... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD,... more ... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD, CHARLES R. DOARN, MBA ... The RGB values were measured from each swatch using Adobe (Adobe Systems, Inc., San Jose, CA) Photoshop's eyedropper tool. ...
Circulation. Cardiovascular quality and outcomes, 2014
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke ris... more Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatme...
... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD,... more ... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD, CHARLES R. DOARN, MBA ... The RGB values were measured from each swatch using Adobe (Adobe Systems, Inc., San Jose, CA) Photoshop's eyedropper tool. ...
Circulation. Cardiovascular quality and outcomes, 2014
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke ris... more Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatme...
Assessment of the logistics, economic feasibility, and accuracy of presurgical and postsurgical t... more Assessment of the logistics, economic feasibility, and accuracy of presurgical and postsurgical telemedicine consultations is reported. Virtual patient-surgeon consults were achieved through the use of desktop and laptop computers, digital video, and still cameras using two communications modalities. Patients were selected from rural clinics in the southern Oriente region and from communities located in the Andes Mountain range outside of Cuenca, Ecuador. Patients were evaluated preoperatively and postoperatively by general surgeons working with the Cinterandes Foundation, a not-for-profit organization providing surgical care in remote regions of Ecuador in cooperation with the Ministry of Health's primary care program. Preoperative and postoperative telemedicine consultations had a high measure of clinical accuracy and some economic value. Data were collected from several sites throughout the country during the course of the project. Formidable challenges were encountered and are reported here.
Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to ... more Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to urologic training and the care of patients in remote regions. The multiple arms and threedimensional vision of the da Vinci robotic system provide a platform conducive to long-distance telementoring and telesurgery. Whereas prior telesurgical efforts have used dedicated lines for information transmission, the public Internet offers a less expensive alternative. It was the intent of this study to test the validity of using the da Vinci system in urologic telesurgery, and to conduct telerobotic nephrectomies using the public Internet.
As unmanned extraction vehicles become a reality in the military theater, opportunities to augmen... more As unmanned extraction vehicles become a reality in the military theater, opportunities to augment medical operations with telesurgical robotics become more plausible. This project demonstrated an experimental surgical robot using an unmanned airborne vehicle (UAV) as a network topology. Because battlefield operations are dynamic and geographically challenging, the installation of wireless networks is not a feasible option at this point. However, to utilize telesurgical robotics to assist in the urgent medical care of wounded soldiers, a robust, high bandwidth, low latency network is requisite. For the first time, a mobile surgical robotic system was deployed to an austere environment and surgeons were able to remotely operate the systems wirelessly using a UAV. Two University of Cincinnati surgeons were able to remotely drive the University of Washington's RAVEN robot's end effectors. The network topology demonstrated a highly portable, quickly deployable, bandwidth-sufficient and low latency wireless network required for battlefield use.
The VitalPoll Telemedicine System (VTS) was designed and developed for wireless home healthcare. ... more The VitalPoll Telemedicine System (VTS) was designed and developed for wireless home healthcare. The aims of this study were: to design the architecture and communication methods for a telemedicine system; to implement a physiologic routing hub to collect data from different medical devices and sensors; and to evaluate the feasibility of this system for applications in wireless home healthcare. The VTS was built using Bluetooth wireless and Internet technologies with client/server architecture. Several medical devices, which acquire vital signs, such as real-time electrocardiogram signals, heart rate, body temperature, and activity (physical motion), were integrated into the VTS. Medical information and data were transmitted over short-range interface (USB, RS232), wireless communication, and the Internet. The medical results were stored in a database and presented using a web browser. The patient's vital signals can be collected, transmitted, and displayed in real time by the VTS. The experiments verified no data loss during Bluetooth and Internet communication. Bluetooth and the Internet provide enough bandwidth channels to tranmit these vital signs. The experimental results show that VTS may be suitable for a practical telemedicine system in home healthcare.
Catastrophic events including those sparked by terrorism have cast a pall over society in recent ... more Catastrophic events including those sparked by terrorism have cast a pall over society in recent years. Events such as September 11th or the bombing of the Alfred P. Murrah Federal Building in Okalahoma City demonstrated a sudden surge in telephone call volume. These events indicated that communications systems, including cellular, can fail as a result from damage or capacity overload. Cellular systems have significant capacity given the limited radio spectrum allocated but much like airlines that oversell seats because inevitably some passengers do not show up, cellular providers typically have more customers than operational spectrum can handle in aggregate. Normally this is perfectly acceptable because a high percentage of the customer base would never be making calls simultaneously; except in an emergency. Such emergencies can be active or passive in nature. The release of dangerous airborne agents is one such scenario. The purpose of this study was to use a portable air particulate sensor as a data acquisition platform to evaluate the capability of real-time data throughput using existing wireless topologies, Java, eXtensible Markup Language (XML) and Internet protocols when cellular transmission frequencies are compromised. Results show that high levels of cellular voice traffic in a given area can hamper simultaneous data communications; however, Low Earth Orbiting Satellites (LEOS) can provide redundancy.
Telemedicine is traditionally associated with the use of very expensive and bulky telecommunicati... more Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world. Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine. Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps. Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.
Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to imp... more Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to improve quality of healthcare in hospital, nursing home, and remote environments. The objective of this study was to determine reliability of vital-signs monitoring systems in extreme environments. Three climbers were monitored 24 hours while climbing through Khumbu Icefall. Data were transmitted to Everest Base Camp (elevation 17,800 feet) and retransmitted to Yale University via telemedicine. Main outcome measures (location, heart rate, skin temperature, core body temperature, and activity level) all correlated through timestamped identification. Two of three location devices functioned 100% of the time, and one device failed after initial acquisition of location 75% of the time. Vital-signs monitors functioned from 95%-100% of the time, with the exception of one climber whose heart-rate monitor functioned 78% of the time. Due to architecture of automatic polling and data acquisition of biosensors, no climber was ever without a full set of data for more than 25 minutes. Climbers were monitored continuously in real-time from Mount Everest to Yale University for more than 45 minutes. Heart rate varied from 76 to 164 beats per minute, skin temperature varied from 5 to 10°C, and core body temperature varied only 1-3°C. No direct correlation was observed among heart rate, activity level, and body temperature, though numerous periods suggested intense and arduous activity. Field testing in the extreme environment of Mount Everest demonstrated an ability to track in real time both vital signs and position of climbers. However, these systems must be more reliable and robust. As technology transitions to commercial products, benefits of remote monitoring will become available for routine healthcare purposes.
To determine whether a low-bandwidth Internet connection can provide adequate image quality to su... more To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote realtime surgical consultation.
To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, lo... more To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Retrospective cohort study. Primary care practices of an academic healthcare system. Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. P...
... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD,... more ... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD, CHARLES R. DOARN, MBA ... The RGB values were measured from each swatch using Adobe (Adobe Systems, Inc., San Jose, CA) Photoshop's eyedropper tool. ...
Circulation. Cardiovascular quality and outcomes, 2014
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke ris... more Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatme...
... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD,... more ... TIMOTHY J. BRODERICK, MD, BRETT M. HARNETT, BS, NATHANIEL R. MERRIAM, BFA, VANISH KAPOOR, MD, CHARLES R. DOARN, MBA ... The RGB values were measured from each swatch using Adobe (Adobe Systems, Inc., San Jose, CA) Photoshop's eyedropper tool. ...
Circulation. Cardiovascular quality and outcomes, 2014
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke ris... more Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatme...
Assessment of the logistics, economic feasibility, and accuracy of presurgical and postsurgical t... more Assessment of the logistics, economic feasibility, and accuracy of presurgical and postsurgical telemedicine consultations is reported. Virtual patient-surgeon consults were achieved through the use of desktop and laptop computers, digital video, and still cameras using two communications modalities. Patients were selected from rural clinics in the southern Oriente region and from communities located in the Andes Mountain range outside of Cuenca, Ecuador. Patients were evaluated preoperatively and postoperatively by general surgeons working with the Cinterandes Foundation, a not-for-profit organization providing surgical care in remote regions of Ecuador in cooperation with the Ministry of Health's primary care program. Preoperative and postoperative telemedicine consultations had a high measure of clinical accuracy and some economic value. Data were collected from several sites throughout the country during the course of the project. Formidable challenges were encountered and are reported here.
Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to ... more Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to urologic training and the care of patients in remote regions. The multiple arms and threedimensional vision of the da Vinci robotic system provide a platform conducive to long-distance telementoring and telesurgery. Whereas prior telesurgical efforts have used dedicated lines for information transmission, the public Internet offers a less expensive alternative. It was the intent of this study to test the validity of using the da Vinci system in urologic telesurgery, and to conduct telerobotic nephrectomies using the public Internet.
As unmanned extraction vehicles become a reality in the military theater, opportunities to augmen... more As unmanned extraction vehicles become a reality in the military theater, opportunities to augment medical operations with telesurgical robotics become more plausible. This project demonstrated an experimental surgical robot using an unmanned airborne vehicle (UAV) as a network topology. Because battlefield operations are dynamic and geographically challenging, the installation of wireless networks is not a feasible option at this point. However, to utilize telesurgical robotics to assist in the urgent medical care of wounded soldiers, a robust, high bandwidth, low latency network is requisite. For the first time, a mobile surgical robotic system was deployed to an austere environment and surgeons were able to remotely operate the systems wirelessly using a UAV. Two University of Cincinnati surgeons were able to remotely drive the University of Washington's RAVEN robot's end effectors. The network topology demonstrated a highly portable, quickly deployable, bandwidth-sufficient and low latency wireless network required for battlefield use.
The VitalPoll Telemedicine System (VTS) was designed and developed for wireless home healthcare. ... more The VitalPoll Telemedicine System (VTS) was designed and developed for wireless home healthcare. The aims of this study were: to design the architecture and communication methods for a telemedicine system; to implement a physiologic routing hub to collect data from different medical devices and sensors; and to evaluate the feasibility of this system for applications in wireless home healthcare. The VTS was built using Bluetooth wireless and Internet technologies with client/server architecture. Several medical devices, which acquire vital signs, such as real-time electrocardiogram signals, heart rate, body temperature, and activity (physical motion), were integrated into the VTS. Medical information and data were transmitted over short-range interface (USB, RS232), wireless communication, and the Internet. The medical results were stored in a database and presented using a web browser. The patient's vital signals can be collected, transmitted, and displayed in real time by the VTS. The experiments verified no data loss during Bluetooth and Internet communication. Bluetooth and the Internet provide enough bandwidth channels to tranmit these vital signs. The experimental results show that VTS may be suitable for a practical telemedicine system in home healthcare.
Catastrophic events including those sparked by terrorism have cast a pall over society in recent ... more Catastrophic events including those sparked by terrorism have cast a pall over society in recent years. Events such as September 11th or the bombing of the Alfred P. Murrah Federal Building in Okalahoma City demonstrated a sudden surge in telephone call volume. These events indicated that communications systems, including cellular, can fail as a result from damage or capacity overload. Cellular systems have significant capacity given the limited radio spectrum allocated but much like airlines that oversell seats because inevitably some passengers do not show up, cellular providers typically have more customers than operational spectrum can handle in aggregate. Normally this is perfectly acceptable because a high percentage of the customer base would never be making calls simultaneously; except in an emergency. Such emergencies can be active or passive in nature. The release of dangerous airborne agents is one such scenario. The purpose of this study was to use a portable air particulate sensor as a data acquisition platform to evaluate the capability of real-time data throughput using existing wireless topologies, Java, eXtensible Markup Language (XML) and Internet protocols when cellular transmission frequencies are compromised. Results show that high levels of cellular voice traffic in a given area can hamper simultaneous data communications; however, Low Earth Orbiting Satellites (LEOS) can provide redundancy.
Telemedicine is traditionally associated with the use of very expensive and bulky telecommunicati... more Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world. Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine. Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps. Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.
Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to imp... more Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to improve quality of healthcare in hospital, nursing home, and remote environments. The objective of this study was to determine reliability of vital-signs monitoring systems in extreme environments. Three climbers were monitored 24 hours while climbing through Khumbu Icefall. Data were transmitted to Everest Base Camp (elevation 17,800 feet) and retransmitted to Yale University via telemedicine. Main outcome measures (location, heart rate, skin temperature, core body temperature, and activity level) all correlated through timestamped identification. Two of three location devices functioned 100% of the time, and one device failed after initial acquisition of location 75% of the time. Vital-signs monitors functioned from 95%-100% of the time, with the exception of one climber whose heart-rate monitor functioned 78% of the time. Due to architecture of automatic polling and data acquisition of biosensors, no climber was ever without a full set of data for more than 25 minutes. Climbers were monitored continuously in real-time from Mount Everest to Yale University for more than 45 minutes. Heart rate varied from 76 to 164 beats per minute, skin temperature varied from 5 to 10°C, and core body temperature varied only 1-3°C. No direct correlation was observed among heart rate, activity level, and body temperature, though numerous periods suggested intense and arduous activity. Field testing in the extreme environment of Mount Everest demonstrated an ability to track in real time both vital signs and position of climbers. However, these systems must be more reliable and robust. As technology transitions to commercial products, benefits of remote monitoring will become available for routine healthcare purposes.
To determine whether a low-bandwidth Internet connection can provide adequate image quality to su... more To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote realtime surgical consultation.
To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, lo... more To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. Retrospective cohort study. Primary care practices of an academic healthcare system. Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. P...
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