A feasibility study of an Internet-based telemedicine system for consultation in an ophthalmic emergency room

We examined the feasibility of a low-bandwidth, Internet-based tele-ophthalmology system for consultation in an ophthalmic emergency room. Forty-nine patients (98 eyes) with complicated cases were seen during night shifts in the ophthalmic emergency room. Ocular images were taken using a slit-lamp connected to a video camera, processed and transmitted to a senior physician by email. A telephone was used for real-time audio communication. Each case was re-examined by the same senior physician the following day. The time needed to capture and to process the images was 5 min (SD 2). Each case was given a feasibility score (0-100%), which was defined as the contribution made by the transmitted images in presenting clinical details which could not have been described verbally. High feasibility scores (mean scores ranging from 85 to 90) were found for the following images: ocular surface, anterior chamber, anterior chamber angle, pupils, lens, optic nerve and macula. In contrast, images of vitreous and peripheral retina received low feasibility scores (mean score 65). There was 100% agreement between the diagnosis made during consultation and the on-site examination made by the senior ophthalmologist later on. Ninety-eight percent of the patients stated that they would prefer being examined under the telemedicine system on their next emergency room visit, rather than the traditional resident on-site examination.     

Integration of telemedicine into emergency medical services

We developed an integrated model of telemedicine services in emergency medical care. The architecture was designed to support pre-hospital management. The experimental work was carried out with the collaboration of the emergency medical services (EMS) in Madrid. Two different study populations were defined: a control population using conventional EMS protocols and a population using the telemedicine system. The telemedicine system was based on a telepresence service; electrocardiograms and images were transmitted from the ambulance to the health emergency coordination centre. The cost of dealing with 100 patients using telemedicine was C6030 less than the cost of conventional care. The response times using telemedicine were significantly lower.     

The feasibility of telemedicine for the training and supervision of general practitioners performing ultrasound examinations of patients with urinary tract symptoms

Ultrasound examinations were carried out by a general practitioner on patients who presented with lower urinary tract symptoms. To assist in the interpretation of ultrasound anatomy, still images were captured during the ultrasound examination and transmitted to a university expert. In total 15 telemedicine sessions were conducted, using PC-based videoconferencing equipment connected by ISDN at 128 kbit/s. Fifteen patients were randomly selected and both the transmitted and hard-copy images (printed on thermal paper) were graded for technical quality. Data were missing for 13 of the possible 105 paired comparisons, as some images could not be evaluated. Overall agreement between the technical quality scores for the transmitted and hard-copy images was poor (weighted kappa=0.04). The 105 transmitted images were also rated for their diagnostic quality: 90% were classified as diagnostic and 10% were judged to be non-diagnostic. The results show the feasibility of tele-ultrasound in primary care. The general practitioner concerned benefited from regular ultrasound training and supervision, and achieved a satisfactory level of clinical competency in scanning the prostate, bladder and kidneys.     

军队远程医疗会诊环节规范化管理研究

目的：探讨军队远程医疗会诊规范化管理。方法：收集和检查了上海85医院远程会诊中心执行会诊的病历质量，并建立病案系统。结果：会诊中心4年共执行远程医疗会诊658例；其中传送会诊病历599例(91％)，影像图像392例(60％)，会诊意见单595例(90％)，采集了会诊实况录像203例(31％)。病历质量分析显示，58％的远程病历能被认可，1794幅放射影像图像中只有80％的影像图像被认为可阅读。结论：远程医疗会诊的最佳操作是远程病历应该预先传送，传输的病史应该完整，图像应该可阅读；为确保远程医学网络数据传递安全性和保密性，应采用专网专用的会诊软件；会诊资料收集多媒体化，病案标识和分类标准化，以及会诊病例管理信息化是远程医疗会诊规范操作的三个基本环节。     

Telemedicine: an emerging health care technology

Telemedicine uses advanced telecommunication technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers. All telemedicine applications require the use of the electronic transfer of information. Telemedicine encompasses computer technologies using narrow and high bandwidths for specific types of information transmission, broadcast video, compressed video, full motion video, and even virtual reality. There are many types of common medical devices that have been adapted for use with telemedicine technology, and many clinical services can be provided via telemedicine to patients who live in physician shortage areas. The greatest challenges for telemedicine in the twenty-first century are financing, safety standards, security, and infrastructure.     

远程医疗应用中无线便携式头盔的设计

目的：为解决远程音像采集方面存在的诸多问题,研制一套便携式远程医疗设备——无线远程便携式头盔终端。方法：选取能够自动完成快速而高精度调焦的微型摄像头,实现远程医疗图像的采集;采用UDA1344实现对麦克风输入的模拟声音信号进行A/D转换,形成串行数字音频流。利用采用uCos多任务实时操作系统的头盔主操作系统将采集到的音频、视频数据进行压缩处理后,通过短距离无线数据传输与本地网络联结,通过本地网关连入Internet网络。结果：无线远程便携式头盔能够进行图像采集及声音传输,具备自动调焦、摄像、双向对讲功能,通过无线网络与远程医疗服务器联结,实现远程图像和声音传输功能。结论：无线远程便携式头盔可用于远程急救、远程手术转播等远程医疗服务,它的应用将推动远程医疗朝实用化方向迈进一大步。     

Guidelines for filming digital camera video clips for the assessment of gait and movement disorders by teleneurology

Digital still cameras capable of filming short video clips are readily available, but the quality of these recordings for telemedicine has not been reported. We performed a blinded study using four commonly available digital cameras. A simulated patient with a hemiplegic gait pattern was filmed by the same videographer in an identical, brightly lit indoor setting. Six neurologists viewed the blinded video clips on their PC and comparisons were made between cameras, between video clips recorded with and without a tripod, and between video clips filmed on high- or low-quality settings. Use of a tripod had a smaller effect than expected, while images taken on a high-quality setting were strongly preferred to those taken on a low-quality setting. Although there was some variability in video quality between selected cameras, all were of sufficient quality to identify physical signs such as gait and tremor. Adequate-quality video clips of movement disorders can be produced with low-cost cameras and transmitted by email for teleneurology purposes.     

Low-bandwidth telemedicine for pre- and postoperative evaluation in mobile surgical services

Low-bandwidth telemedicine was used for the pre- and postoperative evaluation of patients treated by a mobile surgery service in remote Ecuador. Realtime and store-and-forward telemedicine was employed, using PCs connected via the ordinary telephone network. Between February 2002 and July 2003, 144 patients were studied preoperatively and 50 postoperatively. It was possible to establish 20 satisfactory preoperative realtime connections, which allowed good-quality, simultaneous audiovisual transmission. Thus, there were 124 preoperative assessments done by store-and-forward telemedicine and 50 postoperative assessments. Diagnoses and management plans made by a surgeon using telemedicine were compared with those made independently by a second surgeon, who saw the patient face to face. Due to poor quality of the transmitted images, 43 patients were excluded from the preoperative study and 13 from the postoperative study. In the 101 preoperative evaluations, there was agreement in 78 cases (77%); in the 37 postoperative evaluations, there was agreement in 36 cases (97%). Telemedicine may reduce the time required on site for preoperative planning, and may provide reliable postoperative surveillance, thus improving the efficiency of mobile surgery services.     

Near real-time echocardiography teleconsultation using low bandwidth and MPEG-4 compression: feasibility, image adequacy and clinical implications

We assessed the feasibility, image adequacy and clinical utility of a tele-echocardiography service which combined video compression with low-bandwidth store-and-forward transmission. Echocardiograms were acquired by a hospital geriatrician, compressed and transmitted using both near real-time (urgent) and delayed (pre-programmed) protocols via an Internet connection to the notebook PC of a remote cardiologist. Clinical utility was evaluated as a change in therapeutic management. During a one-year period, 101 tele-echocardiography consultations were successfully performed (feasibility = 100%) on 95 patients (age 22-95 years), admitted with cardiovascular or neurological diagnoses (24% of the consultations were urgent). In total, 4617 files (1.4 GByte of data) were transmitted, 2669 of which were short video clips. On average, 46 files (13.8 MByte) were transmitted (mean duration 10 min) at each examination. Consultations (both urgent and pre-programmed) were clinically useful in 83% of examinations. Logistic regression analysis showed that both a low left ventricular systolic function and the examination indication were determinants of clinical utility. The transmitted images were considered adequate for diagnosis in 100% of the pre-programmed teleconsultations. Tele-echocardiography using MPEG-4 video compression is a feasible, adequate and clinically useful tool for telemedicine.     

Patient and physician satisfaction with telemedicine for monitoring vital signs

We evaluated user satisfaction with realtime telemedicine for monitoring vital signs. Over eight weeks, 20 patients and 12 residents in family medicine participated in the study. At the end of the study, the patients and doctors completed a questionnaire detailing satisfaction with the service. Responses were obtained from 18 of the 20 patients and were generally positive: 61% were comfortable using the system and 94% did not believe that the technology had a negative effect on their relationship with the health-care provider. Eleven physician responses were obtained. Physicians were more uncertain about the benefits of the service: only 45% felt that telemedicine could adequately assess patients, although 82% felt that telemedicine would be an important part of primary-care services. From a user perspective, our study showed that patients were more satisfied with the telemedicine service than were doctors.     

Telemedicine applications for the regional paediatric cardiology service in Northern Ireland

The regional paediatric cardiology centre in Northern Ireland has a telemedicine network linking the neonatal units of three district general hospitals using ISDN and IP-compliant equipment. We have previously reported the use of ISDN transmission at 128 kbit/s for remote echocardiography. In a series of 61 patients, a total of 59 transmitted scans were of sufficient diagnostic quality to confirm or exclude the presence of major congenital heart disease (CHD). There were three diagnostic errors (7%). Subsequently, we have examined the use of ISDN transmission at 384 kbit/s. Echocardiographic studies were carried out on 21 patients and all were followed up. Fourteen patients (67%) had CHD confirmed. There were two diagnostic errors (10%). Our experience of transmitting live echocardiographic images suggests that ISDN at 384 kbit/s provides the optimum balance between the clarity of the transmitted images and costs. We expect that IP videoconferencing will offer similar quality but at a lower running cost, and are currently assessing it in a pilot study. All sites within our network will remain capable of ISDN transmission until the efficacy and reliability of IP transmission has been demonstrated in a controlled trial. The clinical telemedicine service has led to the earlier diagnosis of and instigation of appropriate treatment for CHD.     

Efficacy of telemedicine in occupational therapy: a pilot study

The purpose of this pilot study was to determine the efficacy of using a less costly, low-bandwidth telemedicine system to evaluate occupational therapy clients in rural areas. Four residents (aged 63 +/- 10.2 years) from rural Tillery, North Carolina, were evaluated via either The Kohlman Evaluation of Living Skills or The Canadian Occupational Performance Measure. An occupational therapist in Tillery administered one of these tools, while a second occupational therapist at East Carolina University simultaneously scored the same tool by telemedicine link. Comparison of their responses revealed scoring differences in only one of four administered evaluations. Video images were insufficient for visualization of finer movements, but audio quality was excellent. The authors conclude that select occupational therapy evaluation data can be accurately transmitted and properly scored using low-bandwidth telemedicine systems.     

The quality of medical records in teleconsultation

We collected and examined the medical records from telemedicine cases dealt with by the telemedicine centre of Shanghai Hospital No. 85. This centre handles the second largest number of teleconsultations in the entire network. There were 658 telemedicine cases in total. The medical records included the patient record in 599 cases (91%), transmitted images in 392 cases (60%), the consultant's opinion in 595 cases (90%) and a video-recording of the teleconsultation in 203 cases (31%). The quality of patient records was reviewed and found to be acceptable in 58% of cases. In total, 1794 radiology images (85% of all images) were transmitted via the telemedicine network. The consultant considered 352 of them (20%) to be unreadable on the screen (i.e. 80% of radiology images were considered to be acceptable). For optimum performance of telemedicine, the patient record and associated images should be delivered in advance and the relevant parts of the patient record should be available during a teleconsultation. Three aspects of the management of the medical records for teleconsultations are particularly important: multimedia collection, standardization of patient/record identification and classification, and information management.     

Patient and physician satisfaction in a clinical study of telemedicine in a hypertensive patient population

We studied patient and physician satisfaction with telemedicine for the care of a hypertensive population. Once recruited, participants were seen both in person and via telemedicine (in random order) on the same day. After each meeting, patient and physician satisfaction surveys were completed. In the 12-month study, there were 107 pairs of visits. The physicians reported a small but significant increase in workload, mental effort, technical skills and visit duration for telemedicine when compared with face-to-face consultations. They noted that the telemedicine system worked well in the majority of cases and could reduce the need for future treatment. Patients reported slightly but significantly higher satisfaction scores for the following for in-person than for telemedicine meetings: technical quality, interpersonal care and time spent. Patients reported high satisfaction scores for both telemedicine and in-person visits.     

Technical evaluation of a low-bandwidth, Internet-based system for teleconsultations

A low-bandwidth telemedicine system was evaluated in eight community hospitals connected to a central hospital via the Internet. PCs were used with videoconferencing software and modem connections to the telephone network. The average data connection rates, still-image transfer times and live-video transmission rates were determined. The time to send 640 x 480, 320 x 240 and 160 x 120 pixel, 24-bit still images ranged from 29 s to 411 s. The average file transfer times for a 10 s MPEG video-clip was 8.6 min. The average live video frame rate was 1 frame/s (at the best image quality), with an average latency of 3 s. The results suggest that Internet-based videoconferencing is acceptable for certain telemedicine applications.     

战创伤分级救治远程支持系统的研究与应用

目的:研究战创伤分级救治远程支持系统的组成和技术手段。方法:运用微波数字传输和GSM生命体征信息传输两种技术,通过自行组网,建立由多功能无线遥控摄像系统、平战两用远程监护系统组成的远程支持系统。结论:建立了野战医疗所局域网络和远程监护网络,实现了伤员后送和救治过程中各种音视频信息、生命体征信息的动态、持续和无线远程传输,突出了伤员分级救治的实效性,拓展了战创伤救治空间,为提高紧急救治效率、缩短"黄金"救治时间、降低战创伤伤员死亡率和致残率提供了有力保证。     

Qualitative and quantitative assessment of video transmitted by DVTS (digital video transport system) in surgical telemedicine

Real-time video pictures can be transmitted inexpensively via a broadband connection using the DVTS (digital video transport system). However, the degradation of video pictures transmitted by DVTS has not been sufficiently evaluated. We examined the application of DVTS to remote consultation by using images of laparoscopic and endoscopic surgeries. A subjective assessment by the double stimulus continuous quality scale (DSCQS) method of the transmitted video pictures was carried out by eight doctors. Three of the four video recordings were assessed as being transmitted with no degradation in quality. None of the doctors noticed any degradation in the images due to encryption by the VPN (virtual private network) system. We also used an automatic picture quality assessment system to make an objective assessment of the same images. The objective DSCQS values were similar to the subjective ones. We conclude that although the quality of video pictures transmitted by the DVTS was slightly reduced, they were useful for clinical purposes. Encryption with a VPN did not degrade image quality.     

基于IPv6的远程医学细粒度数据传输的研究

目的:为了解决远程医学关键业务数据流在互联网上传输出现的网络延时较大和数据丢包较多等问题,进行互联网协议版本6(IPv6)的流标签远程医学细粒度数据传输新方法的研究。方法:在用户端使用IPv6数据包新增的流标字段,将不同类型的远程医学数据流的服务质量参数写入其中。在互联网传输过程中采用流标签网关识别分类和数据传输服务质量(QoS)保证技术。结果:对不同业务类型的远程医学数据流实现了细粒度的数据传输。结论:使用IPv6流标签细粒度区分数据流,较好的解决了网络延时和数据丢包对数据传输的影响,可以将有限的网络资源充分的应用到需要的服务上,提高远程医学数据传输端到端的服务质量。     

A network-reactive model for distributed telemicroscopy

We have developed a network-reactive robotic telemicroscopy system that uses high-speed image processing and quality of service (QoS) feedback to maximize performance. In tests, four magnifications (4x, 10x, 40x, 60x) of a section stained with haematoxylin and eosin were used. Up to 25 clients, distributed across two Internet domains, accessed the server. When given control of the microscope, any of the clients could direct the microscope to change focus and objectives within 3 s and move the stage to any x-y position within 1 s. Transmission rates of 50-200 kbit/s were achieved for video (320 x 240 pixels at 24 bit/pixel). Performance varied according to the complexity of the images being transmitted. The 25 simultaneous users were supported without affecting the operation of the server and the system overhead was relatively small. The server's message-processing time and the network transmission delay amounted to 83 ms. The compression ratio of five previously stored video-sequences ranged from 336:1 to 1213:1. The underlying model for this system could serve a wide range of telemedicine and distance-learning applications.     

Diagnosis of congenital heart disease in neonates by videoconferencing: an eight-year experience

Over an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans were inadequate. Hands-on echocardiograms were performed subsequently on 116 of the remaining 127 cases (91%). Major CHD was diagnosed in 42 of the 116 infants (36%) and minor CHD in 49 (42%). The telemedicine diagnosis was accurate in 97% of the cases (kappa = 0.90). There were four diagnostic errors. Transfer to the regional unit was avoided in 95 patients (72%). The present study shows that high diagnostic accuracy is possible using a telemedicine link to transmit images obtained with the assistance of real-time guidance by a paediatric cardiologist. The results also demonstrate the importance of an expert interpreting the echocardiographic images, since the accuracy of diagnosis was considerably improved (the kappa coefficient increased from 0.14 to 0.90).