PREGNANCY INDUCED

HYPERTENSION
&
TELEMEDICINE
ASKLEPIOS
Howard University, College of medicine
Program director : Dr Celia Maxwell, MD
Project supervisor : Dr ERNEST L. CARTER, MD PhD

Aristotle University, Medical school

Program director : Dr Nicos Maglaveras
KLEOPATRA KOURAKI MD
SUPERVISOR : Dr ERNEST L. CARTER MD PhD

WASHINGTON DC, August 2002

HOWARD UNIVERSITY
Index
1. OVERVIEW
2. MARKETING
3. WORKFLOW
4. MEDICAL PERIPHERALS
5. TELECOMMUNICATIONS
6. FINANCIALS
1. OVERVIEW
Purpose of the project
Develop a system that will allow the home
monitoring of pregnant women with
Pregnancy Induced Hypertension (P.I.H.)
with the use of telemedicine
What is Pregnancy Induced
Hypertension
 Pregnancy Induced Hypertension or Preeclampsia
is a potentially life-threatening complication of
pregnancy
 It causes mild to severe hypertension in a
previously normotensive pregnant woman
 It also causes problems with placental blood
supply to the fetus
 Sometimes it affects the mother's liver, kidney,
and brain function. Women with severe
preeclampsia can develop life-threatening
seizures (eclampsia).
RISK FACTORS
 Mother under 18 or over 35 years old
 First pregnancy
 Multifetal gestations
 Preeclampsia in a previous pregnancy (30%
recurrence)

 Chronic hypertension
 Diabetes
 Kidney problems
 Obesity
 SYMPTOMS
• Weight gain
• Swelling of hands and face
• Headaches

• Visual disturbances (scotoma, blurred vision, flashing

lights)
• Decreased urine output
• Nausea and vomiting
• Abdominal pain
TESTS

 Signs of hemolysis (elevated LDH, Bilirubin)

 Thrombocytopenia
 Elevated liver function tests
 Elevated uric acid
 Proteinuria
 What is Telemedicine
Telemedicine is the use of advanced
technology to exchange health information
(audio , visual , text )

and provide health care services (diagnosis,

consultation, treatment, education) across
geographic, time, social and cultural barriers
What is the aim of Telemedicine
A Telemedicine project is successful, when it
achieves to
Save time

Save money

Improve the quality of healthcare

It may seem complicated…
But in reality, it is just a network of physicians
requiring consults from an expert
2. MARKETING
Europe
Mediterranean
Greece
Macedonia

Population: 2 675 000

Target area

Thessaloniki : 1 100 000

1-2 hours distance : 820 000
2-3 hours distance : 755 000
 Population
Thessaloniki : 1 100 000 Grebena : 40 000
Kozani : 155 000

Pieria : 130 000 Kastoria : 55 000

Imathia : 150 000 Florina : 55 000

Pella : 145 000 Serres : 200 000

Kilkis : 90 000 Drama : 105 000

Serres : 200 000 Kavala : +145 000

Chalkidiki : + 105 000 755 000

820 000
Estimated patients’ number
Population living in target area : 2 700 000
Average national birth ratio : 10 children per
1000 citizens per year
⇓
Estimated pregnancies : 27 000 per year
Occurrence of pregnancy induced hypertension :
6-8%
⇓
Estimated patients : 1 890 per year
Competition
In the target area around the city of Thessaloniki
there are
 Several obstetricians, but none with expert
knowledge on antepartum fetal ultrasounds
 Several clinics for childbirth without organized
Intensive Care Units able to handle severe cases
 No organized Neonatology Intensive Care Units
(NICU)
 Current situation
 On suspicion of preeclampsia, patients travel to
Thessaloniki to get diagnosed and determine a
treatment plan

 Patients with mild preeclampsia travel to

Thessaloniki to see one of the 5-10 experts on
fetal ultrasound for follow-up, sometimes
staying overnight

 Patients at risk come to Thessaloniki to get

hospitalized, receiving daily or weekly visits
from their relatives
 Current cost for patient
30 $ for local physician
60 $ for consultant
150 $ for ultrasound session
60 $ daily hospitalization fees

30 $ for traveling expenses

60 $ for lodging
Traveling and lodging expenses for visiting relatives


Each follow-up visit : 250$
4 weeks hospitalization : 1800$+family expenses
Our solutions
 Create a web page that will enable the home
monitoring all of the patients on a daily basis

 Create 6 remote sites scattered around the

target area, able to perform fetal monitoring
and fetal ultrasounds and transmit them to
the consultant

 Create one consultant site in Thessaloniki,

receiving ultrasound images and reviewing
patient data
Advantages
1. Pregnant women stay at home and receive day-
to-day monitoring without being hospitalized until
it is absolutely necessary
2. Patients don’t have to travel 1 to 3 hours to
undergo scheduled or emergency ultrasounds
3. Patients’ relatives don’t have to travel to visit
them

Save Time
Save Money
Improve Quality
 Proposed cost
• 150$ weekly monitoring fee
• 100$ for teleultrasound sessions (estimated
number/patient: 3)
• 50$ for weekly house calls (estimated
number/patient: 6)

Average follow up duration : 4 weeks


Total cost / patient is 1200$
3. WORKFLOW
i. Initial Diagnosis
 She visits her Obstetrician
A woman gets obstetrician for suspects
pregnant a follow-up P.I.H.
 Obstetrician’s Local
Inform
assistant contacts physician’s
consultant
remote site and assistant
site about
requires consult schedules time
new patient
& date for
consult
 Physician conducts examination &
enters data into internet database
•Demographics
•History of pregnancy
•Maternal health

Patient When ready,

arrives at assistant notifies
remote consultant site
site Assistant
•Turns on Echo & Fetal monitor
•Turns on telecommunication
equipment (VTC)
•Sets up linkage
 Consultant notifies
Consultant he/she is ready
for consult VTC
reviews
patient record • Introduction with
patient
• Clarifies details of
record with
physician
Ultrasound Physician places Consultant
transducer in
protocol positions stores images
needed
Consultant gives
instructions (only approves
audio)
If needed: Consultant VTC
General stores images Discuss
examination needed patient
Physician sends approves condition
images with
physician
Consultants gives
& patient
instructions (only
audio)
 Consultant gives
orders
immediately

Diagnosis &
Treatment plan

Consultant reviews
Consult ends
patient’s electronic
record and sends
orders later
 Assistant
No P.I.H
Gives patient
equipment and
Instructions for
Start Home home monitoring
P.I.H. mild Monitoring Schedules visits for
Ultrasound

<23 GW Advice on termination

P.I.H. severe
23-33 GW Hospitalization

Fetus Induce
>33 GW Amniocentesis
mature Labor

Fetus Corticosteroids
immature 48h
Follow up
a. Home monitoring
b. House call
c. Visit to Local practice
a. Home monitoring
3 times daily :
measure blood
pressure

Once a day :
fill in form with
measurements
and complaints

Send data Consultant’s

through the assistant
If necessary:
necessary internet reviews new
Type in data on a daily
questions or basis
request
teleconference
with consultant
 Urgent Notify Consultant
immediately

Not certain Notify consultant

the same day

Consultant
reviews new
data
Normal Consultant reviews data
once a week
 Assistant sends email
once a week for
Normal reassurement

Call patient, give

Urgent order for
hospitalization
Pathological
Adjustments Send instructions
needed over internet

Not sure, Notify local

need for physician Physician’s assistant
Ultrasound schedules appointment
or house call Notify with patient and notifies
patient consultant’s assistant

Answers patient’s questions,

if asked for, schedules
teleconference appointment
 b. House call
Once a week or on
Consultant’s request
Physician makes
house call and

Takes to Lab
and scans lab
results to send
over internet

Draws blood

Consultant reviews
results along with
the weekly data
Stores and from the patient
Performs fetal forwards
monitoring information to
consultant
 c. Visit to Local practice
Physician
Reviews patient record
Examines patient
Enters new data into record

Patient
When ready,
arrives at
assistant
remote site
notifies
Every 3 consultant site
weeks Assistant
On Notifies consultant site
Consultant’s
Turns on Echo & Fetal monitor
request
Turns on telecommunication
equipment (VTC)
Sets up linkage
 Consultant notifies
Consultant he is ready for
consult VTC
reviews new
data on patient •Conversation with
record patient
•Clarifies details of
record with
physician
 General Echo VTC
examination
Physician places Discuss
Physician transducer in patient
sends images protocol positions condition
Consultants Consultant gives with
gives instructions (only physician &
instructions audio) patient
(only audio)
Consultant stores
Consultant images needed
approves
Consultant
approves
 Consultant gives
orders
immediately

Diagnosis &
Treatment plan

Consultant reviews
Consult ends
and sends orders
later
4. MEDICAL
PERIPHERALS
CONSULTANT SITE
• PC with high resolution screen
• VTC
• Server with storage room
Estimated price : 2 500$

Estimated price : 500$

Estimated price : 15 000$

REMOTE SITE
• PC
• VTC
• ULTRASOUND
• FETAL MONITOR
• GENERAL EXAMINATION CAMERA
The AMD-5600 Curved Array Probe for the
SmartProbe UltrasoundTM is used for all
obstetrical and abdominal scanning applications.
The 3.5 MHz probe has the familiar look and feel
of big system probes.
Specifications
•Frequency: 3.5MHz
•Elements: 128
•Pitch (mm): 0.520
•Elevation Width (mm): 15.0
•Geometric Focus (mm): 90
•Azimuth Radius (mm): 65.0
•Azimuth Length (mm): 66.6

List Price : $14,000

 Specifications

•Dimensions: 4.72" (120mm) L x 2.37"

(60mm) W x .99" (25mm) D
•Weight (including battery): Approximately
0.40 lbs. (180g)
•Battery type: 1 x 9V alkaline
•Modulation: FM Tone
•Center Frequency: 1900Hz
•Frequency Deviation: 100Hz/1mV

The AMD-9600 Personal 12/8 Lead •Memory Size: 32KB

Cardiotocogram (CTG) •Sampling Rate: 375 samples/second
Recorder/Transmitter can send
comprehensive ECG data anytime, anywhere via •LBS Resolution: 39m V
an acoustic coupler connection. The AMD-9600 •Frequency Response: 0.05Hz to 150Hz
Personal 12/8 Lead ECG has a 3 wire patient
cable and 4 fixed ECG electrodes for recording •CMRR Ratio: 60dB or better (at 50/60Hz)
the 12 or 8 lead ECG. The recorded ECG is then •Input Range: +2.5mV
transmitted to a workstation running AMD-9500
Receiving Software, where it can be interpreted •Input Impedance: >1212 ohms
immediately by medical professionals. The AMD- •DC Offset Correction: +200mV
9600 uses the AMD-9500 Receiving Software,
Applications include diagnosis of cardiac
symptoms, remote cardiac monitoring and heart List Price : $860
monitoring during clinical trials.

The AMD-2500 general examination
camera is the first analog camera to
combine power zoom, auto focus, freeze
frame capture, and electronic image
polarization in one diagnostic device.
This multi purpose analog camera has
wide applications in primary care,
emergency medicine/trauma care,
dermatology, ophthalmology, wound
care and is an excellent device to
document sexual abuse or child abuse.
The AMD-2500 general examination
camera is the "do it all, go anywhere"
analog camera!
Specifications
•Dimensions: 2.2"W x 3.7"D x 2.9"H
•Weight: .5 lbs.
•Magnification: Auto-zoom from 1-50x.
•Polarization: Push-button
•Zoom: Push-button
•Pixels: 410,000 from a 1/4" CCD
•Horizontal Resolution: Greater than 430 lines
•Signal to Noise Ratio: Greater than 48dB
•Output Signal: Composite and S-Video
•Output Format: NTSC
•Integrated Freeze-frame: Push-button
•Color Adjustments: Auto white balance
•ACC: Full iris control
•Lighting: Fluorescent
•Operating Temperature Range: 0 degree C - 40 degree C
•Operating Humidity: Less than 90%
•Power Consumption: 5W
•Voltage Range: 110/220 VAC 10%, 50/60 Hz, or 12VDC
•Lens: General purpose lens close focus, 50x polarized
lens, and optional 200x polarized contact lens
List Price : $5,490
HOME
• PC with internet OR Fax machine

• Optional : VTC
Blood Pressure Monitor
Electronic Weight Scale
Vital Signs Monitor
 Specifications

•Dimensions: 2.63" (66.7mm) H x 6.45"

(163.7mm) W x 4.37" (111mm) D
•Weight: Approximately 0.860 lbs. (390g)
•Type: Oscillometric
•Measurement Range: 20-280mmHG (BP);
40-200 beats/minute (Pulse) +3mmHG or 2%,
whichever is greater (BP); +5% (Pulse)
•Display: Digital, character height: 0.63"
(16mm)

The AMD-9200 Blood Pressure Monitor •Pressurization: Automatic, using a

allows users to measure their pulse and blood micropump
pressure in a "one step" monitoring •Depressurization: Constant-Air-Release Valve
procedure to manage hypertension. Once the System
user slips on the blood pressure cuff and
presses the "Start" button, the AMD-9200 •Deflation: Automatic exhaust
Blood Pressure Monitor automatically inflates, •Power source: Four AA batteries (1.5V each)
digitally displays systolic and diastolic blood
pressure, and then automatically transmits •Battery Life: Approximately 3 months with
data to a receiving station over a standard one use/day
phone line. Systolic and diastolic blood •Telephone Connection: RJ-11
pressure data may subsequently be displayed
in graphic and alpha numeric formats. A great
low cost approach to manage hypertension in
List Price : $450
the home. Used with AMD-9100 Multi-Patient
Receive Software
The AMD-9300 Weight Scale is a clinically accurate scale
that electronically sends user weight and automatically
transmits the user’s weight measurement over a standard
phone line to a receiving station. The station collects these
readings in a database and displays the results in graphic
and alphanumeric displays. The AMD-9300 Weight Scale's
reliability and accuracy make routine and long-term
monitoring easy and efficient. Ideal for in home
management of patients with hypertension or diabetes.
Used with AMD-9100 Multi-Patient Receive Software

Specifications

•Dimensions: 2.05" (5.2cm) H x 12.25" (31.1cm) W x

12.01" (30.5cm) D
•Weight: Approximately 5.96 lbs. (2.7kg)
•Measurement Device: Load Cell
•Measurement Range: 0.1 lbs. (50g) to 300 lbs. (136kg)
•Display: Liquid crystal, character height: 1" (2.5cm)
•Operating environment: 10° to 35°C at less than 85%
relative humidity
•Power: One DC-9V Alkaline battery, auto power off
•Telephone Connection: RJ-11

List Price : $636


The AMD-8200 Vital Signs Monitor
automates electronic collection of all body vital
signs information critical for patient evaluation,
including primary care, pediatrics, or home
care. The AMD-8200 Vital Signs Monitor
provides a digital display of temperature,
diastolic and systolic blood pressure, pulse
and blood oximetry SPo2. The system can
store up to 99 sets of data that can be seen
on the monitor or downloaded. The monitor
can be integrated with a PC via an RS-232
port. In addition, a visual and audible alarm
can be set when blood pressure (diastolic or
systolic) or pulse exceed set limits. The
lightweight design and rechargeable battery
allow for easy portability for all primary care,
pediatric, and home care applications
Specifications
•Dimensions: 6.5"(16.5 cm) H x 8.6"(21.8 cm) W x 5.0"(12.7 cm) L
•Weight: 6 lbs. (2.8 kg)
•Data Output: RS-232
•Blood Pressure Accuracy: Meets or exceeds SP10-1992 AAMI
standards
•Cuff Pressure Range: 0-300 mmHg
•Pressure Preset Levels: 120,140,160,200,240 or 280 mmHg
•Systolic Determination: Max: 250 mmHg; Min: 60 mmHg
•Diastolic Determination: Max: 160 mmHg; Min 30 mmHg
•Pulse Rate Determination: Max: 200 bpm; Min: 40 bpm
•Temperature Accuracy: Meets or exceeds ASTM E112-86 standards
•Temperature Determination: Normal and Monitor Mode, Max: 108.0
deg. F (42.2 deg. C); Min: 84.0 deg. F (28.9 deg. C)
•Power Requirements: N. American version: 120 VAC, 60 Hz.
•International version: 220-240 VAC, 50-60 Hz
•Internal Battery: Lead Acid, with external recharger
•Safety Standards: IEC 60601-2-30, UL 2601-1, CAN/CSA C22.2
No.601.1
•Conformity: CE
List Price : $2,995
5.TELECOMMUNICATIONS
Telephone
Telephone lines are available throughout the
target area, allowing for the following functions
• Patients communicate with the remote site to
schedule house calls and ultrasound
appointments
• The patients can call the consultant site any
time an emergency presents itself
• The consultant can call the patient if there are
emergency instructions to be given (e.x.
hospitalization order)
Internet
The entire project is based on the existence of a
web page. The web page can be accessed with plain
internet connection, over POTS or ISDN
The information on the web page is divided into 4
categories, 3 of which need personal password to be
accessed.

All internet users (no password needed)

• Information on Pregnancy Induced
Hypertension and related links
• Information on the organization and the
services provided
Patients (patient password)
• Charts to input daily data
• Ability to communicate with doctor
• Ability to communicate with other patients
• Alerts to remind scheduled appointments

Local obstetrician (remote password)

• Patient history
• Charts to input new data

Consultant (consultant password)

• Patient history
• New data from patients and local physicians
• Ability to communicate with patients
 Daily measurements
Mon Tue Wed Thu Fri Sat Sun

Blood pressure .
8am
4pm

12pm

Pulse

Weight

Urine protein

Fetal
movements
 Complaints
Mon Tue Wed Thu Fri Sat Sun

Swelling (face, feet, hands)

Nausea-vomiting

Headache

Agitation

Visual disturbances
(scotoma, blurred vision)
Abdominal pain

Reduced urine output

Facsimile (fax)

Patients that do not own a PC (personal

computer) are given forms, similar to those
that can be found on the internet page

They fill in the forms in the designated time
and manner and they consequently fax it to the
consultant’s office, where the assistant
transfers the data into the computer database
ISDN

An ultrasound session is required for the initial

diagnosis and thereafter every 3 weeks or
whenever the consultant requests one

The transmission of real-time ultrasound image

of good quality requires the combination of 3
128 K ISDN lines, to achieve the desired
bandwith of 384 Kbps. ISDN lines are available
everywhere in the target area
6. FINANCIALS
EXPENSES
Expenses are divided into 3 categories :
Remote : 6 Remote sites with Physician and
Assistant
Consultant : 1 consultant site with Physician
and Assistant
Corporate : staff, which resides at the same
site as Consultant
 Remote
REMOTE
MONTH 1 6 12 18 24
PERSONNEL Physician 2500 2500 2500 2500 2500
Assistant 1250 1250 1250 1250 1250

EQUIPMENT PC+VTC 3000

ECHO 14000
Fetal Monitor 1000
Camera 5500
Miscellaneous 100 100 100 100 100

ADMINISTRATIVE Rent 250 250 250 250 250

Rennovation 3000
Office expenses 250 250 250 250 250

TELECOMMUNICATIONS Installment 120

Monthly fee 120 120 120 120 120
Charges 130 130 130 130 130

Total/month 31220 4600 4600 4600 4600

Total/month/6 sites 187320 27600 27600 27600 27600
 Consultant
CONSULTANT
MONTH 1 6 12 18 24
PERSONNEL Physician 3750 3750 3750 3750 3750
Assistant 1250 1250 1250 1250 1250

EQUIPMENT PC+VTC 3000

Software 6000
Miscellaneous 100 100 100 100 100

ADMINISTRATIVE Rent 500 500 500 500 500

Rennovation 6000
Office expenses 500 500 500 500 500

TELECOMMUNICATIONS Installment 120

Monthly fee 120 120 120 120 120
Charges 380 380 380 380 380

Total/month 21720 6600 6600 6600 6600

 Corporate
CORPORATE
MONTH 1 6 12 18 24
PERSONNEL Coordinator 1250 1250 1250 1250 1250
Legal 1250 1250 1250 1250 1250
Hardware technichian 3000 1250 1250 1250 1250
Software technician 3000 1250 1250 1250 1250

EQUIPMENT PC+VTC 3000

Server 15000
ISP provider 100 100 100 100 100
Miscellaneous 100 100 100 100 100

ADMINISTRATIVE Rent
Rennovation
Office expenses

TELECOMMUNICATIONS Installment 40
Monthly fee 20 20 20 20 20
Charges 120 120 120 120 120

Total/month 26880 5340 5340 5340 5340

REVENUES
Patients
Target number of patients/month : 72
(12 for each remote site)

Average length of follow-up : 4 weeks

Estimated number of Ultrasounds : 3
Estimated sessions of Fetal Monitoring : 6

Advertising
Insert 6 alternating advertising banners into web page
 REVENUES
MONTH 1 6 12 18 24
Number of patients 6 36 72 72 72

Weekly fee/patient 150 150 150 150 150

Revenues from weekly fee 3600 21600 43200 43200 43200

Fee/ultrasound 100 100 100 100 100

Revenues from ultrasound 1800 10800 21600 21600 21600

Fee/House call 50 50 50 50 50
Revenues from house calls 1800 10800 21600 21600 21600

Advertisement fee 50 50 50
Number of customers 2 2 2
Revenues from ads 433 433 433

Total/month 7200 43200 86833 86833 86833

Total 7200 151200 564198 1085196 1606194
BUDGET

 Total expenses during first year : 670 000$

 Estimated time of breakeven : 14 months
 Estimated monthly profit when target
number of patients is reached : 160 000$
 BUDGET
MONTH 1 6 12 18 24
REVENUES Weekly fee 3600 21600 43200 43200 43200
Ultrasounds 1800 10800 21600 21600 21600
House calls 1800 10800 21600 21600 21600
Advertisement 0 0 433 433 433

EXPENSES Remote 187320 27600 27600 27600 27600

Consultant 21720 6600 6600 6600 6600
Corporate 26880 5340 5340 5340 5340

BUDGET/month -228720 3660 47293 47293 47293

BUDGET/total -228720 -282420 -106662 177096 460854
Conclusion
• Wireless communication, videoconferencing,
and the Internet have made telemedicine a reality
• Telemedicine is still in its infancy, but
undergoing rapid development
• Health-care providers take note: Your practice
is about to become more efficient—and cutting
edge
• The future belongs to 'e-health', the health
sector's equivalent of 'e-commerce'