Telemedicine, Nephrology, Telemedicine, Nephrology, and Renal Pathologyand Renal Pathology

Kim Solez, M.D.Kim Solez, M.D.

Kim.Solez@UAlberta.CAKim.Solez@UAlberta.CA

A transition: Telemedicine, A transition: Telemedicine, telehealth, e-healthtelehealth, e-health

The primary care physician of the The primary care physician of the future is the patient (or parent) !future is the patient (or parent) !

e-health e-health Consumer-drivenConsumer-driven

Telemedicine and Telehealth Telemedicine and Telehealth Provider-drivenProvider-driven

The public will tell us what they want The public will tell us what they want in e-health. Providers no longer in e-health. Providers no longer dictate but become partners with dictate but become partners with

patient or parent.patient or parent.

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Telemedicine - The Past,Telemedicine - The Past,the Futurethe Future

In the past meant mainly phone based In the past meant mainly phone based videoconferencing using phone linesvideoconferencing using phone linesor dedicated ISDN lines, largely or dedicated ISDN lines, largely impractical for developing countries.impractical for developing countries.

In the future, Internet based using suchIn the future, Internet based using suchprograms as Microsoft Netmeeting andprograms as Microsoft Netmeeting andClassPoint, practical for developingClassPoint, practical for developingcountries.countries.

In the past meant mainly phone based In the past meant mainly phone based videoconferencing using phone linesvideoconferencing using phone linesor dedicated ISDN lines, largely or dedicated ISDN lines, largely impractical for developing countries.impractical for developing countries.

In the future, Internet based using suchIn the future, Internet based using suchprograms as Microsoft Netmeeting andprograms as Microsoft Netmeeting andClassPoint, practical for developingClassPoint, practical for developingcountries.countries.

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Telepathology - The Past,Telepathology - The Past,the Futurethe Future

In the past meant mainly real time In the past meant mainly real time robotic stage connection usingrobotic stage connection usingdedicated ISDN lines, largely dedicated ISDN lines, largely impractical for developing countries.impractical for developing countries.

In the future, Internet based using In the future, Internet based using static images from inexpensive digitalstatic images from inexpensive digitalcameras, practical for developingcameras, practical for developingcountries.countries.

In the past meant mainly real time In the past meant mainly real time robotic stage connection usingrobotic stage connection usingdedicated ISDN lines, largely dedicated ISDN lines, largely impractical for developing countries.impractical for developing countries.

In the future, Internet based using In the future, Internet based using static images from inexpensive digitalstatic images from inexpensive digitalcameras, practical for developingcameras, practical for developingcountries.countries.

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Internet technologies the ideal Internet technologies the ideal way to build consensusway to build consensus

Three examples:Three examples:

ISN Disaster Relief Task ForceISN Disaster Relief Task Force

ISN Consensus Conferences - COMGANISN Consensus Conferences - COMGAN

Banff conferences on allograft pathologyBanff conferences on allograft pathology

Three examples:Three examples:

ISN Disaster Relief Task ForceISN Disaster Relief Task Force

ISN Consensus Conferences - COMGANISN Consensus Conferences - COMGAN

Banff conferences on allograft pathologyBanff conferences on allograft pathology

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Banff ClassificationBanff Classification

Internationally agreed upon classificationInternationally agreed upon classification

First developed in 1991, meetings every First developed in 1991, meetings every two years.two years.

Published in KI in 1993 and 1999.Published in KI in 1993 and 1999.

Employs lesion quantitation g,I,t,v,ahEmploys lesion quantitation g,I,t,v,ahcg,ci,ct,cv,mm and standard diagnosticcg,ci,ct,cv,mm and standard diagnosticcategories.categories.

Internationally agreed upon classificationInternationally agreed upon classification

First developed in 1991, meetings every First developed in 1991, meetings every two years.two years.

Published in KI in 1993 and 1999.Published in KI in 1993 and 1999.

Employs lesion quantitation g,I,t,v,ahEmploys lesion quantitation g,I,t,v,ahcg,ci,ct,cv,mm and standard diagnosticcg,ci,ct,cv,mm and standard diagnosticcategories.categories.

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Banff ClassificationBanff Classification

Inflammation does not equal rejection.Inflammation does not equal rejection.

Tubulitis suggests rejection, Tubulitis suggests rejection, intimal arteritis diagnostic of rejection.intimal arteritis diagnostic of rejection.

Three histologic forms, tubulointerstitial,Three histologic forms, tubulointerstitial,vascular, and transmural.vascular, and transmural.

Inflammation does not equal rejection.Inflammation does not equal rejection.

Tubulitis suggests rejection, Tubulitis suggests rejection, intimal arteritis diagnostic of rejection.intimal arteritis diagnostic of rejection.

Three histologic forms, tubulointerstitial,Three histologic forms, tubulointerstitial,vascular, and transmural.vascular, and transmural.

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Banff ClassificationBanff Classification

Anyone can participate in the Banff Anyone can participate in the Banff meetings, on site or remotely.meetings, on site or remotely.

Next meeting April 21-28, 2001Next meeting April 21-28, 2001

Important breakthroughs expected in Important breakthroughs expected in 2001. Chronic rejection classification.2001. Chronic rejection classification.EM and C4D findings specific for EM and C4D findings specific for chronic rejectiion, antibody mediatedchronic rejectiion, antibody mediatedrejection. Donor biopsy classification.rejection. Donor biopsy classification.

Anyone can participate in the Banff Anyone can participate in the Banff meetings, on site or remotely.meetings, on site or remotely.

Next meeting April 21-28, 2001Next meeting April 21-28, 2001

Important breakthroughs expected in Important breakthroughs expected in 2001. Chronic rejection classification.2001. Chronic rejection classification.EM and C4D findings specific for EM and C4D findings specific for chronic rejectiion, antibody mediatedchronic rejectiion, antibody mediatedrejection. Donor biopsy classification.rejection. Donor biopsy classification.

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Communications for BanffCommunications for Banff

Face to face meetings. Letters, faxes, Face to face meetings. Letters, faxes, phone calls. Expensive, cumbersome,phone calls. Expensive, cumbersome,slow.slow.

Since 1994 the Internet has been the mainSince 1994 the Internet has been the mainmeans of communication for this andmeans of communication for this andother projects.other projects.

Face to face meetings. Letters, faxes, Face to face meetings. Letters, faxes, phone calls. Expensive, cumbersome,phone calls. Expensive, cumbersome,slow.slow.

Since 1994 the Internet has been the mainSince 1994 the Internet has been the mainmeans of communication for this andmeans of communication for this andother projects.other projects.

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Origins of cyberNephrologyOrigins of cyberNephrology

In 1994 Michele Hales and I created the In 1994 Michele Hales and I created the WWW page for ISN and RPS, and theWWW page for ISN and RPS, and theNEPHROL discussion group. In 1995NEPHROL discussion group. In 1995we sent first renal biopsy images over the we sent first renal biopsy images over the Internet and has the first international Internet and has the first international medical meeting that one could virtuallymedical meeting that one could virtuallyattend via Internet and CD-ROM, and attend via Internet and CD-ROM, and in 1996 created the first nephrology in 1996 created the first nephrology Internet teleconference (Edmonton-Milan)Internet teleconference (Edmonton-Milan)

In 1994 Michele Hales and I created the In 1994 Michele Hales and I created the WWW page for ISN and RPS, and theWWW page for ISN and RPS, and theNEPHROL discussion group. In 1995NEPHROL discussion group. In 1995we sent first renal biopsy images over the we sent first renal biopsy images over the Internet and has the first international Internet and has the first international medical meeting that one could virtuallymedical meeting that one could virtuallyattend via Internet and CD-ROM, and attend via Internet and CD-ROM, and in 1996 created the first nephrology in 1996 created the first nephrology Internet teleconference (Edmonton-Milan)Internet teleconference (Edmonton-Milan)

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First Phase of NKF cyberNephrology First Phase of NKF cyberNephrology 1997-20001997-2000

Many accomplishmentsMany accomplishments

Email discussion groups - NEPHROL, Email discussion groups - NEPHROL, NEPHDEVEL, NEPHKIDS and progenyNEPHDEVEL, NEPHKIDS and progeny

WWW sites - virtual attendance at meetingsWWW sites - virtual attendance at meetings

AJKD Forum http://www.ajkd.orgAJKD Forum http://www.ajkd.org

Schrier Atlas http://www.kidneyatlas.orgSchrier Atlas http://www.kidneyatlas.org

Renal-Tech computer donation projectRenal-Tech computer donation project

Internet videoconferencing, wireless connectivity, Internet videoconferencing, wireless connectivity, panoramas. panoramas.

WWW site http://www.cybernephrology.orgWWW site http://www.cybernephrology.org

Support of ISN and NKF Support of ISN and NKF Programs. Furthering of new Programs. Furthering of new

technologies.technologies.

WWW sites:WWW sites:

http://www.cybernephrology.org http://www.cybernephrology.org http://www.isn-online.orghttp://www.isn-online.org

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Support of NKF ProgramsSupport of NKF Programs

KEEP, RISEKEEP, RISE

K/DOQIK/DOQI

PARADEPARADE

People like UsPeople like Us

Spring Clinical Meeting , ASNSpring Clinical Meeting , ASN

Publications Publications

Donor Families, Donor Quilt Donor Families, Donor Quilt

Transplant GamesTransplant Games

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Support of ISN ProgramsSupport of ISN Programs

COMGANCOMGAN

RENAL-TECH Computer Donation ProjectRENAL-TECH Computer Donation Project

Video Legacy ProjectVideo Legacy Project

ISN ArchiveISN Archive

Sister Centers Program Sister Centers Program

Teaching Resources Teaching Resources

Discussion Groups Discussion Groups

Assistance to National SocietiesAssistance to National Societies

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Making Full Use of the Favorable Making Full Use of the Favorable Local Environment in CanadaLocal Environment in Canada

Canada is way ahead of the U.S. in the Canada is way ahead of the U.S. in the deployment and adoption of next-generation deployment and adoption of next-generation broadband services: The cross-Canada high-broadband services: The cross-Canada high-speed network backbone, CA*net3, is the speed network backbone, CA*net3, is the world's first national optical research network.world's first national optical research network.

By the end of this year nearly 17% of Canadian By the end of this year nearly 17% of Canadian on-line homes will have a broadband on-line homes will have a broadband connection compared to 8.6% in the U.S.connection compared to 8.6% in the U.S.

Living example of the success of wireless Living example of the success of wireless connectivity! From University of Alberta to connectivity! From University of Alberta to College Plaza cyberNephrology complex.College Plaza cyberNephrology complex.

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New Operating Systems and New Operating Systems and Electronic Publishing FormatsElectronic Publishing Formats

Palm computing platformPalm computing platform

Macintosh OS 10Macintosh OS 10

LinuxLinux

XML document presentationXML document presentation

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Internet use becomes “mainstream” in 2000 Internet use becomes “mainstream” in 2000 - even in Africa!- even in Africa!

1.1. Most health care workers using the Internet.Most health care workers using the Internet.

2.2. Access becoming faster, cheaper.Access becoming faster, cheaper.

3.3. Computers themselves inexpensive.Computers themselves inexpensive.

4.4. No longer necessary to type. Voice No longer necessary to type. Voice recognition reaches 98% accuracy and still recognition reaches 98% accuracy and still improving!improving!

Internet use becomes “mainstream” in 2000 Internet use becomes “mainstream” in 2000 - even in Africa!- even in Africa!

1.1. Most health care workers using the Internet.Most health care workers using the Internet.

2.2. Access becoming faster, cheaper.Access becoming faster, cheaper.

3.3. Computers themselves inexpensive.Computers themselves inexpensive.

4.4. No longer necessary to type. Voice No longer necessary to type. Voice recognition reaches 98% accuracy and still recognition reaches 98% accuracy and still improving!improving!

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Internet Users Worldwide Internet Users Worldwide June 1999 - Nua Internet SurveysJune 1999 - Nua Internet Surveys

World Total 179.00 millionWorld Total 179.00 million

Africa 1.14 millionAfrica 1.14 million

Asia/Pacific 26.97 millionAsia/Pacific 26.97 million

Europe 42.69 millionEurope 42.69 million

Middle East 0.88 millionMiddle East 0.88 million

Canada and USA 102.03 millionCanada and USA 102.03 million

Latin America 5.29 millionLatin America 5.29 million

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The World is Changing - Now! The World is Changing - Now!

September 26, 2001 New Hewlett Packard CEO September 26, 2001 New Hewlett Packard CEO Carly Fiorina said Tuesday that the world is Carly Fiorina said Tuesday that the world is now entering the "renaissance of thenow entering the "renaissance of theinformation age" -- a time when emerging information age" -- a time when emerging technologies and an "always-on Internet" technologies and an "always-on Internet" could transform human experience and could transform human experience and entire industries. "This world is clearly entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." the opportunities ahead are massive."

September 28, 2001 Major advance in September 28, 2001 Major advance in quantum computing announced.quantum computing announced.

September 26, 2001 New Hewlett Packard CEO September 26, 2001 New Hewlett Packard CEO Carly Fiorina said Tuesday that the world is Carly Fiorina said Tuesday that the world is now entering the "renaissance of thenow entering the "renaissance of theinformation age" -- a time when emerging information age" -- a time when emerging technologies and an "always-on Internet" technologies and an "always-on Internet" could transform human experience and could transform human experience and entire industries. "This world is clearly entire industries. "This world is clearly emerging before our eyes," "The shifts ahead, emerging before our eyes," "The shifts ahead, the opportunities ahead are massive." the opportunities ahead are massive."

September 28, 2001 Major advance in September 28, 2001 Major advance in quantum computing announced.quantum computing announced.

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The World is Changing - Now! ... The World is Changing - Now! ... continuedcontinued

November 21, 1999November 21, 1999Clinton Calls for Widespread Clinton Calls for Widespread Internet Access - The New York TimesInternet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their called Sunday for developed nations to ensure their citizens have access to the Internet citizens have access to the Internet "as complete as telephone access," saying "as complete as telephone access," saying that would dramatically reduce the income gap that would dramatically reduce the income gap between rich and poor.between rich and poor.

November 21, 1999November 21, 1999Clinton Calls for Widespread Clinton Calls for Widespread Internet Access - The New York TimesInternet Access - The New York Times FLORENCE, Italy -- President Clinton FLORENCE, Italy -- President Clinton called Sunday for developed nations to ensure their called Sunday for developed nations to ensure their citizens have access to the Internet citizens have access to the Internet "as complete as telephone access," saying "as complete as telephone access," saying that would dramatically reduce the income gap that would dramatically reduce the income gap between rich and poor.between rich and poor.

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The World is Changing - Now! … The World is Changing - Now! … continued - The “Digital Divide”continued - The “Digital Divide”

At a gathering of world leaders who adhere At a gathering of world leaders who adhere to "third way" politics, Clinton said one of to "third way" politics, Clinton said one of the greatest domestic problems facing the greatest domestic problems facing developed countries is the "digital divide" developed countries is the "digital divide" that gives those who have computers an that gives those who have computers an enormous advantage over those who do not.enormous advantage over those who do not.

At a gathering of world leaders who adhere At a gathering of world leaders who adhere to "third way" politics, Clinton said one of to "third way" politics, Clinton said one of the greatest domestic problems facing the greatest domestic problems facing developed countries is the "digital divide" developed countries is the "digital divide" that gives those who have computers an that gives those who have computers an enormous advantage over those who do not.enormous advantage over those who do not.

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The Internet in Europe, Asia, and The Internet in Europe, Asia, and Africa - including KenyaAfrica - including Kenya

Up until now there have been three main barriers to Internet use in Europe, Asia, and Africa: 1. Cost (Much higher than in North America and quite heterogeneous)2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN)3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture)

Up until now there have been three main barriers to Internet use in Europe, Asia, and Africa: 1. Cost (Much higher than in North America and quite heterogeneous)2. Lack of high speed Internet access (Often nothing faster than standard modem or ISDN)3. Language (because most Internet activity is in English it may seem like a very foreign and not-very-attractive culture)

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The Internet in Europe, Asia, and The Internet in Europe, Asia, and Africa - including Kenya - Solutions!Africa - including Kenya - Solutions!

1. Cost - 1. Cost - Communications reform. Flat rate.Communications reform. Flat rate.

2. High speed Internet access DSL 2. High speed Internet access DSL and cable modem coming, faster and cable modem coming, faster than ISDN and cheaper!than ISDN and cheaper!

3. Language - Increasing success 3. Language - Increasing success with non-English resources on the Internet.with non-English resources on the Internet.

1. Cost - 1. Cost - Communications reform. Flat rate.Communications reform. Flat rate.

2. High speed Internet access DSL 2. High speed Internet access DSL and cable modem coming, faster and cable modem coming, faster than ISDN and cheaper!than ISDN and cheaper!

3. Language - Increasing success 3. Language - Increasing success with non-English resources on the Internet.with non-English resources on the Internet.

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Bandwidth considerationsBandwidth considerations

The Internet in high bandwidth environments:The Internet in high bandwidth environments:

Only 35% of human communication is words. Only 35% of human communication is words. With Internet video conferencing can capture With Internet video conferencing can capture gestures, body language, inflections of the gestures, body language, inflections of the voice, facial expression etc. plus share voice, facial expression etc. plus share images, documents, software applications images, documents, software applications with "shared white board" or complete with "shared white board" or complete remote control of other computer! remote control of other computer! Requres 56 K modem or faster connection. Requres 56 K modem or faster connection. Allows telemedicine/telepathology.Allows telemedicine/telepathology.

The Internet in high bandwidth environments:The Internet in high bandwidth environments:

Only 35% of human communication is words. Only 35% of human communication is words. With Internet video conferencing can capture With Internet video conferencing can capture gestures, body language, inflections of the gestures, body language, inflections of the voice, facial expression etc. plus share voice, facial expression etc. plus share images, documents, software applications images, documents, software applications with "shared white board" or complete with "shared white board" or complete remote control of other computer! remote control of other computer! Requres 56 K modem or faster connection. Requres 56 K modem or faster connection. Allows telemedicine/telepathology.Allows telemedicine/telepathology.

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Bandwidth considerationsBandwidth considerations

The Internet in low bandwidth situations:The Internet in low bandwidth situations:

Web site educational content can be placed Web site educational content can be placed on CD-ROMs cheaply and easily so sites on CD-ROMs cheaply and easily so sites can be accessed without going to the can be accessed without going to the World Wide Web. Email-based low World Wide Web. Email-based low bandwidth discussion has been bandwidth discussion has been enormously successful in nephrology and enormously successful in nephrology and transplantation while WWW-based transplantation while WWW-based discussion has not. So potentially discussion has not. So potentially everyone has access to the Internet everyone has access to the Internet resources that have proven most valuable.resources that have proven most valuable.

The Internet in low bandwidth situations:The Internet in low bandwidth situations:

Web site educational content can be placed Web site educational content can be placed on CD-ROMs cheaply and easily so sites on CD-ROMs cheaply and easily so sites can be accessed without going to the can be accessed without going to the World Wide Web. Email-based low World Wide Web. Email-based low bandwidth discussion has been bandwidth discussion has been enormously successful in nephrology and enormously successful in nephrology and transplantation while WWW-based transplantation while WWW-based discussion has not. So potentially discussion has not. So potentially everyone has access to the Internet everyone has access to the Internet resources that have proven most valuable.resources that have proven most valuable.

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Few Countries Out of Reach!Few Countries Out of Reach!

Almost all countries can benefit from Almost all countries can benefit from Internet-based discussion. Internet-based discussion. Email connectivity has reached almost Email connectivity has reached almost everywhere. Very few exceptions: everywhere. Very few exceptions: Countries lacking Internet access include Countries lacking Internet access include only Afghanistan , Angola, Cape Verde, only Afghanistan , Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara.Somalia and Western Sahara.

Almost all countries can benefit from Almost all countries can benefit from Internet-based discussion. Internet-based discussion. Email connectivity has reached almost Email connectivity has reached almost everywhere. Very few exceptions: everywhere. Very few exceptions: Countries lacking Internet access include Countries lacking Internet access include only Afghanistan , Angola, Cape Verde, only Afghanistan , Angola, Cape Verde, the Comoros Islands, Equatorial Guinea, the Comoros Islands, Equatorial Guinea, Libya, Mauritania, São Tome and Principe, Libya, Mauritania, São Tome and Principe, Somalia and Western Sahara.Somalia and Western Sahara.

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"We strongly believe that better telecommunications "We strongly believe that better telecommunications will enhance our ability to deliver improved will enhance our ability to deliver improved quality of life, electronic health and quality of life, electronic health and learning services to previously disadvantaged learning services to previously disadvantaged areas in the continent".areas in the continent".

President Nelson Mandela in an address to the President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998Forum Johannesburg 4-9 May 1998

"We strongly believe that better telecommunications "We strongly believe that better telecommunications will enhance our ability to deliver improved will enhance our ability to deliver improved quality of life, electronic health and quality of life, electronic health and learning services to previously disadvantaged learning services to previously disadvantaged areas in the continent".areas in the continent".

President Nelson Mandela in an address to the President Nelson Mandela in an address to the Africa TELECOM 98 Exhibition and Africa TELECOM 98 Exhibition and Forum Johannesburg 4-9 May 1998Forum Johannesburg 4-9 May 1998

Contact Contact Kim.Solez@UAlberta.CAKim.Solez@UAlberta.CA

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