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TELESONOGRAPHY:
TECHNICAL PROBLEMS, SOLUTIONS AND RESULTS.
TeleSonography can be considered a new diagnostic procedure based on the
possibility to perform in remote areas ultrasound exams which, after a
real-time transmission or as static-like images, allow experts to diagnose
pathologies. The aims of this present study are: assessment of the use
of a software dedicated to ultrasound consult managed by a personnel with
no ultrasound expertise; feasibility of ultrasound consult with not dedicated
connection systems (ISDN lines, Internet); assessment of responses' time
and of the actual possibilities of the clinical impact in critical emergencies
cases. In the period between 24th July and 8th August 2000, at the clinical
ambulatory of Tilos island (Dodecanesum Greece) 30 ultrasound exams have
been performed and transmitted to the Department of Surgery of Pisa University,
(Italy). All of them have been performed on patients coming to the clinical
ambulatory of the island routinely, with no planning at all, and have
been performed by medic and paramedic staff with no expertise in ultrasound
diagnosis, guided at distance via videoconference in order to perform
the most suitable scans for an organ's study: the remote personnel had
as only didactic device a table with the ultrasound scans to perform.
There were on the spot a physician expert in ultrasound diagnosis as supervisor
who, by the way, did not interfere with the performance of ultrasound
scans. The role of the supervisor physician was also to confirm the diagnosis
performed at distance. The transmission was made from the remote area
by an expert in telematics and software. The devices used were: a) Ultrasound
System SonoSite 180 apparatus with a convex 3.5-5 MHz. Probe; b) 2 twin
computers, 1 in Tilos and 1 in Pisa; c) 2 standard computers to perform
teleconference in Netmeeting (Microsoft); d) InVIVO Teleconsult Software
developed and produced by MedCom GmbH distributed in Italy by EBIT; e)
ISDN Line.
All ultrasound exams have been performed with standard scans used usually
and generally accepted for an ultrasound exam performed both routinely
and in emergency. The images' assessment has been considered sufficient
for a correct diagnosis considered that both scans and selection have
been performed by untrained personnel; moreover, in all cases, it was
possible to make a diagnosis of both positive and negative exam, confirmed
by the medical trained personnel on the spot and by the transmission to
Pisa of the selected images. The diagnosis' conformity between the exam
performed in telesonography and the one performed on the spot by the expert
has been of 100 %. It was possible, thanks to the results, to consider
both the diagnosis's reliability together with the exam's feasibility,
and the assessment of the "random" working from the remote area and connection
's time. The working's average of the whole system has been of about 5,43
minutes (range 1,45-20,45 min.) for the direct TeleConsult connection,
and of about 12,30 minutes (range 5,35-32,40 min.) for NetMeeting's working
for the VideoConference. The TeleConsult connection included static images
and dynamic loops' transmission with transmission of scans' sequences
for organ. The mean transmission time for a 2,0 Megabyte file has been
of 5,0 min. (mean speed of transmission: 7Kb/sec). The transmission's
speed depended on loops' size and ISDN line's quality. The mean time of
procedure's working, after the arrival of the images fit for diagnosis,
has been of 9.53 min. including 2 cases of colour images requiring a longer
time. The mean times from working to diagnosis' conclusion have been of
11.06 min. For the interpretation at distance of transmitted images, main
clinical data must be considered besides simple clinical findings' record
of what has been received and transmitted. This means that there must
be a basic medical knowledge and a basic ultrasound diagnosis training
for the main scans. This preliminary experience has allowed the assessment
of ultrasound methodology's actual use as instrumental procedure in remote
areas and the "on field" evaluation of technical problems and their solutions.
It is important indeed: a) assemblage in central and peripheral seat by
qualified expert personnel; b) conformity of ISDN lines to ECC rules;
c) improvement of TeleConsult Software with the possibility to use a Webcam
on the same computer for remote control of untrained personnel; d) technical
and technological basic improvement (like professional Webcam); e) a proper
personnel training to the use of ultrasound apparatus. TeleSonography
could be applied to:1) routine remote diagnoses ; 2) emergency remote
diagnoses; 3) 3rd level consult for peripheral centers; 4) training in
remote areas. It is essential to define the use's modalities, the applications
with clear algorithms and the training procedure of the personnel properly
chosen for this task. The personnel devoted to ultrasound study can be
simply divided into : personnel performing ultrasound scans, personnel
transmitting images and personnel interpreting the transmitted images.
It must be possible to make a precise diagnosis in relation to the patient's
clinical picture: therefore, it is necessary to standardise the diagnostic
protocols and the scans to be acquired. Personnel performing in remote
area must be able to interpret the images, but above all must be able
to get the scans in agreement with the reference centre and to have some
basic informatic knowledge. This is the reason why a one-month training,
at least, is necessary for the technical informatic side and for the performance
of an ultrasound exam with essential elements for the organs' assessment.
But a part from this
important result, what can we do now for the system?
Some other facts in the Island need to be underlined: links with Kos and
Rhodes are changes in the economy of life. Health problems remain tied
to fatalism (acute disease) and to a feeling of anxious resignation (chronic
disease) for most people. There is a new hospital now in Rhodes with a
medium level of activities; this modern Hospital will certainly become
more important as telemedicine reference Hospital for the area depending
on the growth of a telemedicine Greece System, jealously and obviously
self-managed by Regional authorities. But the question is "what is the
model for telemedicine application on the field?"
Authorities have their important responsibilities in the area (about 200.000
islanders) as by the current map.
On this area (49 islands) there are 10 hospitals and 142 peripheral physicians
operating.
In order to point out the problems of Islands' health management, it is
important to suggest the readers an excellent report presented at the
"European Conference on Sustainable Islands Development" (http://www.insula.org/frconf1.htm)
Inn the abstract "Scope of the healthy island initiative", it is reported
by Stamatis Skoutas, M.D., a Greek doctor:
"The remote areas -islands or physically isolated areas where the geophysical
conditions affect the way of living of their inhabitants- have not been
studied regarding the conditions and parameters for the improvement of
the quality of life of the permanent residents as well as of their visitors.
There are two important problems: a) Medical health care is insufficient
and b) exist few opportunities for personal growth of the inhabitants
due to limited interaction with new stimulus.
Human health and healthy environment are essential conditions of demographic
balance, economic growth and social prosperity of the island communities.
However, in the small and remote island communities there is a lack of
appropriate research and development organisations to support meaningful
decisions."
Conclusions:
On the basis of our experience, we have found out probably some correct
answers, but we are no longer available to arrange little discontinuous
pieces of a small telemedicine local system, financially managed by ourselves.
On the other hand, we have now a well assembled "Know how" gained on the
field. We will offer to local area (island's area) authorities articulated
models of telemedicine, as private enterprise.
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