millions




                                 $4,000
                                 $3,500
                                 $3,000
                                 $2,500
                                 $2,000
                                 $1,500
                                 $1,000
                                  $500
                                    $0
                                          1995   1996   1997      1998         1999          2000
                                                               Source: The Age of Internet: Capitalization on the Data Opportunity,
                                                               Information and Interactive Service Report, January 9, 1998
                                                                                                                            4
 Technology:
 Bandwidth Cost Trends




                                            Legend:
                                             OC - Optical Carrier Rates (155 Mbps
                                                   to 4.8 Gbps)
                                             WDM - Wavelength Division Multiplexing
                                             TDM - Time Division Multiplexing




Source: NGN - 1998 Conference Proceedings


                                                                               5
Technology:
Digital Healthcare Products
 Digital Blood Pressure Monitor (Sphygmonometer) - less than 10 Kbits of
  data per second (required transmission rates)
 Digital Thermometer - less than 10 Kbits of data (required transmission
  rates)
 Digital Audio Stethoscope and integrated electrocardiogram - less than 10
  Kbits of data (required transmission rates)
 Ultrasound, Angiograph, - 256 Kbytes (image size)
 Magnetic Resonance Image - 384 Kbytes (image size)
 Scanned X-Ray - 1.8 Mbytes (image size)
 Digital Radiolography - 6 Mbytes (image size)
 Mamogram - 24 Mbytes (image size)
 Compressed and full motion video (e.g., Nasopharyngoscope,
  Opthalmoscope, Proctoscope, Episcope, ENT Scope) - 384 Kb/s to 1.544
  Mb/s (speed)



                                                                              6
Technology:
Teleradiology Applications - Imaging
                   8 to 24 bits per
                   pixel




512 to
4096
pixels
                                               Image Type           Image Resolution    Image Size
                                                                   Spatial   Contrast
                                      Ultrasound                   512x512      x8      256 Kbytes
                                      Other (Angiography,
                                      Endoscopy, Nuclear Med.,     512x512      x8      256 Kbytes
         512 to 4096 pixels           Cardiology, Radiology)
                                      Computed Tomography          512x512     x12      384 Kbytes
                                      Magnetic Resonance Imaging   512x512     x12      384 Kbytes

                                      Digitized (Scanned) X-ray    1024x1250   x12      1.8 Mbytes
                                      Digital Radiography          1024x1024   x8        1 Mbyte
                                                                   2048x2048   x12       6 Mbytes
                                      Mammography                  4096x4096   x12      24 Mbytes



                                                                                                     7
Technology:
Image Transmission Times
 29.1 min.                                                       Note: Service classes changing faster than ever

             Coaxial Modem Range

                                                                    High-Speed Services
                            Medium-Speed Services                   (45 Mb/s - 4.8+ Gb/s)
            Slow-Speed       (384 Kb/s - 45 Mb/s)
             Services                                                 Medical/Scientific
                                Medical Images                          Visualization

               15.0 min.


                                                                   Assumptions:
                                                                        2048 x 2048x 12 bit image
                                                                        No compression


                            32.6 sec.   5.0 sec.     1.1 sec.   325 ms          21 ms          10.5 ms

28.8 Kb/s      56 Kb/s     1.544 Kb/s   10 Mb/s      45 Mb/s    155 Mb/s        2.4 Gb/s       4.8 Gb/s
 (Modem)        (Modem)       (T1)      (Ethernet)      (T3)    (ATM OC-3)    (ATM OC-48)     (ATM OC-96)




                                                                                                            8
 Technology:
 ATM Collaborative Computing
                               Desktop Video
                               Teleconference




                                  Live or stored
Collaborative                     video image
Work Board                        transfer




                                  {Sample:
                                  tissue
 {Sample:                         sample from
 discussing                       patient}
 telemedical
 application}


                                                   9
WDM Technology
 Pre-WDM:
   – On a single strand of fiber, a point-to-point backbone link
     would carry an OC-48 SONET signal at a single wavelength
 With WDM:
   – On a single strand of fiber, a point-to-point backbone link
     could carry multiple wavelengths (color bands) each
     wavelength capable of carrying an OC-48 SONET signal
   – Point-to-point throughput increases by a factor equal to
     number of wavelengths accommodated by the WDM
     equipment (4-8 in 1995)
   – Next development trend in WDM is true optical networking via
     optical cross connects where direct switching of optical
     signals rather than time slots are performed
       • Technology trend towards direct IP over WDM (bypassing
         SONET equipment)


                                                                    10
   Dense Wave Division Multiplexing
   (DWDM) Cost Savings Versus
   SONET
    Take advantage of DWDM bit-rate independence and lack of
     scaling capital expenditure as compared to SONET




Source: NGN - 1998 Conference Proceedings

                                                                11
Technology:
Smart Cards
 Definition
   – Plastic card with embedded silicon chip, 1 to 8 kilobytes of memory,
      microprocessor, operating system in ROM (Read Only Memory).
 Capabilities
   – Typical 1- 8Kbytes storage memory
   – 32kByte chips being developed
   – Price range now $2 to $25 per card (8Kb cards @$2)
 Medical Applications
   – Military experimenting in triage situations (Dog Tag replacements)
   – Insurance firms considering usage to
        • reduce cost of accounting for medical
        • future storage of patient records (assuming medical records
           policy changes takes place)
 Progress
   – Slow, with focus on billing/accounting
   – Expected to take off in near future if policy on records change
 Future
   – Could be useful in remote areas given inexpensive readers available
      (current readers cost $300 +)

                                                 Reference: 3GI home page -http://www.3GI.com/

                                                                                            12
     Technology:
                                                                                                                    Future Services
     Wireless                                                                                                        Digital Voice and Data services
                                                                                                                     Fax / Paging (two-way)
Today’s Services                                                                                                     Full High Speed E-mail / internet access
 Basic voice service                                                                                                    28.8 Kbps to n x 1.5 Mbps
 Fax / Paging (one-way, two-way)
                                                                                          H.320


                                                                                                                               3G Wireless Switch


 Limited e-mail and internet access                                                                                                 VLR/HLR/




     9.6 Kbps to 14.4 Kbps
                                                                                                                                     AUC/EIR




                                                                                                                                                n X DS1 or DS-3   PSTN

                                                                                     Air Interface:
                                                                                      3G                                          MSC
                                                                                      CDMA Based
                                                                                     
                                                                                        5 MHz RF Channels Base Station   BSC

                                                                                                                                   IP Gateway


                                                                                                        Future                                                       Corporate Intranet




                                                                                                                                                                            Video
                                                                                                                                                                            Server


                                                                                                                           Key:
                                       VLR/
                                       HLR/
                                      AUC/EIR                                 ISP                                          AUC              Authentication Center
                                                                                                                           BSC              Base Station Controller
                                                                      -3
                                                                    DS




                                                                                                                           EIR              Equipment Identification Register
                                                                or
                                                                1
                                                              DS
                                                           X
                                                         n




                                                                                                                           HLR              Home Location Register
                                                         nX
                                                              DS
                                                                1o
                                                                     rD
                                                                                                                           ISP              Internet Service Provider
                                                                                                                           MSC              Mobile Switching Center
                                                                       S-
                                                                          3
                               BSC
                Base Station                 MSC                              PSTN
                                                                                                                           PSTN             Public Switched Telephone Network
                                     (Circuit Switched Cards)




                                                                                                                           VLR              Visitor Location Register


                                                                                                                                                                                          13
Technology: Other Available Services
Supporting Telemedical Applications
   Digital Subscriber Loop Services
   Cable Modems
   Frame Relay (predecessor for IP networks)
   Wireless services (cellular, satellite, other)
   Faster CPUs and memory storage explosion
   Future growth of digital record keeping acceptance




                                                         14
Technology:
Summary
 Technology is changing exponentially
 Internet services in urban areas represent a possible
  outreach approach to the public with high bandwidth
  offerings and ubiquity of the services
 Cost of bandwidth is dropping rapidly
 Telemedicine requires bandwidth which is now becoming
  more affordable and available in urban areas
 Urban areas are ripe for considering new technology
  applications as never before (e.g., wireless beyond the
  pager and cell phone explosion




                                                            15
Technology:
Recommendations
 Perform the cost-benefit tradeoff studies now to identify
  longer term applications of new technologies in
  telemedicine
 Due to the explosive nature of technology changes be
  flexible in buying into the new offerings (2 to 3 year
  contracts with options to change or get out; lease as much
  as possible, don’t own your systems)
 Finally, encourage changes in insurance and legal
  restrictions to allow more telemedicine as facts prove their
  benefits.




                                                                 16
Contact Information

   Frank E. Ferrante
    Mitretek Systems, Inc.
    Senior Manager, Systems Engineering and Acquisition
    Center for Telecommunications and Advanced Technology
    7525 Colshire Drive
    McLean, VA 22102-7400

    Ferrante@Mitretek.org    Tel: (703) 610-2905   fax: (703) 610-2984




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