Telemedicine and Teledermatology

Current Problems in Dermatology

Vol. 32

Series Editor

G. Burg Zrich

Telemedicine and Teledermatology

Volume Editor

G. Burg Zrich
36 figures and 19 tables, 2003

Basel Freiburg Paris London New York New Delhi Bangkok Singapore Tokyo Sydney

Library of Congress Cataloging-in-Publication Data Telemedicine and teledermatology / volume editor, G. Burg. p. cm. (Current problems in dermatology ; v. 32) Includes bibliographical references and indexes. ISBN 3805574630 1. Dermatology. 2. Telecommunication in medicine. I. Burg, Gnter. II Series. RL72.T45 2003 616.5dc21 2002030075

Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents and Index Medicus. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Copyright 2003 by S. Karger AG, P.O. Box, CH4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel ISSN 00702064 ISBN 3805574630

Contents

Preface ................................................................................................................................ IX Burg, G. (Zrich) 1 Telemedicine in a New World 1.1 The Telemedical Information Society: Doctors Playground or a Contribution to the Evolution of Healthcare? ................................................ Burg, G.; Denz, M. (Zrich) 1.2 The History of Telemedicine .................................................................................. Cipolat, C.; Geiges, M. (Zrich) 1.3 Technology 1.3.1 The Communication Revolution Goes On Global High-Speed Networks: Setting the Pace for Future Multimedia Applications ............................................................................................ 12 Hffner, A.; Zepter, K. (Zrich) 1.3.2 Image and Video Compression: The Principles Behind the Technology ................................................................................................ 17 Burg, A. (Zrich) 1.3.3 Teledermatology Delivery Modalities: Real Time versus Store and Forward ........................................................................................................ 24 Whitten, P.S. (East Lansing, Mich.) 2 Teleteaching 2.1 Teleteaching Tools in Dermatology on the Web ............................................ 33 Kropf, R.; Cipolat, C.; Burg, G. (Zrich) 2 6

2.2 Telemedical Training at the Department of Gynaecology, University Hospital Zrich ........................................................................................ 39 Haller, U.; Gabathuler, H. (Zrich) 2.3 Towards a Virtual Education in Pharmaceutical Sciences: An Innovative E-Learning Approach ................................................................................ 43 Tran, V .; Lichtsteiner, S.; Ernst, B.; Otto, M.; .V Folkers, G. (Zrich) 3 Teleconsulting: Legal, Ethical and Consumer Aspects 3.1 Changes Patients Expect to Result from Telemedicine .............................. 53 Tachakra, S. (London) 3.2 Satisfaction of Paramedical Personnel ................................................................ 58 Hicks, L.L. (Columbia, Mo.) 3.3 Economic Aspects Saving Billions with Telemedicine: Fact or Fiction? ................................................................................................................ 62 Kristiansen, I.S. (Odense); Poulsen, P.B. (Kolding); Wittrup Jensen, K.U. (Odense) 3.4 Secure Transfer of Medical Data over the Internet: From Regulatory Data Protection Jam to Framework-Based Requirements .................................................................................................................. 71 Boesch, H.; Airaghi, G. (Ksnacht/Zrich) 3.5 Potential of Telemedicine in Primary Care ...................................................... 76 Reichlin, S.; Dyson, A.; Mller, D.; Fischer, A.; Fischer, H.R.; Beglinger, C. (Basel) 4 Fields of Application of Telemedicine 4.1 Telemedicine for the Family Doctor .................................................................... 83 Kurzynski, M.W. (Wroc law) 4.2 Teleradiology .................................................................................................................... 87 Voellmy, D.R.; Marincek, B. (Zrich) 4.3 Telemedicine Applications in Surgery .................................................................. 94 Demartines, N. (Zrich) 4.4 Modern Telepathology: A Distributed System with Open Standards .............................................................................................................. 102 Oberholzer, M.; Christen, H. (Basel); Haroske, G. (Dresden); Helfrich, M. (Zweibrcken); Oberli, H. (Honiara); Jundt, G. (Basel); Stauch, G. (Aurich); Mihatsch, M.; Brauchli, K. (Basel) 4.5 Telecardiology .................................................................................................................. 115 Zeevi, B. (Schaffhausen) 4.6 Telemedicine in Oncology .......................................................................................... 121 Olver, I. (Adelaide, S.A.)

Contents

VI

4.7 Telemedicine in Ophthalmology ............................................................................ 127 Hammack, G.G. (Galveston, Tex.) 4.8 Implementation of a Telepsychiatric Network in Northern Finland ............................................................................................................ 132 Mielonen, M.-L.; Visnen, L.; Moring, J.; Ohinmaa, A.; Isohanni, M. (Oulu) 4.9 Telemedicine and Real-Time Monitoring of Climbers ................................ 141 Satava, R.M. (New Haven, Conn.) 4.10 Telemedicine in Corrections .................................................................................... 148 Hammack, G.G. (Galveston, Tex.) 5 Teledermatology 5.1 Teledermatology in Clinical Use 5.1.1 Dermanet A Tailor-Made Tool for Teledermatology ............................ 154 Khnis, L.; Milesi, L. (Reinach) 5.1.2 Aspects of Quality: Face-to-Face versus Teleconsulting .............................. 158 Granlund, H. (Helsinki) 5.1.3 Teledermatology in the Nursing Home .............................................................. 167 Zelickson, B.D. (Minneapolis, Minn.) 5.1.4 A Survey among Dermatologists in Practice about Teledermatology ............................................................................................................ 172 Glaessl, A.; Coras, B.; Popal, H.; Landthaler, M. (Regensburg); Stolz, W. (Munich) 5.2 Teledermatology-Teaching 5.2.1 Dermatology Online with Interactive Technology (DOIT) ........................ 176 Bader, U. (Zumikon); Cipolat, C.; Burg, G. (Zrich) 5.2.2 Telematics-Based Teaching in Dermatology .................................................... 182 Bhm, K. (Mainz); Wiegers, W. (Darmstadt) 5.2.3 Image Archives, Audio- and Video-Sequences for Teleteaching ...................................................................................................................... 191 Hhn, H.; Esser, W.; Hamm, H.; Albert, J. (Wrzburg) 5.2.4 Dermatology Course 2000: An Interactive Multimedia Dermatology Course for Students Programme Description and First Results .................................................................... 195 Stolz, W.; Roesch, A.; Popal, H. (Regensburg); Arnold, N. (Hamburg); Gruber, H. (Regensburg); Burgdorf, W. (Munich); Landthaler, M. (Regensburg) 5.3 Teledermatopathology 5.3.1 Teledermoscopy .............................................................................................................. 201 Braun, R.P.; Saurat, J.-H. (Geneva)

Contents

VII

5.3.2 Teledermatoscopy in Daily Routine Results of the First 100 Cases ................................................................................................................ 207 Coras, B.; Glaessl, A. (Regensburg); Kinateder, J. (Bayreuth); Klvekorn, W. (Gilching); Braun, R. (Geneva); Lepski, U.; Landthaler, M. (Regensburg); Stolz, W. (Munich) 5.3.3 HistoClinC: A Web-Based Telemedicine Application for Clinicopathologic Correlations in Dermatopathology ................................ 213 Kempf, W.; Reichlin, S.; Burg, G. (Zrich) 6 Global Telemedicine 6.1 Teledermatology in North America ...................................................................... 222 Pak, H. (San Antonio, Tex.) 6.2 Telemedicine Experience in North America .................................................... 226 Qureshi, A.A.; Kvedar, J.C. (Boston, Mass.) 6.3 Teledermatology in Sub-Saharan Africa ............................................................ 233 Schmid-Grendelmeier, P.; Doe, P.; Pakenham-Walsh, N. (Zrich) 6.4 Telemedicine in Europe .............................................................................................. 247 Kropf, R.; Cipolat, C.; Burg, G. (Zrich) 6.5 Telemedicine in Germany .......................................................................................... 252 Tittelbach, J.; Elsner, P. (Jena) 6.6 Teledermatology in Switzerland ............................................................................ 257 Cipolat, C. (Zrich); Bader, U. (Zumikon); Rufli, T. (Basel); Burg, G. (Zrich) Author Index .................................................................................................................... 261 Subject Index .................................................................................................................... 263

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VIII

Preface

Telemedicine holds great potential to revolutionize medical and paramedical services, not only for primary care physicians in remote areas but also for teaching students and for continuous medical education. In the future, consulting and asking for second opinions will be the gold standard of medical care. Disease monitoring will become another telemedical application for patients with heart disease, metabolic diseases, and high blood pressure, etc. Depending on the local requirements and geographical distribution of the partners in a telemedical network, different logistics may be implemented, including real-time, store-and-forward or other hybrid technologies. The implementation of these modern forms of healthcare will probably not save costs, but rather offer better healthcare at the same price. The reliability of telemedical procedures and the cost-effectiveness of face-to-face vs. telemedical care will have to be compared and evaluated by appropriate studies. The term e-health only poorly defines the nearly unlimited number of communication procedures and technologies ranging from telephone and fax through e-mail and digital data transmission of any kind of information in the healthcare market, including telemedicine. Telemedicine, however, refers to a more stringent definition of e-health. Telemedicine is defined by the World Health Organization (WHO) as the practice of healthcare using interactive audio, visual and data communications. This includes healthcare delivery, diagnoses, consultation and treatment as well as education and transfer of medical data. Considering this definition, those medical disciplines that rely heavily on imaging techniques are suited especially well for telemedicine, namely radiology

IX

and related disciplines such as surgery and orthopaedics, pathology, dermatology, telecardiology, diabetology, neurology, oncology, otorhinolaryngology, ophthalmology, psychiatry, and many other specialities. This book covers part of the broad spectrum of telemedical applications with special emphasis on teledermatology. The articles were kept relatively short so that various aspects could be covered, including technology, teleteaching, teleconsulting relating to legal, ethical and consumer aspects, and the fields of application in the context of various disciplines. Each article provides a brief overview rather than comprehensive information on details. Telemedicine will certainly add a new dimension to the medical and paramedical healthcare services. Quality will be improved without saving direct costs. However, indirect costs such as time and effort for the patient will be reduced, providing a tremendous benefit for the patient in a modern healthcare system. Telemedicine still encounters some resistance on various frontiers, including physicians, patients, the general population, politicians, insurance companies and healthcare providers. The evolutionary process, however, will proceed. There is no doubt that within 35 years, telemedicine will be an established part of modern healthcare. I wish to thank the contributors to this volume, to the publishers for their excellent cooperation. My thanks are also due to Mrs. Susanna Ludwig and Mrs. Liza Anyawike of S. Karger Publishers for their help and courtesy. Gnter Burg, MD, Zrich

Preface

1 Telemedicine in a New World

Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 25

1.1

The Telemedical Information Society: Doctors Playground or a Contribution to the Evolution of Healthcare?
Gnter Burg, Martin Denz
Dermatologische Klinik, Universittsspital Zrich, Switzerland

On July 10, 1962, the telecommunication satellite Telstar began to transmit international phone calls, radio signals and television programs. People watching TV were aware that they were experiencing an innovation that would change our society. In those days, Michael E. De Bakey was also revolutionizing open-heart surgery. His operations were transmitted live by television using Telstar as a relay. Who at that time could realize that they were witnessing the first steps in modern Telemedicine? Telemedicine is a term that 20 years ago had hardly been coined, 10 years ago was rarely discussed, but today is in almost everyones mouth, both amongst the competent and the incompetent. Telemedicine was fostered by the needs of seafarers and the raw emergencies of battlefields, promoted by worldwide electronic networking and the dizzying progress of information technology, and pushed by healthcare organizations seeking new methods to enhance health services and the high-tech industry who scented a lucrative market. Currently, several hundred pilot projects are underway to test the possibilities of applying information technology to medicine. The World Health Organization (WHO) defines Telemedicine as the practice of healthcare using interactive audio, visual and data communications. This includes healthcare delivery, diagnosis, consultation and treatment as well as education and transfer of medical data. According to this definition, disciplines that rely heavily on imaging techniques are especially suited for telemedicine: (1) radiology and related disciplines such as surgery, orthopedics, and others; (2) pathology, and (3) dermatology.

However, other disciplines that need to transfer medical data at a distance can also benefit from the new technology: (4) telecardiology; (5) diabetology; (6) neurology; (7) oncology; (8) otorhinolaryngology, (9) psychiatry, and many other specialties. There is almost no area of medical or paramedical care in which the implementation of telemedicine could fail to offer some procedural improvement. There are, however, many obstacles hindering the triumphal progress of telemedical applications: (1) Technical and logistical restraints: High-resolution images, such as those used particularly in radiology, pathology and dermatology, need highspeed connections in order to provide a reasonable transfer rate of data. New data transfer media and potent new programs for data compression are still being developed. Nevertheless, the exponentially growing need for storage capacity will be an ongoing challenge. The compatibility of software programs also is an essential prerequisite for the widespread use of telemedicine in the future. (2) Organizational resistance: Looking at the reality of hospitals and healthcare institutions, there is a lack of infrastructure and willingness to implement telemedicine. How can one transmit standardized telemedical data when there is a widespread lack of electronic patient record systems, not to mention the lack of genuinely integrated hospital information systems! How can one integrate telemedicine into optimizing processes in organizations where most of the energy is invested in preserving current habits? How can completely new processes be imagined in a setting where mentioning even known principles such as supply chain management produces, at best, astonishment? We watch as huge misinvestments are poured into administrative-oriented IT systems, while user-centered telemedicine projects are blocked by endless discussions about the lack of evidence for their return on investment. And still, responsibility lies with the physician caring for the patient, no matter whether a consultation is done face-to-face, via phone, fax or telemedicine, while many questions as to liability remain to be clarified. (3) Psychological barriers: We refer to subjective arguments preventing the acceptance of telemedicine by both patients and physicians, such as the fear of a deterioration in the doctor-patient relationship. These barriers are mainly caused by a lack of awareness of the potential positive impact of telemedicine. However, studies have shown that if telemedicine can be explained in the appropriate terms, patients are indeed very ready and willing to accept it. Patients do esteem a tangible improvement in the quality of healthcare. Physicians need to recognize that telemedicine can provide them with new tools to extend and improve their professional competence by allowing them to incorporate specialized knowledge from other disciplines.

The Telemedical Information Society

(4) Lack of reimbursement: A major issue limiting the use of telemedicine in medical practice is the lack of economical incentives. As long as insurance companies persist in refusing to reimburse expenditures for telemedical activities, the application of telemedicine will be limited to the small number of pioneers who are prepared to invest time, money, ideas and energy in this new technology [1]. Neither private health insurers nor governmental health authorities have yet agreed to reimburse expenditures for telemedical consultations, whether on the part of the consultant or on the part of the physician requesting the second opinion. Nevertheless, it is highly encouraging to realize that the use of telemedicine applications, in their many different facets, is growing at the impressive rate of about 20% per year. (5) Ethical and legal considerations: Any technology may be helpful or dangerous, depending on the users sense of responsibility. Ethical principles in medicine are timeless, but they must evolve according to the challenge of previously nonexistent technological possibilities and societal developments. Telemedicine will neither make face-to-face consultations superfluous nor devalue the physician-patient relationship. However, telemedicine does have the potential to improve the quality of healthcare for all patients in the future. It is already mandatory for all telemedical applications that data security is guaranteed and that the patient give his or her agreement to the use of telemedical technologies in the diagnosis or treatment of his or her disease. Reciprocally, legal systems will have to evaluate telemedical procedures as they become standardized. Last but not least, the purposes for which patients data may be collected and the ownership of such data has to be clarified.

Impact of Telemedicine on Healthcare in the Future

Telemedicine will certainly have a major impact on the ways in which information is transmitted in healthcare and on the quality of the transmitted data. Telemedicine by itself will not revolutionize any future healthcare system. From a local perspective it will provide helpful practical solutions but probably not reduce costs. Without doubt it will contribute to increased competence in all institutions that provide healthcare, as global networking makes data and knowledge available independent of time and location. Access to specialized, in-depth knowledge on certain medical issues will no longer be restricted to a limited number of experts, but will become available worldwide wherever needed. On a macro-economic scale, the use of telemedicine as a further tool in healthcare will decisively contribute to the optimization of processes. Therefore, telemedicine could provide not only an improvement in quality, but also a significant reduction in costs. Presuming that patients, healthcare

Burg/Denz

professionals, citizens, economists and politicians will strive in common for the further development of telemedicine in healthcare, this goal is within our reach. Looking back to the 1960s with the satellite Telstar and De Bakeys TV transmission of open-heart surgery, medicine evolved and began to integrate the methods of information and communication technologies into its daily routines. The introduction of any new technology has always been accompanied by a structural and behavioral change in society [2]. Television gives us an example of how information flow was enhanced, enabling and sometimes also impeding communication. As a society, we must learn how to deal with and incorporate the new information and communication technologies into our lifes. They have become as fundamental and invaluable as the three rs of reading, writing and arithmetic. In the same way, an awareness of the responsible and appropriate use of telemedicine tools and methods is gradually evolving in the field of medicine, so that in the future telemedicine will be able to take its rightful place in the instrumentarium of modern healthcare.

References
1 2 Forrester Research 2000: Why doctors hate the net. Report available: http://www.forrester.com/ ER/Research/Report/Summary/0,1338,9114,FF.html Nefiodow LA: Der sechste Kondratieff Strategien zum Strukturwandel in Wirtschaft und Gesellschaft. St Augustin, Rhein-Sieg Verlag, 2001.

Gnter Burg, MD, Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 2550, Fax 41 1 255 4403, E-Mail burg@derm.unizh.ch

The Telemedical Information Society

Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 611

1.2

The History of Telemedicine

Claudio Cipolat, Michael Geiges
Dermatologische Klinik, Universittsspital Zrich, Switzerland

Telemedicine is the delivery of healthcare and the exchange of healthcare information across distances, it includes the whole range of medicine including diagnosis, treatment and prevention of disease, continuing education of healthcare providers and consumers, and research and evaluation, performed when distance is an issue. The roots of telemedicine can be traced back centuries, when medical care was limited to the radius in which the physician was available. As a result, distance between patient and physician played a large role in driving the costs of healthcare and the volume of healthcare delivery. To deliver treatment, patients and providers had to be co-located. Hence, healthcare was limited by the need to relocate people and equipment, distances involved, and the speed of information transfer. Technological advances of the last five centuries have allowed healthcare providers to transmit greater amounts of information at exponentially increasing rates. Johannes Gutenbergs invention of the printing press in 1451 allowed healthcare providers to disseminate information en masse [1]. Advances in transportation and communications soon followed, resulting in decreased costs and increased quality of care. As the speed of land transportation increased, first with the steam engine in 1825, and later with the automobile in 1896 and airplane in 1904, the distance barrier was diminished. Physicians could come to their patients or patients to their physicians with greater ease and in a shorter period of time. Provider and recipient of healthcare had no longer to be at the same place [2]. With new communications technology the telegraph in 1844 and telephone in 1876 patients were able to summon physicians quickly and inexpensively, further shortening the time constraint on healthcare. In addition, physicians could now easily confer with one another, facilitating collaboration and expanding their mutual knowledge base, thereby improving care and the quality of life [3]. The decline in computing cost coupled with a rise in

computing power, the advent of fiber-optic cable, high-powered computers, the World Wide Web and Internet, and satellite communications now permit transfer of specialized medical information at high speeds [4]. Telemedicine is still a relatively new area of interest, and while the technology is rapidly evolving, changing and fascinating, it is still the human factors that tend to determine the success or failure of telemedicine projects. The relatively short history of telemedicine from the 1960s onwards is characterized by many different types of systems, relatively few have endured beyond a few years [57]. In view of the cost of these systems, it is also interesting to note that there has been a remarkable lack of critical evaluation [8]. Most early telemedicine programs did not continue after grant funding ended [9]. While there is generally high-quality clinical ownership of most telemedicine systems in the first instance, this seldom seems to be translated from the initial project leader to other clinicians, and few systems seem to have a real consumer, user or outcome focus. Lack of planning tends to lead to one outcome: the equipment simply sits there and is not used appropriately, or not used at all. While it is true that most telemedicine systems are becoming increasingly user-friendly, it is also still true that many clinicians and other users remain rather fearful of the technology [10]. In general, there is a lack of training given to clinicians before they use videoconferencing or other telemedicine technologies [11]. The Internet stands at the forefront of telecommunications in medicine. Along with the growth of the Internet, higher speed access methods are offering a range of new services such as real-time video and voice communications. Medical education, teaching, and research, as well as clinical practice, will be affected in numerous different ways by these advances.

Birth of the World Wide Web

The US military developed the idea for a national network of computers in the late 1960s. The Advanced Research Projects Agency (ARPAnet) was an experimental network of computers designed to support military research and protect information that could be destroyed during a bomb attack or natural disaster. With this purpose in mind, ARPAnet was designed to function even if one or more of its computer sites were destroyed, as a long distance telecommunication network [12]. Each computer sent its message to adjoining computers until it reached its destination. ARPAnets successor was created in the 1980s by The National Science Foundation (NSF). Five regional supercomputer centers around the US were connected to form the backbone of the Internet. To minimize costs, each member university and research facility paid for its own connection and service.

The History of Telemedicine

This cost-sharing helps make the Internet inexpensive to use. Complicated and cumbersome, the early Internet needed fine tuning. To expedite research for ongoing projects at CERN Laboratories in Geneva, Switzerland (European Laboratory for Particle Physics), consulting software engineer Timm BernersLee [13] developed a system to link documents stored on various computer systems and make the Internets huge knowledge base easily accessible. In 1991, Berners-Lees program the World Wide Web was introduced on the Internet [14]. Each document was given a unique address, or URL (Universal Resource Locator). Telecommunications on the Internet are standardized by a set of communications protocols, the TCP/IP protocol suite, that describe routing of messages over the Internet. A person can figuratively jump from one computer to another and pursue information by following hypertext links. In 1992, Mosaic, the first graphical, easy-to-use Web browser that accesses hypertext documents in a point-and-click environment, was created. Mosaic made it easy not only to locate and retrieve documents on the Internet, but also to view graphics, photographs and videoclips online with the click of a mouse button. Finally, anyone could move around the Net easily and access its vast resources without knowing complex computer languages. With the increasing accessibility of the Internet has come a collection of information. True, it can be a valuable resource; but its lack of formal organization, standards, and quality control can pose challenges for professionals. For the visually oriented specialty of dermatology, sharing images and text on the Internet has great potential. The WWW, videoconferencing, multimedia mail, and image databases facilitate applications of digital images in a visually oriented discipline. For example, an image database is available through the WWW, and can be used for students as well as a reference image atlas for physicians [15]. The resolution, compression and color depth of the image must be optimized to enable fast access and offer acceptable image quality. When a high resolution is chosen, problems with storage space and required computer power may arise. The basic problems of medical resources on the WWW can be classified into three areas: scholastic quality, relevance, and ease of access. Quality is a major problem. The Internet allows anyone with hardware and a connection to publish, and a great deal of material appears to be posted without editorial oversight or peer review. Much of the medical material on the Internet lacks a measurement or assurance of veracity. For most of the high-quality Web resources (peer-reviewed especially), payment is needed. The resources pertaining to the field of dermatology include a large palette of options; journals, textbooks, atlases, associations, databases, clubs, mailing lists, etc.; however, these resources may vary in their quality, relevance, or ease of access [16]. The Internet is also a medium for accessing various databases, such as MEDLINE, MEDLARS, AIDSLINE, etc. MEDLINE is the most used

Cipolat/Geiges

medical database by healthcare professionals, and was adapted to the computer for the first time in the 1960s. The advantage of MEDLINE is the possibility of using Medical Subject Headings (meSH) search and the reliability of the indexed sources. The Internet has altered the paradigm of scientific communication and, in the near future, may change not only the way of accessing information, but medical practice itself. Due to the recent technical achievements in computing, we are now able to access instantly resources around the world. Also, this facilitates a huge and increasing free flow of information between specialists worldwide.

History of Telemedicine in Space Medicine

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine research and applications. Since the first days of suborbital flight, telemedicine has been transformed by the increasing complexity of space operations. Today, telemedicine capabilities go far beyond monitoring healthcare. The Remote monitoring of crew, spacecraft, and environmental health has always been an integral part of the NASAs operations [17]. In-flight monitoring is the combination of subjective and objective analytical methods that allow flight and ground personnel to sustain human health in the space flight environment. With the consultation assistance of ground controllers, in-orbit crews with pre-flight medical training are usually able to respond to unexpected events. In addition, flight controllers on the ground are able to evaluate specific health criteria, consult with onboard crew medical officers, and agree upon medical protocols. In-orbit astronauts have reported a wide range of medical events [18]. During the beginning stages of the Space program, telemetry of flight suit data, in conjunction with voice communications, allowed ground controllers to analyze basic physiological parameters (e.g., blood pressure, pulse, ventilation, ECG data). Project Gemini (19651966) astronauts served as test subjects for studies in sleep patterns, balance disturbance, and nutritional changes. Although these data were collected and recorded, they were not downlinked real-time during the mission. A new addition for the Apollo project (19681972) was the biosensor harness, an integrated suite of equipment that measured several health parameters for the crew at critical mission stages and transmitted them back to Earth [19]. These data included O2 consumption, CO2 production, Temperature, ECG, synchronous phonocardiography, ventilation, and heart rate and were near real-time delivered to Mission Control Center with less than a 2-min delay. In the Space Shuttle program (1981 until today) a tracking and data relay satellite system provides real-time communication of

The History of Telemedicine

biomedical information from Shuttle crews to mission control, a significant step for modern telemedicine. The NASA effort to monitor and maintain crew health, system performance, and environmental integrity in space flight is a sophisticated and coordinated program of telemedicine combining cutting-edge engineering with medical expertise. As missions have increased in complexity, NASA telemedicine capabilities have grown apace. At the same time, the terrestrial validation of telemedicine technologies to bring healthcare to remote locations provides feedback, improvement, and enhancement of the space program. The International Space Station will serve as a test bed for the telemedicine technologies to enable future missions as well as improve the quality of healthcare delivery on Earth. Virtual reality, immersive environments, haptic feedback, and nanotechnology promise a new stage in the evolution of telemedicine.

Telemedicine for Airline Passengers and Seafarers

Airline passengers and seafarers are different examples of people who can benefit from telemedicine [20]. An example of distance between patient and healthcare provider is the passenger on board an airplane who requires medical treatment. Unless a doctor is flying on the same aircraft, the care of the patient is entrusted to the onboard personnel [21]. Airplanes are always in contact with an air traffic control center by radio. In case of a medical emergency, the air traffic control center can act as a communications bridge between the aircraft and healthcare staff on the ground. In 1935, Prof. G. Guida in Rome established the International Radio Medical Center (CIRM), with the purpose of offering shipmasters free radio medical assistance. In 1950, the Italian government established the CIRM as a foundation by means of a legislative decree. In this decree, the competence of the CIRM was also extended to assistance of airline passengers and of patients resident in areas without medical facilities as a medical service, with a medical staff of 10 physicians and 49 specialist consultants providing radio medical assistance 24 hours a day [22].

References
1 2 3 4 Garrison F: History of Medicine. Philadelphia, Saunders, 1929. Wootton R, Craig J: Introduction to Telemedicine. London, Royal Society Medicine Press, 1999, pp 1207. Zajtchuk R, Gilbert GR: Telemedicine: A new dimension in the practice of medicine. Dis Month 1999;45:200261. Warnke F: Computer manufacturing: Change and competition. Monthly Labor Rev 1996, pp 618.

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5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Preston J, Brown FW, Hartley B: Using telemedicine to improve health care in distant areas. Hosp Community Psychiatry 1992;43:2531. Yellowlees P, McCoy WT: Telemedicine A health care system to help Australians. Med J Aust 1993;159:437 438. Bashshur RL: On the definition and evaluation of telemedicine. Telemed J 1995;1:1930. Whitten PS, Allen A: Analysis of telemedicine from an organisational perspective. Telemed J 1995;24:122125. Elford R: Telemedicine activities at memorial University of Newfoundland: A historical review, 19751997. Telemed J 1998;4:207224. Allen A: The role of the consultant in telemedicine. Healthcare Inform Manage 1995;9:1316. Zundel KM: Telemedicine: History, applications and impact on librarianship. Bull Med Libr Assoc 1996;84:7179. Glowniak J: History, structure and function of the Internet. Semin Nucl Med 1998;28:135144. The Web Maestro: An interview with Tim Berners-Lee. Technol Rev 1996;99:32 40. Sitaru C: Dermatology resources on the Internet: A practical guide for dermatologists. Int J Dermatol 1998;37:641 647. Bittorf A, Krejci-Papa NC, Diepgen TL: Development of a dermatological image atlas with worldwide access for the continuing education of physicians. J Telemed Telecare 1995;1:4553. Krejci-Papa NC, Bittorf A, Huntley A: Dermatology on the Internet. A source of clinical and scientific information. J Dermatol Sci 1996;13:1 4. Nicogossianc AE, ber DF, Roy SA: Evolution of telemedicine in the space program and earth applications. Telemed J E Health 2001;7:115. Longitudinal Studies of Astronaut Health, National Aeronautics and Space Administration, 2000 (unpubl data). Doarn CR, Nicogossian AE, Merrell RC: Applications of telemedicine in the United States Space Program. Telemed J 1998;4:1930. Rizzo N, Fulvio S, Camerucci S, Carvalho M, Biagini M, Dauri A: Telemedicine for airline passengers, seafarers and islanders. J Telemed Telecare 1997;3(suppl 1):79. Bagshaw M: Telemedicine in British Airways. J Telemed Telecare 1996;2(suppl 1):3638. Amenta F, Dauri A, Rizzo N: Organization and activities of the International Radio Medical Center (CIRM). J Telemed Telecare 1996;2:125131.

Claudio Cipolat, MD, Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 2550, Fax 41 1 255 4403, E-Mail cipolat@der.usz.ch

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1.3 Technology
Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 1216

1.3.1

The Communication Revolution Goes On Global High-Speed Networks: Setting the Pace for Future Multimedia Applications
Andreas Hffner, Karoline Zepter
Dermatologische Klinik, Universittsspital Zrich, Switzerland

The Information Society

Information, awareness, publicity and communication have always been intrinsic aspects of human expression and of society. In the last few decades, however, a revolution has occurred in the instruments available for those seeking to collect, process and distribute information and this revolution has had a profound effect on the interaction between the various actors in society, and on their decisions [17]. At the beginning of the last century, basic communication tools were speaking, writing and printing. Later, the telephone, radio, cinema and television were major steps forward in distributing information. Computers have become available only for a comparatively short period of time and their capacity has been continuously expanded by steadily increasing calculation power and their arrangement in local area networks (LANs). These developments were also accompanied by rapidly increasing interconnectivity of the various tools, using them in combinations for various purposes. The Internet, being directly within reach for a major proportion of our societies, was revolutionary, not only because of its accessibility, but also because it offers access to virtually unlimited amounts of information and in addition, more rapid means of communication. The personal computer is thus now the center of a global electronic network of appliances and systems, interacting to offer unprecedented possibilities for the collection, processing and communication of information. So, as the new

information technology and its networks advance and becomes more pervasive, economic operations and activity in general are becoming increasingly knowledge-based and directed by information; and the scope in which knowledge is expressed is becoming global. This global knowledge-based community, with its increasingly dominant information and communications networks, the new technology they use and the information they pass on, the interrelationship between this information, the networks and the various levels of government and people, is called The Information Society.

Uses Multimedia

Core technologies, empowering these new information societies, can be summarized under the term multimedia the blending of images, graphics, sound, voice, videotext and other information within a human interface that uses capabilities to access and present information. Essentially, multimedia systems allow the end user to share, communicate and process a variety of information in an integrated manner. In a distributed environment, for example, it may incorporate multiple sources of various media spatially or temporally. Similarly, in modern business systems, the integration of various types of media such as data, text, graphics, animation, voice and full video has gained significant impact considering the current applications of computers in education and training, retailing, entertainment and manufacturing sectors. Recent advances in key enabling technologies, such as groupware, speech generation, graphical user-interfaces have raised the demand for multimedia applications and thus also for an ever more advanced network infrastructure.

And High-Speed Networks

Twenty-five years ago, consumers had little choice. In telephony, usually government-owned companies controlled all equipment, services and prices. In television, a handful of networks and the governments that supported them dominated. By the 1980s, however, things were changing. Consumers became more influential with regard to their telephone equipment, tariff models became more diverse and telephone lines began to be used for data transmission as well as voice. They could also opt to pay for better TV service by subscribing to cable. In the 1990s, mobile technologies became affordable and ubiquitous.

The Communication Revolution

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Internet Access Evolution

Dial-in (POTS)

Dedicated Line

Service Modem, POTS (V.90)

Transmission Rate 56 000 bit/s down 33 600 bit/s up

ISDN

128 kbit/s

Satellite
W

Cablemodem

512 128 400

kb/s down kb/s up kbits/down kbits/s up

ss L irele

oca

l Lo

op

TCP over Satellite Asymmetric

128

Dial-in (POTS)
N

Cable

1,5 bis 9 Mbit/s down

Digital Subscriber Line (ADSL) 16 bis 640 kbit/s up Single Line Digital Subscriber Line (SDSL) High Data Rate Digital Subscriber Line (DHSA) Very High Data Rate Digital Subscriber Line (VDSL) Wireless Local Loop (WLL) 13 bs 52 Mbit/s down Up to 34 Mbit/s 2.048 Mbit/s 1.544 Mbit/s

ISD

Fig. 1. Internet access evolution: while few kilobit connections were the standard only 10 years ago, available network speeds reach up to 34 Mbit/s today.

Changing uses of existing networks inevitably exposed fundamental flaws and limitations. Cable and satellite networks, though fast, were inherently one-way, which rendered them ineffective wherever interactivity and two-way communications were required. Copper-based voice networks, while two-way, were too slow for high volumes of data; and, because these networks relied on dedicated connections, they tended to be uneconomical for many forms of data communication. Mobile networks suffered from bandwidth and quality-of-service limitations as well as network interoperability challenges. The seeds of a broadband revolution are seen in how todays networks are evolving to deal with these limitations. Copper-based networks have been given new life with the deployment of xDSL (digital subscriber line) technologies that enable faster transmission and simultaneous voice and Internet use over a single line. Cable networks are being enhanced with new two-way controlled equipment that enables interactive TV

xD SL

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and internet-based services. Satellite services are being enhanced with two-way strategies that make them more useful, cost-effective, and interesting to a wider range of users (fig. 1). The seeds of a broadband revolution are dispersed not only with new technologies, but also in the new models of interaction that open the doors for new forms of consumer-controlled services. Consumers are beginning to actively influence and participate in the broadband revolution. They are increasingly drawn away from connectivity-only services and all-you-can-eat content strategies to value-based products and services that enable them to customize what they use and how they use it. Informed consumers ever more recognize that they not only consume content, they also create it, content is about them and they are part of it.

To Transport Increasingly Vital Information

Aside from professional and entertainment use, lifestyle activities, including the use of information systems to gain or enable medical advice, enter the stage of these new product/service classes. One example is the concept of an Internet-based computerized patient record (iCPR). Today, medical care is fragmented even for those who are not geographically mobile. It is the exception rather than the rule for a patient to receive medical care from only one provider. Not only was the volume of information lower in previous generations, continuity of medical care was more often maintained through enduring patient-physician relationships, making the explicit recording of this information less critical than is currently the case. For this reason, unlike some applications of computers in medicine (NMR scans, for example), the concept of the iCPR, was not so much driven by the underlying technology which made it possible to do something new, as by a recognition that networked computers offered a better or even the only way to meet the basic challenge of medical informatics, that is to provide comprehensive information at the right place and time. With an elevated life expectancy and accustomed to international traveling, people, particularly those with chronic diseases, notably raise their demands on availability and accessibility of personal medical data and documents. Hence, an extensively documented and continuously updated health record will become more and more important and provides a novel, local and medical independence, unknown so far. A seamless summary of existing medical data and documents adds to confidence in therapeutical decisions and helps to prevent unnecessary strain on the patient such as redundant examinations or multiple concomitant

The Communication Revolution

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pharmaceutical prescriptions. Finally, electronic health records assist in minimizing the risk of malpractice which in turn lowers ensuing costs for health insurance providers and employers. It remains a major task of the future to define the standards for this integrative master platform, for the storage and administration of health data from heterogeneous sources. The transition to the computer-based patient record has only begun. In spite of the grossly unmanageable state of the paper medical record, it remains the repository for the overwhelming majority of actual clinical data. These data kept in inhospitable dungeons of Medical Record Rooms are in fact the sources which are used today for the delivery of patient care, and as the basis of a significant amount of clinical research. The problems surrounding the iCPR make clear that the real broadband revolution is not so much about speed, but much more about content. It is the need to define how content is gathered, organized, valued, how content is protected, and how content is delivered. As broadband technologies evolve, they are enabling higher transmission speeds, enhanced quality of service, new models of content storage, and new computing appliances. But these technologies are only the enablers of the broadband revolution not the revolution itself.

References
1 2 3 Margaritidis M, Polyzos GC: Adaption techniques for ubiquitous Internet multimedia. Wirel Commun Mob Comput 2001;1:141163. Papavassiliou S: Network and service management for wide-area electronic commerce networks Int J Netw Manage 2001;11:7590. McFarland D: Multimedia in higher education; Katharine Sharp Review, No 3, Summer 1996 (ISSN 10835261). School of Library, Archival and Information Studies, University of British Columbia. Gendreau T: A broadband revolution? Yes, but think content, not just speed. www.mindport.com/ factsheets/BBRevolution.pdf Gunasekaran A, Love PED: Current and future directions of multimedia technology in business. Int J Inform Manage 1999;19:105120. Kimura H: A study on structure and quality of multimedia network systems for education using satellite interactive communication. Electronics Commun Jpn 1998;81:355365. The European Commission: The Information Society and Development (2001) ER/04 Economic Analysis.

4 5 6 7

Andreas Hffner, MD, Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 2550, Fax 41 1 255 4403, E-Mail ach5@derm.unizh.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 1723

1.3.2

Image and Video Compression: The Principles Behind the Technology

Andreas Burg
Zrich, Switzerland

Image and Video Compression: The Principles Behind the Technology

The capacity of telecommunication systems has grown rapidly in recent years. Nevertheless, the transmission of multimedia streams has remained a major challenge. The required data rates to transmit the raw video streams data exceed by far the capacity of modern networks. Table 1 summarizes the required bit rates for the transmission of raw video data for some typical applications. The goal of Video and image compression algorithms is to reduce this large amount of raw data to match the capacity of the network before it is transmitted. At the receiver the compression procedure needs to be reversed to restore the original data stream. This procedure is called decompression. Most of todays compression schemes for multimedia applications allow a certain amount of information to be lost in the compression process in order to achieve the necessary high compression ratios [1]. (These schemes are classified as lossy compression algorithms, as opposed to lossless algorithms which are typically used for text, programs and other data.) As a consequence, the original data stream cannot be perfectly restored at the receiver. This leads to a loss in quality of the media after decompression, however it also provides a means to trade quality for compression ratio in order to allow to adapt the bit rate of the data stream to the capacity of the transmission channel [2]. The most generally used compression schemes for the transmission of life video data (such as MPEG-2, H.263 and MPEG-4 [3]) are based on the same principle ideas and algorithms. Their structure is shown in figure 1.

Table 1. Required bit rates for the transmission of raw video data for some typical applications Application Format Bit rate, Mbits/s 600 120 36 9 Medium

Video (high quality) Video (low quality) Video conference Mobile video phone

HDTV PAL/NTSC CIF (352 288) QCIF (172 144)

Ethernet (100 Mbits/s) Cable modem (512 Kbits/s) ISDN (128256 Kbits/s) UMTS (144 384 Kbits/s)

Preprocessing

Prediction

Transformation

Quantization

Entropy encoding

Postprocessing

Reconstruction

Inverse transformation

Inverse quantization

Entropy decoding

Fig. 1. Video compression.

Preprocessing

In the preprocessing stage the frames that arrive from the video source are first converted into the so-called YUV color space. In this representation, each picture element (pixel) is represented by its luminance (Y) and its chrominance (U and V). The Y component defines the brightness of the pixel, while U and V determine its color. As the human visual system (HVS) is much less sensitive to the latter, a first compression of the image can be performed by reducing the resolution (subsampling) of the two chrominance components by a factor of 2 in either only the vertical or in both the vertical and horizontal direction. With this measure the overall amount of data of the incoming frames is already reduced to two thirds or to one half respectively.

Prediction

The goal of the next step(s) is to remove redundant information from the video stream. In this context the term redundant describes a piece of information

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that is contained in the data stream but is already known at the receiver from previously received data and from a set of a priori fixed rules and facts. If this is the case it is not necessary to retransmit this information and it can be removed or replaced by a much shorter hint to the decoder where this information can be found. An analysis of typical video streams show that they in fact do contain a large amount of redundancy which is the key to the success of all modern compression schemes. It turns out that most of this redundancy can be covered with a set of only two simple rules that are easily observed and can be applied successfully in almost all cases: (1) a frame in a sequence is similar to its preceding and subsequent frames, and (2) most pixels in a frame are very similar to the pixels in their vicinity. In most video compression schemes the prediction stage uses the first rule to remove the so-called inter-frame correlation or redundancy caused by the similarities (correlation) of subsequent frames. This is done by making a guess about the current frame using only information from previous frames together with a set of rules. Only the difference between the guess (predictor) and the actual frame (the error frame) is transmitted. The better the predictor matches the actual frame, the smaller is the remaining amount of actual information that needs to be conveyed. The original data can be restored by the receiver (or decoder) by simply computing the same predictor as the encoder and adding it to the received error frame. The simplest form of prediction assumes that two subsequent frames are identical. The predictor for each frame is simply the preceding frame. A much more complex, however also more efficient scheme is the so-called motion estimation and compensation. This technique is used in most of todays video compression algorithms such as MPEG-2/4 and H.263. It assumes that the main cause of differences between subsequent frames is the presence of motion of the entire scene (moving camera) or of single objects within the scene. To exploit this, a frame is partitioned into multiple square (MPEG-2/H.263) or arbitrarily shaped (MPEG-4) regions. For each of these regions the compression algorithm searches the surrounding area in a previously encoded frame to find the best match (or the best predictor). Its displacement is called a motion vector. The predictor is again subtracted from the region in the current frame and the resulting error is transmitted together with the corresponding motion vector. This is necessary to allow the receiver to reconstruct the original image (fig. 2). However, in reality, using prediction for every frame in a video sequence turns out to have some significant disadvantages: (1) as each frame would depend on previous frames, which themselves also depend on even older frames, it is impossible to start a sequence at an arbitrary time; (2) if an error occurs during the transmission of a frame it will propagate into all subsequent frames, and (3) if an abrupt scene change occurs there might be very little correlation

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Fig. 2. Motion estimation.

between subsequent frames and no suitable predictor might be found for a frame. To counter these problems, modern algorithms introduce so-called I(ntra)frames in regular intervals. These frames are as opposed to the predicted D(ifferential)-frames encoded by themselves, independent of any previous frames. The frequency of these I-frames depends on various parameters such as the type of scene or the quality of the transmission channel. In most cases it is also variable and it is left to the encoder to decide when the insertion of an I-frame is appropriate.

Transformation

After the prediction step, most of the redundancy caused by inter-frame correlation has been removed. The next step aims at removing or reducing the remaining redundancy within a single D-frame or more important the redundancy within the I-frames by exploiting the so-called intra-frame correlation. This is achieved through the use of algebraic transforms which have the ability to remove correlation. The best possible transformation for this purpose is the so-called Karhunen-Loeve transformation. While it achieves theoretically the optimum performance, it is not suitable for a real application as it requires knowledge on the statistics of the image which is not a priori available. Instead it has been found that for typical image data so-called sub-band coding schemes with their good energy compaction properties have a very similar performance. Moreover, they also have the ability to separate information to which the human visual system is more sensitive from information to which it is less sensitive by transforming the data into the frequency domain. This approach is also being used for the compression of still images [4] and these compression schemes are often referred to as transform-based algorithms. The two most common transforms are the Wavelet and the 2D Discrete Cosine Transform (2D-DCT ).

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The former is, due to its higher complexity, currently only being used for still images (for example in the new JPEG-2000 standard) and is not further discussed here. The latter is part of all three major video compression systems (MPEG-2, H.263 and MPEG-4). It is a block-based transform which is typically applied to image regions of either 8 8 or 16 16 pixels. The result of the transformation of such a block is a new block of the same size in the frequency domain. The first element in the top left corner represents the DC component, while the other elements represent the horizontal and vertical AC components. The frequency increases with the distance from the DC component and the highest spatial frequencies are therefore located in the lower right corner of the frequency domain block. This transformation is still lossless and reversible. Therefore, no quality degradation has been caused so far.

Quantization

In the frequency domain representation a quantization step is applied to the transformed image data. Thereby each coefficient is quantized using a predetermined step size. At this point, one makes use of the fact that the human visual system is by far less sensitive to the high spatial frequency components of an image than to the lower frequency components. This is exploited by simply applying more coarse quantization steps to the higher than to the lower frequency AC components. As the quantization cannot be reversed at the receiver, it introduces a degradation in the image quality. This step is the place where the trade-off between compression ratio and quality is performed.

Entropy Coding

While after these preprocessing and transformation steps the amount of correlation and information in the frames has been greatly reduced, no actual compression has been performed yet. This is only done in the Entropy-Coding step. All entropy-coding algorithms [5] by themselves are lossless data compression algorithms. This means that a data stream that has been compressed at the transmitter can be fully restored at the receiver. The decompressed data will be 100% identical to the original data and no further information will be lost. Without the described preprocessing schemes these algorithms are the same that are used for the lossless compression of text documents, software or databases. Their theoretical principles were first described by Shannon, who found that the amount of information in any kind of message (or data stream) could

Image and Video Compression

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be quantified and in order to do this it would be necessary to know the probabilities of all symbols within the message. These can easily be found by counting the number of their occurrences and by dividing it by the overall message length. Herewith the amount of information in the message could now be computed as:
E = log 2 ( P( Si ))
i

The result of this formula is called the entropy of the message. It is the theoretical minimum number of information bits that is required to store its entire content. Entropy-coding algorithms aim at reaching this limit as close as possible. While Shannons theorem puts a lower bound on the achievable compression ratio, it does not yet define how this bound can actually be reached in practice. However, since the discovery of these information theoretic principles, a number of compression algorithms have been developed which can be loosely categorized as: (1) LZW codes; (2) arithmetic codes; (3) run-length codes, and (4) prefix codes. The first two (LZW coding and arithmetic coding) do not play a major role in the encoding of multimedia streams. This is mainly due to their complexity and due to their problems of recovering from transmission errors. Instead, the much simpler run-length coding and the so-called prefix-coding schemes are used in most of todays standards to perform the actual data compression. If both algorithms are used, run-length coding is always applied first. The essence of the generic run-length coding algorithm, the so-called zero-run-length coding, exploits the fact that after the previously explained preprocessing steps most of the data in the stream consists of zeros. It collapses runs of subsequent zeros into a single zero followed by the number of zeros in the run. Different variations of this basic idea are in use. Some algorithms, for example that a non-zero number, are always followed by one or many zeros. They simply encode every non-zero symbol with the symbol, followed by the number of subsequent zeros. Which scheme is optimal and how it is actually implemented depends on different aspects of the preprocessing and on which prefix-coding scheme is applied afterwards. The last step is the prefix coding. In general, prefix-coding schemes achieve compression by representing symbols with a high probability of occurring with shorter code words, while longer code words are used for less frequent symbols. The name comes from the fact that each code word starts with a prefix which might vary in the number of bits. It determines the length of the code word. However, when the code is generated it must be guaranteed that none of these prefixes starts with a bit sequence which might be found in any of the symbols in the alphabet. Various techniques are known to construct such codes with

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different properties. One of the most widely known is the so-called Huffman code. It achieves the highest possible coding efficiency that can be realized with this kind of algorithm.

References
1 2 3 4 5 Ebrahimi T, Kunt M: Visual Data Compression for Multimedia Applications. Proc IEEE 1998;86: 11091125. Hanzo L: Bandwidth-efficient wireless multimedia communication. Proc IEEE 1998;86: 13421382. Battista S, Casalino F, Lande C: MPEG-4: A multimedia standard for the third millennium. IEEE Multimedia 1999(OctDec):7483. Pennebacker WB, Mitchell JL: JPEG Still Image Compression Standard. New York, Van Nostrand, 1993. Nguyen-Phi K: Contextual coding and data compression. Diss, Tech Univ, Vienna 1997.

Andreas Burg, Haldenstrasse 14, CH8124 Maur (Switzerland) Tel. 41 1 632 6095, Fax 41 1 632 1194, E-Mail apburg@iis.ee.ethz.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 2431

1.3.3

Teledermatology Delivery Modalities: Real Time versus Store and Forward

Pamela S. Whitten
Department of Telecommunication, Michigan State University, East Lansing, Mich., USA

Teledermatology is the delivery of dermatologic patient care through telemedicine technologies. The dermatologist uses telecommunications equipment to evaluate clinical and laboratory data, as well as to diagnose and prescribe therapy for patients located at a different physical location. In general, the goals of teledermatology are to reach out to people residing in underserved areas, to decrease the costs of providing some health services, and to improve the quality of care. Research in the field of teledermatology has examined an array of issues. Simple feasibility of teledermatology was an important first question. Projects such as the one conducted between Jackson Memorial Hospital, a major teaching hospital of the University of Miami School of Medicine, and prisons in Florida demonstrated that a two-way microwave link could be employed by a dermatologist to assess a patient [1]. Other pioneering projects sought to assess the accuracy of teledermatology. In 1972, black and white bidirectional interactive television was installed at Logan Airport in Boston and Massachusetts General Hospital. Researchers reported that in almost all cases diagnoses made over the system were equivalent to diagnoses made in person [2]. In another early study, researchers at Dartmouth-Hitchcock Medical Center concluded from a 1974 clinical trial that the quality of the physician-patient relationship was not modified by the telemedicine equipment [3]. More recent evaluation efforts in this field have certainly focused on accuracy [4, 5]. Important to document are the current projects comparing outcomes between teledermatology and traditional care. Wootton et al. [6] found that there were no significant differences in clinical outcomes between teledermatology and conventional outpatient dermatology care in a project conducted in

Northern Ireland. Another study conducted in Hong Kong [7] concluded that teledermatology, as part of a multitelemedical service to institutional patients, is highly reliable in relation to diagnostic and management accuracy and well received by patients. Though studies appear to consistently document positive outcomes in relation to teledermatology, one cannot have a complete grasp of this field without understanding the two categories of teledermatologic care, namely real time and store and forward. This chapter seeks to document this difference through a brief explanation of both, a look at important research conclusions for both approaches, and a discussion of the advantages and disadvantages for each.

Real-Time Teledermatology

The delivery of teledermatology services is through one of two means: store-and-forward, computer-based systems and real-time, videoconferencing systems. The medical aspects of dermatology can be achieved for the most part with either approach. Diagnostic procedures and therapeutic interventions can be recommended through both approaches. Either system may have a dermatoscope (skin scope) and a microscope camera as additional features. However, the actual delivery technique varies dramatically among the two approaches. In real-time teledermatology, videoconferencing equipment is employed to allow for synchronous activity between two or more parties. This modality enables a dermatologist to see and hear a patient through this video connection. This facilitates a direct interaction in real time between a dermatologist, a patient, and any personnel (typically a nurse or general practitioner) co-located with the patient presenting the patient/images. While live video images can be transmitted through analog phone lines, these images are traditionally slower and of poorer quality. Thus, digital lines are usually preferred (e.g., ISDN, T1). By increasing bandwidth, motion handling is improved therefore decreasing the amount of motion artifacts. Bandwidth requirements are typically determined by the size and resolution of images sent, required turn around time, and expectations of peak use [8]. Researchers in the UK [9] demonstrated that the color and temporal resolution of live video images could be improved by changing from a hand-held, single chip video camera to a tripod mounted, three sensor chip camera. Opinions differ regarding whether real-time video is required for teledermatology or if digital images will suffice. A number of projects have documented the success of real-time teledermatology. For example, a project conducted within the Baltimore Veterans Affairs Medical Center in Baltimore, Maryland, sought to compare live two-way interactive video examinations with

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traditional in-person exams in regard to diagnostic agreement and patient/ provider satisfaction [10]. Project researchers concluded that patients were equally satisfied with both modalities; physicians preferred in-person examinations, and physician diagnostic agreement was quite high between the real-time teledermatology and in-person visits. The largest studies examining teledermatology have employed the use of videoconferencing equipment to provide real-time diagnoses and clinical management [11]. A variety of studies have evaluated the diagnostic accuracy of videoconferencing [1217]. Such studies have documented a range of diagnostic accuracy from 54 to 80%. However, most of these studies assume that in-person consultations are the gold standard that is always correct. Research in the field of real-time dermatology has also demonstrated high degrees of patient and provider satisfaction [18, 19]. However, physicians tend to display greater comfort with their in-person diagnoses than their videoconferencing diagnosis [10]. Patients, on the other hand, almost universally accept real-time teledermatology. A project employed in the Highlands of Scotland demonstrated a high degree of both patient and physician satisfaction with teledermatology real-time consultations. Patients living on remote islands reported access to rapid opinions and launching of treatment when teledermatology was used to augment the bimonthly in-person clinics [20]. A number of other real-time teledermatology projects have been launched to meet specific health system goals. For example, a teledermatology project at the Crozer-Keystone Health System has been conducting telederm clinics with Pennsylvania State Prisons since 1998 and has performed hundreds of consultations to date. In this project, the dermatologist employs desktop videoconferencing equipment and physicians reported less than ten cases where they were unable to make a diagnosis due to image quality [21]. One of the overriding goals for this project was to reduce costs associated with transporting shackled patients with armed guards to hospitals for care. In another project launched by Tripler Army Medical Center in Hawaii, health providers sought to address challenges faced by uniquely remote service providers stationed on Republic of Marshall Islands, comprising 60 atolls in the center of the Pacific basin. Realtime teledermatology services have proven a welcome solution for clients residing tremendous distances from providers [22]. In general, projects employing real-time teledermatology have demonstrated diagnostic accuracy, efficacy and user satisfaction. This delivery modality possesses several documented advantages and disadvantages. Proponents of real-time teledermatology argue that it creates a more effective communication interaction by enabling three-way discussions between a patient, general practitioner and dermatologist. In a synchronous event, a dermatologist can ask a patient a direct question or ask to see something from a different angle.

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Another advantage relates to the increased amount of available information. Simply put, there is a greater amount of clinical information potentially available compared with store-and-forward solutions. Yet another advantage relates to new educational opportunities that arise. A specialist is able to provide spontaneous and interactive education and training to a generalist while a consult is happening. Other documented advantages suggest that real-time, live videoconferencing is pragmatic for monitoring treatments over great distances and is a cost-effective solution for long-distance services [11]. Critics of this mode of delivery argue that a significant disadvantage lies in its lack of cost effectiveness for services provided over short distances. Sometimes the picture quality is poorer when compared with some sophisticated store-and-forward solutions. Another disadvantage relates to the time required of those participating in the event. It is often difficult to coordinate the schedules of specialists, patients and a provider to present the patient at the remote end. And, when there is a technical problem, expensive medical time is wasted. In summary, literature reports that providing dermatological services via real-time videoconferencing is a feasible solution in regard to quality of care and acceptance. Initial teledermatology projects typically relied on such synchronous systems, and many continue to employ this solution. However, the technologies employed to provide teledermatology are increasingly asynchronous. It is to a discussion of these store-and-forward solutions that we now turn.

Store-and-Forward Teledermatology

Store-and-forward solutions employ technologies to capture selected digital images and transmit them asynchronously to specialists to be reviewed at their convenience. Typically a digital camera is employed to capture still digital images on a digital monitor. The main parameter impacting the quality of display on a digital monitor is the number of pixels and the number of bytes per pixel. Computers used to transmit these images need to have the capability to deal with large, image-based files. The recent expansion in digitally acquired radiology systems led to the development of picture archiving and communication systems (PACS) to address the need of increased capacity in digital storage. PACS facilitate the capture, storage, retrieval and display of digital pictures. More sophisticated systems provide software that allows for additional patient details such as a short case history. As with real-time videoconferencing, store-and-forward solutions must also take into account transmission speeds for images. Because many images

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are quite large, a large amount of bandwidth is required if the image must be received in a short amount of time. However, the flexibility inherent in this asynchronous solution often allows for slower transmission speeds to meet providers needs. It is commonly accepted that the future of teledermatology will focus primarily on store-and-forward techniques [11]. Most studies published to date for this technique have employed lower resolution, lower cost solutions. High et al. [23] conducted a comparison of store-and-forward and traditional face-to-face consults for 92 patients and concluded existing inexpensive digital technologies (an inexpensive camera and widely available computer equipment) can be used to develop an accurate store-and-forward system. Another study conducted in the UK [24] concluded that use of a video camera to store digital images allowed for a reasonably accurate diagnosis. However, these researchers felt the software they employed was not reliable (6 of 194 cases could not be viewed) and that it was not easy to use. Whited et al. [25] employed a digital camera capable of taking images of resolution 1,280 1,000 pixels to study 168 skin images from 129 patients. The authors of this study determined that digital image consultations and clinic-based examinations were of comparable diagnostic reliability. Store-and-forward dermatology projects have popped up in a number of unique contexts. One project conducted with 29 residents in a nursing home concluded that teledermatology is accurate and may replace some onsite consultations by offering quality care in a cost-effective manner [26]. In another project, a web-based, store-and-forward teledermatology system has been in place at Walter Reed Army Medical Center since 1998. Several hundred consults have been performed for outlying military primary care clinics. More than 50% of the patients had their condition treated at the primary care facility, never having to make a trip to see their dermatologist in person [27]. Other studies suggest that a range of digital store-and-forward systems are feasible [2831] and can provide cost-effective teledermatological services to rural residents [28, 31]. Though considered the delivery alternative with the most potential by many, store-and-forward solutions also possess both advantages and disadvantages [11]. Among its strengths is the fact that it is an inexpensive and effective means of providing diagnosis and management plans. Accuracy has been demonstrated to be reliable in a number of studies. A great number of images can be reviewed in a single sitting which may convenient for dermatologists. It may also prove to be faster than a traditional referral. Some dermatologists report that the time needed to complete the evaluation is often less than that of the live interactive teledermatology consultation, since the social formalities between the doctor and patients are absent [32].

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The reported disadvantages of store-and-forward dermatology often revolve around communication shortcomings. For example, the specialist is unable to communicate directly with the patient or referring physician to gather information. Some dermatologists report a loss of patient rapport. The asynchronous nature of store and forward also limits educational opportunities with primary care providers which is an option in real-time teledermatology. Finally, many dermatologists report that this is a repetitive and boring way to practice their craft [11]. Despite the shortcomings of store-and-forward as well as real-time teledermatology, both modalities exhibit a promising future.

A Forward Glance

The potential value of teledermatology is great in rural and medically underserved areas that do not have easy access to providers specializing in the diagnosis and management of skin diseases. Primary care providers should be able to take advantage of this technique as a greatly simplified and costeffective means of referring a patient to an urban dermatologist. Perednia et al. [33] report, however, that primary care providers in general are reluctant to refer patients with skin conditions, even when the primary care provider possesses low confidence in the correct diagnosis and treatment plan for a condition. In their Oregon-based study, the researchers found that the installation of a teledermatology system dramatically increased the number of patients referred for a specialist evaluation. They report that a number of cases emerged in which use of the telemedicine technology system resulted in reversing conditions that had been poorly controlled prior to the teleconsultation. They concluded that teledermatology may improve the practice of referring appropriate cases for specialty review. In general, whether real-time or store-and-forward technologies are employed, there are a number of generic advantages. First, it appears that management plans are just as effective as those in traditional consultations. Teledermatology levels the playing field by facilitating equitable services between urban and remote areas. A number of studies indicate that patient costs (e.g., travel time, time off work) are decreased for patients [11]. In addition, equipment costs are falling while image quality is simultaneously improving. Ultimately, teledermatology could facilitate shorter waiting lists for specialty care. However, there are also generic disadvantages that must be addressed for both delivery modes. Providers are often resistant to change. Some patients will always require an in-person visit for a wide range and often unpredictable reasons. Finally, security and privacy concerns must be addressed on an ongoing basis to prevent liability issues from looming too large.

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Overall, the future looks bright for both real-time and store-and-forward technologies. Initial evidence points to acceptable levels of accuracy, feasibility and satisfaction with both solutions.

References
1 Sassmore L, Sanders J: Final report: An evaluation of the impact of communications technology and improved medical protocol on health care delivery in penal institutions, vol 1: Executive Summary, NSF grant GI39471, Dec 1976. Murphy RLH Jr, Fitzpatrick RB, Hayes HA, et al: Accuracy of dermatologic diagnosis by television. Arch Dermatol 1972;105:833835. Johnson MLT: A model for televised remote dermatological consultation. Unpubl report, 1974. Vidmar DA, Cruess D, Hsieh P, et al: The effect of decreasing digital image resolution on teledermatology diagnosis. Telemed J 1999;5:375383. Whitlock WL, Pujals JS, Keough GC, Dingbaum AM, Beaty NB, Mease AD, Poropatich RK: Tricare region 3 teledermatology: Clinical consequence. Telemed J 2000;6:122. Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, Mathews C, Steele K, Loane MA: Multicentre randomized control trial comparing real-time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. BMJ 2000;320:12521256. Chan HHL, Woo J, Chan WM, Hjelm M: Teledermatology in Hong Kong: A cost-effective method to provide service to the elderly patients living in institutions. Int J Dermatol 2000;39:774778. Malone FD, Athanassiu A, Nore J, DAlton ME: Effect of ISDN bandwidth on image quality for telemedicine transmission of obstetric ultrasonography. Telemed J 1998;4:161165. Loane MA, Gore HE, Corbett R, et al: Effect of camera performance on diagnostic accuracy: Preliminary results from the Northern Ireland arms of the UK Multicare Teledermatology Trial. J Telemed Telecare 1997;2:8388. Lowitt MH, Kessler II, Kauffman CL, Hooper FJ, Siegel E, Burnett JW: Teledermatology and in-person examinations: A comparison of patient and physican perceptions and diagnostic agreement. Archives of Dermatology 1998;134:471476. Jeedy DJ, Wooton R: Teledermatology: A review. Br J Dermatol 2001;144:696707. Oakley AMM, Astwood DR, Loane M, et al: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. NZ Med J 1997;110:5153. Gilmour E, Campbell SM, Loane MA, et al: Comparison of teleconsultations and face-to-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Br J Dermatol 1998;139:8187. Loane MA, Corbett R, Bloomer SE, et al: Diagnostic accuracy and clinical management by realtime teledermatology. Results from the Northern Ireland arms of the UK Multicentre teledermatology Trial. J Telemed Telecare 1998;4:95100. Lesher JL, Davis LS, Gourdin FW, et al: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. J Am Acad Dermatol 1998;38:2731. Loane MA, Gore HE, Bloomer SE, Corbett R, Eedy DJ: Preliminary results from the Northern Ireland arms of the UL Multicenter Teledermatology trial: Is clinical management by realtime teledermatology possible. Journal of Telemedicine and Telecare 1998:4(suppl 1):35. Phillips C, Burke WA, Allen MH, et al: Reliability of telemedicine in evaluating skin tumors. Telemed J 1998;4:59. Loane MA, Bloomer SE, Corbett R, et al: Patient satisfaction with real-time teledermatology in Northern Ireland. J Telemed Telecare 1998;4:3640. Selickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 1997;133: 171174. Jones DH, Chrichton C, Macdonald A, et al: Teledermatology in the Highlands of Scotland. J Telemed Telecare 1996;2:79. Snow J: Teledermatology in correctional healthcare. Telemed J 2000;8:188.

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Norton SA, Burdick AE, Phillips CM, Berman B: Teledermatology and underserved populations. Arch Dermatol 1997;133:197200. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776783. Taylor P, Goldsmith P, Murray K, Harris D, Barkley A: Evaluating a telemedicine system to assist in the management of dermatology referrals. Br J Dermatol 2001;144:328333. Whited JD, Hall RP, Simel DL, et al: Reliability and accuracy of dermatologists clinic-based and digital image consultations. J Am Acad Dermatol 1999;41:693702. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 1997;133:171174. Welch ML, Hon SP, Poropatich RK: The impact of the web-based store-and-forward teledermatology consult system in the national capital area. Telemed J 1999;5:41. Tait CP, Clay CD: Pilot study of store-and-forward teledermatology services in Perth, Western Australia. Australas J Dermatol 1999;40:190193. Pak HS, Welch M, Poropatich R: Web-based teledermatology consult system: Preliminary results from the first 100 cases. Stud Health Technol Inform 1999;64:179184. Bergmo TS: A cost minimization analysis of a real-time teledermatology service in Northern Norway. J Telemed Telecare 2000;6:273277. Burgiss SG, Julius CE, Watson HW, et al: Telemedicine for dermatology care in rural patients. Telemed J 1997;3:227233. Burdick AE, Berman B: Teledermatology; in Bashshur RL, Sander JH, Shannon GW (eds): Telemedicine: Theory and Practice. Springfield, Thomas 1997, pp 225247. Perednia DA, Wallace J, Bartlett M, Marchionda L, Gibson A, Campbell E, Morrisey M: The effect of a teledermatology program on rural referral patterns to dermatologists and the management of skin disease. Medinfo 98: Proceedings of the Ninth World Congress on Medical Informatics, 1998, pp 290293.

Pamela S. Whitten, PhD, Department of Telecommunication, Michigan State University, 409, East Lansing, MI 488241212 (USA) Tel. 1 517 432 1332, Fax 1 517 355 1292, E-Mail pwhitten@msu.edu

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2 Teleteaching

Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 3338

2.1

Teleteaching Tools in Dermatology on the Web

Roger Kropf, Claudio Cipolat, Gnter Burg
Dermatologische Klinik, Universittsspital Zrich, Switzerland

At the beginning of the era of the so-called information society, the option of teleteaching medical information to students, graduates and postgraduates becomes more and more an important issue. Just imagine the current situation which many universities around the world are confronted with. Each year they have to cope with an ever-rising number of students demanding for places and personnel to help them in their studies of the chosen fields of interest. Campuses and auditoriums, often once designed for quite a limited number of students, however certainly appropriate at the time of planning and construction, now tend to become increasingly crowded and sometimes truly overfilled. The number of front lectures professors are required to give is also rising as science advances. Additionally, each year there is an ever-increasing number of theoretical and practical facts due to newly discovered scientific findings to become part of the curricula and subsequently have to be taught to students and postgraduates alike in order to keep them up to date with what is going on in the fields of science. As a result of scientific achievements, there are also more and more sub-disciplines to emerge especially from the fields of natural sciences. Loss of coordination and the apparent lack of interactive teaching programs are further facts to contribute to the problems of many universities. How could these problems be solved? With the introduction of computer technology and especially the coming to life of the WWW (World Wide Web) with all its possibilities and applications, a whole new way of making relevant medical information available to persons in need of it is introduced. There is no longer the need to attend lectures

and courses by being physically present at the place and time they are held. Instead the learner can access the information he is in need of directly from home or computer rooms at the campus. Thus it would be and at the very moment already is quite a popular approach to support medical education by means of using computer technology. The advantages are quite obvious. The freeing of personal resources, campus space and in the long run reduction of educational costs. The use of computer technology in teleteaching opens completely new ways of learning and will alter the overall appearance of education. Instead of the many front lectures, which are often criticized, the student will learn independently for himself, and/or in small groups. Also, postgraduates and practicing doctors profit from the availability of up-to-date information through the internet.

Teleteaching Tools and Multimedia in Medicine

The main useful elements used in teleteaching medical information with special regard to dermatology include the following items: lectures over the Internet; online databases with various elements of multimedia (e.g. slide collections, video media, audio media, etc.); electronic textbooks; case presentations; resource lists; link collections pointing to further resources, and interactive training programs. Most of the information delivered this way is constituted of various forms of multimedia. These forms mainly consist of texts, images, graphs, films, animation sequences, three-dimensional representations, sounds, speeches, etc. and function as message transmitters between author and user. In general, the advantages of multimedial learning are improved visualization of otherwise hard to show or explainable processes, interaction, simulation, easy and fast investigation and of course the possibility to learn over distance, as well as the independence of a firmly structured time schedule as is the case with most curricula.

Teleteaching in Dermatology

In dermatology there is a special need for teleteaching tools, because the number of illnesses and dermatological conditions to be presented to students is

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limited by the number of patients visiting the hospital and the diseases they suffer from. Frequently occurring dermatological diseases can easily be presented. On the other hand, rare dermatological diseases, like xeroderma pigmentosum, which a doctor sees only a few times if at all in all his years of clinical practice, are hard if not impossible to show to students and other clinicians as real cases. Thus the use of teleteaching tools in order to present such cases in detail provides an excellent way of making this relevant information available despite the rareness of the disease. In the following section, the advantages and disadvantages of different kinds of teleteaching tools in dermatology as they can be found on the Internet are discussed and one or two examples are also given. Lectures over the Internet Lectures in dermatology over the Internet are a useful way of teleteaching important aspects of dermatology like skin efflorescences, systematic dermatology as well as frequent and rare dermatological diseases and pharmacotherapy. The primary focus is on students, but when rather rare and complex dermatological cases are presented, it can be also a valuable source of information for clinicians and practicing doctors. Naturally the use of multimedia, especially the use of high-quality dermatological images, as well as intelligent and well-planned navigation interfaces to quickly retrieve the required information, are crucial points of the overall quality of the online lecture.
Prof. Dr. med. G. Burg, University Hospital Zrich, Switzerland http://www-usz.unizh.ch/vorlesung/index.html username and password required Introduction to Basic Dermatology, Virtual Hospital, University of Iowa, USA http://www.vh.org/Providers/Lectures/PietteDermatology/BasicDermatology.html

Online Databases Especially in dermatology, the construction of large databases, presenting primarily dermatological images and to some extent other types of multimedia like video sequences and speeches commenting medical procedures or diagnoses, is also an import way of teleteaching. These image databases as they can be found on the WWW are quite variable in form quality and completeness of their content in regard to the entire field of dermatology. Some feature wellplanned navigation and information retrieval interfaces, while others do this to a lesser degree or even lack these important features. Some have also a kind of quiz mode where one can first choose the region of the body, then is presented randomly selected images with the diagnosis masked by asterisks. After having established a diagnosis, the correctness of ones assumption can be checked. Most of the image or slide databases display thumbnail images with an additional zoom function which is an extremely important feature in regard to

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download time and establishing a correct diagnosis. Also a crucial point in the overall quality of these slide collections is that one can actually perceive the relevant skin changes which means that the images must be of highest quality and authenticity of color.
An Comprehensive Internet Atlas of Skin Histopathology http://www.muni.cz/atlases The Comprehensive Online Dermatology Information Service for Health Care Professionals http://www.dermis.net Dermquest A Resource for Dermatologists and Dermatology Residents http://www.dermquest.com

Electronic Textbooks Electronic textbooks about dermatology are an additional way of teleteaching dermatological knowledge. Since the use of textbooks or scripts represent a standard for education, it lies near that these textbooks are also made available online. Unfortunately most authors simply publish the entire textbook on the Internet in exactly the same way as it was printed without realizing that it is more difficult to read and comprehend textual information when read from a monitor than from a traditional book. Therefore, it is very important not to present too much textual information per page in order to avoid that the user gets quickly exhausted and consecutively loses interest. Another drawback is that most of these textbooks lack interaction with the user. Nevertheless, electronic textbooks also represent a valuable source of dermatological information when properly done.
The Electronic Textbook of Dermatology, University of New York, USA http://www.telemedicine.org/stamford.htm Dermatology Textbook at Emedicine.com http://www.emedicine.com/derm/contents.htm

Case Presentations The online presentation of dermatological cases with varying degrees of difficulty, is an especially useful way of teleteaching since this form of presenting dermatological information matches closest the real situation in which students and especially clinicians and practicing doctors are confronted with in their clinical practice. The learning potential can be very high according to the form in which the cases are presented. For example, the doctor can be required to ask questions about the case, to have a look at the clinical picture, to order virtual laboratory data and other examinations, to formulate a hypothesis, to establish a diagnosis and/or differential diagnosis and finally to choose the appropriate treatment.

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Cases presented in this form contain a high level of interaction and encourage the user to act like in the real situation. If hyperlinks to further medical resources are provided, the solving of such cases represents an extremely valuable form of teleteaching. But as with all teleteaching tools it is very important that the cases are extended and updated on a regular basis to maintain quality levels.
Interactive Dermatology Cases http://apps.medsch.ucla.edu/medyear3/derm/ Virtual Dermatology, University of Indiana, USA http://erl.pathology.iupui.edu/cases/dermcases/dermcases.cfm

Resource Lists The display of resource lists is also a valuable way of presenting relevant dermatological information. The main target group are postgraduates and clinicians seeking further knowledge or doing research on a certain topic. Also for undergraduates it is helpful to know that these resource lists exist and can be accessed.
Cambridge Clinical Reviews Dermatology http://axis.cbcu.cam.ac.uk/calreviews/summaries.asp?FilterField Subject_Area& FilterValue Dermatology Dermatological Resources, College of Medicine, University of Iowa, USA http://tray.dermatology.uiowa.edu/#Dermatology

Link Collections Link collections are a quite a traditional way of presenting information, but they do not present the information itself. They simply point or hyperlink to the source. A frequent problem with hyperlink collections is that the contents of the source hyperlinks are pointing to should be peer reviewed and rated to insure quality and relevance. Another problem with hyperlinks is that unfortunately all too often they are dead, which means the source is no longer there or the contents have been removed or relocated from the WWW. It is therefore important to look through link collections on a regular basis. They should also be updated regularly to keep up with the latest advances in the field of dermatology.
Sicklehut Medical Links http://homepages.ihug.co.nz/~jfung/dermatology/links.htm

Interactive Training Programs From a didactical point of view, interactive programs constitute certainly the most promising and important teleteaching tools in dermatology. There are quite a few on the Web now, but their quality of teaching needs to be assessed to insure a rewarding e-learning experience.

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These interactive programs consist mainly of parts of the teleteaching items that were just presented. To give an example: Dermatological cases of a certain topic (e.g. viral infections) are presented and while trying to solve the case, basic facts about viral infections such as epidemiology, clinical picture, laboratory findings, etc. are introduced to the user as background information. At the end of such a module usually an exam about the relevant facts in the form of mainly multiple-choice questions provides a first repetition of the facts that were just learned. The main problem with interactive programs is also that they must be updated regularly and extended to cover the entire field of dermatology.
Dermatological Practice 2000, University of Regensburg, Germany http://www.derma2000.de/

Conclusion

Dermatology is well suited for teleteaching by using computer technology. Concepts and programs as they can be found on the WWW are promising, however the contents of these applications need further adaptation in order to provide full learning benefits and acceptance.
Roger Kropf, MD, Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 3340, Fax 41 1 255 4403, E-Mail Roger.Kropf@der.usz.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 3942

2.2

Telemedical Training at the Department of Gynaecology, University Hospital Zrich

Urs Haller, Heinz Gabathuler
Departement fr Frauenheilkunde, Universittsspital, Zrich, Switzerland

Starting Position (from 1978 to 1996)

Since the Department of Ob/Gyn (consisting of the clinics for Obstetrics, Neonatology, Gynaecology and Endocrinology) moved into the new building Nordtrakt I of the University Hospital of Zrich, gynaecologists of the city and nearby areas have developed an increasing interest in the continuing medical education offered by this department as advanced training seminars Thursday afternoons in the lecture hall. These well-organized, advanced training sessions, with experts and referees from Switzerland and other countries, became well known. Even physicians from neighbouring cantons and from nearby countries came to Zrich, and in time the lecture hall seating 300 was often completely full. The question then arose as to whether a transmission into other lecture rooms would solve the space problem, or if it might be better to make use of modern teleconferencing technology and transmit these advanced training seminars externally as well.

Teleconferencing from 1997 to 2001

Participants that came from far away travelled up to 6 h to attend a seminar of 3 h. In 1996, our colleagues from the canton of Wallis asked for a teletransfer of these advanced training session to Brig. At this time came the same request from the gynaecologists in Basel. Our Ob/Gyn Department, together with TV-Uni, decided therefore to transmit these seminars, originally organized for the gynaecologists of the local area, to Basel and Brig.

2002 Multipoint

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Fig. 1. Teleconference transmission in gynaecology and obstetrics.

In 1997, the transmission was organized with an ISDN line (128 kbits/s) from Zrich to Basel, and in 1998 a multipoint system to Basel and Brig was set up, each with an ISDN line organized via a provider who was responsible for the routing. It soon became clear that the 128 kbit/s of the single ISDN line was not sufficient for the combination of audiovisual methods used in the advanced training. The desired quality could not be generated for moving objects, projected slides and especially the display of videos. While Brig kept on using one single ISDN line, Basel upgraded the system to three lines with a total of 384 kbit/s in 2000. At the same time, St. Gallen and Bellinzona installed a system with three lines. Due to irregularities from the side of the provider, the concept was prolonged with a new provider and Switch. With a multipoint transmission via the canton of Ticino, the telemedical training was carried on in 2001 with great success (fig. 1).

Perspectives for 2003

The number of groups interested in transmission of our sessions of continuing medical education continues to increase. Next year, transmission coverage is

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IP-Codec 1

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Fig. 2. Combined ISDN/IP technology: USZ 2002/03 with IP-MCU and IP/ISDN Gateway.

planned for the following new sites: Aarau, Thun and Meran, each with three ISDN lines (384 kbits/s) (fig. 1). In the meantime the technology at the University Hospital of Zrich is set up to utilize the IP technology at least in the hospital itself. This has the advantage that external conference sites can be offered the same technology, if they have the adequate set-up at their disposal. Alternatively, a combined ISDN/IP technology can be offered. The advantage for the organizer is that the routing can be self-organized via an ISDN-WAN to external ISDNCodecs or via Switch over the firewall of the University Hospital in IP-WAN to external IP-Codecs. These possibilities are now being tested and improved within the technical departments of the University Hospital and TV-Uni (fig. 2).
Advantages and Disadvantages of ISDN Videoconferencing

Based on our experiences, the use of ISDN videoconferencing has the following advantages: (1) cost-efficient technology; (2) internationally widespread technology, and (3) guaranteed bandwidth.

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The following disadvantages can be listed: (1) limited resolution; (2) adaptation of movements dependent on the amount of ISDN lines; (3) presentations sometimes have to be filmed down-converter VID; (4) mixed use of multipoint 128/384 kbit/s is error-sensitive, and (5) interactivity with use of multipoint is hardly used.

Future Prospectives and General Problems of Videoconferencing

Concerning the technology, we expect the following developments for the IP future: (1) mixed ISDN IP technology; (2) IP technology will substitute the mixed use; (3) in-house routing, and (4) videostreaming: post-production for Internet use of the advanced training. One of the main problems is the fact that the funding of advanced training courses is not explicitly organized. The question of who is to pay for the costs of such teleconferencing in the future must be clarified: Should it be the clinics (which normally have no budget for this), or the participants themselves? Another interesting possibility might be sponsoring, which should be initiated by the organizer or by the external users. In this case, the new provisions and effects of the anticorruption laws of the new medicament laws have to be taken into account.
Urs Haller, MD, Departement fr Frauenheilkunde, Universittsspital Rmistrasse 100, CH8091 Zrich (Switzerland) Tel. 41 1 255 5200, Fax 41 1 255 4433, E-Mail urs.haller@fhk.usz.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 4351

2.3

Towards a Virtual Education in Pharmaceutical Sciences

An Innovative E-Learning Approach

Van Van Trana, Salome Lichtsteinerb, Beat Ernst b, Marc Otto c, Gerd Folkers a
a

ETH Zrich; bUniversity of Basel and c pnn AG, Switzerland

The new curriculum of pharmaceutical science at the ETH Zrich and at the University of Basel is designed to educate a scientifically and technically competent pharmaceutical scientist. Imparting basic knowledge about cognition of drugs, the education aims for optimally safe and qualitative drug handling. A special emphasis is put on finding and investigating new therapeutical and diagnostical methods. The Pharmaceutical study is dedicated in its first 2 years to natural sciences and pharmaceutical fundamentals. The following 2 years especially focus on the whole spectrum of the drug. Thereby students learn in lecture, laboratory and seminar about different aspects of drugs, e.g. from drug discovery, to their reabsorption and transport in the body, and from their application to the effects on the patient. After 4 academic years, students graduate with a diploma. For the degree of a Federal-certified pharmacist, a 12-month course of practical work in a public pharmacy is mandatory: students are provided with the opportunity to gain greater experience in patient-centered learning and in working with health practitioners. The goal is to qualify pharmacists for expanded responsibilities in healthcare services and provision of rational drug therapy. Within this framework, the Institute of Pharmaceutical Sciences at the ETH in Zrich and the Department of Pharmacy at the University of Basel established in May 2000 a Center of Pharmaceutical Sciences. The aim of this Pharma Center is to achieve a worldwide leading position in pharmaceutical education. The first step towards this target is implemented in Pharmaceutical

Chemistry in which scientific emphasis is put on structures and properties of organic medicinal and pharmaceutical compounds, as well as the mechanism of drug effect and the relationships between the chemical, structural, physicochemical properties and the biological activity.

Analyzing the Problem Developing a Solution

For a deeper understanding of biomedical sciences, conventional types of media such as text, overhead and blackboard are not sufficient anymore. In the last decades, sophisticated scientific technology has enabled accurate investigation of complex data at a molecular level. As a result, the type of knowledge and data which are supposed to be taught has changed tremendously. This progress demands new teaching technology in order to properly represent the complex data. Although a high qualitative three-dimensional (3D) visualization of a structure can definitely improve ones understanding, manipulation and simulation of a structure are actually more essential for a deeper understanding. For example, the molecular interactions between a receptor and its ligand is crucial in understanding the mechanism of drug effect. For a complete understanding of such molecular interactions, both the receptor and the ligand are better represented in real-time 3D. In addition, students should have the option to observe and manipulate these objects at a molecular level by themselves. This is important since students understand a subject better if they construct it themselves step by step, rather than being told what it is and simply asked to remember it [1]. Where could this be done better than in virtual space? Further, these possibilities should not be given only to one person in front of his own screen but should be shared with all collaborators no matter where they are located physically. All participants should be present as virtual individuals in the same virtual space at the same time and should have access to the same data. This allows a real-time discussion of complex data and supports much more efficient and constructive teamwork. Computer-based media and high-tech communication roomware are tools to enable these requirements. This is one reason why computer-based media are integrated into the curriculum. A second reason is due to the fact that research in biomedical sciences is a very progressive development resulting in tremendously accelerated generation of information and increase of knowledge. 80,000 papers about new impacts in drug discovery, new indications, new mechanisms of drug interactions and other biomedical items are estimated to be published every year. Obviously, the density of information for a professor to teach and a student to learn grows rapidly. This phenomenon is a real challenge for teaching institutions. Since the goal of every teaching institution is to provide

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the newest results of research to the students, they are faced with essential questions like How can teachers update their lectures as fast as the turnover of new information accelerates? and How much of this huge amount of new discovery and information can be taught without extending the duration of the study? Additionally, even less time is available due to a planned shortage of lecture. How can these problems be solved? Definitely, an enhanced teaching strategy has to be developed in order to support students to obtain the most possible of what is available. Firstly, the new concept should offer a medium into which contents of lectures can be shifted and pedagogically well presented to supplement the shortage of lecture. Secondly, this concept should guarantee the constant availability of the newest results of research. And finally it should train students in self-studying as well as in collaborating within a team. New media like TELEPOLY (videoconferencing system), Learning Homepage, Web-Based Training (WBT), Virtual Laboratory and high-tech Communication Roomware are major factors in achieving this purpose (see below: State of the Art). Integration of these new teaching technologies into the curriculum improves education to a level which meets the demands and standards of the modern society. Hence, it will be an important contribution to the quality assurance in healthcare education. As it can be seen from other institutions and companies, immense expenditure is made to implement new teaching technologies for their quality assurance. However, this is only provided if its potential is exploited and intelligently applied. Aside from educational institutions, employees in life science sectors are also targeted by computational teaching technologies. Nowadays, healthcare professionals are expected to attain continuous education in order to handle the extreme increase of knowledge. Healthcare professionals need new ways of education, since on one hand, traditional forms of professional education are very expensive and on the other hand the standards to be met are constantly rising. To meet these requirements we have founded a spin-off company of the Swiss Federal Institute of Technology Zrich, named pnn. pnn is dedicated to develop online courses for the education of healthcare professionals (CME, continuous medical education). Online courses can offer cost-efficient education that complement traditional forms of face-to-face courses. pnn has identified three education scenarios: reference, update and study. The reference scenario offers a quick search for short definitions and explanations. The study scenario allows more detailed learning. The update scenario assumes that the user is already experienced in a certain field and that he is interested in an

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update of the latest developments. To acquire that update the user would probably invest about 1020 min to study a focused course or information. pnn believes that this update scenario covers a big part of the professional training. It has therefore developed different frameworks of courses to offer pedagogically standardized frameworks for the update scenario. In order to make up for the disadvantages of learning from an anonymous computer, pnn courses use interactive elements, extensive visualization and mechanisms to individualize the learning experience. In the update scenario the time spent with a course is very short. Hence it is essential that the user interface is self-explanatory, robust and simple to avoid any distractions from the material to be learned. The biggest challenge of frameworks for the update scenario is to optimize the balance of a simple user interface and powerful mechanisms to allow a user to define to himself the amount of information he wants to absorb and the level of detail he wants to study. To lower entry barriers, the applied technologies ensure that all course material is suited for the small band internet.

State of the Art

TELEPOLY TELEPOLY is a videoconferencing system jointly developed by the two Swiss Federal institutes of Technology in Zrich and Lausanne in 1995/96. The simultaneous transmission of several channels of high-quality video and sound enables a synchronous and interactive teleteaching in pharmaceutical chemistry between the ETH Zrich and the University of Basel. Initiating TELEPOLY was the first step in integrating new media into the pharmaceutical education. This system aimed to facilitate a synchronous and interactive distance team-teaching where one professor can hold his lecture for both classes at the same time. The potential of TELEPOLY in the lecture context has been investigated and evaluated for a period of 2 years with focus on the reliability and quality of the transmission technology and the acceptance of the system. The results of this evaluation showed that TELEPOLY proved to be a very reliable technology, able to guarantee stable and undisturbed transmission. The students acceptance of TELEPOLY was strongly influenced by the quality of the course, their motivation and two variables of interaction. Averaged over the whole sample, the participants demonstrated an almost neutral position towards TELEPOLY compared to the traditional lecture mode [2]. Top Class: A Learning Homepage Simultaneously, Top Class a learning homepage was initiated to provide students a support of the lecture of pharmaceutical chemistry. It contains

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handouts with learning objectives of all topics taught in the lectures and overheads which can be printed out. Test questions to control ones standard of knowledge and an e-mail system to contact the professor or other students are further services. The aim of this learning homepage is to support the active and self-managed learning of the students.

The Necessity of New Teaching Media

In both approaches, the TELEPOLY as well as Top Class, are not able to present contents of a lecture in a pedagogically high level for self-studying. Self-studying will become more and more crucial yet, partly due to the shortage of face-to-face lecture hours but also to the necessity of lifelong learning. Compelled to this situation, the development of a new learning environment is necessary to support students self-studying. Web-Based Training is an appropriate medium. It allows the representation of contents using text, pictures, animations and sounds to support a better understanding of complex data. TELEPOLY combined with WBT allows the professor to hold lectures for both classes at the same time and to teach fundamentals. By using WBT and the learning homepage, students can learn the details by themselves and study wherever and whenever they like. In addition to this freedom, WBT offers three more advantages: first, it enables 3D visualization of complex biochemical data that is otherwise difficult to explain in words; second, it allows interactivity with the data and third, it gives the students the opportunity to study at their own pace. These three advantages point out WBT as a very valuable pedagogical medium. As mentioned above, 3D visualization of complex data may certainly provide better understanding compared to 2D visualization or verbal explanation. But the ability to integrate and apply the knowledge in different practical situations can only be acquired through simulation exercises. Hence, a Virtual Laboratory is being set up. In the Virtual Laboratory, students can use virtual molecules to experiment the chemical structure of a drug, their pharmacokinetic and pharmacodynamic properties. The true power of the Virtual Laboratory lies in the possibility that students will be able to modify interactively the structure of the drug and then study the pharmacokinetic and pharmacodynamic consequences of their modifications. For example, molecular models will bear their calculated or experimental properties mapped on their surfaces and will change those properties during manipulation. Exercises including synthesis suggestion, space filling and configuration analysis, biological properties, receptor interactions and drug development for clinical trials will help students to understand the complex interdisciplinary process of drug research. Experience shows that this goal is difficult to reach with conventional teaching techniques.

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Most people consider a general flaw of WBT or e-learning to be the lack of social contact between the students and professor. However, the contact and interaction between students and professors can actually be improved. By shifting lecture contents to the Web, professors will get more time for direct interaction and contact with their students. More seminars or meetings can be organized, where students and professors discuss interactively about several issues or questions. This kind of direct interaction is not substitutable by any media since the interpersonal emotion, such as a professors infectious enthusiasm and motivation or that certain excitement that goes along with being in a class cannot be expressed and experienced by on-line learning. However, it is important to stimulate ones interest and motivation. Laboratory experiments and skills are further examples that cannot be practiced and learned on the computer. Due to these reasons, traditional teaching cannot absolutely be substituted by online learning. Therefore, the concept of combining all advantages of each medium creates an ideal curriculum for the students. Aside from self-studying, teamwork is and will remain very important all modern research in life sciences has switched to teamwork. Only big teams, linked together worldwide, are able to create real breakthroughs in basic and medicinal sciences. Therefore, proper high-tech communication tools are crucial for high-level teaching and research. To prepare students for this working situation, there is a plan to establish a completely new scientific environment which combines virtual worlds with the real world of a library. This so-called Vireal Lab (virtual-real-Lab) will be located in the library of the Institute of Pharmaceutical Sciences at the ETH in Zrich [3]. Using high-tech communication roomware, this lab will stimulate interactive teamwork. Interactive tables and white boards with built-in electronic devices provide easy access to the Internet, databases and local computer network. This approach creates a completely new type of synchronous and asynchronous interactive collaboration in practical work, seminar teaching and research meetings. The book The Digital University [4] supports this view of the significant role for asynchronous collaboration within higher education. The project will be accompanied from the beginning by a group of psychologists who aim to develop and conduct thoughtful evaluation to determine the impact of this approach.

Our Aim Optimal Integration of New Learning Media

One of the most important roles of an academic education is to prepare each student for tomorrows challenge. Nowadays the abundance of knowledge

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Table 1. A new concept: An approach to combine traditional education with new educational technology. As a starting point, a pedagogical analysis has been made to determine learning objectives for each topic of the curriculum. For each learning objectives the best appropriate learning mode is specified. Appropriate learning modes including lectures, WBT, laboratory experiments and seminars are combined in order to build a newly considered curriculum. A consistent virtual attendance and a learning homepage will support students with help, lecture documents, glossary and many other services. Achieving learning objectives through: Info unit Lectures (basic principles) Learning objectives are previously determined WBT (extensive information) Self-study of theoretical knowledge Laboratory Real and virtual laboratory corresponding with the lecture topics Problem-based learning Implementation and consolidation of theoretical knowledge Virtual attendance Learning homepage with lecture documents, learning objectives, glossary, forum and chat, searchengine, etc. Seminar Interactive team work using high-tech communication roomware to solve and discuss problems Collaborative learning

in pharmaceutical sciences obligates us to change the way we learn, but more importantly the way we teach. Obviously, a new educational strategy has to be implemented to raise the standard of education to a more flexible and up-todate level. As such, it can provide more independent, technical and socially competent students. These abilities allow students to be up to date and in line with todays information-science society. At the Institute of Pharmaceutical Sciences at the ETH Zrich and the Department of Pharmacy at the University of Basel, a project is running to create such a new concept of education, aiming to enhance and guarantee the quality of the education. Subsequently, an approach is presented in table 1 in which new teaching technology with its enormous interactive potential and traditional education, being complementary, will combine to create a more appropriate curriculum.

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This concept will be implemented in collaboration with pedagogy experts and under contribution of a group of students, assistants, and post-doctors as peer reviewers. By using new educational technology the primary intention is to improve education and not just to be la mode. Consequently, previous lecture outlines and notes are not just transposed to the Web to be online. The whole curriculum will be pedagogically reanalyzed in order to find a more appropriate teaching strategy. The pedagogical analysis will involve: (1) reconsideration of the importance and up-to-dateness of all topics; (2) determination of scientific and nonscientific learning objectives, e.g. communication and interpersonal skills, presentation techniques and time management; (3) classification of each scientific learning objective according to the six grades of Bloom [5] which includes knowledge, comprehension, application, analysis, synthesis and evaluation; (4) determination of basic knowledge needed to achieve each learning objective, and accordingly (5) choosing of appropriate teaching method, medium and examination mode. Based on this pedagogical analysis, new teaching technologies will be accordingly adjusted to the curriculum. Unfortunately, the converse process where the curriculum is tried to be adjusted to new teaching technologies has been observed very often. Although the technology of e-learning is in the limelight, pedagogical concepts have the most impact on the quality of teaching and learning. Clearly, this approach is very unique. Work is now in process for developing successful application and integration of this concept into higher education. Its success is not likely to be obvious until its implementations occur and considered evaluations are accomplished.

Acknowledgements
Especially, we would like to thank Leonardo Scapozza, Pavel Pospisil and Juliana Chen for their valuable comments and advice. We are indebted to Patrick Kunz who supports us with his excellent pedagogical knowledge and to Christof Hanser for his commitment for the Vireal Lab project.

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References
1 2 3 4 5 Stokstad E: Reintroducing the intro course. Science 2001;93:16081610. Kunz P: New information and communication technologies in education: Evaluation of the videoconferencing system TELEPOLY; Diss, No 40217, ETH Zrich 2001. www.vireal.ethz.ch Hazemi R, Hailes S, Wilbur S (eds): The Digital University. Berlin, Springer, 1999. Bloom BS: Human Characteristics and School Learning. New York, McGraw-Hill, 1976. URL: www.pharma.ethz.ch URL: www.pharma.unibas.ch URL: www.pharmacenter.ch URL: www.pnn.ethz.ch

Van Van Tran, ETH Zrich, Winterthurerstrasse 190, CH8057 Zrich (Switzerland) E-Mail vanvan.tran@pharma.anbi.ethz.ch

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3 Teleconsulting: Legal, Ethical and Consumer Aspects

Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 5357

3.1

Changes Patients Expect to Result from Telemedicine

Sapal Tachakra
Accident and Emergency Unit, Central Middlesex Hospital, London, UK

Telemedicine is an exciting new technology that is highly thought of by some governments, but bureaucrats are a little more cautious. Patients and planners need to know what is likely to be possible and more importantly, what patients will expect of telemedicine in the future.

A Focus Group

A focus group of 12 persons who had telemedicine used on them for their minor injuries met at weekly intervals to arrive at some conclusions of what they could expect of telemedicine in the future. The facilitator stressed the need to consider the changes that would occur.

Its Views

The group felt that the following changes would occur. Rationalization of Care More local care would occur because of the increased use of nurses to perform tasks normally done by doctors and because those doctors could do more specialized work. If there were any uncertainties, telemedicine would be available for advice. More primary care would be required to deal with the bulk of the consultations for which patients are referred to specialists. The greater use of nurse practitioners would mean that general practitioners would have the opportunity

to specialize in one field and call themselves specialoids, and if practising in a group, would have all the cases related to his/her speciality referred to him/her. Easy access to specialists would be possible when the specialoid only needed to book an appointment infrequently with the specialist who would in most instances be able to provide an opinion after a screen diagnosis. The great advantage of telemedicine is its great educational potential. Fewer tertiary care centres were envisaged because it was felt that patients would be prepared to travel considerable distances if it were absolutely essential. This would mean fewer more centralized tertiary centres. More home care will be required by an ageing population. It was noted from some examples around the world that many home visits to the elderly could be performed from an office by a nurse, if the person had a TV set-top camera, basic codec and connected through a plain old telephone line. This would remove the cost of time and transport of community nurses. Control of Costs Change of DGH use would occur because of the large amount of work performed by general practitioners and specialoids. The size of the district general hospital (DGH) would shrink and the role of the specialist would also change. DGHs will be destabilized by groups of general practitioners who will dictate the configuration of services. Closure of some DGHs will occur as these are taken over by general practitioners and specialoids to provide a community-friendly service so patients will not be vociferous in their resistance of such change if the facility that replaces the old DGH provides most of the services that were once provided by the hospital. Although some specialists will be uncomfortable with such change, they will go along with it when it becomes inevitable. Newer and different healthcare facilities which are custom-built for the changing environment of provision of healthcare. It is an axiom that healthcare planners must always envisage what a hospital should be like in 20 years time and then have the courage to build such a facility. These facilities would be linked by all manner of communication links to healthcare personnel who will have a variety of devices available to them ranging from a notebook computer to in most cases a palmtop communicator. More accountable doctors and nurses as patient power increases due to the use of telemedicine. Patients will be able to demand telemedical consultations and the dismissive attitude of doctors and nurses will have to change. Anyone who has viewed how they appear on a screen during a patient consultation will immediately realize the unflattering appearance of men and women on the screen.

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Multiskilled personnel will ensue as telemedicine will allow many professionals to undertake a greater variety of work than before. Value will be judged by the effectiveness of such multiskilling. Quality Control Evidence-based medicine will be easier to practice because telemedicine will require the use of clinical protocols to facilitate a clear understanding by both sides about what is being considered. All patients will expect a certain standard of treatment and this can only be possible with protocols. There will be squeals about individual clinical freedom but they will not work with a wellinformed patient population. Checks and balances: The use of telemedicine will, in the long run, make it easier for official bodies to gauge the performance of a doctor or a service by the better information-gathering that will ensue. Attitude to Change More open doctors will be the result of lessening of the awe in which doctors are held. Condescending, arrogant doctors will be drummed out of the system as patients start seeing healthcare as just another service. The use of the Internet is already having a profound impact in some areas. Less bluff and bluster are likely to be the result of doctors and nurses seeing themselves on a screen. With the disadvantage of distance, there are enough groups finding out that patients are asking more questions when telemedicine is used. Less hierarchical organizations are highly likely because of the need of multiskilling and efficiency. Knowledge which was a premium commodity will be so easily accessible that the professional role will change. Less shroud waving is inevitable as patient groups refuse to accept the standards set by professional organizations. Such groups already understand that they are not well represented by the professional organizations of doctors and nurses, they will enter into a dialogue about the risk-benefit analysis of certain restrictive practices. Permanence of the change process is certain because the information revolution has only just begun. Some entrenched attitudes are being broken down, many others will follow, but like in previous social and industrial revolutions, the changes will be permanent.
Discussion

The Business Week issue of October 17, 1994, had a feature entitled Rethinking Work: Is America Ready? The theme centred on the problems of

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a changing work dynamic and its effects on social and political networks. Much of the focus on changing the work environment has been on virtual companies. Major corporations have tried the virtual corporation philosophy and are only slowly solving some of the problems. They replaced offices and desks with computers, mobile phones and video-conferencing in common areas. This may sound far-fetched in the hospital environment, but such change will come when professionals understand the advantages and clinicians become independent contractors signing contracts with healthcare purchasers when a combination of market forces and management theorists provide more efficient models of work [1]. More than a decade ago, Jeff Goldsmith [2], a noted futurist, predicted Technology and shifting practice patterns are transforming the contemporary hospital into the critical care hub of a dispersed network of medical and social services spread across the community and knit together by computer networks and health insurance contracts.Add telemedicine to computer networks and the possibilities are limitless. What is new about modern telecommuting is that communication and computer technology are more simplified and affordable so that many other job categories can be accomplished away from the central office [3]. In healthcare, a rather traditional industry, such changes have not occurred because of the forces of conservatism. Many factors are likely to increase the growth of telecommuting. Among them, in the USA, are the federally mandated programs designed to decrease air pollution by reducing commuting [46], the explosion in telecommunications and computer technology in recent years [7, 8], and the social change that demands a balance between work and family life [9]. This change has already started in Europe. All these factors are likely to be even more relevant with video-conferencing in healthcare. The most successful workers who telecommute have a proven ability to perform at a high level and they also have a great level of knowledge of their job and its demands, having been employed by the organization for several years [10]. Some companies reject the use of such agreements because they would violate the basic climate of trust that they have for their employees [11]. However, all is not as rosy as it seems [12]. Attention to psychosocial hazards in the work environment should become an increasingly important component of occupational safety and health interventions. Research findings have linked a number of measurable psychosocial characteristics with negative psychological, physical and physiological consequences. The economic trends of a decline in wages, a move away from manufacturing base, increased hours of work, a decline in unionization rates and poorly implemented technological changes will create jobs with such hazards. Such changes may also have a bearing on medicine. However, other studies indicate that although the levels of comfort in the use of technical equipment were reported to be only moderate

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on entry to the nursing workplace, subjects rapidly acquired high levels of comfort in relation to equipment handling [13]. There should be a similar experience among doctors.

Conclusion

There are unique opportunities that will be available with telemedicine. Nurses, radiographers, pharmacists, etc., are liable to be the big winners if they are open to change. The most heartening perspective is of Nancy Fagan [14] who advises Make workplace changes work for you.

References
1 2 3 4 5 6 7 8 9 10 11 12 13 14 Gibbs M: Workplace changes affect nurses. Mich Nurse 1995;9:9. Goldsmith J: A radical prescription for hospitals. Harv Bus Rev 1989;89:107. Goodrich JN: Telecommuting in America. Bus Horiz 1990;33:3137. Ross R: The telecommuting imperative. PC World 1993;11:5255. Grey B: Telecommuting: The time is now. Home Office Comput 1992;10:6. Henricks M: The virtual entrepreneur. Success 1993;40:4144. Sullivan N: Yesterday, today, tomorrow: The evolution of the home office. Home Office Comput 1993;11:4550. Bellinger A, La Van H: Telecommuting: Has its time come? Home Office Comput 1992;10:5056. Farrah BJ, Dagen CD: Telecommuting policies that work. Hum Resources Mag 1993;35:5052. Bailey DS, Foley J: Pacific Bell works long distance. Hum Resources Mag 1990;35:5052. Cauldron S: Working at home pays off. Pers J 1992;71:4049. Cahill J: Psychosocial aspects of interventions in occupational safety and health. Am J Ind Med 1996;29:308313. Pelletier D: Diploma-prepared nurses use of technological equipment in clinical practice. J Adv Nurs 1995;21:614. Fagan NQ: Make workplace changes work for you. Radiol Technol 1998;67:367368.

Sapal Tachakra, MD, Consultant and Clinical Director, Central Middlesex Hospital, Acton Lane, Park Royal, London NW10 7NS (UK) Tel. 44 20 8453 2250, Fax 44 20 8453 2507, E-Mail Sapal.Tachakra@tinyworld.co.uk

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 5861

3.2

Satisfaction of Paramedical Personnel

Lanis L. Hicks
Department of Health Management and Informatics, University of Missouri, Columbia, Mo., USA

Satisfaction of Paramedical Personnel

The structure, financing, technology and knowledge of the healthcare industry is currently experiencing substantial changes. These changes result in increased accountability, loss of autonomy, an emphasis on outcomes and constraints on resources [1]. The rapidity and magnitude of these changes are creating increased stress for individuals working in the healthcare industry. This stress results because these changes create risk and uncertainty, since it is impossible for individuals to anticipate and predict all consequences associated with the changes. It is the uncertainty associated with the risk that creates much of the stress among employees in the healthcare sector, and the stress often reduces job satisfaction. Individuals working in rural areas also often experience increased stress because of the inherent characteristics of the rural practice environment. The stress-inducing characteristics exacerbated in rural practice include: isolation, heavy workloads, the diversity of skills needed, limited access to technologies, lack of flexibility in staffing patterns, lower and compressed salary scales, lack of continuing education and career opportunities, and inadequate numbers [2, 3]. In addition, many rural systems lack resources to be able to cushion the consequences of the changes that occur. As stress increases, job satisfaction often decreases, leading to increased staff turnover and poorer performance, which, in turn, increases training costs and disrupts the continuity of care received by patients [4]. Telemedicine is another change agent that can have conflicting impacts on the workers in the healthcare industry. Telemedicine has the potential to decrease stress associated with many of the characteristics of rural practice: reduce feelings of isolation, improve continuing education opportunities, increase diversity

in skills available and increase access to sophisticated technology. Alternatively, telemedicine can also increase the complexity of delivering care in rural communities, thereby creating pressures and stress for workers in healthcare [5]. This chapter examines levels of satisfaction and perceptions of impacts that changes in the healthcare industry are having on rural health paraprofessionals. These levels and perceptions are examined by type of paraprofessional (nurses, therapists, other direct patient care allied health professionals) and by work site of respondents (hospital, nursing home and other ambulatory care sites). The study was conducted among direct patient care paraprofessionals (non-physicians) in six rural counties in Missouri.

Method
The paraprofessionals included in the study were nurses (registered nurses, licensed practical and vocational nurses, certified nursing aids); therapists (physical, respiratory, occupational, speech), and technicians (laboratory, medical, pharmacy, radiology, rehabilitation, dental) and allied professionals (paramedics, clinical social workers, nutritionists). The organizations included were hospitals, nursing homes, county health departments, home health agencies, clinics and provider offices in the counties. The survey included 30 Likert-scale questions involving satisfaction, changes and communications; 9 background questions, and an open-ended question on the effects of technology on the respondents job. In the sample, there were 6 hospitals, 14 nursing homes, and 26 other sites; of these, only 2 nursing homes declined to participate in the study. The questions on the survey were clustered into satisfaction with job and career, impacts of changes in health industry on work, global issues impacting work and communications among providers. The 30 Likert-scale questions were adopted from a previously validated instrument, the Work Life Survey [6].

Results

During August 1998, 1,108 surveys were distributed to workers in the 44 organizations participating in the study, and 556 completed surveys were collected (a response rate of 50.2%). There were 256 surveys returned by workers in hospitals (a 53.5% response rate), 209 by workers in nursing homes (a 45.1% response rate), and 91 by workers in the other sites (a 56.1% response rate). There were 359 responses returned by nurses, 93 by therapists, and 104 by other paraprofessionals. Response rates for paraprofessionals cannot be calculated because the profession of the non-respondents is not known. On the survey, the job satisfaction questions focused on the current work situation of the respondent; the career satisfaction questions focused on the general satisfaction with the career the individual had selected. In this survey,

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the paraprofessional respondents were generally satisfied with their job and with the careers they had selected. However, 12.6% indicated they would not choose their current career, if given the opportunity to select again, and 28.9% indicated that their current work situation was a source of major frustration. In addition, only 67.5% indicated they would recommend their career to others. While these numbers are not large, they do reflect a level of frustration and dissatisfaction that could have an impact upon job performance in the organizations in which these individuals were employed. There was not a significance difference among nurses, therapists and other paraprofessionals regarding their level of satisfaction with jobs and careers. In the series of questions regarding factors impacting the healthcare industry, 46.2% indicated that the government was having a substantial impact on their work. The range among type of professional was from 50.6% of therapists, to 46.1% of nurses, to 40.0% of other paraprofessionals. In addition, while managed care has not made noticeable inroads into rural areas of Missouri, it is obviously impacting the perceptions and stress levels of the rural health services labor force. Managed care was viewed as having a large impact by 38.9% of therapists, 35.6% of nurses, but only 22.0% of other paraprofessionals. Computers and other information technology were also viewed as having a large impact on their work by 32.3% of respondents. In addition, 31.5% of respondents indicated that technology in healthcare was having a large impact on their work. Telemedicine was not viewed as having a large impact (only 19.2% indicated it as having a large impact); this result is expected, since telemedicine was not widely available in rural Missouri at the time of the survey. Communication between staff and administration appears to be an issue, with 18.3% indicating that communication was inadequate, and another 28.1% indicating that it was somewhat adequate. Only 20.4% indicated that communication between staff and administration was very adequate, with 33.2% indicating it was moderately adequate. Alternatively, communication among staff appears to be better, as reflected by only 8.1% indicating it was inadequate and 27.0% indicating it was only somewhat adequate. Poor communication between administration and staff increases uncertainty about what is occurring, and increases stress among workers. Telemedicine offers an opportunity to improve communications, which can improve job satisfaction among workers. There were significant differences by type of organization on career satisfaction and administrative communications (p 0.0004, Kruskal-Wallis test for both). In general, paraprofessionals employed in other settings had the highest levels of satisfaction with job and career, while those employed in hospitals had the lowest levels of satisfaction, although their levels of satisfaction were still relatively high. These findings were consistent with the results from

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hospital-based paraprofessionals indicating larger impacts by many factors in the healthcare sector. In general, the larger the change occurring, the lower job satisfaction is. This occurs because of uncertainty and the stress associated with that uncertainty.

Discussion

The findings in this survey are similar to earlier studies of health professionals: while their work is personally rewarding, the amount of stress is high, leading to substantial amounts of dissatisfaction with current jobs and careers. The introduction of telemedicine, while not a solution for all contributors to stress and dissatisfaction, may alleviate some of the factors directly by reducing isolation and improving continuing education opportunities, and indirectly by improving communications within and among organizations and professionals. As telemedicine is implemented, additional studies evaluating its impact on levels of satisfaction among paraprofessionals is needed.

References
1 2 3 4 5 Their SO, Geligns AC: Improving health: The reason performance measurement matters. Health Aff 1998;17:2629. Bruce TA: Professional preparation for rural medicine. J Rural Health 1990;6:523526. Pickard MR: Education of nurses for rural practice. J Rural Health 1990;6:527533. Blegen MA: Nurses job satisfaction: A meta-analysis of related variables. Nurs Res 1993;42: 3641. Hicks LL, Boles KE, Hudson ST, Koenig S, Madsen R, Kling B, Tracy J, Mitchell J, Webb W: An evaluation of satisfaction with telemedicine among health care professionals. J Telemed Telecare 2000;6:209215. SGIM Career Satisfaction Study Group. Physician Work Life Survey. Cecil G. Sheps Center for Health Services Research, 1997.

Lanis L. Hicks, MD Department of Health Management and Informatics, University of Missouri, 324 Clark, Columbia, MO 65211 (USA) Tel. 1 573 8828418, Fax 1 573 8826158, E-Mail HicksL@health.missouri.edu

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 6270

3.3

Economic Aspects Saving Billions with Telemedicine: Fact or Fiction?

Ivar Snb Kristiansena, Peter Bo Poulsenb, Kim U. Wittrup Jensena
a

Institute of Public Health, Health Economics Research Unit, University of Southern Denmark, Odense, and bMuusmann Research & Consulting, Kolding, Denmark

Telemedicine is a fascinating example of how new technologies can offer new medical diagnostic and therapeutic services, or offering existing services in a way that is more convenient to the patient or the doctor. It would be a bonus if such technologies also save billions [1] as have been claimed in the past. The aim of this paper is scrutinize such statements. The first section presents briefly basic principles of economic evaluation, the second presents a review of economic studies of telemedicine, while the third provides a general discussion of the cost-effectiveness of telemedicine technologies. A core assumption in economic theory is that resources are scarce. Devoting resources to one intervention or programme means that some other alternative programme cannot be implemented. This means that use of resources always means loss of opportunities and loss of (health) benefit elsewhere (opportunity cost). Economic evaluation aims to estimate resource use (i.e. opportunity cost) and health consequences (benefits) of medical interventions in order to guide resource use in a way that yields the maximum health benefit from scarce resources. In principle, medical programmes, including telemedicine applications, fall into one of nine types (table 1, AI) depending on costs and health consequences. If telemedicine has lower costs and greater health benefits than alternative modes of care (table 1, C), telemedicine is costsaving and dominant and should definitely be chosen. If costs are greater but benefits smaller (table 1, G), telemedicine is dominated, and the conclusion is opposite. When advocates of telemedicine claim that it can save billions, it would imply that we have dominant strategy in favour of telemedicine. Whether the costs are smaller and benefits greater is an empirical question that needs

Table 1. Costs and health consequences (benefits) of telemedicine applications compared to traditional technologies Costs Health consequences (benefits) worse with telemedicine Lower with telemedicine Unchanged Greater with telemedicine A Value judgement on the basis of CEA/CUA D Choose the traditional technology G Choose the traditional technology (dominant strategy) unchanged better with telemedicine C Choose telemedicine (dominant strategy) F Choose telemedicine I Value judgement on the basis of CEA/CUA

B Choose telemedicine E Even value of the two alternatives H Choose the traditional technology

CEA

Cost-effectiveness analysis; CUA

cost-utility analysis.

thorough analysis. If the costs are greater, but the benefits also greater from telemedicine compared to traditional technologies, the choice would depend on what health benefit the resources could generate in other applications. Medical interventions are said to be cost-effective if the additional health benefits justify the additional costs, but this term does not necessarily imply that interventions are cost-saving. The aim of health economic evaluation is indeed to assess costs and health benefits of medical interventions in order to devote resources to interventions that in total makes most good to people. In table 2 we have outlined the different types of economic evaluation. The term cost-benefit analysis (CBA) is frequently misused in the medical literature, because saved healthcare costs are used as the only valuation of benefits [e.g. 24]. However, in economics, CBA implies that we put a money value on health benefits, because health benefits often are of a greater value to the individual than just the saved healthcare costs. Economists would therefore hesitate to classify an analysis as CBA unless health benefits are accounted for. In the context of healthcare, real cost-benefit analyses are very rarely undertaken. Instead, cost-effectiveness analyses (CEA) are employed. Here, we measure the benefits in life years gained or some other natural unit such as for example breast cancer detected. By comparing the cost per life year gained or cost per cancer detected, one can make priorities by choosing those interventions with the lowest cost per unit of benefit. A special version of the CEA is the cost-minimization study. Here, it is assumed that two or more types of

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Table 2. Methods for economic evaluation of healthcare interventions/programmes Type Cost-effectiveness analysis (CEA) Cost measure Monetary unit Benefit measure Health benefits are measured in natural units such as gained life years, symptom-free years, avoided heart attacks, etc. Interpretation Health programmes are ranked according to their cost per unit of health benefit. The lower the cost per unit, the higher the priority Health programmes are ranked according to their cost per QALY. The lower the cost per unit, the higher the priority The programmes with the lowest cost is chosen

Cost-utility analysis (CUA)

Monetary unit

Quality-adjusted life years (QALYs)

Cost-minimization analysis

Monetary unit

No measure of benefit as the competing programmes are assumed to be equal in terms of outcome Monetary unit

Cost-benefit analysis (CBA)

Monetary unit

Costs are compared to benefits without any comparison with alternative programmes. A programme is recommended if the benefits are greater than the costs

healthcare programmes have the same health outcome. Then one needs only to estimate costs, and choose the programme with the lowest cost. In order to make comparisons across different programmes or interventions easier, health benefits can be measured as so-called quality adjusted life years (QALYs) in cost-utility analysis (CUA). It should be noted that, except for CBA (which is rarely undertaken), economic evaluation of telemedicine (and other healthcare programmes) always involve comparing costs and health outcome for telemedicine with some other type of care. A core concept in economics is the term marginal. By marginal (or incremental) cost we mean additional costs compared to something else. If an apple costs 1 dollar and an orange 3 dollars, the marginal cost of the orange is 2 dollars. If the radiology programme costs 3 million and the traditional mode of care costs 2.5 million, the marginal cost is 0.5 million. If the benefit were 10,000 correct diagnoses with the telemedicine programme and 8,500 with the alternative mode, the marginal benefit were 1,500 correct diagnoses. This simple

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example illustrates two important issues. First, when discussing the costeffectiveness of telemedicine, the alternative (comparator) is crucial. A telemedicine application may be more or less costly than other modes of care, depending on what is chosen as comparator. Valid economic evaluation therefore requires a proper comparison group, preferably in a randomized controlled trial. Second, we need solid evidence on the health consequences of the alternative programmes. Often, the introduction of a therapy or health technology, such as telemedicine, is advocated on the basis of the burden of illness that can be avoided. This is when the cost-of-illness (COI) analysis is carried out. However, this type of analysis is not useful for priority setting because it does not account for health benefits from the use of resources. The reason for this is that COI is not a comparative analysis as no alternatives are considered, but only the total costs to society in relation to a disease without considering the benefits. Thereby COI does not provide the decision-maker about the opportunity costs and marginal use of resources. This is the reason why this type of analysis is not included in table 2.

Methods
To review the economic evaluation of telemedicine applications, we used three searches in electronic databases. The two first searches were quite similar in that they encompassed Medline, Health Star, Embase and CINALH using the terms telemedicine, telepsychiatry, teleradiology and teleconsult combined with assess, evaluat, feasib and pilot. In the third search the same search terms were used, but only Medline and NHS Economic Evaluation Database (NHS EED) were searched. Additionally, the database of INAHTA (International Association of Health Technology Agencies) was searched. The first search was conducted by Ohinmaa et al. [5] and resulted in 784 hits until November 1998. They included evaluative studies of telemedicine, but excluded studies without any control group. This review included 29 studies of which 19 presented some economic data or a full economic evaluation. Ohinmaas review was updated for the period November 1998 to November 1999 by two of us (ISK & PBP) using the same search strategy except that it was restricted by the additional terms cost, economics and cost-effectiveness [6]. Additionally, the electronic databases described above were searched using the terms telemedicine and cost. This resulted in 137 hits, but after exclusion of studies not meeting quality and content criteria, only 11 studies with economic data and some sort of comparison group were included. The 19 economic studies in the Ohinmaa review [5] and 11 studies of the Kristiansen et al. [6] review are summarized as tables 3 and 4 in the latter review [6]. To review publications after November 1999, we searched Medline (December 1999 to September 2001) and NHS Economic Evaluation Database (19992001) using the same search strategy as in the review by Kristiansen and Poulsen [6]. This additional search resulted in 404 hits of which 40 studies were selected for detailed scrutiny on the basis of the

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404 abstracts. Of the 40 studies, 15 were not real economic evaluation or lacked a comparison group, while the remaining 25 were included in this review [24, 728]. This means that in total 55 (19 11 25) economic evaluations of telemedicine are considered in this chapter.

Results

Of the included studies, 4 were CEA and 51 were cost-minimization studies. Seven of the studies did state that they intended to perform a CBA, but did only use saved costs as the measure of benefit. These studies have been classified as cost-minimization studies in this study. Twenty-nine studies included costs covered by hospitals or clinics while 40 included costs to other sectors of the healthcare system. Thirty-four of the 55 studies covered transport costs. Only 7 studies had a broad societal cost perspective including costs covered by other sectors or by patients. Five studies explored indirect costs (production gains or losses). For 44 of the studies, the alternative mode of care was explicitly described, but only in 6 cases patients were randomized to mode of care. In many of the studies it was difficult to judge whether the comparison to telemedicine was realistic or correctly analysed. The 4 CEA had different measures of health benefit. One study used avoided patient transfers (assuming that this represent a health benefit), one used successful examination and one used blood pressure reduction in mm Hg. Only one of the studies used a direct measure of health benefit in terms of life years gained. None of the studies measured and valued health benefits in terms of QALYs. Discounting of future costs and benefits was performed in 6 analyses, while depreciation of capital investments was performed in 20 additional studies of the 55 economic evaluations. Economic evaluation is, just like clinical practice, based on uncertainty. In economic analysis the extent to which uncertainties may influence the results is explored by changing the parameters of the study in so-called sensitivity analysis. Such analyses ought to be performed in every economic evaluation, but were in fact performed only in 23 of the 55 studies included. When performed, only the simple one-way sensitivity analysis used, implying that one parameter is varied at a time. Twenty-six studies concluded that the telemedicine application would reduce healthcare costs which means that they fall into category B or C in table 1. In 18 studies the results indicated that telemedicine might be cost-saving given some minimum of patient throughput, while 7 studies concluded that

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telemedicine would incur higher costs than alternative modes of care. The rest of the studies had unclear conclusions.

Discussion

The number of economic evaluations of telemedicine applications is still somewhat limited, but clearly increasing. The published studies are heterogeneous with respect to type of application and technology, clinical setting, geography, type of patients and type of economic analysis. Some general conclusions might nevertheless be justified on the basis of the review. First, few studies report results where it is clear that telemedicine in routine practice is compared to a proper alternative practice, and only 6 studies randomize patients to avoid bias in the results. The economics methodology is most often fairly simple with cost-minimization as the clear dominant approach. The fact that only a minority of the studies employ standard methods such as discounting and sensitivity analysis indicates a lack of basic methodological skills. Rather, some of the studies may leave the impression that the authors aim to prove that their application is cost-saving. Unfortunately, there are few signs that the quality of the economic analyses is improving over time. This harsh critique of the literature, however, should be seen against the background of the methodological problems in this area. Technologies are rapidly developing, and the researchers are aiming at a moving target. A thorough and time-consuming study will tend to be outdated once it is finished. Rapidly changing technologies and prices will soon make a good study irrelevant. Measuring true costs to society might be difficult in an area of monopoly pricing or public services free of charge to the patient. Telemedicine technologies typically have high capital costs that may be offset by avoided time and transport costs. These savings will however depend on the patient volume. For the reader of studies, it is frequently difficult to judge whether the publications report real routine use or an ideal telemedicine service run by enthusiasts. Very little is known about patients preferences for telemedicine versus traditional modes of care. Most authors seem to assume that patients prefer medical services in their local area rather than travelling to remote facilities. While this clearly might be the case, some patients may prefer to get a greater medical centre where they may believe the expertise is higher. The development of telemedicine technologies requires collaboration between medical and commercial interests. Such interactions are necessary as well as legitimate, but may impact the conduct of research as well as presentation of results. Currently, there is a great concern about commercial

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influences on research, and guidelines for disclosure of conflicting interests have been adopted by major journals (ref. JAMA statement). Interestingly, only 6 studies reported on commercial sponsoring of all studies we have identified. Are Telemedicine Services Cost-Effective? The answer to this important question has to be seen in the context of the published literature. First, a variety of technologies have not undergone economic evaluation, and second the quality of most publications is poor to fair rather than good. Even though telemedicine services incur additional costs, there is little doubt that these costs can partly or fully be offset by savings in other areas such as transport. The study by Bergmo et al. [8] in 2000 is a nice example that still-image telemedicine actually saves costs, if the travel distance for the patient is long enough or the number of patients in an area is large enough. This was the case in 18 of 44 Norwegian municipalities included in Bergmos study. It is clear from the published literature, however, that telemedicine in many cases incurs net additional costs, but may be preferred by patients due to convenience or better health outcome. Whether the telemedicine technology is then cost-effective (i.e. resources cannot generate more health benefit elsewhere), cannot be judged from the published literature simply because many of the studies are not designed to address this issue. Telemedicine should be judged on a broader basis than simply costs and health benefit. To the extent patients prefer telemedicine despite equal health outcome, such preferences should be accounted for in the economic studies, for example by measuring patients willingness to pay (WTP) for telemedicine. None of the studies reviewed has measured patients WTP for the telemedicine alternative. Also, many societies place a great value on geographic equality (equal medical service in all geographic areas), and telemedicine services may certainly overcome geographic barriers. Unfortunately, this issue is seldom raised although there exist exceptions [7]. Policy-makers should ideally consider all costs, benefits and preferences when choosing between telemedicine and traditional services. Organization and financing of healthcare may represent barriers here. If telemedicine services are paid by one organization, and avoided transport cost are saved by another, it is not obvious that the decision-maker will opt for telemedicine even if it is preferable from a societal standpoint. In Norway this has clearly been a problem because telemedicine costs are covered by hospitals or primary care providers while the National Health Insurance enjoy the cost-savings. Therefore, a separate analysis exploring which budgets are influenced by telemedicine services ought to be carried out, together with a full societal economic evaluation, when its introduction is considered.

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Conclusion

We conclude that the number, quality and design of published economic evaluations in the area of telemedicine still are not as good as one would wish. First, most of the studies only pay attention to the cost side of the economic evaluation leaving out assessment of health outcome. Second, some of the studies do not describe a clear comparator to the telemedicine application. Third, it is not often clear whether the studies describe long-term routine use of telemedicine or some demonstration project. Fourth, the perspective of most of the studies is fairly narrow in that only hospital costs are considered. Fifth, the lack of randomized designs makes the studies subject to bias in assessment of costs and in particular health outcome. Sixth, many studies do not employ basic standard methods such as discounting or sensitivity analysis. The quality level in this area of medical publishing indicates that editors of telemedicine journals may do well in using referees with knowledge of economic evaluation. The scientific literature in this area leaves little doubt that telemedicine services can be cost-saving, but we lack a sound basis for more general conclusion about its cost-effectiveness. While a 1995 Lancet editorial concluded that the economic benefits of telemedicine have yet to be proved [29], a recent BMJ review states that telemedicine is immature in that relatively little information exists about its cost-effectiveness [30]. It is time to stop talking about saving billions through telemedicine, and rather spend time and effort on high-quality evaluation of an interesting and promising group of technologies.

References
1 2 Gryts G: Saving billions from telemedicine (in Norwegian). Oslo, Dagens Nringsliv (newspaper), Oct 16, 1999. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al: A comparison of realtime and store-and-forward teledermatology: A cost-benefit study. Br J Dermatol 2000;143: 12411247. Patel T: A cost-benefit analysis of the effect of shipboard telemedicine in a selected oceanic region. J Telemed Telecare 2000;6(suppl 1):S165S167. Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, et al: Multicentre randomised control trial comparing real-time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. BMJ 2000;320:12521256. Ohinmaa A, Hailey D, Roine R: The assessment of telemedicine. General principles and a systematic review. 99. http://www.inahta.com. Ref type: Report. Kristiansen IS, Poulsen PB: Saving billions with telemedicine Fact or fiction? (in Norwegian) Tidsskr Nor Lgeforen 2000;120:23052311. Bergmo TS: A cost-minimization analysis of a real-time teledermatology service in northern Norway. J Telemed Telecare 2000;6:273277. Bergmo TS, Breivik E, Pedersen S: Will the use of still image electronic referrals save costs? (in Norwegian) Tidsskr Nor Lgeforen 2000;120:17771780.

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Brownsell SJ, Williams G, Bradley DA, Bragg R, Catlin P, Carlier J: Future systems for remote health care. J Telemed Telecare 1999;5:141152. Dawson A, Cohen D, Candelier C, Jones G, Sanders J, Thompson A, et al: Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: A health technology randomized assessment. J Telemed Telecare 1999;5:220230. Chan HH, Woo J, Chan WM, Hjelm M: Teledermatology in Hong Kong: A cost-effective method to provide service to the elderly patients living in institutions. Int J Dermatol 2000;39:774778. Della MV Cortolezzis D, Beltrami CA: The economics of telepathology A case study. J Telemed , Telecare 2000;6(suppl 1):S168S169. Doolittle GC: A cost measurement study for a home-based telehospice service. J Telemed Telecare 2000;6(suppl 1):S193S195. Elford DR, White H, St John K, Maddigan B, Ghandi M, Bowering R: A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland. J Telemed Telecare 2001;7:7381. Harno K, Paavola T, Carlson C, Viikinkoski P: Patient referral by telemedicine: Effectiveness and cost analysis of an Intranet system. J Telemed Telecare 2000;6:320329. Harno K, Arajarvi E, Paavola T, Carlson C, Viikinkoski P: Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics. J Telemed Telecare 2001;7:219225. Johnston B, Wheeler L, Deuser J, Sousa KH: Outcomes of the Kaiser Permanente Tele-Home Health Research Project. Arch Fam Med 2000;9:4045. Kennedy C, Yellowlees P: A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: Preliminary results. J Telemed Telecare 2000;6 (suppl 1):S155S157. Kildemoes HW: Reduced delay of thrombolytic therapy for patients with acute myocardial infarction: A health economic study (in Danish). Copenhagen, Danish Institute for Health Services Research, 2002. Lamminen H, Tuomi ML, Lamminen J, Uusitalo H: A feasibility study of real-time teledermatology in Finland. J Telemed Telecare 2000;6:102107. Lamminen H, Lamminen J, Ruohonen K, Uusitalo H: A cost study of teleconsultation for primarycare ophthalmology and dermatology. J Telemed Telecare 2001;7:167173. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Evans C, Hicks N, et al: A randomized controlled trial assessing the health economics of real-time teledermatology compared with conventional care: An urban versus rural perspective. J Telemed Telecare 2001;7:108118. McCue MJ, Hampton CL, Malloy W, Fisk KJ, Dixon L, Neece A: Financial analysis of telecardiology used in a correctional setting. Telemed J E Health 2000;6:385391. Mielonen ML, Ohinmaa A, Moring J, Isohanni M: Psychiatric inpatient care planning via telemedicine. J Telemed Telecare 2000;6:152157. Rosenfeld BA, Dorman T, Breslow MJ, Pronovost P, Jenckes M, Zhang N, et al: Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Crit Care Med 2000; 28:39253931. Simpson J, Doze S, Urness D, Hailey D, Jacobs P: Evaluation of a routine telepsychiatry service. J Telemed Telecare 2001;7:9098. Torok M, Kovacs F, Doszpod J: Cost-effectiveness of home telemedical cardiotocography compared with traditional outpatient monitoring. J Telemed Telecare 2000;6(suppl 1):S69S70. Tuulonen A, Ohinmaa T, Alanko HI, Hyytinen P, Juutinen A, Toppinen E: The application of teleophthalmology in examining patients with glaucoma: A pilot study. J Glaucoma 1999;8:367373. Telemedicine: Fad or future? Lancet 1995;345:7374. Wootton R: Recent advances: Telemedicine. BMJ 2001;323:557560.

Ivar Snb Kristiansen, MD, Institute of Public Health, Health Economics Research Unit, University of Southern Denmark, 19 Winslow Park, DK5000 Odense (Denmark) Tel. 46 65 503843, Fax 45 65 918296, E-Mail isk@sam.sdu.dk

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3.4

Secure Transfer of Medical Data over the Internet: From Regulatory Data Protection Jam to Framework-Based Requirements
Hannes Boesch, Gianluca Airaghi
Arpage AG, Ksnacht/Zrich, Switzerland

The Internet has become a common communication medium. Increasing Internet communication is a trend also in healthcare. However, two specific facts engender skepticism about this trend: first, patient and healthcare data in general are considered sensitive, therefore requiring a higher degree of protection against abuse, and second, the Internet is basically insecure. The combination of these two facts has led to the common feeling that there is a security issue about the transfer of medical data over the Internet. Various regulatory bodies have therefore promulgated specific requirements regarding the transfer of medical data over the Internet. Among others, the data protection authorities have issued specific guidelines. It is our opinion that the state-of-the-art data protection regulations correspond only in part to technical reality and feasibility criteria. In the following we would like to suggest an alternative approach based on the security onion of Bruce Schneier (Secrets and Lies, Digital Security in a Networked World, New York, Wiley, 2001). 1. From the point of view of cryptography, the secure electronic data transfer strikes on three main aspects: Confidentiality: Confidentiality relates to keeping secrets. It answers the following question: Have unauthorized persons gained knowledge of the transferred data? Identification and authentication: Identification and authentication relate to digital identity. They answer the following questions: Who is the origin of the data transfer and how can they prove their identity?

Integrity: Integrity relates to modifying transferred data. It answers the following question: Have the data been abusively modified since the last authorized modification? These three aspects are also three main working fields within cryptography. Specific algorithms have been conceived in connection with each of them. Take the Secure Socket Layer protocol, the ceremonial for securing Web traffic supported by almost all Web browsers and Web servers. SSL supports not less than 9 different encryption algorithms dealing with confidentiality, 14 key exchange algorithms dealing with identification/authentication and 2 algorithms dealing with integrity. 2. Data protection considers the secure transfer of data over the Internet from a different point of view as cryptography. The specific objective of data protection is to avoid the abusive, unlawful use of data. Data protection is concerned about Internet security issues only whenever data are transferred over the Internet and the transfer can lead to abusive situations in respect to the transferred data. The aspects of confidentiality, identification/authentication and integrity, encountered above, still remain basic. However, the concrete approach chosen by data protection regulators (see for example www.edsb.ch/d/themen/gesundheit/uebertragung.htm for the Swiss Data Protection Commissioner) focuses on three main rules: Rule A: It is recommended to transfer medical data via the Internet only if the data transfer is not abusive and the quantity of transferred data is limited to the minimum. Rule B: Whenever medical data are transferred over the Internet, they shall be anonymous or at least pseudonymous. Rule C: If there is no alternative to the transfer of non-anonymous or nonpseudonymous medical data over the Internet, then technical security standards shall apply. This approach has significant limits. Data protection aims to restrict Internet-based communication in healthcare: Rule A renders Internet use subsidiary to other media; Since anonymization and pseudonymization are very hard to handle in daily life, Rule B impedes both useful and usable Internet data transfer. All these restrictions do not correspond to the needs of efficient healthcare reality, which is moving fast towards Internet-based communication. And after all restrictions, data protection ends up in referring to and relying on technical security standards (Rule C): If reliable security standards exist and can be trusted to, then there is no need for restrictions! 3. Let us therefore shift the focus from Internet use restrictions to technical security standards. Dealing with security from a technical point of view means dealing with high complexity. In order to reduce complexity, models are necessary. Following Bruce Schneier, Internet security can be conceived as an onion with a kernel surrounded by several layers (fig. 1).

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Network security Networked computer security Computer security

Protocols

Cryptography

Fig. 1. The Security Onion.

The kernel of Internet security is made of cryptography and security protocols. Cryptography is a branch of mathematic science dealing historically with specific algorithms conceived for keeping data confidential (encryption). Today, cryptographic algorithms cover all of the aspects mentioned above, that means confidentiality, identification/authentication and integrity. Security protocols are ceremonials combining cryptographic algorithms with infrastructure requirements in order to achieve specific security goals in real life. Specific goals are for example the exchange of encrypted data over the Web, the identification of a person accessing confidential resources or the authentication of the author of an e-mail. Specific security goals are not achieved through cryptography and security protocols alone, but in general through the interaction with the remaining layers of the onion. Computer security deals, among others, with controlling the access to and the use of data and software available on computers. Computers connected to other computers are networked: networked computer security deals with controlling the flows between computer and network and determines which data flows are trusted/allowed and which are not. Networked computers build networks: network security deals with preventing all kinds of attacks like,

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Table 1. Security layers and relating issues Layer Cryptography Protocols Computer security Networked computer security Network security Security aspects and issues Algorithms for confidentiality, identification/ authentication, integrity Security protocols (S/MIME, SSL/TLS), online/offline certificate distribution methods Rights management, uninterrupted power supply, physical access protection Filters, malware detection, access control on resources Firewall, virtual private networks, tunneling, e-mail security, intrusion detection, other

for example, blocking or modifying intended communication, engendering unintended communication and granting not allowed access to data and resources. 4. A basic scheme such as the security onion helps because, according to a very basic axiom, there is nothing such as absolute security. Concrete security systems are always based on a preliminary decision about the general security level to be achieved. The security onion helps in defining the security level layer by layer (table 1): Consider that the security level to be achieved within a certain system is always the product of the security achieved on each of its layers. Take for example a computer on which a firewall software runs. Firewalls are designed for granting network security. However, if the access to the computer on which the firewall software runs is not restricted (let us say: no password required), then the almost complete lack of computer security reduces remarkably the security level of the whole system. 5. The security onion is a reasonable model allowing not only to design rough Internet security profiles, but also to examine existing security technologies and infrastructures in healthcare. The Health Info Net (HIN) is the Swiss nationwide secured Extranet platform for healthcare professionals and institutions. HIN is based on a technology called ASAS, the Arpage Security and Access Services. Applying the above scheme to the ASAS technology leads to the overview as per table 2. Table 2 shows that the ASAS security onion is rather complete. Only malware detection is not covered, but the market offers here a high variety of different products which can be easily integrated into ASAS in order to implement a complete security policy. 6. Security technologies such as ASAS and infrastructures such as the Swiss HIN show that a broad coverage of security requirements can be implemented

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Table 2. The ASAS security profile Layer Cryptography Protocols Computer security Networked computer security Network security Security issues covered by ASAS Algorithms for confidentiality, identification/ authentication, integrity S/MIME, SSL/TLS, online certificate verification Fine-grained rights management Access control on resources (URL) Firewall components, VPN, tunneling, e-mail security

easily and efficiently based on generally accepted security standards. Although Internet remains basically insecure, technology allows today to define and implement complete security profiles for specific (medical) communities. Within these trusted communities, security and free data transfer can finally substitute all Internet use restrictions: definitely a new paradigm, and not only for data protection regulations.
Hannes Boesch Arpage AG, Zrichstrasse 64, CHKsnacht (Switzerland) Tel. 41 1 910 6674, Fax 41 1 910 6686, E-Mail boesch@arpage.ch

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3.5

Potential of Telemedicine in Primary Care

Serge Reichlina,b, Anthony Dysonb, Daniel Mller b, Andreas Fischer b, Hans Rudolf Fischer c, Christoph Beglinger c
a c

Department Innere Medizin, Kantonsspital Basel; bMedgate AG, Basel and Abteilung fr Gastroenterologie, Kantonsspital Basel, Switzerland

Telemedicine is defined as the delivery of healthcare and sharing of medical knowledge over a distance using telecommunication systems. The term telemedicine is usually associated with modern telecommunication systems: transmission of electronic medical records and images, remote monitoring of a patients vital parameters, teleconferencing and interactive teleteaching. This is illustrated by the definition of telemedicine adopted by the Swiss Telemedicine Association: use of telecommunication and information technology in the healthcare system to overcome a physical separation between patient and treating physician, as well as between physicians [1].

Mobile Communication Technologies

The rapid technological progress in the last decade, with the deployment of high-speed, high-bandwidth telecommunication systems around the world and the development of devices capable of capturing and transmitting images or other data in digital form, has led to a surge of interest in telemedicine. In parallel, the information and communication technology (ICT) market is growing fast in size and importance [2]. The convergence of Internet technology and mobile communication is a significant development. As a logical consequence, the so-called third-generation or 3G networks combine these technologies to provide mobile Internet or mobile data services [3]. With the World Wide Web booming, the general public has gained easy access to a variety of information, some of which initially intended for

professionals. This has brought with it security concerns. These issues can be avoided by maintaining the information in a private network, isolated from the public Internet, i.e. an intranet. Security is achieved at the cost of accessibility. The solution to this dilemma is the extranet, i.e. the use of Internet communication paradigms to allow secure access to private information to closed user groups over the public Internet [4]. Typical extranet application scenarios involve employees of an organization (e.g. a hospital) that need to access sensitive information or services, when physically far from the organization premises. In telemedicine this might comprise communication between two physicians or between a patient and his physician. Further, personal mobility is playing an ever-increasing role in modern lifestyle. This applies to both professional and leisure activities. Enter the mobile extranet. In this concept, two principles are merged: the need for personal and/or terminal mobility and the need for access to information and services. Telemedicine is a field that stands to benefit greatly from the application of the mobile extranet.

Patient-Focused Healthcare

Increasingly, patients are managed at home, in part because the cost of inpatient care is a major concern in various countries. In many instances in the past, however, providing medical care at home just resulted in a shift of the costs rather than cost savings complicated diseases require sophisticated treatment strategies with frequent home visits. Many people are seeing telehomecare as a potential solution to the dilemma. Using low-cost equipment and regular telecommunication networks, the level of care of a patient at home can be improved through increasing the frequency of contacts, at a much lower cost per contact as compared to physical visits [5]. Further, patients have access to a growing body of healthcare-related information, empowering them to take more responsibility for their healthcare decisions. The technical developments already described, together with a generation which is increasingly comfortable with the new media forms, pave the way for new healthcare delivery systems in which patients and healthcare providers can interact in a multimodal, flexible way, independent of physical location. With these factors in mind, healthcare providers and pharmaceutical companies have to develop fitting disease management concepts. The development of mobile extranet infrastructures and integrated communication tools could form the basis for patient focused, flexible, mobile healthcare delivery.

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Telecommunication in Healthcare

Telemedicine encompasses a wide range of clinical applications. Current telemedical literature deals mainly with point-to-point communication, i.e. between a patient and a healthcare provider (teleconsultations and home telenursing), between physicians (teleradiology, telepathology, teledermatology or other specialized consulting) or transmission of recorded data from a patient to a treating physician (medical record transmission or remote monitoring). Despite many pilot deployments and clinical studies published over the last 45 years, two recent reviews both concluded that the evidence with respect to either effectiveness or cost-effectiveness of telemedicine is still limited [6, 7]. Nevertheless, certain clinical applications which involved the measurement and transmission of bio-data have shown promising results: home monitoring brought about a reduction of the mean arterial pressure in patients with essential hypertension [8], transtelephonic arrhythmia monitoring appeared more effective than ambulatory ECG measurement [9] and daily home spirometry facilitated early detection of infectious exacerbations in patients with cystic fibrosis [10]. Unfortunately, these point-to-point applications do not make use of and therefore do not profit from the mobile, internetworked characteristics of modern communication and information technology.

Towards Networked Healthcare

The next step forward is to conceive and implement new, networked approaches. The lack of integration of the various point-to-point services, diagnostic devices and participants on a unified platform is the major obstacle at this stage. A variety of different sensor devices are available that can be used by patients to measure certain functions. As an example, blood glucose monitoring is well known and widely used for controlling diabetes [11]. In a similar way, sensors monitoring vital functions are available for many chronic diseases: blood pressure measurement for poorly controlled hypertension, pulse oximetry and respiratory flow data in patients with obstructive pulmonary disease, ECG monitoring in patients with arrhythmias, pulse oximetry in patients with sleep apnoea, etc. Depending on the clinical indications and the individual patient, different biological parameters would have to be monitored, by using a variety of devices. Currently, patients are trained to interpret the measured data and take the appropriate steps themselves. More and more manufacturers have begun to implement connectivity into their devices; however, current implementations use specific software and specific services that primarily aim to transmit

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Patient

Medical contact centre

Centre of competence

General practitioner

Fig. 1. Networked healthcare.

the results from the patient to the general practitioners personal computer. The market strategy of most equipment distributors is to persuade general practitioners to provide their patients with equipment for monitoring their illness. These devices would then transmit the stored data at regular intervals to the treating physician via conventional telephone and/or mobile communication networks. Unfortunately, standardization of devices, interfaces and software is still lacking and poses a serious hurdle, preventing or hindering the use of different sensors by a single patient. It should be noted that most suppliers are anxious to market their own proprietary hardware and software components for the patients and the information recipients. Since these devices use different communications platforms, operating systems, hardware components and interfaces, a general practitioner is obliged to run various systems in parallel, sometimes on different platforms, if he wants to offer his patients a comprehensive telemedical service. In our view, the current strategy is doomed to fail for organizational and financial reasons alone and will demand too much of general practitioners. On the basis of these experiences and observations, attempts are underway to develop a new strategy for the telemedical monitoring of patients in the form of medical contact centres, offering their services to patients and doctors around the clock. These teleconsultation centres act as interfaces between the patient, the treating physician and the medical competence centre (e.g. teaching hospital) (fig. 1). Communication between the patient, treating doctor and

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medical competence centre is established by different means using a mobile extranet as well as a conventional or mobile telephones. Clinical as well as technical feedback to patients and doctor-to-doctor dialogue is provided. Both patient and data triage are facilitated.

The MOEBIUS Project

The information society technology project MOEBIUS (Mobile ExtranetBased Integrated User Services) is funded by the European Community [12]. MOEBIUS aims to test the above-mentioned integrated mobile extranet concept: it entails a modern IT infrastructure along with an integrated communications tool for healthcare applications. The culmination of the MOEBIUS project is the realization of a feasibility study using mobile technology in different aspects of patient-focused healthcare. Two different clinical trials are testing two different groups of patients to gain experience in networked healthcare, supported by MOEBIUS technology. The first trial is tackling cardiac risk factor management in young obese patients, and the second trial is testing the system in a group of elderly people monitoring their oral anticoagulation. Other medical sensors could easily be plugged in to the modular infrastructure. The mobile extranet used in these trials was based on General Packet Radio Service (GPRS), as it was the most attractive mobile data transfer technology available. Due again to the modular infrastructure, new solutions, such as Cellular IP and Universal Mobile Telecommunication System (UMTS) can be adopted as soon as they become available.

Integrated Primary Care

Medical data transfer over a mobile extranet embedded into a medical network will be a success when adequate communication between the patient, the treating physician, the contact centre and the medical competence centre is assured, forming the cornerstone of integrated primary care. This implies that technology is seen merely as a tool used in a comprehensive framework of healthcare delivery. Patient as well as data triage will be facilitated, ensuring that the right patient receives the right level of care at the right time. To get there we will need to be open to all possibilities technology can offer. On the other hand, we must carefully and critically evaluate the outcomes from a medical as well as economic point of view.

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References
1 2 3 4 5 6 7 8 SGTM Swiss Association of Telemedicine: Definition of Telemedicine. Retrieved 2001 from URL: http://www.sgtm.ch Deloitte & Touche: The Emerging European Health Telematics Industry. Market Analysis. A Health Information Society Technology-Based Industry Study Ref C13.25533, 2000. Standage T: Survey: The mobile internet: The Internet, untethered. The Economist, Oct 13, 2001. Smith V: The Strong Extranet White Paper. Thawte Consulting South Africa. Retrieved 2000 from URL: http://www.thawte.com/certs/strong extranet/ whitepaper. html Wheeler T: Strategies for delivering tele-home care-provider profiles. Telemed Today 1998;6: 3740. Roine R, Ohinmaa A, Hailey D: Assessing telemedicine: A systematic review of the literature. CMAJ 2001;165:765771. Wootton R: Recent advances: Telemedicine. BMJ 2001;323:557560. Rogers MA, Small D, Buchan DA, Butch CA, Stewart CM, Krenzer BE, Husovsky HL: Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized, controlled trial. Ann Intern Med 2001;134:10241032. Wu J, Kessler DK, Chakko S, Kessler KM: A cost-effectiveness strategy for transtelephonic arrhythmia monitoring. Am J Cardiol 1995;75:184185. Izbicki G, Trachsel D, Rutishauser M, Perruchoud AP, Tamm M: Early detection of exacerbation of lung infections in patients with cystic fibrosis by means of daily spirometry (in German). Schweiz Med Wochenschr 2000;130:13611365. Koschinsky T, Heinemann L: Sensors for glucose monitoring: Technical and clinical aspects. Diabetes Metab Res Rev 2001;17:113123. IST Information Society Technologies: IST homepage. Retrieved 2001 at URL: http:// www.cordis.lu/ist

9 10

11 12

Christoph Beglinger, MD, Abteilung fr Gastroenterologie, Universitt Basel, Petersgraben 4, CH4031 Basel (Switzerland) Tel. 41 61 2655175, Fax 41 61 2655352, E-Mail beglingerc@uhbs.ch

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4 Fields of Application of Telemedicine

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4.1

Telemedicine for the Family Doctor

Marek W. Kurzynski
Wroc law University of Technology, Faculty of Electronics, Division of System and Computer Networks, Wroc law, Poland

Telemedicine is emerging as a new means of medical practice by combining communications and computer technologies with medical expertise. It provides a more cooperative activity between different medical institutions and more comfortable connections between the patient at home and the physician, independently of their locations [13]. Such an idea is especially attractive for family doctors (general practitioners) because very often the area of their practices is quite extensive and furthermore the place of their professional activity is located far away from the consulting and information centers. Hence all efforts having as a final goal to elaborate telemedicine systems dedicated to the practice of family doctor are deeply motivated. Family doctor practices occupy the forefront in primary healthcare systems in many countries. The basic family doctors task should be assurance of fundamental and continuous health services, dedicated to the individuals, families and to the local community, independently of age, sex and kind of diseases. A family doctor must take care of patients from the moment of birth to the death. Primarily, the family doctor takes the decisions and activities for the live saving and care of a patients health. The range of the family doctors competencies is extensive. A family doctor should be able to undertake minor surgical interventions, apply first aid and consultations and should examine the patients within the domain of internal medicine, laryngology, gynecology, childrens diseases and many other specializations.
Telemedicine Services for the Family Doctor Practices

According to the above characteristics of a family doctors activities, the two following arrangements of telemedicine service for family doctor practices

play a crucial role: (a) telemonitoring of patients in remote areas and (b) teleconsulting. Patient monitoring is performed to keep track of a life-threatening event. Although patient monitoring systems are mostly installed in intensive or coronary care units, many chronic patients discharged from hospitals, elderly and disabled people at home also often need intensive monitoring [4]. The cost of sending medical staff to attend to patients at home is generally very high. To provide a comparably reliable but inexpensive way of monitoring patients at home, we suggest a monitoring service with the following functional requirements: (1) vital signs crucial to assess the patient state such as ECG, respiration, body temperature, blood oxygen saturation, blood pressure, blood sugar level, etc. should be continuously monitored in the real-time mode; (2) the family doctor and patient should be able to talk faceto-face with each other, and (3) a life-threatening or intervention-requiring situation should be identified to generate alarms, which alert the family doctor. The two-way communication between patient and doctor allows the patient to ask for advice. The family doctor could also supervise a patients therapeutic actions. For the diagnosis of difficult cases, a general practitioner sometimes needs a specialists consultation. It is here where videoconference systems offer very attractive and convenient possibilities. During a consultation, a family doctor and a specialist in the teleconsulting center exchange patient information, opinions, treatment suggestions and perform cooperative work on the same data in the WYSIWIS (What You See Is What I See) mode.

Computer Implementation TelFam System

A project of the Telemedicine System for the Family Doctor Practices, TelFam, has been developed by the Department of Systems and Computer Networks at Wrocl aw University of Technology in close collaboration with the Department of Family Medicine, Medical Academy of Wrocl aw [5, 6]. The system covers the academic family medicine center and ten family doctors practices (both urban and rural) within the range of 100200 km. The TelFam system serves a local population of 25,000 inhabitants in the Lower Silesia Region (Western Poland) its structural scheme is shown in figure 1. The TelFam system covers two basic telemedicine services, namely telemonitoring of patients and teleconsulting. The system architecture comprises three main components: the server in the teleconsulting center, the doctors workstation and the patients home units.

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Department of Family Medicine and Regional Teaching Unit

Wal brzych 60100 km

Legnica 60100 km

Wroclaw 080 km

Jelenia Gra 100130 km

Zielona Gra 120200 km

Family doctors (3 practices)

Family doctors (1 practice)

Family doctors (3 practices)

Family doctors (1 practice)

Family doctors (2 practices)

Fig. 1. Structural scheme of family telemedicine system in the Lower Silesia Region.

Monitoring of Patients on Remote Sites We developed the PC-based patients and doctors station using the ISDN telephone communication network, which makes fast digital communication possible. The doctors workstation is equipped with a microphone, speakers and videocamera. The patients workstation also has a microphone, speakers and videocamera, but has an additional biological signal acquisition unit having various physiological parameter modules. The TCP/IP protocol is used for the communication between workstations. The patients biological signals are transmitted to the doctors workstation and next are displayed and additionally undergo analyzing and processing procedures (in real time), which include searching the R-peak, QRS complex, finding the heart rate, HRV signal, QRS time, and comparing measured and calculated values with the range of normal and threshold values. Teleconsulting Using WYSIWIS mode With the TelFam system, the Department of Family Medicine would serve as an information and consulting center for family physicians, based on scheduled teleconsultations (e.g. in cardiology, allergology, diabetology, neurology) and a videoconference system. Two consultation physicians can cooperatively work on multimedia documents consisting of text, pictures, images, sound, animation, graphical signs, etc. in the WYSIWIS mode. Since multimedia documents are typically very large, it is not sensible to transmit them during a cooperative conference, but these objects must be converted into a common format and sent to the consultant center before consultation. This means that the action of the TelFam system is divided into the following three independent distinct phases [7]: (1) Document creation: First, the basic information for the teleconference from different sources is collected and structured into a multimedia document.

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A patients document consists of several files of various nature, for example, a text file can contain results of a patients examinations, a sound file can give the ECG signal interpretation, an image file can include microscopic, X-ray or USG images, etc. (2) Transmission: In the next phase the document must be sent to the consultation partner. For this purpose in the TelFam the electronic mail system is used, which has many interesting advantages (the possibility of sending any data, the prospective partner need not be present in order to receive the message, the system can be configured with regard to different priorities of documents (e.g. non-urgent messages can be sent later at a tariff suitable time, reducing transport cost)). (3) Consultation: After the transmission phase, both partners have the same documents on line and the teleconsultation can begin. Both partners can discuss about the multimedia document in the WYSIWIS mode, which means that during cooperative work on for example an image file, it is possible to point with the mouse an anomaly on a medical image, to add different annotations (lines, circles, polygons, text) to the discussed images and they can be seen from the partner immediately after the action. In summary, the functional specifications of a telemedicine system for family doctor practices have been outlined. The TelFam system, designed to support real-time consultations among healthcare providers via a computer network and facilitate an innovative home monitoring and remote care from doctors to their patients, has also been presented.

References
1 2 3 4 5 6 7 Doughty K: Telemedicine. Fam Med 1998;2:3637. Balas EA, Jaffrey F, Kuperman GJ, et al: Electronic communication with patients. Evaluation of distance medicine technology. JAMA 1997;278:152159. Yellowlees PM, Kennedy C: Telemedicine: Here to stay. Med J Aust 1997;166:262265. Park SH, Ryu SH, Jeong T, et al: Real-time monitoring of patients. Proc 20th Conf IEEE/EMBS, Hong Kong 1998, pp 13211324. Puchala E, Wozniak M: The project of the telemedicine system for family doctor practices. Proc 23rd Conf IEEE/EMBS, Istanbul 2001, pp 10381041. Bujnowska-Fedak MM, Staniszewski A, Steciwko A, Puchala E: System of telemedicine services designed for family doctors practices: Telmed J E Health 2000;6:449452. Kurzynski MW, Puchala E, Wozniak M: TelFam A telemedicine system for the family doctor practices. Proc MIE Conf, Hannover 2000, pp 11311135.

Marek W. Kurzynski, Eng, Wroc law University of Technology, Faculty of Electronics, Division of System and Computer Networks, Wyb. Wyspianskiego 27, PL50370 Wroc law (Poland) Tel. 48 71 3203792, Fax 48 71 3202902, E-Mail kumar@zssk.pwr.wroc.pl

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4.2

Teleradiology
Daniel R. Voellmy, Borut Marincek
Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland

Radiology has always been a mediator between medical and technical sciences. Numerous modern visualization techniques have been developed in cooperation between information technology and medicine, especially radiology. Today, the need for digital radiological images in other medical disciplines is stronger than ever. New applications like preoperative simulation, intraoperative visualization, and robot surgery planning can only be performed with the transfer of digital radiological images [1]. In a narrow definition, teleradiology includes transmission of radiological images, remote radiological services, and all telecommunication within radiology. In a wider sense, teleradiology also comprises transmission of image demonstrations, exam requests, radiological reports, information about radiological exams, and organizational tools like remote scheduling.

Teleradiology Scenarios

Transmission of previous exams: Transmission of previous exams to the investigating radiology institute is important especially in long-term patients, where the correct report may be created only when all previous exams are at hand. Communication of radiological findings is the transmission of radiological images and reports back to the ordering physician and/or to the patient. For emergency or experts consultations, images are acquired in facilities with general radiologists or emergency physicians, but with no experts for specific radiological subspecialties. Images are transmitted to the experts for remote reporting.

In cooperative reporting, the use of image acquisition resources and reporting personnel is optimized [2]. Images are transmitted from decentralized imaging units to reporting units with high-qualification, high-availability radiologists [3, 4]. Some healthcare companies send images to radiologists in other countries to save reporting costs. Remote image processing is performed on cutting-edge technology workstations and software. Economically, it is favorable to keep advanced imageprocessing resources in a few specialized centers. Reference image databases are tools to share radiological knowledge. The best-known example in Europe is the Eurorad database with over 600 international contributions [5]. In remote image archiving, images are transmitted to a central storage provider instead of being stored at the acquisition site. The objective is to save imaging costs and/or to share images among health networks.

Technical Requirements

Image Size Image size depends on the image modality. Transmission time is proportional to image matrix, bit depth and number of images. It is inversely proportional to the image compression ratio and the communication bandwidth. As an example, an average CT scan selection with 40 uncompressed images has a size of about 18 MB. Digital images can be compressed without loss of information, resulting in typical compression ratios of 1:2 to 1:3. Losslessly compressed images may be used for primary reporting without quality problems. Lossy compression results in compression ratios of up to 1:20 or more, resulting in decreasing image quality. It can be used for result communication or image demonstration purposes.

Image Standards in Radiology DICOM is a comprehensive standard for medical images. It defines information objects, including data dictionaries and data formats, and services, including a high-level communication protocol usually based on the TCP/IP protocol. An advantage over other image standards is the great amount of information about the image context (patient, modality, acquisition parameters, etc.). DICOM is rapidly evolving. Relatively new DICOM features are wavelet compression and data encryption.

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TIFF (tagged image file format) is less complex than DICOM, but it contains no specific information about the image context, which has to be provided by the teleradiology application separately. JPEG (joint pictures experts group) is used primarily for image transmission in the Internet environment. It allows image compression from lossless to about 1:20. Computers, Storage, Interconnection, Monitors Modern off-the-shelf personal computers are sufficient for most teleradiological purposes, for image reviewing and even for primary reporting [6]. For the storage of transmitted images, e.g. in a physicians office, inexpensive devices like network-attached storage cabinets are available. To connect a physicians office to teleradiology service providers, affordable data subscriber line (DSL) or cable modems with bandwidths up to 2 Mb/s are available. Even with lower bandwidths, investigations showed that diagnostic motion imaging is possible [7]. Transmission time for an average CT scan selection is about 38 min with an ISDN connection or 72 s with a DSL connection. For image reviewing, a standard cathode ray tube (CRT) color monitor or a flat screen with a resolution of 1,280 1,024 pixels is sufficient. However, for primary reporting of chest or bone images, eventually with previous images, a two-monitor configuration with high-resolution, high-luminescence CRT or flat screen grayscale monitors are required. Minimal requirements for computer equipment as well as image annotation, patient confidentiality, workstation functionality, CRT brightness, and image compression are defined in the guidelines of the American College of Radiologists (ACR) [8].

Types of Teleradiological Interaction

Systems with display synchronization allow interactive remote image interpretation. There are teleconferencing systems with or without radiological add-ons, dedicated peer-to-peer reviewing systems, and remote demonstration systems with special discussion tools. In the asynchronous approach, radiological images are transferred to the remote site for later review. The images can be transferred by any standard protocol, like FTP or DICOM. The partners do not necessarily have to use the same application for display as long as the images are transferred in a standard format. Web distribution in e-health environments is another special case of asynchronous transfer. Images are transferred to Web servers for later retrieve and review. An authentication mechanism is provided to protect unauthorized

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access. Some Web implementations have plug-ins to display full resolution DICOM images. Most of the picture archiving and communication systems (PACS) provide a web interface for Internet browser access.

Challenges to Successful Teleradiology Implementation

System Integration Duplicate data entry is one of the practical obstacles to a more frequent use of teleradiological systems [9]. Telemedical applications should therefore be seamlessly integrated into PACS or electronic medical records (EMR) [4, 10]. Integration into PACS also helps to unambiguously associate images and reports, which is an important security requirement. The lack of EMR standards makes EMR integration a challenging issue. Since most of the images can only be interpreted with the clinical information available, most of the radiologists wait for the paper-based patient record to be available before reviewing or reporting images. For further propagation of teleradiological applications, it is therefore important to implement standardized electronic medical records and standardized communication formats to interchange patient records [11]. Legal Issues In many countries, the radiologist has to be physically present during a patients examination. This legal restriction could be overcome by teleradiology contracts between hospitals where at least one medical doctor, even a nonradiologist, is always present during the patients examination. Legal responsibility after remote diagnosis and the copyright of images are other questions that have still to be resolved in most countries. Economic Challenges Teleradiology has the potential to lower cost of film output, film-posting expenses, waiting, planning, retrieving and reporting times. Additionally, teleradiology services could increase revenues by enhancing reporting volume [12]. However, in many countries, billing rule restrictions do not allow telemedical diagnostics or consultations to be adequately charged. Political efforts to change the funding rules have to be enforced. Security Teleradiology, like all telemedical activities, needs a high security level [13]. Authentication, access control, confidentiality, data integrity, and non-repudiation mechanisms require a comprehensive security concept. The solutions are

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available, but they require a minimum of users and system administrators compliance [14]. Computers containing images should be separated from public networks by firewall systems. Virtual private networks (VPN) are adequate solutions for authentication, access control and confidentiality. The secure hypertext transfer protocol (https) can be used to encrypt images for web distribution. Combined with a strong authentication mechanism, this may be a solution to the confidentiality problem in Web environments. A public key infrastructure (PKI) solves all the issues mentioned above. Images can be signed digitally. Access can be restricted to those who have the corresponding key. Integrity checking and nonrepudiation mechanisms are other features of PKI.

Future Developments

In a few years from now, the conditions for a successful development for teleradiology applications will improve. Empowered by decreasing information technology (IT) costs, internal digital image management, archiving and image distribution will be standard for every hospital. IT security infrastructure will be a commodity. PACS implementations will have standardized and secure wide area network expansions. The aggregation of healthcare institutions to healthcare networks will enhance the need for teleradiological solutions. Therefore, external clinicians will expect radiology reports to be enriched with a selection of relevant images. On request, they will have access to the complete original image series. Images will be available on mobile image display devices. Patients will want to access selections of their images as well. They will compare their images to reference images in publicly available image databases. Consultations will be more frequent, as adequate payment will be established. Existing consultation services will expand, especially on a transnational basis. This will lead to a concentration of radiological experts to a few centers with high-availability, high-qualification specialists. Special niche players will provide visualization services like 3D operation planning, exact anatomic measurement for implant sizing or operation result visualization. For economic reasons, the capital-intensive equipment for these services, as well as the maintenance of the specialized know-how to operate the equipment, will be concentrated in a few centers. Trans-disciplinary teleimaging will establish as a completely new field: images from radiology, endoscopy, pathology, or intraoperative photography will be combined for a more comprehensive clinical visualization.

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Conclusion

Basic teleradiology technology, including powerful interconnection, is available and cost-effective today. Isolated solutions have been successfully implemented. Remote consultation and image-processing services are beginning to establish. The remaining challenges are mostly of a non-technical nature. To ease their use, teleradiological solutions must be an integrated part of the standard workflow in the radiological practice, a goal that is best achieved with a PACS. On the clinicians side, teleradiological images must be a natural part of the clinical documentation, which means to implement an EMR. In some countries, the legal basis for teleradiology is not certain, and billing rules are missing. The solution of the remaining challenges is in progress. Integrated health platforms [15] will render teleradiology a standard procedure of the clinical routine. Teleradiology can be seen as a mandatory element of the ideal medical information system that provides secure and instant access to clinical data, including images, anytime and anywhere [16].

References
1 Walz M, Brill C, Bolte R, Cramer U, Wein B, Reimann C, Haimerl M, Weisser G, Lehmann KJ, Loose R, Georgi M: Teleradiology requirements and aims in Germany and Europe: Status at the beginning of 2000. Eur Radiol 2000;10:14721482. Bidaut LM, Scherrer JR: Telematics techniques for image-based diagnosis, therapy planning and monitoring. Int J Med Inf 1998;52:8191. Ratib O, Ligier Y, Bandon D, Valentino D: Update on digital image management and PACS. Abdom Imaging 2000;25:333340. Bowers GH, Steiner E, Kalman M: Implementing teleradiology in a private radiology practice: Lessons learned. J Digit Imaging 1998;11(suppl 1):9698. Baert A, Frija G, Passariello R, Ringertz H, Caramella D, Sigal R: EURORAD Radiology Certified Cases EAR Database. http://www.eurorad.org 2001. Pysher L, Harlow C: Teleradiology using low-cost consumer-oriented computer hardware and software. AJR Am J Roentgenol 1999;172:11811184. Stewart BK, Carter SJ, Cook JN, Abbe BS, Pinck D, Rowberg AH: Application of the advanced communications technology satellite to teleradiology and real-time compressed ultrasound video telemedicine. J Digit Imaging 1999;12:6876. ACR: ACR Standard for Teleradiology. http://www.acr.org/departments/stand_accred/standards/ pdf_standards/toc.pdf Buxton PJ: Teleradiology Practical aspects and lessons learnt. Eur J Radiol 1999;32:116118. Caramella D, Reponen J, Fabbrini F, Bartolozzi C: Teleradiology in Europe. Eur J Radiol 2000; 33:27. Yamazaki S, Satomura Y: Standard method for describing an electronic patient record template: Application of XML to share domain knowledge. Methods Inf Med 2000;39:5055. Strickland NH: Can PACS make a radiology department more competitive? Eur J Radiol 1999; 32:113115. Ashcroft RE, Goddard PR: Ethical issues in teleradiology. Br J Radiol 2000;73:578582.

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Eng J: Computer network security for the radiology enterprise. Radiology 2001;220:303309. Bundesministerium fr Bildung und Forschung: Telematik im Gesundheitswesen Perspektiven der Telemedizin in Deutschland. http://www.iid.de/forschung/studien/telematik/ telematik_1.html#k1c Arenson RL, Andriole KP, Avrin DE, Gould RG: Computers in imaging and healthcare: Now and in the future. J Digit Imaging 2000;13:145156.

Daniel R. Voellmy, DMT Direktion, Universittsspital, Rmistrasse 100, CHZrich (Switzerland) Tel. 41 1 255 2165, Fax 41 1 255 8987, E-Mail daniel.voellmy@dmr.usz.ch

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4.3

Telemedicine Applications in Surgery

Nicolas Demartines
Department of Visceral and Transplantation Surgery, University Hospital Zrich, Switzerland

Telemedicine is used in most areas of medicine as demonstrated in the other chapters of the present book, and as previously showed in a review, published in 1995, describing 28 different specialties, including veterinary medicine [1]. The word telemedicine applied to surgery includes the use of various new technologies of communication and covers many topics beginning with videoconferences, telementoring, the use of virtual reality for teaching and operation planning [2] and robotics. Telemedicine as a surgical application is supported by works that indicate off-site diagnosis for surgical patients can be performed with a similar sensitivity, varying between 78 and 98%, to that of direct clinical examination [3, 4]. These results confirm our own investigations where an off-site diagnosis using teleconferencing was made in between 85 and 96% of cases [5]. Teletransmission technology for surgical purposes should provide highquality, rapid transmission of medical files, as images play a major role. For example, laparoscopic surgery, a technique based primarily on pictures, is ideal for surgical demonstration, education and practical teaching, assuming highquality image transmission. In addition, to be used regularly by surgical teams, the telematic system must be easy to manage, reliable and inexpensive. Transmission through ISDN lines appears to fulfill most of these requirements. The cost for 1 h of videoconferencing at 384 Kb/s for a Europe-Europe link amounts to EUR 180 (USD 190), and a Europe-USA link, EUR 260 (USD 275). Good transmission quality is achieved with a high information transmission rate. The use of 6 ISDN lines at an information rate of 384 Kb/s resulted in 93.3% recognition of organ structure, and 60% recognition of fine structures [6]. Currently, this configuration allows teleconferencing with the best price/quality ratio, good audio quality, acceptable quality of animated pictures, and low

4,447 3,649 2,907

1,082 546 27 8892 117 9395 1996 1998 1999 2000 2001

Fig. 1. Evolution of the number of publications listed in Medline about telemedicine.

rate of artifacts. A lower transmission rate using 4 ISDN lines at 256 Kb/s induces 12% artifact, compared with only 3% at 384 Kb/s (p 0.02) [7]. An important aspect in the introduction of new technologies in surgery is the scientific evaluation prior to large clinical application. This is of special importance regarding the quality control, and the cost. Telemedicine became popular in the last decade, as demonstrated by the exponential increase in publications listed in Medline (fig. 1). This increase in number of publications does not however give information about the real value of telemedicine, but more on the increasing general and scientific interest on this topic. It means telemedicine needs further proper scientific evaluation [6]. Let us define a few specific terms [8]. Teleconsultation implies a consultation from a distant site, by radio, by telephone or using telematics [9]. Twenty years ago, a comparison between 1,000 diagnoses performed by telephone and diagnoses made using a black and white or color television showed no significant differences in the time used to arrive at a diagnosis or in the frequency of supplementary consultations [10]. On the other hand, the use of modern telecommunication technologies allows the advanced transmission of complex documents for special or challenging problems [11, 12], and teleconferences allow real-time consultations. Teleconferences have become routine in industry and in the business world, and allow participants who may be hundreds or even thousands of kilometers apart to carry out discussions that include sound and images. However, for medical teleconferences, the need for accurately transmitted clinical documents is greater and technical requirements become more important (fig. 2). Based only on the transmitted documents, the experts have to judge and evaluate the

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a
Camera

Video unit

ISDN

Control

c Fig. 2ac. Tools used for ISDN-based videoconference in surgical application.

case and advise the best treatment based on the clinical information transmitted. It is therefore an ideal medium for practicing interactive consultations among specialists and to obtain a second opinion for therapeutic indications without having to move the patient [6]. Multidisciplinary teleconferencing continues to expand: teaching, specialty training and the opportunity to exchange information allow the emergence of new concepts in tele-education and teleconsultation. Our own works show surgical participants in teleconferences have an 86% level of satisfaction [6], confirming preliminary studies from the Mayo Clinic and NASA showing teleconferencing satisfaction levels of between 80 and 90% [13]. Interactivity: Videoconferences offer the opportunity to discuss complex cases in real time over distance, thus increasing the value of teleconsultation in real time. However, this hypothesis needed to be validated by scientific evaluation. This was performed during a surgical teleconference program running between six European University hospitals between 1996 and 1999 [6]. Out of 271 clinical presentations of surgical cases, 60 cases were analyzed in order to judge the value of the interactivity between the expert and surgeons presenting the case. The initially available clinical information was judged adequate in 55% and inadequate in 45% of the analyzed cases. During the interactive discussion, complementary data was provided live by the surgeon in charge of each case, significantly increasing the number of cases having adequate information to 95% (p 0.001) [6]. The opportunity for interactive discussion thus significantly improved the level and quality of clinical information available,

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b Fig. 3. First robot-assisted transatlantic laparoscopic cholecystectomy performed by the team of Jacques Marescaux, University of Strasbourg, France. a Surgeon in New York; b Patient in Strasbourg.

suggesting that this is a key benefit of telemedicine [14]. The importance of interactive case presentation is confirmed by others, e.g., 84% of participants in rural telemedicine in the USA reported using interactive video sessions [15]. These findings highlight a need for real-time interactivity [16]. Telementoring: The next stage extends beyond the discussion of therapeutic and diagnostic tactics, and includes obtaining off-site assistance for a therapeutic step. In telementoring, an expert assists a colleague from a distant site during an invasive procedure: the expert sees the same images as those of the on-site surgeon, and assists him/her step by step in real time during the procedure. Telementoring has been performed and tested successfully during several different invasive procedures [1720]. Telepresence dictates an action from a distant site; the concept dates from some 50 years ago where radioactive isotopes were manipulated using telecommands [21]. Telepresence allows a consulting expert to maneuver, from a distant site, a microscope, a videorecorder, an endoscope or a surgical manipulator and to thus physically perform some task without actually being present [19, 22]. Thus, telepresence is the first step introducing telesurgery and robotics. Telesurgery and Robotics involve the use of robotics and the actual operation is performed by robots commanded from a distant site [23]. Preclinical experiments have been performed in microsurgery, thoracic and vascular surgery, and laparoscopy [19, 24, 25]. Clinical applications are currently in operation in Belgium where telelaparoscopy is quite frequent [26]. The concept was further developed when Marescaux et al. [27] performed the first transatlantic laparoscopic cholecystectomy on September 7, 2001, with the use of a robot (Marescaux Nature). The patient was located in Strasbourg, France, and the surgeon in New York, USA (fig. 3).

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Fig. 4ac. Potential advantages of telesurgery, i.e. better view, degree of freedom, fine work, ergonomics.

The term telesurgery is occasionally wrongly used to describe a videoconference on a surgical subject but it means telesurgical robotics. For clarity, one should definitively distinguish between these two. The potential advantages of telesurgery (robotic) are the mini-invasive approach, a better possible view with possible magnification, an increased degree of freedom of the instruments, a highly fine motion movement and the ergonomics for the operating surgeon (fig. 4). Virtual reality: The use of virtual reality applied to liver surgery will have fascinating repercussions of assisted surgical strategy and surgical simulation on tomorrows surgery. An interesting pioneer work was performed at the European Institute of Telesurgery in Strasbourg, France, by Marescaux et al. [2; http:www/eits.org].

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7 8 2 Tumor 3

5 4 6

Virtuals

Fig. 5. Virtual reality applied to liver surgery.

Using data from the National Library of Medicine, a realistic threedimensional image was created, including the envelope and the four internal arborescences. A computer interface was developed to manipulate the organ and to define surgical resection planes according to internal anatomy. The first step of surgical simulation was implemented, providing the organ with real-time deformation computation. The three-dimensional anatomy of the liver can be clearly visualized. The virtual organ can be manipulated and a resection defined depending on the anatomic relations between the arborescences, the tumor, and the external envelope. The simulation allowed the deformation of a liver model in real time by means of a realistic laparoscopic tool. Using virtual reality concepts (navigation, interaction and immersion), surgical planning, training and teaching for complex surgical procedures may be possible. Validation studies are currently being performed (fig. 5).

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Conclusion

Telemedicine applications in surgery are various, beginning with teleconsultation and telementoring real-time remote assistance during the course of an invasive procedure. Application of robotics allows the realization of operations over a distance, thus allowing direct active guidance for advanced procedures. The major benefit is in teaching and education, with an easier access to expertise. Reconstruction using virtual reality should increase the feasibility and safety of complex surgical procedure by better visualization of the preoperative anatomy, thus allowing a better definition of the surgical strategy. This application is of great importance for education and teaching as well. The development perspectives are in the semiautomatic recognition of structures with development of an interface with the robot, thus opening the door to a semiautomatic robot-assisted complex surgical procedure. It is important for the surgeons to be part of these developments to manage the emergence and the application of these new technologies, and to ensure a proper scientific evaluation to assess the indications, the quality control and the cost-benefit relationship for the surgical patients.

References
1 2 3 4 5 6 7 8 9 10 11 Perednia DA, Allen A: Telemedicine technology and clinical applications. JAMA 1995; 273:483. Marescaux J, Clement JM, Tassetti V et al: Virtual reality applied to hepatic surgery simulation: , The next revolution. Ann Surg 1998;228:627. Wirthlin DJ, Buradagunta S, Edwards RA, et al: Telemedicine in vascular surgery: Feasibility of digital imaging for remote management of wounds. J Vasc Surg 1998;27:1089. Walters TJ: Deployment telemedicine: The Walter Reed Army Medical Center experience. Mil Med 1996;161:531. Demartines N, Mutter D, Otto U, et al: Telemedicine and remote clinical diagnosis in surgery: A comparative study. Arch Surg 2000;135:849. Demartines N, Mutter D, Vix M, et al: Assessment of telemedicine in surgical education and patient care. Ann Surg 2000;231:282. Malone FD, Athanassiou A, Nores J, DAlton ME: Effect of ISDN bandwidth on image quality for telemedicine transmission. Telemed J 1998;4:161. Demartines N, Mutter D, Eisner L, Vogelbach P, Marescaux J, Harder F: Telemedicine: Application, methodolgy and users guide. Swiss Surg 1999;5:73. Ferrer-Roca O, Esteves M, Gomez E: The environment for telemedicine in the Canary Islands. J Telemed Telecare 1998;4:161. Moore G, Willememain T, Bonnano R, Clark W, Martin A, Moglienicki P: Comparison of television and telephone for remote medical consultation. N Engl J Med 1975;13:729. Trippi JA, Lee KS, Kopp G, Nelson D, Kovacs R: Emergency echocardiography telemedicine: An efficient method to provide 24-hour consultative echocardiography. J Am Coll Cardiol 1996;27:1748. Fisher JB, Alboliras ET, Berdusis K, Webb CL: Rapid identification of congenital heart disease by transmission of echocardiograms. Am Heart J 1996;131:1225.

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14 15 16 17

18 19 20 21 22 23 24 25 26 27

Kottke TE, Little Finger L, Trapp MA, Panser LA, Novotny PJ: The Pine Ridge-Mayo National Aeronautics and Space Administration Telemedicine Project: Program activities and participant reactions. Mayo Clin Proc 1996;71:329. Franken EA Jr, Berbaum KS: Subspecialty radiology consultation by interactive telemedicine. J Telemed Telecare 1996;2:35. Hassol A, Gaumer G, Irvin C, Grigsby J, Mintzer C, Puskin D: Rural telemedicine data/image transfer methods and purposes of interactive video sessions. J Am Med Inform Assoc 1997;4:36. Lesher JL Jr, Davis LS, Gourdin FW, English D, Thompson WO: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. J Am Acad Dermatol 1998;38:27. Jones JA, Johnston S, Campbell M, Miles B, Billica R: Endoscopic surgery and telemedicine in microgravity: Developing contingency procedures for exploratory class spaceflight. Urology 1999;53:892. Schulam PG, Docimo SG, Saleh W, Breitenbach C, Moore RG, Kavoussi L: Telesurgical mentoring. Initial clinical experience. Surg Endosc 1997;11:1001. Bowersox JC, Shah A, Jensen J, Hill J, Cordts PR, Green PS: Vascular applications of telepresence surgery: Initial feasibility studies in swine. J Vasc Surg 1996;23:281. Lee BR, Bishoff JT, Janetschek G, et al: A novel method of surgical instruction: International telementoring. World J Urol 1998;16:367. Durlach N, Mavoras A: Virtual Reality: Scientific and Technological Challenges. Washington, National Academy Press, 1995. Bowersox I: Telepresence surgery. Br J Surg 1996;83:466. Bowersox JC, Cornum RL: Remote operative urology using a surgical telemanipulator system. Urology 1998;52:17. Margossian H, Garcia-Ruiz A, Falcone T, et al: Robotically assisted laparoscopic tubal anastomosis in a porcine model. J Laparoendosc Adv Surg Tech A 1998;8:69. Falk V Walther T, Autschbach R, Diegeler A, Battellini R, Mohr FW: Robot-assisted minimally , invasive solo mitral valve operation. J Thorac Cardiovasc Surg 1998;115:470. Cadiere GB, Himpens J, Vertruyen M, Favretti F: The worlds first obesity surgery performed by a surgeon at a distance. Obes Surg 1999;9:206. Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M, Butner SE, Smith MK: Transatlantic robot assisted telesurgery. Nature 2001;413:389391.

Nicolas Demartines, MD, Vice Chairman, Department of Visceral and Transplantation Surgery, University Hospital Zrich, Rmistrasse 100, CH8091 Zrich (Switzerland) Tel. 41 1 255 23 89, Fax 41 1 255 89 42, E-Mail Nicolas.Demartines@chi.usz.ch

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4.4

Modern Telepathology: A Distributed System with Open Standards

Martin Oberholzera, Heinz Christenb, Gunter Haroskec, Markus Helfrichd, Hermann Oberlie, Gernot Jundta, Gerhard Stauchf, Michael Mihatscha, Kurt Brauchlia
a

Department of Pathology and bUniversity Computing Centre, University of Basel, Switzerland; cInstitute of Pathology, Stdtisches Klinikum Dresden-Friedrichstadt, Dresden, Germany; dTechnical University Kaiserslautern, Zweibrcken, Germany; e National Referal Hospital, Honiara, Solomon Islands, and fInstitute of Pathology, Aurich, Germany

The central aims of telepathology are (1) the possibility to get a second opinion concerning a pathological-anatomical diagnosis from an expert outside of the normal pathologists working team, and (2) to deliver primary diagnostics to patients who are treated in hospitals without resident pathologists. All diagnoses in pathology are based on images. Therefore, telepathology is mainly concerned with the exchange of information contained in images. Because images are also diagnostically relevant in many other disciplines in medicine as pathology, a distinction of subgroups in telemedicine [114] is no longer absolutely indicated. Taking care however (i) of the conditions in which images are generated and (ii) of the therewith linked special processing, the distinction among subdisciplines of telemedicine (e.g. telepathology) can be justified. It can really be that the diagnostically relevant images can only be created by means of specific procedures (e.g. intraoperative frozen sections).

Basic Model of Telepathology

The user of a telepathology system wants a system to be available unlimitedly. Unlimited availability means that the system can be (i) used as a routine method with the infrastructure at the actual working place (with the own

computer, with the own microscope, in the own office), (ii) used via an easily accessible universal network, and (iii) used spontaneously to contact any expert without special software. Telepathology has three supporting legs: two partners and a server with a database. The partners and the server are linked with each other via a network. The non-expert asks a question, the expert(s) answer(s) the question. On the server, information of any source (images, text files, audio) are stored, looked at or retrieved from the server. The technological precondition mandatory for the clients is a Web browser being able to execute Java applets [1517], and optionally a small software module controlling the specific imaging facilities of the actors. Our experiences have shown that such a model works well if four technical and functional prerequisites are fulfilled: (i) the images on the server have to be managed by a structured database; (ii) all actions of each partner have to be communicated to the server; (iii) the partners must have a free as possible access to the server, and (iv) the partners must have the possibility to generate images in a simple way. All the tools (modules, see below) of the system permanently communicate their condition to the server or carry out instructions transmitted by the server on behalf of the non-expert or expert(s). All these prerequisites are fulfilled in the modular client-server system iPath (http://telepath.patho.unibas.ch) [18].

Architecture of a Modern Telepathology System

A widely available telepathology system should include four basic modules as single system components operating independently (fig. 1): (i) a module for generating the images (capturing or microscope control); (ii) a module for filing of images or other information on the server (filing); (iii) a module for the function of the expert (expert module), and (iv) optionally a module for remotely controlling the microscope, or another manipulator (microscope control). The images can manually or automatically (in combination with the module microscope control) be inserted in the database. Alternatively, images can be uploaded manually using a Web page. The expert module (realized as Web application) controls the access to the database and contains the module microscope control; this module has been written in Java.

Methods
The software modules of iPath are available as free software under http://ipath. sourceforge.net.

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Non-expert Computer Micro/macroscope Camera Capturing Filing Microscope control Expert module

Internet

Server Computer

Expert Computer

Database Java applets CGI programs

Capturing Filing Expert module

Firewalls

Fig. 1. Basic concept of iPath. iPath consists of five basic (main) software modules (capturing, filing, microscope control, expert module, and database) which are distributed on the three legs: non-expert, expert, and server. Both the expert and the non-expert equally use the expert module in order to obtain access to the database. The server is placed in the Internet and not behind a firewall. CGI: common gateway interface-programs.

The server software (see fig. 1) can either be installed on one of the computers of the partners if only a point-to-point or intranet-to-intranet connection should be used, or on an independent computer (server) located in the Internet. One such Internet server can serve hundreds of users and many simultaneous connections. (Intranet is a local area network (LAN), e.g. of a hospital.) We have concretely realized both possibilities; an intranetto-intranet connection has been installed between the University Hospital Basel (Basel, Switzerland) and the Ospidel Circuitel dEngadinOta (Samedan, Switzerland). The server software is running on a Pentium II Personal Computer with Windows NT 4.0. The module server with database is installed on the computer of the expert (in Basel) for the intranetto-intranet application (for Samedan). For telepathology via the Internet, a server (Pentium II, too) is located at the University Computing Centre, Basel. The hardware modules are demonstrated in table 1. iPath works also with scanning tables of the company Mrzhuser (Wetzlar, Germany). The expert module allows access to the database on the server and to all microscopes, if the module microscope control of the non-expert(s) is linked with the server.

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Table 1. Hardware modules (see text) Location Basel Basel Dresden Honiara Samedan Macroscope Visual Presenter (Elmo) Video Visualizer (Canon) Microscope Axioplan (Carl Zeiss AG) Axioplan (Carl Zeiss AG) Optiphot2 (Nikon) Optiphot2 (Nikon) BH-2 MJLT (Olympus) Scanning table MCU26 (Carl Zeiss AG) Microscope controller (Galai) Camera Video IRIS (CCD camera) (Sony) CoolPix990 (Nikon) GP-KR 222 (Panasonic) CoolPix990 (Nikon) Video IRIS (CCD camera) (Sony) Frame grabber Videum AV (Winnov) Videum PCI (Winnov) Rasterops Video Capture (Rasterops)

Several microscopes can be linked with the server at the same time. The expert module can be called up via conventional Web browsers (Netscape Navigator or Internet Explorer). If the expert establishes contact with any microscope registered at the server, the actual field of view of the microscope located at the non-experts page appears as a video image on his screen on the left upper side (fig. 2). The video image is transmitted in regular periodic intervals (actually 12 s). The quality of the video image and the video image transfer rate can be regulated interactively. A high-resolution image of the video image can be created by the function capture. The high-resolution image appears on the right side of the screen (fig. 2) and is stored directly in the JPEG format in the database at the server. The database is based on an SQL (structured query language) database server; presently we are using Postgresql [19] on our Internet server. The main unit of the iPath database is the discussion group. Each case is stored in a discussion group. A case corresponds to a concrete query of a non-expert to one or several experts. All users are attributed to a discussion group. A single user can be member of various discussion groups. A telepathological consultation consists of four steps: (i) the formulation of a query by the non-expert to one or several experts; (ii) the preparation of images or documents by the non-expert; (iii) the presentation of images or documents to the expert(s), and (iv) the formulation of the answer(s) of the expert(s) to the non-expert. The concrete query and the clinical key information (with the exception of images or other objects) are stored by the non-expert in the field description. The expert writes his report (differential diagnosis, diagnosis, opinion, additional question) into the field comment of the database. A single case can have any number of comments (fig. 3).

Results

iPath can be easily used for active (the partners are in direct contact with each other) and passive consultation because of its modular design.

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Fig. 2. Telemicroscopy. The module microscope control is the tool for telemicroscopy. On the screen of the expert the actual video image (micro- or macroscopical) is shown in the left upper corner. On the right side the already captured high-resolution images are shown. These digitalized images are already stored in the database. The expert can also communicate with the non-expert via the chat function.

Fig. 3. Record of a case (frozen section analysis) in the database of iPath (see text). A chat function as discussion platform is also available for each case.

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Table 2. Validity of telepathology n 139 93 117 128a 151a

a

Author Present study [1] [2] [3] [4]

Sens 0.85 0.92 0.94

Spec 0.93 1.00 0.98

Effic 0.89 0.95 0.93 0.96

PPV 0.92 1.00 0.93 0.98

NPV 0.87 0.90 0.96 0.78 0.90 0.88

min

0.73 0.81

Virtual frozen section analysis. Value for [5]; min minimal value for [ 2SE (min)]; Sens sensitivity; Spec specificity; Effic efficiency; PPV positive predictive value; NPV negative predictive value.

Active Consultation: Frozen Section Diagnosis Intraoperative frozen sections have been performed for the Ospidel Circuitel dEngadinOta (Samedan, Switzerland) for 10 years [20, 21]. For 2 years this service was also offered to the Regional Hospital Burgdorf (Burgdorf, Switzerland). Until 2001, a system was used which consisted of two Macintosh computers, a picture-instrument manager and a relational database (Omnis 4). Timbuctu was used as a data transfer protocol, as network the Integrated Services Digital Network (ISDN) with one B-channel (64 kbit/s). Since half a year, iPath is in use via ISDN and with two B-channels (128 kbit/s) between Basel and Samedan. A systemic analysis of 139 consecutive examinations (performed between 1992 and 1995 with both regional hospitals) and an analysis of 93 examinations (performed only for the Regional Hospital Samedan) [22] has yielded the results shown in tables 2 and table 3. The efficiency of frozen section diagnoses as we observed was in the range of that published by other authors [2325]. The same holds for the values [22, 24]. The number of nonconclusive cases ranges in the literature for frozen section diagnosis made by telepathology between 2.6 and 7.0% [2325]; we observed 6.5%. In a large-scale study a portion of nonconclusive cases of 3.8% was found in conventional frozen section diagnoses [22]. Passive Consultation: Some Examples The main use of the new system iPath [18] is the passive consultation. The working group Bone Tumors at the German Center for Cancer Research, Heidelberg (Germany) has used iPath successfully for 12 months for purposes of passive consultation. The system is a very good platform for the discussion of morphological findings (pathology and radiology).

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Table 3. Nonconclusive cases for telepathological frozen section diagnosis between Basel and Samedan Author Total, n Nonconclusive or false n Steffen et al. [unpubl.] [2] [3] [4] Conventional frozen section [review, 1] 93 117 128 155 118,028 6a 8 9 % 6.5 6.8 7.0 2.6 3.8

a In 3 additional cases, technical dysfunctions happened: the reasons were dysfunction of the ISDN (twice) and of the microscope (once).

In connection with the interpretation of a heart biopsy after a heart transplantation, iPath was used spontaneously by M.O. in order to receive a second opinion of a specialist at the Center for Heart Transplantations of the University of Hannover (Germany). The question was if the rejection therapy which had to be reduced because of severe side effects can be maintained. Anamnestic and clinical key information and the images of the biopsy before and after the reduction of the therapy were stored in iPath. For the contacted expert it was the first touch with iPath. After a spontaneous contact by phone he registered himself in the system and was assigned by the group administrator to the prearranged discussion group. He confirmed the grading made by M.O. 12 h after the query in his comment to the case. In a second case the orientation at a specimen of breast tissue which had to be examined for another hospital was unclear because of uncertainties in the interpretation of the meaning of the attached stay sutures. iPath was used for answering the questions of the pathologist (fig. 4). In this case the pathologist was the non-expert and the surgeon the expert. Within 10 min the problem was solved (registration and administration inclusively). The collaboration with the hospital in Honiara (Solomon Islands in the South Pacific) proved to be very successful. By the end of August 2001, one of the authors (K.B.) had installed a small histological laboratory there and trained the technicians of the hospital in the preparation of histological sections. An old Nikon microscope was at disposition on which a digital camera could be installed. The histological images could be transferred via a laptop computer and the sole Internet connection of the hospital to the iPath server in Basel. In Honiara, iPath developed to a very important key element of help to self-helping.

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Fig. 4. Discussion on the correct orientation of a specimen of breast tissue (see text).

Images of any kind (e.g. also macroscopic findings of patients or of organs or radiographs or electrocardiograms) can be shown worldwide to experts. In this way a histology of a trucut biopsy of a woman was presented telepathologically by H.O. on October 7, 2001. One day later the diagnosis of breast cancer was made and transmitted to the server by M.O. in an Internet caf in Elunda (East of Crete), because M.O. was at that time on vacation in this village. Within the same day the diagnosis was confirmed by a second pathologist in Dresden (G.H.). Another problem arose in Honiara in connection with treating a patient with psoriasis. Macroscopic images (fig. 5) were stored in the database with the following description:
(2001-11-01 04:48: Female patient, 24 years, recurrent episodes of generalized psoriasis, treated by the physicians with methotrexate 2.5 mg every 2 weeks. Recently, prednisolone 20 mg daily was added. No dermatologist in the country. Specialist consult and advice would be very much appreciated. Histology required?).

And here the opinion of an expert (in Europe):

Histology is required (to exclude cutaneous T-cell lymphoma and other types of erythrodermatic dermatoses). If psoriasis could be confirmed, methotrexate in children (or young women) is not recommended. Cyclosporin A is better (25 mg/kg body weight). Cortisone is not recommended, since relapses very often occur sometimes with a tendency to pustular psoriasis. And here the answer of the non-expert (on the Solomon Islands): Our annual budget for drugs is about 3 Euros per person: Cyclosporin would ruin the whole budget of the hospital. Can you offer any alternatives? Skin biopsies were taken, histology is being processed in our lab right now.

The system finds another application by the authors M.M. and M.O. to demonstrate contributors the histological and cytological findings of their cases. At dermatological problems the macroscopic findings are stored in the database

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Fig. 5. Active consultation. iPath cannot only be used in pathology but in all disciplines of medicine (see text).

by the non-experts. The pathological-anatomical findings are then added to the case by the expert.

Discussion

Three theses can be derived from the fundamentals of telepathology (explained above: Architecture of a Modern Telepathology System): (i) modern telepathology should be based on the principle of a radio or television sending station with many listeners or receivers (participants): the station corresponds to the server, the participants to the clients; (ii) the necessary software for performing telepathology should be available modularly and be platform-independent, and (iii) as a network the Internet or ISDN can be used.

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If several partners in pathology should simultaneously analyze morphological findings at anytime, a freely accessible and spontaneous use of Internet is a conditio sine qua non [16, 17, 2631]. However, if the Internet is used as the network, the problem of firewalls has to be considered. Firewalls are computers which filter and control data transfer between the open Internet and the LAN, e.g. of a hospital (intranet) [1618]: the firewalls allow a transfer of data between the hospital and the open Internet only if special network protocols are used (e.g. HTTP (hypertext transfer protocol) and e-mail). A telepathology system which is based on a similar idea as iPath has recently been developed in Great Britain [32]. This system uses Webcam technology [33] and the file transfer protocol (FTP). FTP, however, is not tolerated by all firewalls. However, if telepathology is divided up into modules which collaborate with each other in an intelligent and useful manner, systems can be realized without the necessity of changing and modifying the configurations of the individual firewalls [18]. Equally, the information exchange between two LANs (e.g. via ISDN) should be drawn up as a client-server system. Under these conditions the server is installed on the computer of one of the two partners (as for the telepathology system between Basel and Samedan). Apart from a very fixed direct computerto-computer-connection, it may also be useful to connect two LANs using routers or to connect one computer (e.g. the workstation of the non-expert at a regional hospital) to a remote LAN. To ensure privacy of transferred data it is possible to use (i) a private network link (e.g. ISDN) and (ii) to encrypt sensitive data prior to the transfer. We are using the HTTPS (secure HTTP). The input of nonencrypted patient data in iPath is prohibited. The function of a server can generally be separated into a few exactly defined components, these are: (i) the receipt of information (text documents, images); (ii) the evaluation or interpretation of received information; (iii) the preparation of newly generated information for the users linked, and (iv) the remote control of instruments (fig. 6). The evaluation or interpretation of received information is performed via algorithms. Such an algorithm can be the a priori knowledge of an expert but also a mathematical algorithm as it is used for the telepathological DNA analysis [34, 35]. The receipt, the working up and the passing on of data through the server should be supported by a carefully conceived and clearly structured database on the server [18, 21, 32]. Wells et al. [6] criticized mainly that adaptations of commercially available telepathology systems by the manufacturers are taking too long. The demand for rapid and flexible adaptations can be fulfilled by means of a modular design of telepathology systems because individual components can be changed easier

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Client 3

Client 2 Client 5 Client 4 Microscope Steering functions Microscope Macroscope Tool x Client 6 Client 1 Results Documents Tool x Client 6 Client 1 Macroscope

Algorithm 1 Algorithm 2 Algorithm 3

Expert Computer Computer

Fig. 6. The server is the backbone of the new telemedicine systems and carries out the following functions: (i) it receives images from various image sources and users (Client 1, Client 6); (ii) it enables an evaluation of images via algorithms (experts or computer programs); (iii) it disposes the results of the evaluation to all clients; (iv) it routes status information and commands between the experts remote microscope control and the microscope on the non-experts side.

and faster than entire systems. The experiences until now with iPath have shown that a parameterization of the various modules and tools and therefore adaptations of the system at specific conditions of the environment is possible in an easy way. An actual analysis of the state of the art in telepathology [6] seems to indicate that the time for insular solutions is over. The new aim must be to find the smallest common denominator in technology and informatics for a realistic and useful application of telepathology and for a permanent adaptation of the method to the user needs. This new conception of telepathology must lead to a change of old paradigms. Such a change is accompanied by two main options: (i) the thinking about the new developments in telepathology has to move from monolithic isolated systems to more modular and generally available solutions [36], and (ii) a globalization will also comprehend telepathology soon. What it means has been shown with the project South Pacific cited in this paper.

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Acknowledgements
The authors thank the University Computing Centre, University of Basel, for providing and hosting the iPath-server. The use of iPath on the Solomon Islands was made possible by a financial grant of the association Medicine in South Pacific, Dr. Hermann Oberli. Furthermore, the project iPath was supported by a grant of the European Research Program Telematics. The authors express their thanks to Dr. med. R. Frscher for the competent editorial collaboration.

References
1 2 3 Bhatia RS: Telepathology: Advantages and problems. J Assoc Physicians India 2000;48: 456457. Della Mea V Beltrami CA: Diagnostic telepathology through the Internet. Histopathology 1998; , 33:485. Hufnagl P, Bayer G, Oberbamscheidt P, Wehrstedt K, Guski H, Hauptmann S, Dietel M: Comparison of different telepathology solutions for primary frozen section diagnostic. Anal Cell Pathol 2000;21:161167. Kayser K, Szymas J, Weinstein R: Telepathology: Telecommunication, Electronic Education and Publication in Pathology. Berlin, Springer, 1999. Liang WY, Pan CC, Chiang H: Real-time dynamic telepathology through the Internet: Evaluation of a new and economic technology at Taipei Veterans General Hospital. Zhonghua Yi Xue Za Zhi (Taipei) 2001;64:277282. Wells CA, Sowter C: Telepathology: A diagnostic tool for the millennium? J Pathol 2000;191:17. Walter GF, Matthies HK, Brandis A, von Jan U: Telemedicine of the future: Teleneuropathology. Technol Health Care 2000;8:2534. Aas IH: A qualitative study of the organizational consequences of telemedicine. J Telemed Telecare 2001;7:1826. Lewis K, Gilmour E, Harrison PV Patefield S, Dickinson Y, Manning D, Griffiths C: Digital , teledermatology for skin tumours: A preliminary assessment using a receiver operating characteristics (ROC) analysis. J Telemed Telecare 1999;5(suppl 1):S57S58. Caramella D, Reponen J, Fabbrini F, Bartolozzi C: Teleradiology in Europe. Eur J Radiol 2000; 33:27. Mizushima H, Uchiyama E, Nagata H, Matsuno Y, Sekiguchi R, Ohmatsu H, Hojo F, Shimoda T, Wakao F, Shinkai T, Yamaguchi N, Moriyama N, Kakizoe T, Abe K, Terada M: Japanese experience of telemedicine in oncology. Int J Med Inf 2001;61:207215. Coma de Corral MJ, Pena HJ: Quo vadis telemedicine? Rev Neurol 1999;29:478483. Clarke B: Psychotherapy under construction. Can telepsychiatric and online services mirror the traditional counseling experience? Behav Healthc Tomorrow 1999;8:36, 3840. Schroeder JA, Voelkl E, Hofstaedter F: Ultrastructural telepathology Remote EM diagnostic via Internet. Ultrastruct Pathol 2001;25:301307. Hadida-Hassan M, Young S, Peltier S, Wong M, Lamont S, Ellisman M: Web-based telemicroscopy. J Struct Biol 1999;1125:235245. Petersen I, Wolf G, Roth K, Schluns K: Telepathology by the Internet. J Pathol 2000;191:814. Wolf G, Petersen D, Dietel M, Petersen I: Telemicroscopy via the Internet. Nature 1998;391: 613614. Brauchli K, Christen H, Haroske G, Meyer W, Kunze KD, Oberholzer M: Telemicroscopy by the Internet revisited. J Pathol 2002;196:238243. http://www.postgresql.org

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Oberholzer M, Fischer HR, Christen H, Gerber S, Bruhlmann M, Mihatsch MJ, Famos M, Winkler C, Fehr P, Bachthold L, et al: Telepathology with an integrated services digital network a new tool for image transfer in surgical pathology: A preliminary report. Hum Pathol 1993;24: 10781085. Oberholzer M, Fischer HR, Christen H, Gerber S, Bruhlmann M, Mihatsch MJ, Gahm T, Famos M, Winkler C, Fehr P, et al: Telepathology: Frozen section diagnosis at a distance. Virchows Arch 1995;426:39. Steffen B, Gianom D, Winkler C, Hosch HJ, Oberholzer M, Famos M: Frozen section diagnosis using telepathology. Swiss Surg 1997;3:2529. Adachi H, Inoue J, Nozu T, Aoki H, Ito H: Frozen-section services by telepathology: Experience of 100 cases in the San-in District, Japan. Pathol Int 1996;46:436441. Baak JP, van Diest PJ, Meijer GA: Experience with a dynamic inexpensive video-conferencing system for frozen section telepathology. Anal Cell Pathol 2000;21:169175. Della Mea V Cataldi P, Boi S, Finato N, Dalla Palma P, Beltrami CA: Image sampling in static , telepathology for frozen section diagnosis. J Clin Pathol 1999;52:761765. Della Mea V: Telepathology and the Internet. Telemed Today 1999;7:1718, 44. Della Mea V Beltrami CA: Telepathology applications of the Internet multimedia electronic mail. , Med Inform (Lond) 1998;23:237244. Della Mea V Beltrami CA: Current experiences with Internet telepathology and possible evolu, tion in the next generation of Internet services. Anal Cell Pathol 2000;21:127134. Fontelo PA: Telepathology and the Internet. Adv Clin Pathol 1997;1:9596. Okada DH, Binder SW, Felten CL, Strauss JS, Marchevsky AM: Virtual microscopy and the Internet as telepathology consultation tools: Diagnostic accuracy in evaluating melanocytic skin lesions. Am J Dermatopathol 1999;21:525531. Szymas J, Wolf G: Telepathology by the internet. Adv Clin Pathol 1998;2:133135. Rogers N, Furness P, Rashbass J: Development of a low-cost telepathology network in the UK National Health Service. J Telemed Telecare 2001;7:121123. Surveyor Corporation: Webcam32 home page. http://www.surveyor.com/webcam32_software.html Haroske G, Giroud F, Kunze KD, Meyer W: A telepathology-based virtual Reference and certification centre for DNA image cytometry. Anal Cell Pathol 2000;21:149159. Haroske G, Meyer W, Oberholzer M, Bocking A, Kunze KD: Competence on demand in DNA image cytometry. Pathol Res Pract 2000;196:285291. Furness PN, Bamford WM: Telepathology. Curr Diag Pathol 2001;7:281291.

Martin Oberholzer, MD, Department of Pathology, University of Basel, Schnbeinstrasse 40, CH4003 Basel (Switzerland) Tel. +41 61 265 2525, Fax +41 61 265 3194, E-Mail moberholzer@uhbs.ch

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4.5

Telecardiology
Benjamin Zeevi
Card Guard AG, Schaffhausen, Switzerland

Cardiovascular disease (CVD) afflicts more than 60 million people in the USA and 57 million people in Europe. In 2000, the annual direct and indirect costs of treating cardiovascular disease in the USA alone were estimated at more than USD 298 billion. CVD includes, inter alia, coronary heart disease, congestive heart failure (CHF) and arrhythmias, and in 2001 was the number 1 killer in the USA and Europe. CVD is the most common chronic disease, as well as one of the most expensive diseases for healthcare providers. As a result, cardiovascular diagnoses and treatments have always been the frontier in using new technologies. Coronary heart disease includes myocardial infarction and angina pectoris. Myocardial infarction affects 7.3 million people in the USA, and an estimated 1.1 million Americans will have a new or recurrent coronary attack each year. Angina pectoris affects 6.2 million people in the USA. In 1996, arrhythmias were estimated in 3.9 million Americans with more than 700,000 hospital discharges. Of these, approximately 2 million suffered from atrial fibrillation and flutter, the most common heart rhythm disorder. CHF affects 4.7 million people in the USA and approximately 555,000 new cases are reported each year. The total annual cost of CHF is more than USD 21 billion, and is attributed to the high costs of re-hospitalization among CHF patients. Approximately 2050% of CHF patients are re-admitted to hospitals within 30 days of discharge [1, 2]. Telecardiology is the practice of cardiology which utilizes telecommunications, and as such is a new alternate and cost-effective means of providing cardiac care. Telecardiology has one common goal to reduce the healthcare costs of chronically ill patients while providing them access to healthcare providers and maintaining their quality of life. Telecardiology has been nibbling around the edges of the field of cardiology for many years, and many cardiology

applications in telemedicine have generated the most widespread interest among providers and patients. Telecardiology originated more than 30 years ago, as the need for monitoring the first generation of implanted pacemaker patients led to the development of single-lead transtelephonic electrocardiograms. At present, individuals with pacemakers appear to make up the largest group receiving transtelephonic cardiac monitoring services. Industry sources suggest that the US pacemaker population included an estimated 680,000 patients, with approximately 140,000 of these receiving cardiac monitoring services during 1996. Transtelephonic pacemaker follow-up monitoring is used mostly in the USA, and is capable of detecting pacemaker generator malfunction, battery depletion, and lead failure [3, 4]. Telecardiology now uses state-of-the-art telecommunication and image compression technologies to manipulate tele-data. These include electrocardiograms, echocardiograms, X-rays, MRI, CT, cardiac catheterization, heart sounds and multiple vital signs to monitor cardiac patients from their home or office, and for remote consultation between cardiologists, as well as between general practitioners and cardiologists. Some of the telecardiology applications are conducted in high-tech hospital-based telemedicine rooms (echocardiograms, cardiac catheterization) but most of the telecardiology applications can be performed from a patients home. Telecardiology programs are not only connected to the consulting services but provide interpretations (ECG, echocardiogram), home health services and continuous patient and physician education. Most telecardiology applications, with the exception of transtelephonic electrocardiograms, are limited to their utilization mainly because of the high cost of the equipment and absence of reimbursement. This article will focus on telecardiology applications at home.

Transtelephonic Electrocardiogram

Twelve-Lead ECG Transtelephonic 1- to 12-lead ECG has been used for many years in evaluating patients with chest pain and symptoms suggesting possible arrhythmia such as palpitations, dizziness, presyncope and syncope. Shortening the time interval between initial chest pain and appropriate intervention is a critical factor in immediate and long-term outcome for cardiac patients. Emergency care services or mobile care units play a key role in the chain of survival concept of the National Heart Attack Alert Program Coordinating Committee. They recommend use of transtelephonic 12-lead electrocardiograms for fast diagnosis and intervention, or the pre-warning of

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receiving hospitals based on confirmed pre-hospital diagnosis. Similarly, the Task Force on the Management of Acute Myocardial Infarction (AMI) of the European Society of Cardiology published guidelines suggesting pre-hospital ECG and preferably transmission to the hospital, as the appropriate strategy for pre-hospital intervention [5, 6]. A significant reduction in hospital time delay to treatment was observed in patients transported by emergency medical system when a pre-hospital 12-lead ECG was transmitted from the field using a radio or cellular technology [7, 8]. In parallel to the development of mobile emergency services, personal monitoring systems have been designed which offer high-risk patients continuous access to a cardiac monitoring center where patients medical history and baseline ECGs are held for comparison. Such systems, usually staffed by teams of critical care unit (CCU) nurses and cardiac technicians supported by consultant cardiologists, offer instant remote diagnosis in emergency situations and can organize mobile coronary care units for fast intervention. Correspondingly, they can eliminate false alarms which otherwise may have required unnecessary use of CCU resources. Such telecardiology services have demonstrated reduced patients decision time from 3 h to 44 min when calling the service provider, thus significantly reducing the time to treatment. Decreasing mental stress of patients and their family improves their quality of life. Such a service also has the potential to reduce the cost of medical care through a reduced number of emergency room visits [9, 10]. Telecardiology facilitates real-time discussion and useful support between general practitioners and cardiologists. Several studies have demonstrated that by providing GPs with transtelephonic ECG devices and direct access to a cardiologist for on-line cardiac consultation is a reliable and efficient tool in primary care. An agreement reached regarding a management strategy can, in many cases, obviate the need for patient referral, and can also optimize healthcare costs in terms of reduced emergency room visits, hospital admissions and usage of additional diagnostic tests [11, 12]. Event Recorders Transtelephonic event recorders have been used to diagnose cardiac patients for more than 30 years. Two main types of cardiac event monitors are available, the looping memory recorder which is used mostly for pre-symptoms and the non-looping recorder for post-symptoms. During the last 10 years, with rapid technological advances, the loop recorder has become smaller and more sophisticated, and now features 13 ECG channels, programmable pre- and post-event times, a longer programmable memory, and most recently, different autotrigger functionalities for the detection of asymptomatic arrhythmias.

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Patients usually wear these loop recorders for 25 weeks. Upon patient activation, the looping memory writes the ECG into stored memory including the pre-symptomatic ECG. The patient transmits the recording for diagnosis to a monitoring center, which is staffed by trained nurses and ECG technicians. Cardiac event recorders are used for the diagnosis of palpitations, dizziness, pre-syncope and syncope, dyspnea, and chest pain, especially during intermittent symptoms. Clinical trials have demonstrated that cardiac event recorders yield more diagnoses and are more cost-effective than 48-hour Holter monitoring in patients with palpitations, syncope and pre-syncope. Cardiac event recorders are also a better choice when presenting symptoms which may correlate with events that can result in prompt patient triage or emergency care [1317]. Cardiac event recorders are mostly used in the USA where reimbursement for their usage exists, however their use in the rest of the world is limited. Home Monitoring for Patients with CHF CHF is a major health problem, and accounts for a large proportion of medical care expenditures. It is the most common indication for hospitalizations in Medicare populations. Re-hospitalization following heart failure admission is also common, particularly for the elderly, of whom 45% are re-admitted within 6 months. As a result, programs were developed to optimize outpatient treatment and prevent hospital re-admissions. These multidisciplinary programs consist of patient education, automated reminders for medication compliancy, daily self-monitoring of weight and vital signs (blood pressure, ECG, SpO2) for the detection of deterioration, and 24-hour telephone access to the healthcare provider. Many studies have demonstrated a marked improvement in the patients functional status, reduced emergency room visits and hospital admissions, thus lowering medical costs. Patients were pleased and comfortable with the use of this equipment [1823]. Twelve-Lead Digital ECG for Clinical Research Pharmaceutical companies use Clinical Research Organizations (CROs) to test the safety and effectiveness of their products. More than 50% of these tests are geared to the evaluation of cardiovascular and respiratory drugs. Additionally, most other drug evaluations require ECG monitoring of cardiovascular side effects. CROs are continually seeking ways to make the clinical trial phase, involving the management of sizeable patient groups and large amounts of data, a more timely and cost-efficient process. From the fall of 2002 the FDA will only accept ECG data collected for clinical trials in digital annotated format. Thus using 12-lead transtelephonic digital ECG for clinical research combined with central reading of the tracing is now mandatory for the CROs.

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It is likely that telecardiology will grow and its usage will expand around the world in the coming years. Telecardiology will mature sufficiently as its advantages are realized for enhancing patient care at a lower cost.

References
1 2 3 4 5 American Heart Association, Heart and Stroke Facts, 2001. Organization for Economic Cooperation and Development, 1998. Cardiovascular Monitoring Equipment Markets: USA, Europe, Japan. Frost & Sullivan, 1999. Platt S, Furman S, Gross J, et al: Transtelephonic monitoring for pacemaker follow-up 19811994. PACE 1996;19:20892098. National Heart Attack Alert Coordinating Committee Access to Care Subcommittee: Staffing and equipping emergency medical services systems: Rapid identification and treatment of acute myocardial infarction. Am J Emerg Med 1995;13:5866. Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology: Acute myocardial infarction: Pre-hospital and in-hospital management. Eur Heart J 1996;1:4346. Kereiakes DJ, Gibler B, Martin LH, et al: Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: A preliminary report from the Cincinnati Heart Project. Am Heart J 1992;123:835. Karlsten R, Sjoqvist BA: Telemedicine and decision support in emergency ambulances in Uppsala. J Telemed Telecare 2000;6:17. Roth M, Herling V Vishlitzki V: The impact of a new cardiac emergency service on subscribers , requests for medical assistance: Characteristic and distribution calls. Eur Heart J 1995;16: 129133. Roth N, Lamov Z, Carthy Z, et al: Potential reduction of costs and hospital emergency department visits resulting from prehospital transtelephonic triage. Clin Cardiol 2000;23:271276. Shanit D, Cheng A, Greenbaum RA: Telecardiology: Supporting the decision-making process in general practice. J Telemed Telecare 1996;2:713. Scalvini S, Zanelli E, Domenighine D, et al: Telecardiology community: A new approach to take care of cardiac patients. Cardiologia 1999;44:921924. Lintzer M, Pritchett E, Pontinen M, et al: Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol 1990;66:214219. Wu J, Kessler D, Chakko S, et al: A cost-effectiveness strategy for transtelephonic arrhythmia monitoring. Am J Cardiol 1995;75:184185. Kinlay S, Leitch J, Neil A, et al: Cardiac event recorders yield more diagnoses and are more costeffective than 48-hour Holter monitoring in patients with palpitations. Ann Intern Med 1996;124: 1620. Fogel R, Evans J, Prystowsky E: Utility and cost of event recorders in the diagnoses of palpitations, presyncope and syncope. Am J Cardiol 1997;79:207208. Zimetbaum P, Kim KY, Ho KKL, et al: Utility of patient-activated cardiac event recorders in general clinical practice. Am J Cardiol 1997;79:371372. Heidenreich P, Ruggerio C, Massie B, et al: Effect of a home monitoring system on hospitalization and resource use for patients with heart failure. Am Heart J 1999;138:633640. Cordisco ME, Benaminovitz A, Hammond K, et al: Use of telemonitoring to decrease the rate of hospitalization in patients with severe congestive heart failure. Am J Cardiol 1999;84:860862. Nanevicz T, Piette J, Zipkin D, et al: The feasibility of a telecommunications service in support of outpatient congestive heart failure case in a diverse patient population. Congest Heart Fail 2000;6: 140145. Program cuts CHF hospitalizations up to 84%. CHF Dis Manage 2000;June:6164.

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Johnston L, Wheeler J, Deuser J, et al: Outcomes of the Kaiser Permaente Tele-Home Health Research Project. Arch Fam Med 2000;9:4045. Shah N, Der E, Ruggiero C, et al: Prevention of hospitalization for heart failure with an intensive home-monitoring program. Am Heart J 1999;138:633640.

Benjamin Zeevi, MD Vice President Business Development 8, Medical Director, Card Guard AG, Rheinweg 7, CH8200 Schaffhausen (Switzerland) Tel. 41 52 632 0050, Fax 41 52 632 0051, E-Mail bzeevi@cardguard.com

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4.6

Telemedicine in Oncology
Ian Olver
Royal Adelaide Hospital, Cancer Centre, University of Adelaide, S.A., Australia

Teleoncology has been defined as delivering clinical oncology services at a distance and has come to encompass the use of electronic devices to aid clinical diagnosis, treatment and follow-up based on the transfer of video images of clinicians and patients and data including pathology and radiology images, graphics and text [1, 2]. An initial application of telemedicine technology to oncology was recorded in 1990 where psychiatrists raised the possibility of using interactive video to manage psychosocial problems in cancer patients [3].

Range of Uses

A common model for teleoncology is real-time videoconferencing. Even within this model there are several possibilities. The opinions of a multidisciplinary cancer team can be provided to rural and remote centers that may only be served by generalists [4]. Here the teleoncology link is between clinicians. The patients case is presented and the interaction is enhanced if the patients radiology and pathology can be presented and discussed. This provides a second opinion for the remote clinician. A second model is clinicians videoconferencing with remote patients and their referring clinician or nurse who provides details of the physical examination, which cannot be done by telemedicine [1]. These interactions can occur hospital to remote hospital, hospital to community center, or to a home or community to home. Once in place, the link can be used for any patient support measure or educational activity. It enhances peer review and is part of quality assurance.

A further use for teleoncology is to obtain second opinions by storing all the patients data, including case notes, imaging and pathology digitally, then forwarding them to experts, often internationally for second opinions which can be digitally returned [2]. These systems require less bandwidth and do not require the sender and receiver to be in convenient time zones. More specialized uses of teleoncology equipment include the data transfer for CT-based remote 3D radiation oncology treatment planning [5]. Experts from a distance can direct endoscopies in remote centers and selected surgical techniques, such as prostatic biopsy can be performed [6].
Equipment

At the top of the range, the equipment required is a purpose-built telemedicine theater at a tertiary center for staging multidisciplinary meetings, with the capability of demonstrating radiology, pathology and including multimedia educational facilities. These use ISDN (integrated systems digital network) lines, and conferences can be recorded on videotape. The cost of roll-away units, which can be used in any room equipped with an ISDN, has fallen dramatically over the past decade to be affordable by most hospitals, while a PC equipped with a camera is the cheapest equipment for digital videoconferencing [7]. Using the ordinary telephone system, personal computers can be equipped with small cameras for Internet-based conferencing while a videophone is cheap and simple to install in patients homes.
Evaluation of Teleoncology

Evaluating teleoncology is difficult because of the many models used. Since often a major aim is to export multidisciplinary oncological expertise to a rural or remote area, the number of patients and clinicians evaluating such a link will be small and there have not been standardized evaluation tools to enable data to be pooled. There is also a difference between a videoconferencing service where the teleoncology is used to supplement face-to-face consultations and therefore the patients and clinicians have the ability to compare the two, and those links where videoconferencing adds oncological expertise where none had previously existed outside of sporadic phone calls to a variety of specialists and where distance precludes the choice of regular face-to-face consultations. Patient Satisfaction One of the early studies of patient satisfaction with teleoncology was from the University of Kansas where outreach clinics, subject to cancellation

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when the oncologist was unable to travel due to bad weather, were supplemented by a videoconferencing link [8]. They used a 12-question survey with 5-point scales and were able to compare onsite and telemedicine consultations. The total patient population surveyed was 39. The teleoncology consultation compared favorably to onsite visits except following onsite consultations where patients described more difficulty in being candid in a videoconference, although in subsequent experience only 3 of over 250 patients have declined to use the videoconference [1]. Levels of satisfaction with the telemedicine consultation also correlated with the oncologist seen. Similar patient satisfaction with initial interviews was recorded in a teleoncology evaluation in Scotland [9]. In a subsequent study in Kansas using semistructured interviews, patients saw convenience of access as a self-evident advantage of teleoncology [10]. This largely negated the disadvantages of wishing to limit teleoncology consultations to routine follow-ups rather than being used to convey more sensitive issues despite the fact that this had occurred. There may be anxiety about having a nurse at the remote end or the frame tension of not knowing who is outside the view of the camera at the doctors end. Patients also expressed concern about the reliability of a nurse as a proxy examiner. In Australia, we reported a teleoncology model of remote clinicians presenting patient data to a tertiary center multidisciplinary team without the patient being present, but surveyed the remote patients to assess their level of satisfaction [4]. Generally, the patients were satisfied by having obtained a range of expert opinions and because they were either saved travel or had their length of stay away from home reduced if a prior teleoncology consult had taken place. Clinician Satisfaction The Kansas teleoncology project reported a survey of their tertiary-based clinicians who were conducting videoconferencing clinics with rural cancer patients, which suggested general satisfaction [11]. Physicians and surgeons in the Scottish study, who found the equipment easy to use, recorded similar satisfaction. They considered the videoconference better than a phone call but gave no reasons for this. There were some problems scheduling all the participants to be together at the same time. In Missouri, rural allied health professionals were surveyed as telemedicine units were being installed to collect baseline data in order to evaluate the impact on their work. Just over 18% anticipated that telemedicine would have a large effect on their work [12]. In our Australian evaluation of videoconferencing between 20 clinicians in a tertiary and remote center, all found it useful [4]. The isolated clinicians felt better supported and the tertiary clinicians reported improved communications over

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the use of a telephone only. The remote clinicians valued the input of a multidisciplinary team and cited educational and peer review activities as strengths of the system. Decreased clinician traveling time was also seen as an advantage. The difficulties with teleoncology were grouped into technical issues such as breakdowns, problems with impersonality of not knowing all the healthcare workers at either end of the teleoncology consult which could also be problematic for patient confidentiality, and lack of a reimbursement for a videoconference. From our experience in establishing teleoncology it is useful to identify a champion at either end of the proposed link to promote it to colleagues [13]. Occasional face-to-face visits can decrease the impersonality of the teleoncology link. Most importantly, telemedicine should not disrupt normal practice. We hold all our multidisciplinary meetings in the teleoncology theater, whether a videoconference occurs or not, and arrange for pathology and radiology to be available before the videoconference because it is the usual practice of pathologists and radiologists to prepare their reports rather than give instant opinions. The prior data can be sent in hard copy or digitally depending on what equipment is available.

Economic Evaluation

There is a paucity of data on the cost-effectiveness of teleoncology and indeed of telemedicine generally. Hakansson and Gavelins [14] literature survey found only 16% telemedicine publications mentioned economics, and Whitten et al. [15] found that most studies were inadequately designed or conducted and was unable to perform a meta-analysis. One of the problems of assessing cost-effectiveness is the need to identify a comparator to the teleoncology link. The Kansas program was able to compare the costs of a videoconference with a physician visiting an outreach clinic and found the cost for teleoncology to be less, but still 5 times higher than if the patient had come to the parent clinic [16]. Even then, costing can be difficult because a doctor while traveling also loses the opportunity to consult with patients in that time [17]. Once the telemedicine equipment is purchased it can be put to multiple uses. It can for example be used for educational purposes and revenue generated from that [18]. The cost of the equipment can be defrayed over a lifetime and teleoncology becomes more cost-effective as the volume of consultations increases [19]. Costing the equipment should allow for the future decreases in these equipment costs [17]. Associated with the Australian study we found that introducing a teleoncology consultation prior to a patient being transferred from a remote center to the metropolitan center for adjuvant radiotherapy in breast cancer translated

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into a decrease in the average length of stay of 8.35 days and that is the data around which our cost analysis can be built [4].

Medicolegal Issues

The medicolegal issues with telemedicine are not unique but shared by other distant communications and medical consultations [4, 20]. Obviously there are the same issues of privacy and confidentiality as with any consultation, but it may not be apparent to the patient if there are people off camera at one end of the link. Any record made of the consultation should be confidential. Liability for an opinion may be problematic, particularly in direct consultations with patients who have a clinician with them to report on the physical examination. This may be more confused if the teleoncology link crosses state or international boundaries. Any electronic information on the Internet or directly transmitted should be accurate. Also, if a teleoncology link exists to improve the quality of remote specialist care, could a remote clinician be liable for not using it?
The Future

As teleoncology equipment becomes more sophisticated in the quality, quantity and speed of information transfer, yet becomes cheaper, it will become a more attractive candidate for solving the problems of access to multidisciplinary specialist care for rural and remote communities [4]. Future uses may encompass everything from education utilizing virtual reality to remote guidance of nanotechnology therapeutic devices.

References
1 2 Doolittle GC, Allen A: Practising oncology via telemedicine. J Telemed Telecare 1997;3:6370. Vorozhtcov G, Chissov V Danilov A, Kazinov V Sokolov V Frank G: Perfect DiViSy technology , , , for video network in medicine (Moscow Information Network for Teleoncology); in Nerlich M, Kretschmer R (eds): The Impact of Telemedicine on Health Care Management. Moscow, IOS Press, 1999, pp 119125. Lipsedge M, Summerfield AB, Ball C, Watson JP: Digitised video and the care of outpatients with cancer. Eur J Cancer 1990;26:10251026. Olver IN, Selva-Nayagam S: Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Telemed J 2000;6:213218. Stitt J: A system of teleoncology at the University of Wisconsin Hospital and Clinics and Regional Oncology Affiliate Institutions. Wisc Med J 1998;97:3842. Purkable TL, Bauer JJ: A telementored transrectal ultrasound-guided prostate biopsy. Stud Health Technol Inform 1999;62:275277. Yellowlees PM, Kennedy C: Telemedicine; here to stay. Med J Aust 1997;166:262265.

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Allen A, Hayes J: Patient satisfaction with teleoncology: A pilot study. Telemed J 1995;1:4146. Kunkler IH, Rafferty P, Hill D, Henry M, Foreman D: A pilot study of teleoncology in Scotland. J Telemed Telecare 1997;4:113119. Mair F, Whitten P, May C, Doolittle GC: Patients perceptions of a telemedicine speciality clinic. J Telemed Telecare 2000;6:3640. Allen A, Hayes J, Sadasivan R, Williamson SK, Wittman C: A pilot study of the physician acceptance of teleoncology. J Telemed Telecare 1995;1:3437. Hicks LL, Boles KE, Hudson ST, Koenig S, Madsen R, Kling B, Tracy J, Mitchell J, Webb W: An evaluation of satisfaction with telemedicine among health-care professionals. J Telemed Telecare 2000;6:209215. Olver IN: Telemedicine: Prospects and realities. Med Today 2001;1:8183. Hakansson S, Gavelin C: What do we really know about the cost-effectiveness of telemedicine? J Telemed Telecare 2000;6(suppl 1):3336. Whitten P, Kingsley C, Grigsby J: Results of a meta-analysis of cost-benefit research: Is this a question worth asking? J Telemed Telecare 2000;6(suppl 1):46. Doolittle GC, Harmon A, Williams A, Allen A, Boysen CD, Wittman C, Mair F, Carlson E: A cost analysis of a teleoncology practice. J Telemed Telecare 1997;3(suppl 1):2022. Mair FS, Haycox A, May C, Williams T: A review of telemedicine cost-effectiveness studies. J Telemed Telecare 2000;6(suppl 1):3840. Allen A, Doolittle G: Teleoncology; in Bashshur B, Sanders JH, Shannon GW (eds): Telemedicine Theory and Practice. Springfield, Thomas, 1997, pp 249264. Zollo S, Kienzle M, Loeffelholz P, Sebille S: Telemedicine to Iowas correctional facilities: Initial clinical experience and assessment of program costs. Telemed J 1999;5:291301. Brahams D: The medicolegal implications of teleconsulting in the UK. J Telemed Telecare 1995;1: 196201.

Ian Olver, MD, Royal Adelaide Hospital, Cancer Centre, University of Adelaide, North Terrace, Adelaide, SA 5000 (Australia) Tel. 61 882 225577, Fax 61 882 322148, E-Mail ian.olver@adelaide.edu.au

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4.7

Telemedicine in Ophthalmology
Glenn G. Hammack
Health Informatics and Telemedicine, University of Texas Medical Branch in Galveston, Tex., USA

Ophthalmology has frequently been included in discussions of the promise of telemedicine and its impact on medical care [1, 2]. Complete overviews of the topic have recently appeared in ophthalmologic literature in Great Britain [3], the USA [4] and India [5]. Teleophthalmology was identified in a study of telemedicine challenges and a framework to overcome them [6]. Ophthalmology is a frequently evaluated discipline in telemedicine, due to its status as a frequent referral need of the primary care practitioner.

Pilot Projects

Ophthalmology has been evaluated in a significant number of telemedicine pilot projects over the past 10 years. In Australia, ophthalmology via telemedicine has been piloted in the prison population [7]. Preliminary evaluation of remote evaluation of diabetic retinopathy has been done [8]. The British military has evaluated tele-ophthalmology in the field [9]. In Israel, primary care ophthalmology via telemedicine has been explored [10]. Triage of ocular emergencies via telemedicine has been tested in Australia [11, 12]. Ophthalmology was included in a telemedicine evaluation in the Azerbaijan Republic [13], and a telemedicine link between Hawaii and the Kwajalein Atoll in the Pacific included ophthalmologic consults [14]. A specially designed space medicine pack for NASA, evaluated in the USA, included ocular imaging equipment [15]. There are few medical disciplines in telemedicine that have had this diversity of application and experimentation.

TM Technologies for Ophthalmology

The advent of ophthalmology applications in telemedicine has followed the development of reasonable cost digital imaging devices that can perform in low light levels. The charge-coupled device (or CCD) color camera, developed for the consumer camcorder industry, revolutionized digital ocular imaging instruments. The availability of these new devices since 1990 has enabled the development of ophthalmic telemedicine. Typical devices required for ophthalmic telemedicine are (1) a video-equipped slit-lamp biomicroscope and (2) a digital fundus camera. Some applications require a camera for imaging the external eye and adnexa as well. There are two commonly used strategies in ocular telehealth for sharing of ocular examination images. Store and forward uses electronic still images as the examining technology. These images are captured and then are electronically shared between the patient location and specialist for evaluation. Specific digital image formats for ophthalmic images have been proposed [16]. This technology was used to image the eye during spaceflight to evaluate spacecraft air quality [17], and also provided ophthalmic consult capabilities for servicemen in Kuwait [18]. The alternative to store and forward imaging is real-time video. This modality requires connectivity of sufficient bandwidth to support moving video, usually 128 kbps or more. This technology was utilized in many of the ophthalmology telemedicine clinical pilot projects noted above, and in the clinical applications noted below. In addition to patient use, real-time video has been used in ophthalmology education to support an international conference [19] and live telementoring of surgery [20].

Clinical Applications

Telemedicine has been applied to diverse clinical challenges in ophthalmology. Use of telemedicine in diagnosing strabismus was evaluated [21]. Store-and-forward images were e-mailed from Cuba and Romania to the USA for evaluation, and the method was found to be effective. Another evaluation found telemedicine diagnosis of strabismus accurate with the exception of small vertical deviations [22]. Comprehensive management of diabetic eye disease has been undertaken [23]. Digital ocular images were found to be clinically comparable to standard Early Treatment Diabetic Retinopathy Study (ETDRS) photographic images for the diagnosis and evaluation of the ocular signs of diabetes. Real-time video was found to be effective in allowing remote consultations between a general practitioner and ophthalmologist [24]. Applications in remote screening with telecommunications via satellite have

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been successful [25]. A digital indirect ophthalmoscope has been developed and successfully evaluated for retinal and anterior segment conditions [26]. Post-surgical evaluation of patients who have had ophthalmic surgery [27] had high user acceptance. Glaucoma management via telemedicine [28] demonstrated lower costs per visit for rural patients but noted a decreased quality of ocular images as compared to university clinic photography. Telemedicine has been used for post-operative follow-up of corneal transplant patients [29] and also evaluated for early diabetic retinopathy screening [30]. Telemedicine has provided innovative developments in clinical teaching, through the development of an integrated computer multimedia system for ocular teaching and collaboration [31]. In addition, significant interdisciplinary education efforts have been supported by ocular telemedicine [32].

Effectiveness of Telemedicine in Ophthalmology

The clinical impact of ophthalmic telemedicine programs is not consistent, and there is little similarity to the evaluation methods between studies. Recently, in South Africa, a combination telemedicine system that provided ophthalmology services demonstrated decreasing use over time due to technical and organizational concerns [33]. A Finnish study found ophthalmic telemedicine to be cost-effective only when more than 110 patients per year were seen using the system [34]. Viewing the electronic images on a telemedicine system caused practitioners to lose confidence in diagnosis before they lost accuracy when compared to photographic images [35]. Clinical and technical protocols were found to be key in maintaining diagnostic confidence with a telemedicine system, and operational success was limited due to the cost of the digital ocular imagers needed and the skilled personnel required to operate them [36]. A significant study compared ocular examinations conducted via telemedicine and by conventional methods to a reference standard. There was high agreement between the accuracy of the telemedicine examinations and the conventional examinations [37].

Conclusions

There have been a significant number of ophthalmic telemedicine programs developed and implemented. It remains unclear whether ophthalmic care is suitable for the medium of telemedicine. Some studies show a high reliability of ocular telemedicine consults. Others indicate that the costly ocular imaging equipment and skilled personnel required at the patient site prevents

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ophthalmic telemedicine from being effective. Definitive clinical and economic successes have yet to be documented. More study is required, with consistency in study design and evaluation techniques.

References
1 Morin JE, Klein SA, Verdi MG, Mehl DC, Gimbel HV Cuzzani O, Gupta SC: Introduction of new , telemedicine applications into ophthalmology. Standardized evaluation of transmission modalities. Stud Health Technol Inform 1996;29:642648. Flowers CW Jr, Baker RS, Khanna S, Ali B, March GA, Scott C, Murrillo S: Teleophthalmology: Rationale, current issues, future directions. Telemed J 1997;3:4352. Murdoch I: Telemedicine. Br J Ophthalmol 1999;83:12541256. Li HK: Telemedicine and ophthalmology. Surv Ophthalmol 1999;44:6172. Prasad S, Nagpal M, Sharma OP, Nagpal PN: The impact of information technology on the practice of ophthalmology. Ind J Ophthalmol 2000;48:237243. Lamminen H, Voipio V Ruohonen K: Telemedicine framework and applications in dermatology , and ophthalmology. Ann Med 2001;33:222228. Barry CJ, Henderson C, Kanagasingam Y, Constable IJ: Working toward a portable tele-ophthalmic system for use in maximum-security prisons: A pilot study. Telemed J E Health 2001;7: 261265. Tennant MT, Rudnisky CJ, Hinz BJ, MacDonald IM, Greve MD: Tele-ophthalmology via stereoscopic digital imaging: A pilot project. Diab Technol Ther 2000;2:583587. Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M: The first telemedicine link for the British Forces. J R Army Med Corps 1998;144:125130. Shanit D, Lifshitz T, Giladi R, Peterburg Y: A pilot study of tele-ophthalmology outreach services to primary care. J Telemed Telecare 1998;4(suppl 1):12. Rosengren D, Blackwell N, Kelly G, Lenton L, Glastonbury J: The use of telemedicine to treat ophthalmological emergencies in rural Australia. J Telemed Telecare 1998;4(suppl 1):9799. Blackwell NA, Kelly GJ, Lenton LM: Telemedicine ophthalmology consultation in remote Queensland. Med J Aust 1997;167:583586. Samedov RN: An Internet station for telemedicine in the Azerbaijan Republic. J Telemed Telecare 1998;4(suppl 1):4243. Delaplain CB, Lindborg CE, Norton SA, Hastings JE: Tripler pioneers telemedicine across the Pacific. Hawaii Med J 1993;52:338339. Crump WJ, Levy BJ, Billica RD: A field trial of the NASA Telemedicine Instrument Pack in a family practice. Aviat Space Environ Med 1996;67:10801085. Papakostopoulos D, Everingham M, Gogolitsyn Y, Dodson K, Papakostopoulos S, Dean-Hart JC: Comprehensive standardized ophthalmic telemedicine. J Telemed Telecare 1997;3(suppl 1):4952. Ogle JW, Cohen KL: External ocular hyperemia: A quantifiable indicator of spacecraft air quality. Aviat Space Environ Med 1996;67:423428. Lattimore MR Jr: A store-forward ophthalmic telemedicine case report from deployed US Army Forces in Kuwait. Telemed J 1999;5:309313. Papakostopoulos D, Williams A, Ramani V Hart CJ, Dodson K, Papakostopoulos S: Evaluation of , the first international teleconference in ophthalmology. J Telemed Telecare 1999;5(suppl 1):1720. Camara JG, Rodriguez RE: Real-time telementoring in ophthalmology. Telemed J 1998;4: 375377. Helveston EM, Orge FH, Naranjo R, Hernandez L: Telemedicine: Strabismus e-consultation. J Am Assoc Pediatr Ophthalmol Strab 2001;5:291296. Cheung JC, Dick PT, Kraft SP, Yamada J, Macarthur C: Strabismus examination by telemedicine. Ophthalmology 2000;107:19992005. Bursell SE, Cavallerano JD, Cavallerano AA, Clermont AC, Birkmire-Peters D, Aiello LP, Aiello LM: Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic

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24 25 26 27 28

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Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy. Ophthalmology 2001;108:572585. Blomdahl S, Maren N, Lof R: Tele-ophthalmology for the treatment in primary care of disorders in the anterior part of the eye. J Telemed Telecare 2001;7(suppl 1):2526. Constable IJ, Yogesan K, Eikelboom R, Barry C, Cuypers M: Fred Hollows lecture: Digital screening for eye disease. Clin Exp Ophthalmol 2000;28:129132. Yogesan K, Cuypers M, Barry CJ, Constable IJ, Jitskaia L: Tele-ophthalmology screening for retinal and anterior segment diseases. J Telemed Telecare 2000;6(suppl 1):9698. Murdoch I, Bainbridge J, Taylor P, Smith L, Burns J, Rendall J: Postoperative evaluation of patients following ophthalmic surgery. J Telemed Telecare 2000;6(suppl 1):8486. Tuulonen A, Ohinmaa T, Alanko HI, Hyytinen P, Juutinen A, Toppinen E: The application of teleophthalmology in examining patients with glaucoma: A pilot study. J Glaucoma 1999;8: 367373. Shimmura S, Shinozaki N, Fukagawa K, Tsubota K: Telemedicine in the follow-up of corneal transplant patients. J Telemed Telecare 1997;3:227228. Schiffman JS, Tang RA: Is tele-ophthalmology the answer to diabetic retinopathy screening? Telemed Today 1997;5:38. Hariprasad R, Shin DS, Berger JW: An intelligent, interactive platform for ophthalmic teaching, telemedicine, and telecollaboration: Design considerations and prototype construction. Stud Health Technol Inform 1999;62:124129. Beauregard D, Schiffman JS, Tang R: Collaborative telemedicine between optometry and ophthalmology: An initiative from the University of Houston. Stud Health Technol Inform 1999;64: 173178. Gulube SM, Wynchank S: Telemedicine in South Africa: Success or failure? J Telemed Telecare 2001;7(suppl 2):4749. Lamminen H, Lamminen J, Ruohonen K, Uusitalo H: A cost study of teleconsultation for primarycare ophthalmology and dermatology. J Telemed Telecare 2001;7:167173. Briggs R, Bailey JE, Eddy C, Sun I: A methodologic issue for ophthalmic telemedicine: Image quality and its effect on diagnostic accuracy and confidence. J Am Optometr Assoc 1998;69: 601605. Schiffman JS, Li HK, Tang RA: Telemedicine enters eye care: Practical experience. J Ophthal Nurs Technol 1998;17:102106. Nitzkin JL, Zhu N, Marier RL: Reliability of telemedicine examination. Telemed J 1997;3: 141157.

Glenn G. Hammack, MD, Director of Health Informatics and Telemedicine, University of Texas Medical Branch in Galveston, 2201 Market Street, Suite 718, Galveston, TX 775551006 (USA) Tel. 1 409 7472601, Fax 1 409 7472603, E-Mail glenn.hammack@utmb.edu

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4.8

Implementation of a Telepsychiatric Network in Northern Finland

Marja-Leena Mielonen, Leena Visnen, Juha Moring, Arto Ohinmaa, Matti Isohanni
Department of Psychiatry, University Hospital of Oulu, Finland

The domain of telemedicine (medicine at a distance) is considered to include all the electronic communication which takes place over a telematic network and the numerous special commercial applications of image and sound transmission involved in it. The application of telemedicine means that the examination of a patient, control visits and treatment are possible through the use of telecommunications, making the experts help and the transfer of patient information to the right place possible regardless of where the patient or the relevant information is actually located. Telemedicine also involves consultations and supervision between professionals. Telepsychiatry refers to interactive psychiatric communication through a telematic network, which permits simultaneous sound and image connections between two or more consultative parties. The principal telepsychiatric communication method is videoconference, which can replace the customary consulting hours whenever the patients and their families live a long distance away from the doctor. Videoconferencing has been defined as the use of television sets linked by telephone lines to enable a group of people to communicate with each other in sound and vision [1]. One of the advantages of using videoconference contacts is that the expert knowledge can be attained when and where it is needed. In this way it is possible to enhance regional equity. Another possibility is to exploit modern technology in treatment, consultation, supervision and teaching by medical staff. Our aim is to use videoconferencing and its applications in Northern Finland and describe this implementation here. The only university hospital of this area is located in Oulu. Because videoconferencing saves travelling, time, trouble and expenses, it is rapidly increasing as a means of daily patient care

and staff training in Finland. However, there is not yet sufficient evidence about the cost-effectiveness of videoconferencing in psychiatry.

Historical Development of Videoconferencing

The application of the videoconference method in medicine began in the 1950s. Experiments conducted in Nebraska in 1959 were published in the first documentation on that process [2]. Experimentation continued subsequently in different parts of Canada and the USA [35]. As a precursor of videoconference equipment, a videophone was developed in the USA in 1964. It was first used experimentally in conditions such as internal TV transmission in the hospital, and the equipment was also used for surveillance of other connections. In the 1990s, the cost of videoconferencing decreased substantially owing to the development of low-cost, PC-based equipment and reductions in the cost of telecommunication. At the same time, the quality of both sound and picture improved. Videoconferencing has subsequently been employed successfully for many purposes in telepsychiatry.

The Use of Videoconferencing in Psychiatry in Oulu

The first telepsychiatric experiments in Finland were carried out at the Department of Psychiatry of Oulu University Hospital in 1995. The Department of Psychiatry set up a system of videoconferencing applications in the spring of 1995 in cooperation with two regional pilot health centres and two educational establishments on patient work, e.g. family therapy, patient negotiations, counselling, teaching and administrative negotiations. A detailed description of the project has been published elsewhere [68]. The novel Telpsyko project for the years 20012002 aims to set up an integrated distribution system for public health service facilities (the best expertise available at the time, treatment cooperation, cost-effectiveness) and to improve the quality of shared information both in data production (reliability, quickness, ease of use, compatibility and confidentiality), and to create a reliable infrastructure (sufficient resources, confidentiality, accessibility). The results so far have been promising. Interactive videoconferencing provides an easy, fast and relatively inexpensive method to offer psychiatric services across long distances [69]. Below, we will present some preliminary practical conclusions based on this project.

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Norway

Sweden

60 miles (n.100 km)

A r c t i c C ir c l e
Rovaniemi
Tornio Kuusamo Taivalkoski

Russia

Department of Psychiatry Oulu University Hospital f Pulkkila Yliviesk a Kokkol a

Suomussalmi Kajaani

Finland

Savonlinna Imatra Kuusankoski Turku Hanko Clinical responsibility area of Oulu University Hospital

Fig. 1. Connections from Oulu University Hospitals Department of Psychiatry.

Responsibility Area Oulu University Hospital is responsible for the demanding specialized medical care of a population of approximately 720,000, serving the whole of Northern Finland. In this area, the need for psychiatric community services has increased markedly at the expense of hospital treatment. During 2001, the Clinic of Psychiatry had a total of 600 h of telepsychiatric connections. 40% of the on-line time was used for teaching, 24% for occupational supervision, 16% for consultations and patient negotiations and 20% for training. The overall number of consultations did not increase in this region, but a greater proportion of the consultations and discussions were done by videoconferencing [8, 9]. The supervision and training that the health service staff needed were mostly obtained from the Department of Psychiatry, Oulu University Hospital (fig. 1).

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Practical Experiences The experiences in patient care have been positive. The patients and their families have been less negative about videoconferencing than expected. The attitudes of the staff have become more positive along with the increase in participation and user experience. The workers who carried out family therapy sessions and supervision pointed out, among other things, that the participants have to take turns to speak in a videoconference and cannot speak simultaneously, as normally in a family session. This helps to structure the interaction. Participants in family therapy and supervision generally want to continue with videoconferences. It is important to discover the possible shortcomings in the examination that might affect treatment via videoconferencing. The normal physical contact is lacking in a videoconference, such as shaking hands and touching. It is not possible to sense smell, for example. The significance of these factors has not been properly evaluated yet. Nowadays, many health organizations use the new technology in their distance-caring practice. The participants in a videoconference should know each other beforehand. At the beginning of the videoconference, the content of the meeting should be explained, especially to first-time patients and relatives. The videoconferencing treatment sessions are entered in the patients case records. The doctor or other specialist always needs to assess the suitability, acceptability and legality of the decisions concerning a patient reached via videoconferencing. Written consent for treatment is recommended. The current Finnish legislation does not recognise the use of videoconference systems in treatment. Legally, videoconferencing is equated to conventional telephone consultation, and the legal responsibility is therefore at the site where the patient is. Furthermore, can we equate a videoconference with a face-to-face consultation? In most clinically relevant aspects we can, but not in all. For example, how does one estimate the patients suicide risk on the basis of a videoconference, if one must settle the (legal) responsibility issues? The consulting doctor can never take full responsibility for a patient. Cases have been reported from Australia in which a specialist working through telepsychiatry has, under the requirements of a mental health act, performed an assessment of a patient who has been confirmed to be mentally ill by a magistrate [10, 12]. In our previous study [6], the personnel, patients, relatives and other social and healthcare staff who had participated in videoconferences were given a user survey questionnaire after the sessions. The participants were satisfied with the quality of the audio, the quality of the video, and the general quality of the videoconferencing interaction. The participants were seldom unhappy after videoconference negotiations. Technically, the connections could be established nearly in every time.

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Cost Savings Telepsychiatry is feasible for clinical negotiations with people in remote areas instead of the conventional face-to-face negotiations at the ward [8]. At the Department of Psychiatry, Oulu University Hospital, patient care planning negotiations are arranged with the psychiatric personnel of the primary care units and the relatives in the municipality. According to our feasibility study [8], both primary and special care personnel, relatives and patients assessed the quality of both technical factors and the negotiation itself to be good. Over half of the primary care personnel would have been unable to participate in conventional negotiations at a psychiatric ward due to the long distances. The most important reason for the primary care personnel to arrange the negotiation by videoconferencing was the costs. Of the respondents, 90% were satisfied with the quality of the communication via videoconferencing [8]. The price range of the videoconferencing equipment available in Finland is wide. In 2001, the prices varied within EUR 12,00050,000 (1 EUR USD 1.8). The installation costs of the ISDN lines were about EUR 330 per line. The lease for one ISDN line was about EUR 20 per month. The cost of a videoconference is 6 times the cost of a telephone call. The lease for the gateway needed for a multipoint conference (i.e. a conference connecting more than two sites) varied (13 ISDN) from EUR 40 to 60 per site when the system was used for domestic and district calls. In the Department of Psychiatry of Oulu University Hospital, the cost of the PC-based videoconferencing equipment and three ISDN lines was approximately EUR 15,000. The health centres used similar equipment. At the moment, even cheaper equipment alternatives are available [8, 9]. The costs of videoconferencing were half of the costs of conventional negotiations. For a Kuusamo health centre doctor, it takes an entire working day to travel to a psychiatric meeting in the Oulu University Hospital, the distance being about 200 km (fig. 1). The cost of a 1.5-hour meeting for him is about EUR 300. A comparison of the travelling and videoconferencing alternatives shows that videoconference is economically feasible between Kuusamo and Oulu. The cost-saving can be obtained with a relatively small number of meetings (2530) per year, assuming that 30% of the transmissions from the Department of Psychiatry and 60% of those from the health centres are between these sites. However, efficient use of the videoconferencing equipment lowers the fixed costs per transmission, and then the only significant cost of telepsychiatry in videoconferencing is the salary costs of the participants [8]. Negotiations via videoconferencing are, in the long run, cost-saving compared to the conventional practice. Videoconferencing can improve the quality of psychiatric care and increase cooperation between primary and secondary care units.

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Table 1. Practical requirements in videoconferencing A special videoconference room or other space needs to be provided The quality of sound is important picture and sound must be integrated A clear picture is important in practice, three ISDN lines (i.e. 384 kb/s) are necessary A zoom function on the camera has been found to be useful An ability to control the camera is required at both ends A document camera (for the purpose of the show text or figures) or a PC for the slide show important especially for teaching The novice benefits from the experienced technical assistant

Practical Requirements Staff training takes time, and many doctors, nurses and other workers personally contact others via videoconferencing. A good videoconferencing situation demands very much from both the user technology and the environment (table 1). The videoconference room should be situated in or near the admission area. The videoconferencing room must be peaceful and soundproof for professional secrecy. The compatibility of the equipment should be guaranteed by standardization; compatibility problems have occurred from time to time, and these have impeded communications. Naturally, one should seek to avoid cancellation of previously agreed appointments with the patient. However, we were sometimes unable to establish a contact because either the sound or the image did not transfer adequately between the conference points. We always assess the use of the videoconference system in psychiatry from the point of view of different user parties, operation, productivity and acceptability as well as effectiveness. According to our experience, when videoconferencing is started, it is necessary to give written instructions and to provide staff training. The goal is to make each professional able to act independently in an on-line situation. Beginners make a lot of mistakes (light, angle of view and audibility), but acquire more skills along with increasing experience. The participants experience of videoconferencing and familiarity with the equipment increases the likelihood of a successful videoconference. Each situation should be planned beforehand, and the special features possibly involved in it should be borne in mind [6]. What Should Be Taken into Account in Preparing a Videoconference? It is important to notice the basic things that improve the quality of videoconferencing. Using a checklist, one can avoid making mistakes with technical situations, consultation and therapy (table 2). User training will be necessary for professionals, because videoconferencing is a fairly demanding technique. It has turned out that the people who only use the equipment occasionally tend

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Table 2. The checklist of a videoconference Send the invitations to attend the videoconference in time by e-mail or phone Be personally interested Prepare an implementation plan Act correctly Have somebody chair the group discussion Introduce the participants Ask people to take turns to speak Remember the importance of nonverbal communication Remember the etiquette and aesthetics Remember the ethical guidelines Ensure the patients privacy and information security Multipoint connections require planning, testing, familiarity with every place and careful information

to forget the instructions more quickly. The equipment should also be tested in time before the beginning of the conference. Communication and interaction via videoconferencing involve certain limitations, which is why it is important to give attention to on-verbal communication and interaction.
Strengths and Problems of Videoconferencing from the Viewpoint of the Staff

Videoconferencing is one method of communication with patients and one way to provide mental health services. If the videoconferencing connection is bad, it will also give a poor image of ones organization and ones skills. Table 3 shows the strengths and problems of videoconferencing from the viewpoint of the staff.
Conclusion

Even though our telepsychiatric experience extends only over 7 years, the experimentation with videoconferencing has confirmed its suitability for psychiatric work. Videoconferencing provides much more information to the participants than a telephone conference, and it is suitable for interactive communication of various kinds. Our cost estimations have also shown that videoconferencing with PC-based equipment is economical in telepsychiatry between primary and special care units, even with a relatively low level of utilization (about once every 2 weeks), if the distances are long and the costs of the loss of working time are high and the equipment is also used for other purposes [8, 9]. Similar cost-savings have also been reported in Australia [1012].

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Table 3. The strengths and problems or imitations of videoconference Topic Costs Strengths Saves travel time and costs Multiple-point negotiations A good price-to-quality ratio Transfer of information instead of patients An open therapeutic and learning environment Better than no treatment Problems and limitations Use of working hours High acquisition costs Rapid technological development Dependence on the availability of communication lines Scarcity of telemedical evidence The technical preparation and implementation of the videoconferencing are the most general causes, which turn over total connections Requires planning and preparation Stress due to change The user interface is not yet easy to use Distance work may detract from the social relations inherent in normal work Problems with the patients privacy and information protection Slow changes in legislation Fears and prejudices Need to create new operating routines Excessive expectations may be applied to videoconferencing Professional peoples attitudes and prejudices

Process

New technologies facilitate work A seamless chain of treatment and services Quality A quick way to get expert help More versatile information than over the telephone Improves the quality of psychiatric services Networked and multiprofessional cooperation Development of communication methods among the staff Facilitates contacts with colleagues working in healthcare centres Novelty Reduces patients fears more quickly due to promptness of service Inspires people to be innovative

In normal clinical practice, the need to consult experts in psychiatry may arise suddenly. In a videoconference, the patient and the family have access to expert help and can easily participate in the consultation at the same time, especially in an acute psychiatry service [13]. Financial savings in the costs of equipment and telecommunication, as well as in the new ways of working, may be substantial, as telepsychiatry becomes more common. Finnish municipalities are very interested in developing their health services by investing in telemedicine equipment, the goal being an improvement in healthcare and a reduction in costs. Telemedicine is considered part of the overall healthcare process.

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Since videoconferencing equipment is still relatively new and expensive, the assessment of telemedicine has become more and more important [7]. It is also assumed, in agreement with Yosino et al. [14], that the reliability of remote psychiatric diagnostic interviews and services via videoconferencing equipment will be improved by the next generation of broad-band Internet infrastructure (2 Mb/s). We are convinced that videoconferencing will be defending its place in clinical work and training during the upcoming decade.

References
1 Stanberry B: The Legal and Ethical Aspects of Telemedicine; in Wootton R (ed): Research Associate & Associate Lecture Seafarers International Research Centre, Cardiff University UK, RSM Press, 1998. Benschoter RA, Wittson CL, Ingham CG: Teaching and consultation by television. Hosp Commun Psychiatry 1965;16:99100. Preston J, Brown FW, Hartley B: Using telemedicine to improve health care in distant areas. Hosp Commun Psychiatry 1992;43:2532. Dongier M, Tempier R, Lalinec-Michaud M, et al: Telepsychiatry: Psychiatric consultation through two-way television: A controlled study. Can J Psychiatry 1986;31:3234. Dwyer TF: Telepsychiatry; psychiatric consultation by interactive television. Am J Psychiatry 1973;130:865869. Mielonen ML, Ohinmaa A, Moring J, Isohanni M: The use of videoconferencing for telepsychiatry in Finland. J Telemed Telecare 1998;4:125131. Ohinmaa A, Reponen J and Working Group: A model for the assessment of telemedicine and a plan for testing of the model within five specialities. FinOHTA Report No 5, Helsinki 1997. Mielonen ML, Ohinmaa A, Moring J, Isohanni M: Psychiatric inpatient care planning via telemedicine. J Telemed Telecare 2000;6:152157. Mielonen ML, Ohinmaa A, Moring J, Isohanni M: Videoconferencing in telepsychiatry; in Resnick H (ed): Innovations in Social Work and Education (in press). Trott P, Blignault I: Cost evaluation of a telepsychiatry service in northern Queensland. J Telemed Telecare 1998;4(suppl 1):6668. Werner A, Anderson LE: Rural telepsychiatry is economically unsupportable: The Concorde crashes in a cornfield. Psychiatr Serv 1998;49:12871290. Yellowlees P: The use of telemedicine to perform psychiatric assessments under the Mental Health Act. J Telemed Telecare 1997;3:224226. McLaren P, Ball CJ, Summerfield AB, Watson J, Lipsedge M: An evaluation of the use of interactive television in an acute psychiatry service. J Telemed Telecare 1995;1:7985. McLaren P, Ball CJ, Summerfield AB, Watson J, Lipsedge M: An evaluation of the use of interactive television in an acute psychiatry service. J Telemed Telecare 1995;1:7985. Yoshino A, Shigemura J, Kobayashi Y, Nomura S, Shishikura K, Den R, Wakisaka H, Kamata S, Ashida H: Telepsychiatry: Assessment of televideo psychiatric interview reliability with presentand next-generation internet infrastructures. Acta Psychiatr Scand 2001;104:223226.

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Marja-Leena Kuusimki Mielonen, MD, Department of Psychiatry, University Hospital of Oulu, PL 29, FIN90229 Oulu (Finland) Tel. 35 88 3152011, Fax 35 88 336169, E-Mail marja-leena.kuusimki@ppshp.fi

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4.9

Telemedicine and Real-Time Monitoring of Climbers

Richard M. Satava
Yale Endolaparoscopic Surgery Center, New Haven, Conn., USA

The use of vital signs monitoring (VSM) with remote transmission of healthcare data are beginning to emerge with the commercialization of new wireless sensor technologies. The importance of such capability was never more appreciated than in May 1996, when 5 climbers died during an assault on the summit of Mount Everest. The tragedy was documented by Jon Krakauer in Into Thin Air [1] and Brougton Coburn and David Beshears in Everest, Mountain Without Mercy [2]. Two of the climbing team actually died a few hundred meters from Camp 2 where the rest of the team were huddled during a storm; had their position and vital signs been known, they could have been saved. Like the battlefield or the remoteness of space, the use of such emerging technologies can be the difference between life and death. In May of 1998 and again in 1999, the Everest Extreme Expedition (E3) established a telemedicine clinic at Mt. Everest Base Camp (EBC) to prove the technical feasibility of telemedicine in such remote, extreme conditions. This report focuses upon the monitoring of vital signs in real time during the 1999 E3.

Materials and Methods

The United States military, academia and even the commercial sector have developed a number of systems of wearable location and VSM devices [3]. The system used for E3 was from Fitsense Technologies, Inc. (Wellesley, Mass., USA) (fig. 1) and consisted of four principal components: (1) the vital signs sensors, including heart rate, temperature, electrocardiogram (EKG) and motion (accelerometers), which were strapped across the chest and swallowed in a pill; (2) the global positioning satellite (GPS) device which is commercially available and accurate to within 0.75 m longitude and 1.01 m latitude; (3) the telecommunications system with a radiofrequency (RF) of 918 MHz, also commercially available but

Fig. 1. The VSM system of Fitsense, Inc., demonstrating (right to left) the GPS module, the central processing hub, and the RF transmitter (courtesy of Dr. Tom Blackadar, PhD, Fitsense Technologies, Inc., Wellesley, Mass., USA). repackaged into a miniaturized wearable configuration, and (4) an ingestible temperature pill [4] (not shown in figure 1). Due to the rugged terrain on Mt. Everest, a strategically placed transceiver on the adjacent Mt. Pomori was required to receive and retransmit the signals from the wearable systems on climbers to EBC containing the receiver, signal processor and laptop computer; from there the data was sent via satellite (Imarsat) using TCP/IP (Transmission Control Protocol/Internet Protocol) where it was grounded in Malaysia and routed to an Internet backbone and into a conference room at Yale University School of Medicine in New Haven, Conn., or Walter Reed Army Medical Center in Washington, D.C. (fig. 2). This data consisted of time stamps (Greenwich Mean Time (GMT)), GPS location, heart rate, activity status, skin temperature and core body temperature. In addition, during both 1998 and 1999, there were daily telemedicine rounds from EBC and Yale University to review the previous day patients in the telemedicine clinic, perform real-time consultation and detail progress of medical experiments. Only in May 1999 was the technical feasibility of the wearable monitor system tested during two ascents from EBC to Camp 1 (19,500 ft) through the arduous and treacherous Khumbu Ice Fall (fig. 3).

Results

In order to be practical and useful in real time, data must be presented in an intuitive format that can relate the key information rather than obscure and confuse with non-essential data. Figure 4 illustrates the home screen of the laptop computer which was the custom-designed interface for viewing the data from the climbers. On the left-hand side is a scale map of the terrain between EBC and

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Real-Time Physiologic Monitoring From Mt. Everest (E399)

Satellite Climber wearing sensors, locator and transmitter 64kbps IP connection

Internet Cloud

TCP/IP
High speed tail circuit

Earth station

Repeater station on Kalapathar

Standard laptop and satellite phone

Everest Base Camp

Real-time vital signs monitoring at Yale University

Fig. 2. Diagram of the telecommunications pathway from the individual climber back to the conference room at Yale University School of Medicine (author: B.H.).

Fig. 3. Crossing a deep crevasse on the Khumbu Icefall, using ladders roped together (courtesy of James Williams, Climbing Team Leader, Jackson, Wyo., USA).

Camp 1, demonstrating the trail and location of an individual climber. The large concentration of data points in the upper left is at Camp 1, where the climbers established camp and remained overnight. One small excursion slightly beyond

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Fig. 4. The laptop computer screen, showing the intuitive graphical interface. On the left is the terrain map of Mount Everest with the overlay of the climbers position, and on the right are the individual climbers vital signs (courtesy of Dr. Tom Blackadar, PhD, Fitsense Technologies, Inc., Wellesley, Mass., USA).

Camp 1 for purposes of photographic documentation can be noted heading diagonally to the upper left corner. In addition, there is a large skew of 1 climber position due to malfunction (most likely miscalculation of GPS satellite signal capture). The inset in the lower left corner is a reference graphic representation of the vertical ascent which is usually taken to the summit, with the numbers representing the locations of the four camps. On the right side of the screen are the thumbnail graphics of the continuous vital signs summaries of the 3 climbers (2 being active at the time of the screen capture) along with their latest updated values. Clicking on any of the climber boxes reveals the detailed individual vital signs screen which provides specific overall information as well as the chronological, high-fidelity presentation of the data points which were acquired in real time and plotted every 5 min. The data was monitored in real time and then was stored on both the receiving computer and the wearable datalogger. Whenever there was a loss of transmission, the datalogger would continue to store the data, and then retransmit the entire data from the last successful transmission. The VSM functioned for 95100% of the time, with the exception of 1 climber whose heart rate monitor functioned 78% of the time. The heart rate varied from a minimum of resting at 86 to strenuous exercise of 164 beats per minute (bpm), depending upon activity. The climbers had different baseline heart rates

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before the ascent, usually in the 100120 range after acclimatization. The Sherpa had a lower baseline (86100 bpm). All of the climbers had increase of heart rate to the 150 range, often (but not always) correlating to rapid increase in the actigraph. The skin temperature sensor functioned extremely well with the maximum variability of skin temperature of 22.134.3C (usually 510C over the duration of a strenuous climb of 69 h) and was much greater than the core temperature variation of 36.739.6C, but was usually within 47C of core body temperature. There was no direct proportionality between the skin and core body temperature, and there were a few times when skin temperature trended in the inverse of core temperature. The core temperature pill was extremely accurate, and fluctuated only 13C over the duration of a climb. An interesting phenomenon with the temperature pill is that it was possible to tell when the climber was taking a drink of liquid (either hot or cold) since there is a sudden change (usually 13C) in pill temperature. The correlation between heart rate, activity level, skin temperature and core temperature was not consistent, though there were numerous intervals of 1020 min when a sudden dramatic increase in heart rate was accompanied by a rise in actigraph level, skin temperature and even a gradual and persistent increase in core body temperature. Unfortunately, the strenuous nature of the climb did not permit an event recorder to indicate what any individual climber was doing at the sudden change in vital signs. The VSM had a loss of transmission rate from 3 to 12%, with the exception of 1 climber that must have had an improper affixing of the leads for the heart rate and activity monitor because of erratic loss of signal with only 56% data acquisition during the later descent portion of the trek (though no vital signs signals were lost for more than 35 min or 7 serial recordings). The GPS location functioned well in 2 of the 3 climbers. One VSM initially had an excellent functioning, however after a short time the system became erratic in location acquisition and then totally failed, while the two other systems continued to function perfectly well at the same time and place. The reliability of acquiring location on the two functioning GPS systems for continuous monitoring was 100%.

Discussion

One direction of the future of telemedicine seems to be pointing to continuous monitoring of health status, especially in those individuals with chronic disease states. In April 1999, a workshop on Home Care Technologies for the 21st Century sponsored by the National Science Foundation (NSF) and the Center for Devices and Radiologic Health (CRDH) of the Food and Drug Administration (FDA) reported that it is anticipated that healthcare will

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migrate to a more proactive, preventative model rather than reactive, episodic model utilized today (with): Intelligent wearable sensors, trend analysis tools, predictive algorithms [5]. There seems to be a consensus that wearable, wireless transmission of health data is commonplace, however there are no documented reports of continuous real-time monitoring of vital signs on an ambulatory person in truly remote or hazardous conditions. The VSM system was robust, fault-tolerant (resampling when a GPS signal was not acquired or when a vital sign was not detected) with graceful degradation and intuitively monitored through the graphical interface. There was the expected variability of quality of service of transmission of the data, however the entire system provided a continuous update upon the location and health status of climbers under extreme duress. In addition, the E3 demonstrates that continuous remote monitoring of an individual is possible, even on a global scale. However, this expedition was very expensive, not only the equipment but also the telecommunications costs. Under certain circumstances, such as the battlefield, space exploration, deep-sea activities or high-profile expeditions, the cost could be justified. On a daily basis, in non-extreme circumstances, routine vital sign monitoring can become routine. As the hospitals, nursing homes and assisted-living communities become more high-tech with built-in information systems infrastructure, it will become cost-effective to wirelessly plug in a VSM system to the existing infrastructure. The NASA is legendary for technology transfer from experimental, high-cost, one-of-a-kind device to the commercial sector for affordable, mass-produced devices. As always, initial concept and feasibility of a new technology begins with proof under extraordinary circumstances, such as the E3, which can then lead to the development and implementation of the same systems for daily living to improve the health of every person.

Acknowledgements
Support for this research was provided through a grant from Olympus America, Inc., Yale, Conn.; NASA Commercial Space Center for Medical Informatics and Technology Applications, and the Saint Charles Hospital, Port Jefferson, N.Y., USA.

References
1 2 3 Krakauer J: Into Thin Air. New York, Villiard Books, 1998, pp 322337. Coburn B, Beshears D: Everest: Mountain Without Mercy. Willard/Ohio, National Geographic Society Press, 1997, pp 7687. Satava RM: Virtual reality and telepresence for military medicine. Comput Biol Med 1995;25: 229236.

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Mittal BB, Sathiaseelan V Rademaker AW, Pierce MC, Johnson PM, Brand WN: Evaluation of an , ingestible telemetric temperature sensor for deep hyperthermia applications. Int J Radiat Oncol Biol Phys 1991;21:13531361. Dighe A, Warren S: Smart healthcare systems and the home of the future; in Winters J, Herman W (eds): Workshop on Home Care Technologies for the 21st Century: http://www.hctr.be.cua.edu/ hctworkshop/HCTr_F.htm

Richard M. Satava, MD, Yale Endolaparoscopic Surgery Center, 40 Temple Street, Suite 3-A, New Haven, CT 06510 (USA) Tel. 1 203 7649069, Fax 1 203 7649066, E-Mail richard.satava@yale.edu

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4.10

Telemedicine in Corrections
Glenn G. Hammack
Health Informatics and Telemedicine, University of Texas Medical Branch in Galveston, Tex., USA

Delivery of healthcare is an expected component of incarceration. The quality of healthcare delivery within correctional settings such as prisons, jails and other detention facilities has been an issue of human rights concern. As recently as the 1970s, correctional healthcare was primitive, with prison or jail inmates to providing healthcare services to one another in some cases. Today in many nations healthcare provision to the incarcerated is greatly improved, rivaling and in some cases exceeding levels available to the general population. In the USA, litigation forced many changes and set minimum standards for inmate healthcare [1]. Standards for correctional healthcare provision are now established at national and international levels [24]. Many of these include mandatory on-site review and accreditation.

Characteristics of the Correctional Environment

The physical limits of incarceration make correctional medical care a very controlled environment. Patient access to healthcare ranges from voluntary (where the patient self-refers for care) to escorted (where the patient is physically brought to the caregiver). Aspects of care not typically monitored in free-world ambulatory healthcare, such as medication administrations or simple treatments, are carefully logged. In the USA, a litigious atmosphere results in correctional healthcare receiving several levels of internal and external oversight and procedural compliance monitoring. The incarcerated population is proving to be a concentration point for several important infectious diseases [5]. Attention is being focused on the public health risks posed as inmates are released back into the general population after incarceration [6].

Qualified specialist management of hepatitis, tuberculosis, and HIV are critical needs in correctional care. The close proximity and isolation of the incarcerated population also make nuisance conditions spread quickly. Correctional healthcare providers have increased exposure risks for these serious and nuisance conditions. They also endure an increased risk of physical assault due to the nature of the patients they serve.

Development of Correctional Telemedicine

Correctional care was included in some of the earliest expectations for telemedicine [7]. The earliest efforts occurred in the 1990s as pilot or demonstration projects [810]. These applications provided specialist consultations to the inmate population. Integrated Services Digital Network (or ISDN) telecommunications was used to provide video and audio teleconferencing between a prison facility clinic and the base location for the consultants, usually a medical college or university. In most studies, the initial remote prison site was used as a telemedicine hub to which inmates were transported for care. The hub location is chosen such that transport of the inmates to the hub is less distance than to the consultant location. After analysis of the effectiveness of the initial location, additional telemedicine hubs are implemented [9, 11]. ISDN-based telemedicine networks provide live continuous bidirectional audio and video [12], with still image store and forward being utilized in some cases. The Internet has been used for store and forward inmate healthcare [13]. Internet Protocol (or IP) is now emerging as an alternative to ISDN telecommunications for videoconferencing. In the USA, correctional telemedicine programs are being developed in many states.

Benefits of Correctional Telemedicine

Reduced inmate transport has been reported as a benefit of correctional telemedicine. In Texas, 95% of the telemedicine consults saved one or more trips to an external clinic for outpatient specialty services [9]. In Ohio, correctional telemedicine is credited with reducing the costs of providing inmate medical care by lessening or eliminating the need for additional security guards, vans and chase vehicles [14]. Inmate patients have reported high acceptance of telemedicine care [9, 15, 16]. Correctional telemedicine has also obtained high use satisfaction ratings from consulting specialists and remote site presenters [9, 14]. All studies noted improved access (reduced wait times) to specialist care using telemedicine compared to physically transporting inmates outside of the correctional environment.

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Correctional Telemedicine Methods

Most correctional telemedicine systems provide bidirectional video and audio between the provider and the patient. Currently, ISDN-based systems comprise the majority of these systems. IP-based systems are gaining slowly in popularity as cost and data security concerns are addressed by the telecommunications industry. The provider site is equipped with a camera to image the provider, and professional-quality video monitor for viewing the patient image. The remote (patient) site is similarly equipped, and may have additional imaging tools. Copy-stand type document imaging cameras with adjustable lighting are used to provide remote viewing of photographs or documents. Many of these are equipped with backlight (lightbox) to allow remote imaging of radiographic films. Additional medical video cameras are utilized, providing otoscopy, fundoscopy, and laryngoscopy. Other medical telepresence technologies such as digital telestethoscopy are used. In most ISDN-based telemedicine systems, facsimile (fax) transmission provides sharing of the written medical record between the patient location and provider location. Some correctional systems are using electronic medical record systems to share medical information, eliminating the need for faxing. At the patient location, a presenter is used to provide remote examination services. This individual can be a nurse, physician assistant, or physician. Clinical routine for the presenter will include pre-visit preparation of chart summaries and pertinent chart documents for faxing. At the time of videoconference, the presenter will perform needed physical examination or imaging techniques, and will assist with the patient interview and encounter documentation. Typically, a nurse or physician extender will act as remote presenter for primary care-oriented visits. Physicians are most likely to present on specialist consultations. In the correctional setting, telemedicine is used for chronic care provision rather than acute care. Correctional telemedicine has most frequent use in access to specialty disciplines for referrals, initial consults and post-operative consults. Specific medical disciplines noted as being successfully provided via telemedicine include dermatology [17, 18], cardiology, radiology [19], neurology [20], gastroenterology [8], and ophthalmology [12, 20].

Cost-Effectiveness of Correctional Telemedicine

Cost-effectiveness of telemedicine has been documented, with varying levels of impact. In East Carolina, the cost to transport a patient 160 km from prison was estimated to be USD 700 per visit. In contrast, the cost of a telemedicine consultation was estimated at USD 70, a 90% cost reduction [8]. A later review of the same correctional telemedicine program using a return-on-investment (ROI)

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analysis yielded a more conservative 4-year ROI for the telemedicine system [21]. An Ohio study stated that an overall break-even point for their correctional telemedicine program occurred at 129 consult visits per 3-month period [10]. This same study reported a cost per medical consult at USD 255.19 per visit for telemedicine versus USD 263.51 for a face-to-face encounter, a savings of USD 8.48 per visit. A similar study from Iowa placed the break-even point at 275 telemedicine visits per year [11]. Analysis of telemedicine cardiology services showed a varying benefit dependent on use [22]. Initial visit volumes of 25 per year resulted in telemedicine services costing USD 45 per visit more than traditional clinical encounters. As volume increased, telemedicine service cost savings were USD 46 per visit. An integrated analysis of both patient transport and medical care costs for HIV care in Virginia reported a real cost savings of USD 14,486 for 165 visits over 7 months [23]. Transport savings totaled USD 35,640 and medical care savings USD 21,123. The operating costs of the telemedicine system totaled USD 42,277. A subsequent analysis by the same study group showed costs of USD 401 per face-to-face visit compared to USD 387 per telemedicine visit, a savings of USD 14 per encounter [24].

Conclusions

Correctional medicine has characteristics that make it amenable to telemedicine. High security and transport costs are associated with bringing the incarcerated patient out of prison and into the traditional clinic for care. Telemedicine has provided improvements in access to specialty care for this population. Patient, referring provider, and consulting provider satisfaction ratings have been high. Telemedicine has proven cost-effective in correctional care.

References
1 Ruiz v. Estelle, 503 F Supp 1265 (SD Tex 1980), aff d in part and revd in part, 679 F 2d 115 (5th Cir 1982), amended in part and vacated in part, 688 F 2d 266 (5th Cir 1982), cert denied, 460 US 1042, 103 S Ct 1438, 75 L Ed 2d 795 (1983). Records of the United States Court of Appeals. 2001 ACA Accreditation Standards. American Correctional Association, Lanham, Md, USA. 2001 Accreditation Standards, National Commission on Correctional Health Care, Chicago, Ill, USA. World Health Organization: Healthy prisons A vision for the future. Report of the First International Conference on Healthy Prisons, Liverpool, UK, March 2427, 1996. Geneva, WHO/ Liverpool, University of Liverpool, Department of Public Health, 1996. Hammett TM: Making the case for health interventions in correctional facilities. J Urban Health 2001;78:236240.

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10 11 12 13 14 15 16 17

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Freudenberg N: Jails, prisons and the health of urban populations: A review of the impact of the correctional system on community health. J Urban Health 2001;78:214235. Burdick AE, Mahmud K, Jenkins DP: Telemedicine: Caring for patients across boundaries. Ostomy Wound Manage 1996;42:2630, 3234, 3637. Kesler C, Balch D: Development of a telemedicine and distance learning network in rural eastern North Carolina. J Telemed Telecare 1995;1:178182. Brecht RM, Gray CL, Peterson C, Youngblood B: The University of Texas Medical Branch Texas Department of Criminal Justice Telemedicine Project: Findings from the first year of operation. Telemed J 1996;2:2535. Brunicardi BO: Financial analysis of savings from telemedicine in Ohios prison system. Telemed J 1998;4:4954. Zollo S, Kienzle M, Loeffelholz P, Sebille S: Telemedicine to Iowas correctional facilities: Initial clinical experience and assessment of program costs. Telemed J 1999;5:291301. Yogesan K, Henderson C, Barry CJ, Constable IJ: Online eye care in prisons in Western Australia. J Telemed Telecare 2001;7(suppl 2):6364. Slipy SM: Telemedicine and interconnection services reduce costs at several facilities. Prison and health system partner with Ameritech. Health Manage Technol 1995;16:52, 55. Mekhjian H, Warisse J, Gailiun M, McCain T: An Ohio telemedicine system for prison inmates: A case report. Telemed J 1996;2:1724. Anonymous: Prison telemedicine gets an enthusiastic thumbs up from the inmates. Telemed Virt Real 1998;3:61, 72. Mekhjian H, Turner JW, Gailiun M, McCain TA: Patient satisfaction with telemedicine in a prison environment. J Telemed Telecare 1999;5:5561. Phillips CM, Murphy R, Burke WA, Laing VB, Jones BE, Balch D, Gustke S: Dermatology teleconsultations to Central Prison: Experience at East Carolina University. Telemed J 1996;2: 139143. Norton SA, Burdick AE, Phillips CM, Berman B: Teledermatology and underserved populations [erratum appears in Arch Dermatol 1997;133:819]. Arch Dermatol 1997;133:197200. Bonnin A: Medical tele-imaging: A good chance for the future (in French). Bull Acad Natl Med 1999;183:11231136. Barry CJ, Henderson C, Kanagasingam Y, Constable IJ: Working toward a portable tele-ophthalmic system for use in maximum-security prisons: A pilot study. Telemed J E Health 2001;7: 261265. Zincone LH, Doty E, Balch DC: Financial analysis of telemedicine in a prison system. Telemed J 1997;3:247255. McCue MJ, Hampton CL, Malloy W, Fisk KJ, Dixon L, Neece A: Financial analysis of telecardiology used in a correctional setting. Telemed J E Health 2000;6:385391. McCue MJ, Mazmanian PE, Hampton C, Marks TK, Fisher E, Parpart F, Krick RS: The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia. Telemed J 1997;3:1117. McCue MJ, Mazmanian PE, Hampton CL, Marks TK, Fisher EJ, Parpart F, Malloy WN, Fisk KJ: Cost-minimization analysis: A follow-up study of a telemedicine program. Telemed J 1998;4: 323327.

Glenn G. Hammack, MD, Director of Health Informatics and Telemedicine, University of Texas Medical Branch in Galveston, 2201 Market Street, Suite 718 Galveston, TX 775551005 (USA) Tel. 1 409 7472601, Fax 1 409 7472603, E-Mail glenn.hammack@utmb.edu

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5 Teledermatology

5.1 Teledermatology in Clinical Use

Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 154157

5.1.1

Dermanet A Tailor-Made Tool for Teledermatology

Lorenz Khnis, Laura Milesi
Dermanet Reinach, Switzerland

A Bit of History

Dermanet is a completely integrated total solution for the everyday routine of dermatology in practices and hospitals (fig. 1). The basic idea goes back to the early days of the Internet age. It has to be understood against a background of rapidly accelerating change in a medical environment in which increasingly comprehensive care targets must be met with decreasing financial and staff resources. In such a context, the key parameters are quality assurance, cost effectiveness, and the utilization of potential synergies. For this reason, in 1995, a group of Swiss dermatologists in cooperation with Roche Pharma (Schweiz) AG (www.roche-pharma.ch) decided to set a development goal in this direction. The requirements for the use of a platform of this kind were defined at a start-up workshop. It was clear from the outset that the project could be achieved only by intensive cooperation between an array of experts, not only from dermatology, but also from applications software, system safety, optics, and imaging. The first prototype of the dermanet communication suite software version 1.0 became available in 1997 in German, French and English. It was tested for several months by a pilot group of 20 dermatologists from all over Switzerland for its usefulness in practice and its use in the everyday routine of dermatology. The user-friendliness and functionality of the software was optimized in various workshops, held each year, and by means of regular written and verbal questionnaires. The system was practice-tested to make it increasingly practiceperfect. Version 2.1 of the dermanet communication suite software was ready for marketing in 1998. Two years later, version 2.2 of the software was completed

Fig. 1. Dermanet see www.dermanet.ch for details.

with various adjustments and expansions, including those required to deal with adaptation to the year 2000. Today, all the university hospitals in Switzerland (Basle, Bern, Geneva, Lausanne and Zurich) are linked to the dermanet platform and make their specialist services available on it. In addition, 2530% of independent Swiss dermatologists use dermanet in their work with colleagues and centers of excellence. An abiding concern throughout the whole development period was to be compatible with the most important standards and open to future requirements and developments, so that these could be incorporated and made available rapidly and efficiently. The program also constantly imported improvements from standard consumer-level developments to obviate dependence on outdated expensive and complicated specialist technology. We should like to take this opportunity of thanking once again all those who helped, with their presence, their precision and their knowledge, to make dermanet into what it is today.

A Tailormade Tool for Teledermatology!

A Lot of Content Dermanet is made up of various local and Internet-based subcomponents that can be exchanged on a modular basis and are subject to constant further development: The most important in daily hospital or private practice are the digital camera and patient administration software. Based on the Nikon Coolpix 900 digital camera line, various special adapters were developed that are now used in many dermatology practices, e.g. a digital

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dermoscope for epiluminescence microscopy, a digital microadapter for histopathology, and a slide adapter for digitizing existing slides. The resulting digital image material whether clinical, histologic or dermoscopic is archived simply and unambiguously by the patient administration program within the dermanet communication suite software. It is then readily available for retrieval, whether searched by patient, diagnosis, skin site, etc. Within seconds it can be displayed, reassessed, compared, printed or e-mailed for further opinion. The expert structure and constant updating of the database add strength to the doctor-patient relationship, enabling the individual specialist to offer state-of-the-art advice and treatment informed by consultation with colleagues and centers of excellence, thereby optimizing patient care and satisfaction. As well as the secure and anonymous exchange of data via the Internet (data, images, spoken communications), the dermanet system also provides an interactive teleconferencing function, allowing simultaneous consideration and diagnosis of digital image material regardless of location. Its prime purpose is to accelerate access to second opinion. In addition, inter-university continuing medical education (CME) forums for dermatologists are held several times each month. An increasing number of dermatologists from regional quality assurance groups are now using this function for monthly virtual seminars. Completing the array of services available through the dermanet system platform is an Internet portal tailored to dermatologists needs (www. dermanet.ch) offering access to all databases of dermatologic interest, on-line journals and Medline services, as well as up-to-date information on the Swiss dermatology scene. All the Internet data exchange services provided by dermanet and all the data access processes run in this context are encrypted by a high-quality specialized software program, ASAS (www.arpage.ch) and give dermanet the status of a high-quality secure Virtual Private Network (VPN), physically located on the server of the FMH, the Swiss Medical Association (www.hin.ch). The most remote dermanet station is in the Kilimanjaro Christian Medical Centres Regional Dermatology Training Centre in Moshi, Tanzania (www.eblue.org, May 2000, Part 1, Vol 42, No 5, p 833). This has proved a constant source of fascinating image material for Swiss university dermatology departments. The Moshi station represents the epitome of knowledge transfer across continents, cultures and economic environments and has been operating superbly for several years. And a Brief Look to the Future Dermanet is currently the only up-and-running total system functioning in the wild that offers dermatologic and telemedical services displaying comparable levels of integration and security. It has created huge new opportunities

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for specialist communication which are still far from being exhausted. Future developments, notably in telecommunications and biometrics, can readily be integrated, seamlessly and cost-effectively, into the modular structure of its software design. Dermanet was developed and tested in Switzerland. This means that it was optimized for an area with dense medical care and a high level of accessibility to all current telecommunications technologies. However, it has already become clear on many occasions that the use of dermanet may be of vital importance in other countries too. This includes countries where the distances between medical service providers and the competence centers involved are greater and where there is less blanket coverage in terms of telecommunications accessibility and performance. This is where dermanet benefits from the fact that it is based on normal consumer level technologies and products, in other words, while it may function slightly faster or slower depending on the infrastructure available, it will always function. Dermanet was optimized for Dermatology. It is essentially visual. This means that it could also be adapted to all other disciplines which are image-based, i.e. where imaging modalities are of major importance. And finally: dermanet is not just a bundle of software and hardware. Dermanet is a community of medical professionals who use it, who are developing it further and who are a part of it in their daily work. And, in conclusion, it is these people, with all their knowledge, their commitment and their readiness to place their own knowledge at the service of (tele)medicine, to whom we would like to offer once again our formal thanks!
Dermanet, Postfach, CH4153 Reinach (Switzerland) Tel. 41 1 991 18 38, Fax 41 1 991 18 38, E-Mail infoderma@dermanet.ch

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5.1.2

Aspects of Quality: Face-to-Face versus Teleconsulting

Hkan Granlund
Department of Dermatology, Helsinki University, Helsinki, Finland

Whenever convenient, consultations in dermatology are preferably performed face-to-face (FTF). Patients appreciate in-person contacts with the physician and physicians are more certain about their judgements when having seen the patient [1]. Meeting patients in our office is also the familiar way we have practised medicine for decades. There are, however, situations when FTF consultations are not easily achieved, i.e. a long distance to a specialist or regional lack of specialists. In these situations we would benefit from a possibility to perform consultations at a distance. Without images, consultations in dermatology are difficult. Telematic technology offers distant communication and rapid exchange of images, i.e. visual impressions of a skin condition, and two types of telematic consultation have been introduced into dermatology. Store-and-forward (SAF) technology has gained popularity in the USA, whereas real-time video-conferencing (RTV) has been more used in Europe. When switching from FTF consultations to telematic consultations, a realistic concern is how to maintain quality of medical service. There are several aspects of quality that have to be fulfilled: accuracy of diagnoses, accuracy of management plans, patient satisfaction, and physicians confidence. Recent years have produced an increasing number of publications which have thrown light on all these aspects of quality, concerning both RTV (table 1) and SAF (table 2) consultations. Unfortunately, most of the studies deal with immediate outcomes and we have little information on what the outcome of telematic consultations is in the long run.

Table 1. Published studies evaluating quality aspects of RTV consultations Study Year of Design publication Patients, n Diagnostic accuracy, % Accuracy of Satisfaction with RTV , management % satisfied plan, % inter-observer intra-observer patient physician Outcome of RTV % , needing referral 50 77 75 78 and 94 59 80 67 59 63 71 72 64 0.473 85 51 44 46 45 692 97100 C 80; GP 98 16 C 81 261 20

Jones [11] Philips [6] Oakley [12] Oakley [13] Lesher [3] Gilmour [9] Lowitt [4] Loane [14] Philips [15] Loane [16] Wootton [17] Loane [18]

1996 1997 1997 1998 1998 1998 1998 1998 1998 1998 2000 2000

? Comp. to FTF Comp. to FTF Open Comp. RTV to FTF/ FTF to FTF Comp. RTV to FTF Comp. RTV to FTF Comp. to FTF Comp. to FTF ? Comp. RTV to FTF Comp. to SAF

51 60 104 83 60/36 126 139 351 107 334 204 96

C Consultant, GP general practitioner. 74% were more confident with FTF. 2 Percentage of patients considering RTV as good as FTF. 3 Kappa statistic.
1

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Table 2. Published studies evaluating quality aspects of SAF consultations Study Year of Design publication Patients, n Diagnostic accuracy, % Accuracy of Satisfaction with SAF, management % satisfied plan, % inter-observer intra-observer patient physician 83 88 9495 90 71 87 75 404 1,441 67 92 194 70 84 76 vs. 801 8189 77 90 87 96 69 RTV SAF 90100 90 Outcome of SAF, % needing referral

Kvedar [19] Zelickson [20] Lyon [21] Whited [22] Harrison [23] Whited [2] White [24] Pak [25] Harrison [26] Gilmour [5] High [7] Taylor [27]
1

1997 1997 1997 1998 1998 1999 1999 1999 1999 1999 2000 2001

Open Comp. to FTF Comp. to FTF Comp. to FTF Comp. to GP Comp. to FTF Open Comp. to FTF Comp.? Comp. to FTF Comp. to FTF Comp. to FTF

18 29 100 12 129

Agreement with histological findings.

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Accuracy of the Diagnoses

A prerequisite for a consultation of good quality is that it offers a possibility to make a correct diagnosis. A correct diagnosis should be the standard goal and whether achieved by conventional methods or by the help of telematic technology should make no difference. There is, however, seldom a correct diagnosis to refer to. In lack of a true standard most evaluations of telematic consultations refer to the FTF diagnosis as the standard goal, as if it were a correct diagnosis. This is of course not true, and must be remembered when evaluating results from studies comparing diagnostic concordance. The agreement about the diagnoses between two observers in FTF has not been studied thoroughly enough, but disagreement has been about 6% in published studies [2, 3]. For some diseases, like tumours, we can use histopathology as a reference standard and as an equivalent to a correct diagnosis. The disease groups that can be evaluated in this way are unfortunately few. Actually only two published studies use histology as the referendum [4, 5]. Most of the other published studies, although stating that they have measured diagnostic accuracy, have in fact measured inter- or intra-observer diagnostic reliability (also referred to as diagnostic precision, repeatability or reproducibility) [2] using the FTF diagnosis as referendum. In published studies the inter-observer reliability of RTV consultations has varied between 51 and 80% (table 1) and in SAF consultations from 70 to 90%. This is not optimal, but quite satisfactory. The intra-observer reliability has been evaluated in fewer studies. Interestingly, the diagnostic reliability has been higher for SAF (8795%) than for RTV consultations (6371%). The number of studies is too small to allow strict conclusions, but if true it could be attributed to a better image quality in SAF. When interpreting results about diagnostic reliability it must also be realized that the studies span over a period of 56 years. During this time the used technology has developed and probably influenced the quality of images.

Accuracy of the Management Plan

Clinical examination alone seldom ends up with a definite diagnosis, but needs reassurance with further examinations and tests before a treatment plan is created. The accuracy of a management plan based on a teleconsultation is an essential part of the quality of the consultation. A management plan of good quality can actually save a false diagnosis. Two dermatologists may arrive at

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different diagnostic decisions, but their management plan can be the same or similar enough to make the diagnosis of lower importance. The management plan consists of recommendations for both further evaluations and for treatment. Both aspects can be used separately to assess accuracy between two types of consultations. Examples of variables used to measure concordance of management plans are the number of referrals, the proportion of suggested biopsies, and the ratio between suggested systemic and local treatments. The agreement between FTC consultations and teleconsultations for management plans has varied between 64 and 72% for RTV and between 87 and 100% for SAF consultations (tables 1, 2). There is surprisingly again a difference in favour of SAF consultations. The quality of a management plan can also be judged from its influence on costs. In Helsinki we have compared RTV consultations to FTF consultations in a study where 22 and 25 patients respectively were assigned to either type of consultation depending on the referral centre. We found no difference in the number of referrals and the number of patients recommended further investigations, but RTV consultations resulted in more treatment instructions [unpubl. data]. This could have reflected a uncertainty with the teleconsultation. Our conclusion is that a RTV consultation does not seem to increase the consumption of healthcare services.

Quality in Terms of Physicians Confidence

Consulting dermatologists involved in teledermatology studies have expressed a positive attitude towards this new type of medical service. When evaluating results from published studies it must, however, be borne in mind that most consultations have been conducted by dermatologists with a special interest in information technology and who are involved in putting forward the new technology. On the other hand, dermatologists who are less experienced with information technology can harbour a strong negative attitude for nonrelevant reasons based on suspicions and fears. Many consultants prefer FTF consultations because they feel more confident with their judgements when based on conventional in-person examinations [6]. In a study by Lowitt et al. [4], 81% of physicians giving RTV consultations were satisfied with their ability to examine the skin. However, in the same study all FTF examinations were satisfactory. It was also noted that higher bandwidth, i.e. better technique, gave more confidence to the consultation. Image quality affects confidence also in SAF consultations [7].

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Confidence is important. It influences the level of agreement in diagnoses and thus diagnostic quality [4, 7]. Improvement in the quality of technology is the base for better confidence. This applies specially to RTV consultations, where affordable equipment still is hampered by weaknesses in image quality, especially blurred motion pictures. SAF technology already enables sufficient image quality, but better exchange of information is needed. Probably a combination of digital images and real-time communication by an ordinary phone call could increase confidence.

Quality in Terms of Patient Satisfaction

The ultimate goal of medical care is of course a satisfied patient. Most clinical interventions on usefulness of teleconsultations have measured at least patient satisfaction. The immediate satisfaction of the patients has scored very high (tables 1, 2). It must, however, be realized that patients confronted with new technology tend to be enthusiastic and to overestimate their immediate satisfaction with its use, i.e. causing a positive bias [8]. If patients have expressed dissatisfaction, it has most often concerned the arrangement of the RTV consultation, where patients have felt uncomfortable or embarrassed [9]. Younger patients seem to accept teleconsultation better than older people [4]. This suggests that teleconsultations will be even more accepted in the future.

Long-Term Aspects of Quality

The question of quality in medical service is not answered until we ask: What really happened to the patient?. A wrong initial diagnosis corrected with the contribution of a right management plan can give a satisfied patient in the end. On the other hand, a patient enthusiastic about the new technology and the untroubled way of meeting with his doctor can become deeply dissatisfied when he or she has the final outcome in his hands. The quality of teleconsultation is not ready for evaluation until a long enough follow-up has been performed to explore what happens to the patient satisfaction over time [8]. In a study were RTV and FTF consultations were compared, we made a follow-up survey 6 months after the initial consultation by sending the patients a structured questionnaire. We asked the patient questions about their present status, whether they had been urged to make a new visit to a physician and how pleased they were with the consultation [unpubl. data]. During the lapsed

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6 months, 44 and 46% of the patients in the RTV and FTF groups, respectively, had had to revisit their GP because they still had problems with their skin condition. Nineteen and 31% in the respective groups had been referred to the consulting hospital for further evaluation. These differences were not statistically significant. Measured on a visual analogue scale graded from 0 to 10, the overall satisfaction with the consultation decreased in both groups, i.e. by 1.2 3.7 in the RTV group and by 1.4 4.5 in the FTF group. The decrease in satisfaction is no surprise, but it is encouraging to notice that there was no difference between convention and teleconsultation.

Discussion

Teleconsultation in dermatology has been produced in two ways, either by SAF or by RTV technology. SAF technology enables good image quality, but is hampered by the lack of real-time conversation with the patient and/or the GP. This clearly decreases the quality of history-taking. In RTV consultations the history-taking can be even better than in standard FTF consultation because the incongruity between the voice and video picture prompts the participants to wait for answers and carefully follow what the discussion partner says. The image quality, although of mandatory importance [10], is however not optimal. RTV consultations also need participation of several people and time has to be arranged for them all. Despite the shortcomings it is surprising how high reliability in terms of diagnostic accuracy and management plans has been achieved in published studies. Patients express high immediate satisfaction with the teleconsultation. The ultimate outcome of a medical service must be measured as a sum of several interventions and can be calculated only after sufficient time of follow-up. In our experience the outcome of standard and teleconsultations seems to be comparable. Teleconsultations do not increase the consumption of healthcare services and the estimation of quality does not seem to decrease with time to any greater extent than what is expected.

References
1 2 Eedy DJ, Wootton R: Teledermatology: A review. Br J Dermatol 2000;144:696707. Whited JD, Hall RP, Simel DL, Foy ME, Stechuchak KM, Drugge RJ, Grichnik JM, Myers SA, Horner RD: Reliability and accuracy of dermatologists clinic-based and digital image consultations. J Am Acad Dermatol 1999;41:693702. Lesher JL, Davis LS, Gourdin FW, English D, Thompson WO: Telemedicine evaluation of cutaneous disease: A blinded comparative study. J Am Acad Dermatol 1998;28:2731.

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4 5 6

7 8 9

10

11 12 13 14

15 16 17

18

19

20 21

22 23 24 25

Lowitt MH, Kessler II, Kauffman L, Hooper FJ, Siegel E, Burnett JW: Teledermatology and in-person examinations. Arch Dermatol 1998;134:471476. Gilmour E, Lewis K, Harrison PV Patefield S, Dickinson Y, Manning D, Griffiths CEM: Digital , teledermatology for unselected skin lesions. Br J Dermatol 1999;141(suppl 55):43. Philips CM, Burke WA, Shechter A, Stone D, Balch D, Gustke S: Reliability of dermatology teleconsultations with the use of teleconferencing technology. J Am Acad Dermatol 1997;37: 398402. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776783. Mair F, Whitten P: Systemic review of studies of patient satisfaction with telemedicine. BMJ 2000;320:15171520. Gilmour E, Campbell SM, Loane MA, Esmail A, Griffiths CEM, Roland MO, Parry EJ, Corbett RO, Eady D, Gore HE, Methews C, Steel K, Wootton R: Comparison of teleconsultations and face-toface consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Br J Dermatol 1998;139:8187. Loane MA, Gore HE, Corbett R, Steele K, Mathews C, Bloomer SE, et al: Effect of camera performance on diagnostic accuracy: Preliminary results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1997;3:8388. Jones DH, Crichton C, Macdonald A, Potts S, Sime D, Toms J, McKinley J: Teledermatology in the Highlands of Scotland. J Telemed Telecare 1996;2:79. Oakley AM, Astwood DR, Loane M, Duffill MB, Rademaker M, Wootton R: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. NZ Med J 1997;110:5153. Oakley AM, Duffill MB, Reeve P: Practising dermatology via telemedicine. NZ Med J 1998;111: 296299. Loane MA, Corbett R, Bloomer SE, Eedy DJ, Gore HE, Mathews C, Steele K, Wootton R: Diagnostic accuracy and clinical management by real-time teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1998;4: 95100. Phillips CM, Burke WA, Allen MH, Stone D, Wilson JL: Reliability of telemedicine in evaluating skin tumors. Telemed J 1998;4:59. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Gore HE, Mathews C, Steele K, Wootton R: Patient satisfaction with real-time teledermatology in Northern Ireland. J Telemed Telecare 1998;4:3640. Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, Mathews C, Paisley J, Steele K, Loane MA: Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. BMJ 2000;320: 12521256. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, Mathews C, Paisely J, Steele K, Wootton R: A comparison of real-time and store-and-forward teledermatology: A cost-benefit study. Br J Dermatol 2000;143:12411247. Kvedar JC, Menn ER, Baradagunta S, Smulders-Meyer O, Gonzalez E: Teledermatology in a capitated delivery system using distributed information architecture: Design and development. Telemed J 1999;5:357366. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 1997;133: 171174. Lyon CC, Harrison PV: Digital imagining and teledermatology: Educational and diagnostic applications of a portable digital imaging system for the trainee dermatologist. Clin Exp Dermatol 1997;22:163165. Whited JD, Mills BJ, Hall RP, Drugge RJ, Grichnik JM, Simel DL: A pilot trial of digital imaging in skin cancer. J Telemed Telecare 1998;4:108112. Harrison PV Kirby B, Dickinson Y, Schofield R: Teledermatology High technology or not? , J Telemed Telecare 1998;4:3132. White H, Gould D, Mills W, Brendish L: The Cornwall dermatology electronic referral and imagetransfer project. J Telemed Telecare 1999;5:S85S86. Pak HS, Harden D, Cruess D, Welch ML, Pos O: Diagnostic correlation: Store-and-forward teledermatology versus in-person evaluation. Telemed J 2000;6:121.

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26 27

Harrison PV: Teledermatology in Morecambe Bay 5 years experience in 1,441 patients. JEADV 1999;12:S96. Taylor P, Goldsmith P, Murray K, Harris D, Barkley A: Evaluating a telemedicine system to assist in the management of dermatology referrals. Br J Dermatol 2001;144:328333.

Hkan Granlund, MD, Department of Dermatology, Helsinki University, Central Hospital, Meilahdentie 2, FIN00250 Helsinki (Finland) Tel. 358 9 471 96186271, Fax 358 9 47186561, E-Mail Hakan.granlund@pp.fimnet.fi

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5.1.3

Teledermatology in the Nursing Home

Brian D. Zelickson
Department of Dermatology, University of Minnesota, Minneapolis, Minn., USA

Teledermatology, or practicing dermatology at a distance, can be a very useful tool given the right clinical setting. The goal of this technology is to allow for the remote transfer of data to improve the efficiency of healthcare. This chapter will evaluate the use of teledermatology in one clinical setting the nursing home. There have been many telemedicine programs initiated with great enthusiasm, which are now no longer in service. The primary reasons for these failures appear to be lack of sustainable funding, lack of physician adoption and/or lack of need. As with adding any new technology, one must first identify the problem and the potential impediments to solving it and then see how best to reconcile all potential issues and road blocks. In the following this chapter will explore the potential need for teledermatology services in the nursing home setting, look at simple technical solutions and finally explore our experience. Teledermatology has been helpful in several clinical settings where dermatology care is scarce and difficult to employ such as in rural or undeserved populations, prisons and in the military settings [13]. Due to the resident population the nursing home is another potential setting where teledermatology can solve several practical problems. Due to inherent structural changes in aging skin the elderly are more likely that the general population to have significant cutaneous disorders [47]. These cutaneous disorders such as pressure ulcers, skin infections and cancers can lead to significant morbidity and costly hospitalizations. Nursing home residents are also most likely to have difficulty in getting medical care services [8]. The current practice in most nursing home settings is to have the primary physician or nurse practitioner direct the dermatologic services and consult a dermatologist only if needed. In some cases a dermatologist may be able to make a nursing home visit while in others the resident has to be transferred to

the specialists office. While in many cases this is an effective way of practice, it is often difficult to get a specialist to make a nursing home visit and the barriers for transporting a nursing home resident may delay or impede adequate specialty care. This can lead to significant morbidity and unnecessary expenditures. Relatively recent data show that 4 of 10 Americans who turned 65 in 1990 will spend a portion of their life in a long-term care facility while the percentage of Americans aged 65 and older will reach almost 22% in 2030 [9, 10]. Furthermore, the cost of healthcare is growing significantly in the USA with no signs of slowing down [11]. All the while, specialists are as busy as ever with less time to be able to make nursing home calls. Thus, the growing nursing home population is at risk for cutaneous disease and due to the poor mobility and potential costly transportation, they do not always have good access to dermatologic care [12]. There are several ways to address the problems associated with access of dermatologic care at nursing homes. Since it is difficult for many residents to travel out of the nursing home, one way to improve care would be to increase the number of dermatologists that make nursing home visits. This would be up to the individual dermatologist and to date is too inefficient for many to adopt. The second would be to employ technology to solve the problem. As with all technologies, the devices used for telemedicine have gone through great advances in the past several years. It is beyond the scope of this chapter to evaluate all the potential devices and systems that can be used for teledermatology. However, it is important to address several main components that are needed in order to give the patient the best medical care possible using teledermatology. The main components are the following: (1) Data acquisition: (a) easy to use, (b) consistent, (c) pertinent associated findings, (d) image acquisition (color, topography, resolution); (2) Transmitting data (real-time or store-and-forward): (a) fast, (b) convenient, (c) easy; (3) Reviewing data: (a) fast, (b) image viewing (color, topography, resolution); (4) Consult reply: (a) timely, (b) accurate; (5) Billing, and (6) Medical/legal issues: (a) malpractice, (b) informed consent, (c) confidentiality. The two basic types of telemedicine systems are live teleconferencing systems and store-and-forward systems. The former requires real-time videoconferencing linking the patient and care give on one end and the consultant on the other end. These systems have shown to be very good for accurately performing teledermatology ranging from 54 to 80% total agreement compared to conventional face-to-face consultations, however they are time consuming and often difficult to arrange for all parties to be available at the same time [3]. The second type of system, or store-and-forward system has also been evaluated for teledermatology. With this system the medical data is recorded and

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forwarded to the consultant and the consultant can review the data at any time and return an opinion. For the sake of this article the following discussion will be focused on a store-and-forward system. Although one comparative study showed store-and-forward systems may be less clinically efficient than realtime videoconferencing, advances in technology and experience should allow for higher resolution images and better data collection to make store-andforward systems the best choice for teledermatology [1316]. As with any type of system, the better the data put in the better it is coming out. Unlike teleradiology where there are strict standards of image resolution, there are no such standards in teledermatology. In addition, the data for teledermatology is a bit more complex. Not only are dermatologists interested in the pertinent patient history, but aspects such as associated findings and the color, topography and feel of the skin are very important in determining a correct diagnosis. All of this data must be accurately transmitted to the consultant. In light of this, the system must include an informed person for acquiring the dermatologic data. This includes pertinent associated history, images with accurate lighting for color and topography as well as images of associated areas. The image resolution should be at least 1,024 768 pixels [17] and a color chip should be inserted in the image in order to control for any color variations at the remote site. The system can be set up to send the data on a private server or through a secure website. Care must be taken to insure patient confidentiality when setting this up. The remote site should also have a screen that allows for high enough resolution as well as a color chip to insure correct color on the monitor. Both sites will need a way to back up and store the data. This can be a formidable task given the size of some of the images being sent, however with improvements in technology there are now many ways to do this, either by printing and keeping a hard copy or backing up the data on another hard drive or disk. As noted above, dermatologic consultations for nursing home residents are currently obtained by either having the resident transferred to a dermatologists office or have the dermatologist come to the resident. A nursing home visit by the dermatologist would be the best scenario from the residents perspective, however this is often time consuming and the specialist may not have the needed supplies to completely take care of the situation i.e. if liquid nitrogen is needed to treat a lesion. Furthermore, it is very inefficient for a dermatologist to spend the time traveling to see only a few patients. For the dermatologist it is most efficient to have the nursing home resident transferred to the specialty clinic, however, for many residents it is difficult if not dangerous to travel. Noting these issues a study was performed using a simple store-and-forward system in the nursing home setting [12].

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This study enrolled 29 patients in which a dermatology consult was requested by the primary care giver. A nurse, who was an infection control nurse working at the nursing home, was notified of the consult and went to fill out a dermatology consult from and take photos of the lesions with a videocamera and images with a 13-inch monitor (final resolution 480 640 lines). A diagnosis and treatment plan was determined by examining a still image and patient history alone and in combination. These were compared to an on-site dermatologic consultation. In this study the correct diagnosis was made for 67, 85 and 88% of the time given the history alone, image alone and both respectively. The correct treatment plan was given 70, 87 and 90% of the time given the history alone, image alone and both respectively. No incorrect treatment plan would have led to substantial morbidity. The system used in this study was easy to use and well adopted by the primary care team, the teledermatology nurse, the patients and the dermatologist. The resolution was poor compared to todays standard, however the results showed very good concordance compared to face-to-face consultations. The cost analysis of the study included a store-and-forward telemedicine system for USD 9,000 with each teledermatology consult costing USD 71 compared to USD 105 and USD 295 the cost of an in-office consult and face-to-face nursing home consult respectively. Despite the cost savings, the program was discontinued for lack of funding for store-and-forward teledermatology. This not an uncommon event and until there is reasonable funding for store-and-forward teledermatology it will be difficult to keep these programs in place. The nursing home setting is well adapted for teledermatology. The residents are at risk for cutaneous disease and there are real barriers to specialty care. Teledermatology is well suited to solve these issues and although the system must be tailored to each individual setting, the set-up costs are relatively inexpensive. A more detailed cost analysis will be needed before permanent funding is in place to sustain this type of teledermatology system.

References
1 2 3 4 5 6 Burgiss SG, Julius CE, Watson HW, Haynes BK, Buonocore E, Smith GT: Telemedicine for dermatology care in rural patients. Telemed J 1997;3:227233. Norton SA, Burdick AE, Phillips CM, Berman B: Teledermatology and underserved populations. Arch Dermatol 1997;133:197200. Eedy DJ, Wootton R: Teledermatology: A review. Br J Dermatol 2001;144:696707. Marks R: Structure and function of aged skin; in Skin Diseases in Old Age. Philadelphia, Lippincott, 1987, pp 112. Olive KE, Berk SL: Infections in the nursing home. Clin Geriatr Med 1992;8:821834. Burd C, Langemo DK, Olson B, Hanson D, Hunter S, Sauvage T: Skin problems: Epidemiology of pressure ulcers in a skilled care facility. J Gerontol Nurs 1992;18:2939.

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7 8 9 10

11 12 13

14

15 16

17

Darnowski SB, Gordon M, Simor AE: Two years of infection surveillance in a geriatric long-term care facility. Am J Infect Control 1991;19:185190. Fama T, Fox PD: Efforts to improve primary care delivery to nursing home residents. J Am Geriatr Soc 1997;45:627632. Brandeis GH, Berlowitz DR, Hossain M, et al: Pressure ulcers: The Minimum Data Set and the Resident Assessment Protocol. Adv Wound Care 1995;8:1825. White JV Lipschitz DA, Dwyer JT, et al: Consensus of the nutritional screening initiative: Risk , factors and indicators of poor nutritional status in older Americans. J Am Diet Assoc 1991;91: 783787. Healthcare Financing Administration, Office of the Actuary, National Health Statistics Group; US Bureau of the Census. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 1997;113: 171174. Loane MA, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, Mathews C, Paisley J, Steele K, Wootton R: A comparison of real-time and store-and-forward teledermatology: A cost-benefit study. Br J Dermatol 2000;143:12411247. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT: Related articles assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000; 42:776783. Perednia DA: Store-and-forward teledermatology. Telemed Today 1996;4:1821. Whited JD, Hall RP, Simel DL, Foy ME, Stechuchak KM, Drugge RJ, Grichnik JM, Myers SA, Horner RD: Reliability and accuracy of dermatologists clinic-based and digital image consultations. J Am Acad Dermatol 1999;41:693702. Ratner D, Thomas CO, Bickers D: The uses of digital photography in dermatology. J Am Acad Dermatol 1999;41:749756.

Brain Zelickson, MD, Department of Dermatology, University of Minnesota, 1002 Medical Acts Bldg, Minneapolis, MN 55422 (USA) Tel. 1 612 3380711, Fax 1 952 4737281, E-Mail zelic002@umn.edu

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5.1.4

A Survey among Dermatologists in Practice about Teledermatology

A. Glaessl a, B. Coras a, H. Popal a, M. Landthaler a, W. Stolz b
a Department of Dermatology, University of Regensburg, Germany and bClinic of Dermatology and Allergology, Hospital Munich-Schwabing, Germany

Most private dermatologic practices in Germany are run by only one dermatologist. Therefore, difficult diagnostic and therapeutic problems cannot be discussed with colleagues a considerable disadvantage in comparison to working in a large department of dermatology. For this reason, the consultation of experts in dermatologic healthcare centers via teledermatology would present a desirable tool for dermatologists working on their own. For these consultations, fast and secure transfer of medical data including high-resolution image data in sufficient quality should be obtained for medical information. Modern telecommunication technologies such as ISDN and Internet are very helpful for data transfer. Communication software allowing live videoconferencing or the sending of image data as attached files via e-mail have become routine proceedings. This investigation shows the standard of the technical equipment available in private dermatologic practices prior to the launching of a teledermatologic project.

Materials and Methods

Eighty-four dermatologists in private practice in Bavaria, located both in cities and rural areas, were contacted by questionnaire. These dermatologists were not pre-selected with regard to their interest in telemedicine but were known to us due to their participation in a balneophototherapy study. Monitoring this study, a teledermatology questionnaire was added to the regular information letters, which included the following topics: computer equipment, operating system software, other technical equipment available in private practice, and the use of image documentation systems.

Results

In all, 54% of questionnaires were returned. Of the dermatologists answering the questionnaire, 33% were younger than 40 years and 23% were older than 50 years. Nowadays, most dermatologists in private practice use computer systems favoring Windows 95 operating software, UNIX, or Apple. Of the dermatologists in private practice with telecommunication equipment (i.e. modems), 74% use the modern ISDN technique and 56% use e-mail regularly, but the percentage of office use and private matters is not known. Only some of the dermatologists surveyed provide their own website on the Internet. In addition, regarding different medical software distributors used in private practice in Germany, most common is the software of Medistar and Compumed. Only 15% use their own digital image documentation system but 46% would be interested in buying such a system within the next year. Documentation of pigmented skin lesions is thought to be the most interesting application for 74% followed by sending images to university medical centers (72%) or cooperating histopathologists (67%), but only 26% would be interested in the automatic diagnosis of pigmented skin lesions. Aspects of teledermatologic applications included in the questionnaire showed the following results: proposing several aspects of possible teledermatologic applications, 55% of the dermatologists in private practice would communicate with dermatologic clinics by teleconsultations, 40% prefer a more common teleconsultation via phone and computer; 41% are in touch with sending attached files via e-mail (store-and-forward technique). The dermatologists main fields of interests for teleconsultations are common therapeutic problems and the differential diagnosis of pigmented skin lesions. Further medical education and positive marketing effects regarding their own private practice could demonstrate other applications of teledermatology for practicing dermatologists. Moreover, 55% are interested in patient-related teleconsultations with dermatologic clinics, only 35% with other practicing dermatologists.

Discussion

These data show that dermatologists in private practice are interested in telemedical applications in medical services. Telemedicine is no suitable tool for daily diagnostic problems of physicians in remote areas. In dermatology, however, it seems to offer a wide range of advantageous telemedical possibilities. A study describing three different telemedicine programs for medically less serviced populations showed dermatologic diagnosing to be mostly

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performed by physicians in remote areas [1]. Furthermore, an effective delivery of dermatologic expertise for geographically isolated practices can be performed using video-conferences with consultant dermatologists in a medical healthcare center [2]. In our survey, dermatologists currently seem to prefer low-tech applications concerning communication hard- and software requirements. A recent study indicating that teledermatology is achievable using a low-technology, low-cost approach confirms that [3]. Other results indicate that most dermatologic cases can be successfully managed by real-time telemedicine only [4]. Detailed data of our survey concerning most favorable applications, hard- and software equipment have already been published [5]. According to this questionnaire, teleconsultation of experts in dermatologic centers is the most favorable application. The quality of digital images used in dermatologic healthcare centers for concordant diagnosis is very important [6]. Recently, other authors have illustrated that teledermatology has the potential for diagnosing and managing cases referred from primary care [7]. Also, digital imaging of suspected skin cancers can reach almost complete agreement both among clinical and digital examination [8]. Telemedicine is acceptable for the patients to referring and consulting physicians [9]. Consequently, travel to dermatologic centers is no longer necessary, especially for people from rural areas. In conclusion, a telemedical service for dermatologists in private practice by specialized dermatologic centers can improve the quality of medical care.

References
1 2 Norton SA, Burdick AE, Phillips CM, Bergman B: Teledermatology and underserved populations. Arch Dermatol 1997;133:197200. Lyon CC, Harrison PV: Digital imaging and teledermatology: Educational and diagnostic applications of a portable digital imaging system for the trainee dermatologist. Clin Exp Dermatol 1997;22:163165. Harrison PV Kirby B, Dickinson Y, Schofield R: Teledermatology High technology or not? , J Telemed Telecare 1998;4(suppl):3132. Loane MA, Corbett R, Bloomer SE, Eedy DJ, Gore HE, Mathews C, Steele C, Wootton R: Diagnostic accuracy and clinical management by real-time teledermatology. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1998;4: 95100. Glaessl A, Schiffner R, Walther T, Landthaler M, Stolz W: Teledermatology The requirements of dermatologists in private practice. J Telemed Telecare 2000;6:138141. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti Q, Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Dermatology 1998;196:299304. Gilmour E, Campbell SM, Loane MA, Esmail A, Griffiths CE, Roland MO, Parry EJ, Corbett RO, Eedy D, Gore HE, Mathews C, Steel K, Wootton R: Comparison of teleconsultations and faceto-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Br J Dermatol 1998;139:8187.

3 4

5 6

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8 9

Whited JD, Mills BJ, Hall RP, Drugge RJ, Grichnik JM, Simel DL: A pilot trial of digital imaging in skin cancer. J Telemed Telecare 1998;4:108112. Reid DS, Weaver LE, Sargeant JM, Allen MJM, Mason WF, Klotz PJ, Langille DB: Telemedicine in Nova Scotia: Report of a pilot study. J Telemed Telecare 1998;4:249258.

Wilhelm Stolz, MD, Clinic for Dermatology and Allergy, Hospital Munich-Schwabing, Klner Platz 1, D80804 Munich (Germany) Tel. 49 89 3068 2294, Fax 49 89 3068 3918, E-Mail wilhelm.stolz@kms.mhn.de

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5.2 Teledermatology-Teaching
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5.2.1

Dermatology Online with Interactive Technology (DOIT)

Urs Bader a, Claudio Cipolat b, Gnter Burg b
a b

Praxis fr Dermatologie und Venerologie, Zumikon, and Dermatologische Klinik, Universittsspital Zrich, Switzerland

History

The computer as an instrument in everyday work is becoming increasingly important. Additionally, it is a well-suited tool for teaching and learning purposes, because it can reduce the costly personal presence of teachers in schools and universities. Also, many university students own a computer or have easy access to computers, as well as the Internet. In international science, the Internet is a fast, accessible and very important tool for exchanging information and access to databases. Despite all these facts, the use of computers and modern communication technologies, including the Internet, in teaching is still very low in Switzerland, even at university level. Therefore, in 1998 the Swiss Federal Government started a program the Swiss Virtual Campus (Campus Virtuel Suisse VCS) which would grant CHF 30 million towards the development of computer-based learning programs for universities in a first step in 1999, and another CHF 30 million in a second step in 2000. In the field of medicine, dermatology is an ideal speciality to develop multimedial teaching concepts, because the skin as an organ is readily accessible and visual aspects are very important. Therefore, the Department of Dermatology of the University Hospital of Zrich (Director: Prof. Burg, Project Coordinator: Dr. Bader) decided to enter the VCS with a proposal for a computerbased dermatology teaching project, which was named DOIT (dermatology online with interactive technology). Among over 100 proposals, the DOIT project was accepted by the VCS in the first group and a grant was given to develop the DOIT program.

The DOIT Project

The CyberDerm DOIT project is primarily a program for dermatological training of medical students, as well as of postgraduates in a further step. Four of the five medical faculties of the Swiss universities will use the program for training of their students: the Dermatological Departments of the University Hospitals of Basel (Director: Prof. Th. Rufli), Bern (Prof. L. Braathen), Lausanne (Prof. R. Panizzon) and Zrich (Prof. G. Burg). The Dermatologic Clinic of Geneva will not be participating. The program is planned to be ready for use for the students in July 2003. In the four participating medical schools, 555 students enter the clinical part of the medical studies each year. The target group are the students in the 4th and 6th years of their studies. Additionally, potential participants in the program are the students of the Medical Faculty of Geneva and of other German- or French-speaking countries. The DOIT project will replace a major part of the lecture as well as bedside teaching and clinical courses, and consists of three parts: (1) CyberLecture a virtual lecture text and atlas, accessible via the Internet. (2) CyberTrainer an interactive training unit (virtual dermatology clinic). This is a computer program with exercises on diagnoses, diagnostic procedures and therapy, both to be used offline and online via the Internet. The cases presented will be updated regularly. The content of the course is adapted to the Lernzielkatalog of the Swiss Medical Faculty and has been approved by the participating medical schools. (3) CyberNet a discussion forum which will be used for discussion of case presentations (in CyberTrainer) in analogy to bedside teaching, but without the need for the patient to be present, and no need for the physical attendance of students and teachers. An already existing virtual student textbook of the lecture is accessible via the Internet (http://www-usz.unizh.ch/vorlesung/; Login: Student, password: Sommer). It was adapted to the Lernzielkatalog and approved by the heads of the participating dermatology units to form part 1 of the project (CyberLecture). The combined use of the three modules will provide the stage for problemoriented learning for students and improve their skills in dermatology, for the benefit of dermatological patients. The pedagogical and didactical objectives of the project are: (1) the student attends a virtual clinical course in dermatology; (2) the student learns to solve dermatological problems on his own, using different databases as well as the Internet for gathering of information; (3) the student has more ease in examining, diagnosing and treating dermatological patients in clinical practice; (4) the student can discuss questions and answers in tutorials; (5) the presence of students, patients and tutors in the classroom and clinic is reduced; (6) partial replacement of frontal lecture, and (7) the examination results are better.

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Content

The patients/cases represent the most common dermatologic diseases in everyday general practice, and the course will focus on diagnosing and treating such common diseases. The content is adapted to the Lernzielkatalog of the Swiss Academy of Medical Sciences. Rare diseases will not be presented in the course. The Lernzielkatalog discerns three groups of diagnoses: Diagnostic value 1: the student must have in-deep knowledge of pathogenesis, clinical picture and therapy of the disease; Diagnostic value 2: the student must have some knowledge of pathogenesis, clinical picture and therapy of the disease, and Diagnostic value 3: the student must have heard of the disease. In dermatology and therefore the DOIT program, the major fields are: infectious diseases of the skin (viral, fungus, bacterial); sexually transmitted diseases; psoriasis/lichen; eczema; urticaria and drug reactions; acne and rosacea; autoimmune disorders of the skin; the so-called collagenoses; genodermatoses; metabolic disorders with skin manifestation; chronic wounds, and tumors of the skin.

Description of the Modules

The CyberLecture is based on the Lernzielkatalog Dermatologie of the Swiss Medical Faculties and the preexisting virtual textbook of the dermatology lecture of Prof. G. Burg (http://www-usz.unizh.ch/vorlesung/). The latter was adapted to the Lernzielkatalog and profoundly specified. Pictures were added, and the content adapted to the weighing of the three groups of diagnoses presented above. The main part (CyberTrainer) consists of patient-based exercises on diagnosis, diagnostic procedures, and therapy. The student will be given multiplechoice questions on clinical examples (virtual patients) given in the program. After answering the questions, she/he sends the answers to the project coordinator, where a program will check the answers and send an immediate feedback with comments to the student. The cases will be presented in a structured scheme: one case consists of three to five clinical or histological pictures, a text part and four to five questions with five possible answers (multiple-choice). One patient can be presented as several cases, therefore more and more detailed questions on each patient are possible. The CyberTrainer program provides the background grid for the cases; these will be added and updated regularly by the project leader and partners. Updates can be downloaded by the Internet.

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To better answer the questions, the student is encouraged to access databases such as Medline and specific to dermatological databases. Links will be available within the program, the most important being CyberLecture, which is also accessible by the Internet. Other links exist to Medline databases, textbooks and dermatological atlases. A link to the Dermatology Clinic of the University Hospital where the participant is studying is established via the Internet and CyberNet, by which the participation and the correctness of the answers can be checked, and which automatically give the appropriate credits. Discussion forums supervised by a specialist in dermatology will take place on a regular basis about the patients presented in the program, and a discussion of the questions and answers can take place. The tutorials are done by using part 3 of the project, CyberNet. The student will receive a confirmation of attendance (credit points) for answering the questions and taking part in the tutorial, respectively. This confirmation will be adequate to the confirmation of attendance of lectures and courses in the beginning, and finally replace them. In the end, the medical student will have an overview on the most important dermatological diseases in everyday general practice, diagnostic procedures and dermatologic therapy with emphasis on aspects unique to the speciality. The effect of the program for the student will be a better performance in examinations.

Technical Aspects

The project is principally based on commercially available hardware: PC system with Microsoft WindowsTM operating system. For online access to the program, internal networks of the university hospitals can be used by students participating physically within the hospitals; students using the program at home can access by the Internet. The software had partially existed already. CyberLecture is a HTML database, an adapted version of the HTML lecture of Prof. Burg for the students of the University of Zrich. The DermaTrainer part as the main part of the project was newly developed from the start. The media approach is based on still images (JPEG format) and text. Inclusion of video strips, diagrams and sound data (for other specialities, such as internal medicine) is possible, but will not be realized in the first phase. Evaluation of commercially available platforms for CyberTrainer showed specific disadvantages, which made them unsuitable for the project. The most extensively studied platforms were: (1) Top Class: contains a lot of tools, easy to handle, expensive, no image database; (2) WebCT: contains a lot of tools, very complex, difficult handling; (3) OLAT: platform of the Institute of Informatics of the University of Zrich; principally a good platform, but no

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personnel available, and (4) Viviance: expensive; unclear questions of standards and copyrights. On the other hand, the VCS is interested in using a single and uniform platform to ensure compatibility among the VCS projects and also started an evaluation of platforms. Interestingly, after some months of evaluation, the VCS actually favors no specific software for its projects. An identical evaluation was started by the medical faculty of the University of Zrich, to ensure future compatibility of computer-based medical teaching projects. This evaluation is ongoing. Because the time schedule of those evaluations did not meet the demands of the DOIT project, it was decided to program a stand-alone project, which has the advantage of independence from limitations of the used platform. Programming started in October 2001 and will be completed by December 2002. The cases are prepared and photographed by the participating dermatology clinics, with adequate distribution of workload and contributions. The inclusion of cases will be continuously ongoing, and extension to more difficult cases for the formation of residents in speciality training and for continuous medical education of dermatologists in practice.

Outlook/Future

A French version of the cases will be prepared by the project partner in Lausanne. The involvement of multiple centers and of specialists for didactic and informatics promote distribution of the program throughout the country and abroad to other German-speaking countries. Elaboration of Italian- or English-speaking versions of some parts of the program, especially the cases and texts, are possible, but not planned in the first phase. If appropriate, the use of the program for other specialities will be possible (e.g. internal medicine).

Other Training Programs in the Internet

Similar projects with different features and focus already exist in the Internet. Below, the most important of them are reviewed and compared to the DOIT project. http://apps.medsch.ucla.edu/medyear3/derm/ Interactive dermatology cases; University of Illinois. Good program, similar to the DOIT project, but not identical. Only 24 cases included. Good interactive features. Only in English language. By Richard B. Usatine, MD, and Brian D. Madden, MD, University of California (UCLA), Los Angeles, Calif., USA. http://www-derma2000.uni-regensburg.de

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Virtual dermatologic clinic; step-by-step-approach to the patient. Questions are multiple-choice, some free text answers possible, no other interaction enabled. When the program is completed, the student has a good overview of the speciality of dermatology. Language: German. By Prof. Landthaler, University of Regensburg, Germany. http://www.dermis.net/bilddb/index_d.htm DOIA and PeDOIA: Dermatology Online Internet Atlas and Pediatric DOIA: Dermatology atlases, directly accessible via the Internet with exceptional pictures and good links. A database, not a teaching program. Not interactive. By Prof. Diepgen, University of Erlangen, Germany.

Urs Bader, MD, Praxis fr Dermatologie und Venerologie, Geissacher 6, CH8126 Zumikon (Switzerland) Tel. 41 43 288 0202, Fax 41 43 288 0203, E-Mail urs.bader@hin.ch

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5.2.2

Telematics-Based Teaching in Dermatology

Klaus Bhma, Wolfram Wiegersb
a Fachhochschule Mainz, Fachbereich I, Mainz, bHealth & Media GmbH, Darmstadt, Germany

Motivation

With the change from a production-oriented to a service-oriented society, better qualifications on the part of the general population are increasingly required. Greater requirements and a wider application of information and communications technology (ICT) make it ever more important that a constant updating and broadening of knowledge and capabilities takes place. As a consequence of this trend, the phases of training and application, once separate, are becoming more and more a continuous, life-long learning and qualification process. According to recent investigations (NUA Internet Surveys: www.nua.com), the number of Internet users was over 500 million in August 2001. Because of this high degree of penetration on the part of information technology, the establishing of computer-based training (CBT) and further education courses would seem to be a logical consequence, whereby modern technology comprises the following concepts: e-learning, online learning, multimedial learning, CBT, and Web-based training (WBT); often these are differentiated on the basis of the medium carrying the content. Thus there exist training courses on CD-ROM (CBT) or some on the Internet, which are accessible via the Internet/Intranet with a Web browser (WBT). The advantages of computer-based learning lie in particular in the integration of local as well as distant students and teachers. The user can choose his times, with individual emphasis, and he can repeat the material being learnt at will. Teachers are enabled to impart basic knowledge and thus to ensure an equal stage of knowledge for all students.

The e-Learning Market

Although traditional teaching and learning methods frequently display insufficient flexibility and availability, they still dominate modern training and further education. But just in the context of continuous training or further education, the time spent and the financial investment often no longer reflect the actual usefulness in a balanced way. With the application of ICT-based teaching and study systems there is a real possibility of clear improvement in the costbenefit relation. The application of such systems permits the more flexible and more individual arrangement of training and further education, and limitations of time and geography can be overcome to some extent. From a technical point of view, increasing performance capabilities in telecommunications and information technology (telematics) already allow not only the imparting of factual knowledge, but also the illustration of complex matters. This is exactly the area for the application of multimedia technology. Experts estimate that cost savings in the region of 2025% can be achieved through the application of ICT in training and further education. The availability of countless WBT courses in various areas of knowledge clearly demonstrates how great the demand for such teaching and study material is. According to the most recent prognoses of IDC Research, the commercial market volume for e-learning in Europe by the year 2005 will be around USD 6 billion. The pioneer in the area of e-learning is the USA. According to prognoses in the IDC report, some 90% of all US colleges and universities will be offering their students courses in the form of e-learning by 2005.

Application of Telematics-Based Learning in the Area of Medicine

Especially in the area of medicine there is no doubt about the necessity of continuous learning. Here, the dynamics of the development in the areas of application and research create a special problem. Along with the consideration of new research results, the constant introduction of new technical aids represents a particular challenge for the qualification of physicians and medical personnel. Furthermore, the Internet offers a completely new type of specialist discussion through the possibility of sending image and video data via e-mail and of live communication in chatrooms. This is of importance e.g. in the interpretation of rare indications for a diagnosis [1]. Medical courses are of interest especially because physicians and clinic personnel, as well as people in medical professions otherwise, must often visit expensive, time-consuming special courses or congresses. While a

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number of courses already exist for the area of medicine both on CD-ROM and in the Internet, many of these remind one rather of an electronic book with pages that must be turned, rather than fulfilling the criteria of a true online course. Users from the area of medicine will probably accept the offers for e-learning further education more readily if they are informed early on about the offer by an official source such as a specialist association or chamber of physicians, or if the contents of the offers are at least generated or certified by such sources. German universities have dedicated themselves recently to various projects concerning the theme of Studying via the Internet, as, for example, the VIROR project (Virtual University Upper Rhine), which offers some medical courses on CD-ROM in study centers as well as some which can be downloaded from the Internet [2].

Demands on the Telematics-Based Learning Environment

For Internet-based learning platforms the following important requirements can be formulated [3, 4]: (1) Use of a standard communications infrastructure such as the Internet or the WWW. (2) Applications must be user-friendly in their conception and attractive in price. In this regard the two most important user groups, teachers and students, must be taken into consideration. (3) Flexibility of the instruction material. In order to attain the greatest possible acceptance of an ICT-based teaching and study system, adaptation to the individual approaches in knowledge dissemination and acquirement is needed. This results in the demand for no limitation to teaching and learning strategies. Both given forms of teaching and self-determined learning must be equally possible. In this context the support of active dealing with study content as a goal should be mentioned. (4) Basically, a teaching and study system must permit individually adapted and demand-oriented learning. Adaptation by the user plays an important role here. This must be guaranteed both on a content level, i.e. that pertaining to instruction material, and on a user-oriented level [5]. (5) At the same time, the social components of knowledge dissemination may not be ignored. Bidirectional communication possibilities and discussion forums, as well as a tutor support, must be integrated in order to permit exchanges with other students and to realize the possibility of putting questions with regard to the instruction content. (6) Sufficient support in creating teaching and learning materials should also be achieved, which would allow a simple modification, updating, and re-use or multiple use of teaching and learning material and thus offer enough potential for cost limitation.

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Physicians

Central access to the learning and training system for group members Internet

Administrator

Medical staff

Tutor Computing server Medical courseware for different knowledge levels

Fig. 1. A model of the architecture for an Internet-based learning environment.

Standard Architecture of a Telematics-Based Learning Environment

The demands described above are fulfilled to a certain degree by available learning platforms. Figure 1 shows a model of the architecture for an Internetbased learning environment [3, 6]. The users of the system, authors, students and tutors, gain access to the courses via the Internet. The student receives his individual environment through the course server, comprising in particular the registered courses, the current state of learning in the courses, and the possibility of contacting other students or the tutor. The administrator has the task of handling the system with regard to technology, but also to content and user accounts. The course server is connected to the data bank, which contains the courses and user information. In addition, a computing server is also connected to the course server, dealing with the need for extensive simulation calculations (see below). Numerous facets must be considered in realizing an ideal learning platform, which cannot be dealt with more closely here. Of especial significance with regard also to future systems are the construction of such systems regarding information technology [6], the optimal design of courses [7], considerations of security [8], support and course standardization [9]. Application Scenarios (Use Cases) in Dermatology The main emphasis in the application of computer-aided learning systems in dermatology is the guarantee of cost-efficiency and, in particular, ensuring

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and expanding the state of knowledge of all participants (students, practicing physicians, and assistant personnel) according to need. The technical prerequisites and the demands on infrastructure (PC, modem) have already been fulfilled or are being set up on the part of the end users to a great extent. For application in the dermatological area the following scenarios in particular can be identified: (1) The conveyance of expert knowledge, especially of transfer benefits, for example special training in the area of diagnostics. Through the use of all media (text, image, sound, video and animation) the matter in question can be imparted in a vivid and, most importantly, interactive way. (2) Simulation training for dealing with the newest medical apparatus can be carried out. The arrangement is of simple simulation programs combined with courses. In this way the build-up of know-how is not accomplished in a purely theoretical manner, but by means of hands-on exploration as well. (3) Access to image and video archives containing case studies. Here the support by up-to-date knowledge management mechanisms is essential, as these permit an efficient search in image and video material. (4) Investigation of conference recordings and the presentation of the corresponding sequences with audio and video support. Here, too, the application of knowledge management is of great importance. (5) Rapid, simple integration of new teaching and training units as well as the updating and extension of existing units in the sense of content re-engineering is enabled. This is achieved by having flexible learning platforms and especially modular course structures, such as a separation of content and layout with XML. (6) A significant role will be played by the certifiability of the courses offered. A successfully completed course should visibly increase the qualification of the physician participating, and should enable him to make economic use of this qualification.

Operation Phase

In the operational phase the aspects of course construction and provision are the main ones to be taken into consideration. Accompanying measures such as tutoring will not be gone into more deeply here. Course Construction For the standardized conveyance of knowledge, courses from a didactic point of view consist of small instruction units, which contain components for imparting expert knowledge, for trying this knowledge out in the form of explorative units, and finally those which test the knowledge acquired. For future course construction the mark-up language XML would be most suitable; this is superior to HTML, which is currently used for the most part as the basis

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language, as XML has greater suitability for data storage regardless of medium. In each course the greatest possible degree of interactivity should be aimed at, as the intention is not to simulate a book with all this technical effort. Basically, the development of a complete WBT course is a task for a whole team of editors, and for this reason the construction of a WBT course can be divided into several single jobs: (1) The author, in this case the dermatologist, delivers the course-relevant content. He is responsible for ensuring that specific characteristics of a particular area of expertise, such as the relatively great degree of visualizing in dermatology, correspond to the instruction content. (2) The online editor takes care of the didactic and content-relevant layout, and of the development of questionnaire tests. (3) The Web designer drafts a graphically sophisticated user surface and the navigation. (4) The programmer finally combines graphics, design and functionality to realize a course. During the operation, the following also fulfils a task: The tutor is the person to turn to for answers to concrete questions, and he is available for the evaluation of questionnaire tests. Tools for Constructing Dermatological Course Units The tools for constructing WBT courses possess varying functions and characteristics, depending upon stage of development and professional status. The simplest tool for constructing a WBT course could in principle be a simple HTML editor, which is, however, only usable in a limited way for the realization of credible multimedia presentations with interactivity. Currently, in the Internet so-called what you see is what you get (WYSIWYG) programs are preferred, which contain ready-made drafts. One chooses from among various options and can attain quite good results without any HTML programming knowledge whatsoever. By choosing ready-made elements, the HTML code is created retroactively, as it were. Professional tools enable the user to not only comfortably develop the pages of the course and the navigation, but also to implement multimedial content, such as audio and video sequences or animated graphics. Should a simple text representation be sufficient, or if knowledge is to be tested in multiple-choice questions, then often relatively simple HTML editors will suffice, with which forms can be created and which have JavaScript commands at their disposal. If, however, complex multimedia WBT courses are to be developed, then one should use the corresponding professional tools, such as Asymetrix Toolbook II Instructor, Macromedia Authorware Attain or Macromedia Dreamweaver Coursebuilder (see example in figure 2). Of great importance is the current ongoing development of courseware standardization. This will further improve the quality, as this will allow the exchange of courses among different domains [911].

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Fig. 2. An example of an dermatological training course for patients and medical staff created with Macromedia Dreamweaver.

Learning Service Providing The model described above represents a complex client server architecture, which requires components such as a WWW server, an applications server, a data bank management system, and a communications infrastructure. Along with the demanding technical requirements of these systems, there is a permanent need for updating the applied components. For this reason, the use of Application Service Providing (ASP) makes sense here. ASP means that software is no longer bought as a product licensed by a firm, but is rented from a so-called Application Service Provider. In the e-learning segment this is also known as Learning Service Providing (LSP). The LSP offer can be regarded as a serious alternative to the existing client-server networks in companies. The economic advantages: instead of investing in software packages and keeping resources available within ones own company for their care, administration and updating, one pays only for the actual use (see table 1).

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Table 1. The advantages of LSP Supplier: Medical societies and associations Users: Students, physicians, workers in the pharmaceuticals industry Flexible access Information access independently of place and time High degree of currency Community training Self-teaching checks Use of standard Internet technologies

Renting instead of buying e-Learning services from one source High efficiency Low starting costs Image profit: combination of subject-specific information with further training offers Certifiability of the further training provided

Outlook

A telematics-based further training program cannot and will not replace the traditional education and further training methods in dermatology in the short term. On the one hand, the advantages as compared to conventional methods must be confirmed, on the other a completely technological approach to education appears neither logical nor desirable. But it is clear even now that telematics-based training represents a necessary supplement for the development of quality lifelong further training. This is true for the clinician, but especially for the practicing dermatologist, who can thus participate in the newest developments in his area of speciality without time-consuming and expensive travel. It is exactly the application of modern Learning Service Providers which has the potential for a more comprehensive availability and flexibility when considering individual needs and seems particularly suited to meet the future needs of further education in the field of medicine.

References
1 Bhm K, Mengel M, Schnaider M: Internet-basierte Aus- und Weiterbildung Das System IDEALS MTS; in Herbst M (ed): Informationsmanagement in der Medizin. Darmstadt, Steinkopff, 1999. Mengel M, Englert G: Die Virtuelle Universitt. Hessen Media, Kassel, Zentraldruckerei der Universitt Gesamthochschule, 2000. Mengel M, et al: A concept and system architecture for IT-based lifelong learning; in Computers and Graphics. Amsterdam, Elsevier Science, 1998, vol 22, No 23. Passo J: Computer-Based Teaching Technology for Software Engineering Education. Oulu, Oulu University Press, 1998.

2 3 4

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5 6

7 8

9 10 11

Martinez M: Key Design considerations for personalized learning on the Web. Educ Technol Soc 2001;4(1). Bhm K, Hornung C, Lindner R: The IDEALS Modular Training System; in Thema Forschung 2/97 Computer Graphics. Worms, Technische Universitt Darmstadt, Marketing und Kommunikation, 1997. Mengel M: Konzepte einer benutzerangepassten graphischen Autorenuntersttzung fr Aus- und Weiterbildung basierend auf einem modularen Kurskonzept. Herdecke, GCA, 2000. Graf F: Secure e-learning; in Steinmetz et al (eds): Communications and Multimedia Security Issues of the New Century, IFIP TC6/TC11. Proc of CMS, Darmstadt 2001. Dordrecht, Kluwer Academic, 2001. ISO/IEC JTC1 SC36 Information Technology for Learning, Education, and Training http://jtc1sc36.org/doc/36N0077.pdf, http://jtc1sc36.org/doc/36N0075.pdf DIN NI: http://www.ni.din.de/sixcms/detail.php3?id 482 Prometeus: http://www.igd.fhg.de/~lindner/PROMETEUS/SIG-DESIGN/Discussion/Spec-FD20010701.doc

Prof. Dr.-Ing. Klaus Bhm, Fachhochschule Mainz, Fachbereich I, Geoinformatik und Vermessung, Holzstrasse 36, D55116 Mainz (Germany) Tel. 49 6131 2859672, Fax 49 6131 2859699, E-Mail boehm@geoinform.fh-mainz.de

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5.2.3

Image Archives, Audio- and Video-Sequences for Teleteaching

Holger Hhn, W. Esser, H. Hamm, J. Albert
Lehrstuhl fr Informatik II, Universitt Wrzburg, Germany

Traditional lectures and conference contributions in dermatology are based to a large extent on the presentation of slides. The clinical slide archives for teaching purposes have frequently been put together over decades from some tens of thousands of photographs produced in daily clinical routine. These large collections are considered as treasures of a clinic and are usually organized according to individual diagnoses or groups of related diagnoses. Due to the large volume of those archives, storage and organizational problems, and the possibility of borrowing and loss, access to specific images may be a severe bottleneck both for lecturers and especially for students. It is more than obvious that this situation can be greatly improved by providing digitized image archives in clinic intranets and (in parts) on the Internet or on CD-ROMs.

Digital Archives

When analyzing the life cycle of digitized dermatological images, the following phases defined by the workflow and usage scenarios of lecturers and students can be identified: (1) selection of slides that meet the demands of both high educational content and high technical quality; (2) generation of the raw digital form; (3) review and processing (cleaning, clipping, ) of the raw material to produce a digital master form; (4) categorization and storage of the master files together with thumbnails for referential purposes in relational databases; (5) navigation in the database and selection of images or other teaching material for lectures, conference contributions or online-/offline courses, and (6) digital recording of presentations that may themselves be categorized and may become an integrated part of the database.

As images are only one type of learning objects in dermatological teleteaching, the phases listed above have to be generalized and adapted e.g. for ordinary texts, audio- and video-sequences. In these cases the concepts carry over nearly unchanged while in terminology thumbnails have to be replaced by summaries for written or spoken text or by keyframes for video-clips, respectively. Learning objects available for students on top of this database include extensive supply of clinical, histological, immunofluorescence and other images on special diagnoses, lectures in simple playback mode, simulated exams or quizzes, and training aids for the diagnostic eye. Along these principles the Department of Dermatology and the Chair for Computer Science II in Wrzburg jointly developed digitized image archives and a software package for generating, presenting and recording lectures and quizzes. This work was part of the SENTIMED (SEmantic Net Toolbox for Images in Medical EDucation) project [1] and was supported by the Bavarian government initiative Multimedia in Education. The tools employed can be easily adapted for other visually oriented medical disciplines like radiology and pathology.

Database Components

The first building block of the package are the digital image archives in SENTIMED which consist of over 4,000 high-resolution slides covering more than 600 dermatological diagnoses. The slides were scanned with best available resolution and stored on a database server providing information about diagnosis, localization, type and color of lesion etc. for each image. In uncompressed format the images were also archived on more than 130 CDs. Categorization of data is supported by a Java application with extensible hierarchical and alphabetical pick lists of diagnoses, localizations, etc. By this, data input can be accelerated and typos are excluded. The lists strictly follow international standards like ICD-10 (International Classification of Diseases) for diagnoses or ICD-0 for localizations. The second database component is the navigation layer which documents the mutual relations of the categorization data in a semantic network. It exploits UMLS (Unified Medical Language System) [2], ICD-9-CM (International Classification of Diseases, Clinical Modification) and MeSH (Medical Subject Headings) [3] to build up a XML database. As results of database queries the integrated pictures of the SENTIMED archives are first shown as thumbnails. For detailed inspection a higher resolution of about 1,024 768 pixels together with the related information given in the archives is displayed by a Java applet. The applet allows two kinds of zooming of regions of the entire image: locally a

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4-fold magnification is calculated from image data without loading data from the server. Alternatively, a CGI script on the clinic intranet server can be called, which extracts and transfers the specified region from the highest resolution image back to the applet. Thus, a high-quality magnification up to factor 8 is reached. The third block consists of authoring tools (mainly Java applications and applets) for generating and presenting lectures or conference contributions. Here also, interfaces to other common presentation tools like MS Powerpoint are provided. Image retrieval is supported by a fast and comfortable search on the SENTIMED image archives. The parts, semantic net and Java tools cooperate in such a way that images found in the semantic net can easily be imported into the application. Furthermore, semantic net information can be extracted to each image shown in the Java applications. While the images and the semantic network are installed on a clinic intranet server, the applications reside on local PCs inside the intranet.

Learning Objects

Care was taken to build an open and extensible system of cooperating modules based on (de facto) standards, wherever these were available. The current Learning Object Modelling Standard (Draft 6.1 [7]) defines a framework for hierarchically composing lectures and quizzes from images, texts, audio- and video-sequences together with their administrative data (authors name, clinical categories, time stamps, ). This allows to work on a common platform for all kinds of media data. It is important that this one platform is supporting lecturers as well as students. Access rights are then controlled by the different roles of users or by special data exports, i.e. for storage on a CD. Appropriate data formats and players for videos and sound have also been tested and ranked. Currently, mp3 for sound material from lectures and for other reading voices is preferred. For video-clips, divX gave the best impression of observed quality/compression ratio. The semantic network can be presented to any user and explored by a standard Web browser inside the clinic intranet. Entry points to the network are several alphabetical and hierarchical lists of e.g. diagnoses or skin regions. Nodes in the semantic network combine information from the SENTIMED image archives, UMLS, MeSH and ICD9-CM. Each of these sources offers links to nodes which are parents, children or siblings of the current node. The interface to the Internet is given by context-sensitive links to external sources like Medline-PubMed [4], RxList [5] or CD Klinische Dermatologie Online [6]. For PubMed access, a Java applet proposes a query which can be modified by editing or browsing in MeSH terms.

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Conclusion

On top of extensive digital image archives a powerful tool with a set of routines was created which efficiently supports lecturers in dermatology to prepare and present lectures or conference contributions. The semantic network layer guides the fast retrieval of images and related information in the context of an intranet/Internet. In a kind of back-loop, complete lectures become themselves part of the archives. On next occasion, an existing presentation can easily be repeated, modified or brought up to date. The integration of further multimedial components like video-clips of diagnostic or therapeutic procedures or graphical animations is easy to accomplish. It seems crucial to us that, except for the technical level (replacing a slide projector by a multimedia projector), no principal reorganization of lecturing is required. At the same time, the technological shift to digital archives can enhance the accessibility of teaching material in dermatology drastically. As a next step, image archives will provide the unique opportunity for students to revise passed or missed lectures and to train their visual knowledge. In recent surveys, students as well as lecturers showed high acceptance of multimedial presentations.

References
1 2 3 4 5 6 7 SENTIMED, URL: http://www2.informatik.uni-wuerzburg.de/sentimed/ National Library of Medicine: Unified Medical Language System (UMLS), USA. URL: http:// www.nlm.nih.gov/research/umls/ Deutsches Institut fr Medizinische Dokumentation und Information, Germany. URL: http:// www.dimdi.de/ National Library of Medicine: PubMed, USA. URL: http://www.ncbi.nlm.nih.gov/PubMed/ RxList The Internet Drug Index, USA. URL: http://www.rxlist.com/ Schmoeckel C, Informatik II, Universitt Wrzburg. CD Klinische Dermatologie Online. URL: http://www.multimedica.de/ Draft Standard for Learning Object Metadata, IEEE P1484.6.1. URL: http://ltsc.ieee.org/doc/ wg12/LOM_WD61_1.pdf

Jrgen Albert, Lehrstuhl fr Informatik II, Universitt Wrzburg, Am Hubland, D97074 Wrzburg (Germany) Tel. 49 931 888 6600, Fax 49 931 888 6603, E-Mail albert@informatik.uni-wuerzburg.de

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 195200

5.2.4

Dermatology Course 2000: An Interactive Multimedia Dermatology Course for Students

Programme Description and First Results

W. Stolz a, A. Roescha, H. Popala, N. Arnold c, H. Gruber b, W. Burgdorf d, M. Landthaler a

c

Departments of aDermatology and bPaedagogy III, University of Regensburg; Dr. Arnold & Schleich GbR College24, Hamburg, and dDepartment of Dermatology, Ludwig Maximilian University, Munich, Germany

Tell me and I forget, teach me and I remember, involve me and I learn. This famous sentence by the philosopher and statesman Benjamin Franklin fits multimedia teaching programmes perfectly. The fast-moving advances in information technology allow a large and ever increasing variety of computer applications, also in medicine. Interactive multimedia teaching programmes present a contemporary alternative to conventional university lectures and many a student might feel motivated to increase his or her knowledge of medical subjects by studying on-line. One of the advantages of multimedia teaching programmes is the possibility for participants to make mistakes without having to justify a wrong decision in public. Consequently, the willingness to make decisions is growing. A further advantage of on-line courses is the possibility of presenting a large variety of case examples which would be quite difficult within conventional clinical dermatology lectures. For example, sexually transmitted diseases can be presented on-line without compromising patients and rather trivial skin lesions such as acne or measles can be shown although such cases are usually not seen in medical university centres. The Dermatology Course 2000 is an on-line multimedia teaching programme that enables students and other interested people to learn dermatology in an interactive way. One important benefit to both students and teachers is the temporal and local independence and, therefore, the possibility of individually

planning their study time. Sound medical knowledge is the basis for the daily work of every physician and the design of the Dermatology 2000 programme aims at the tuition of this theoretical knowledge. The main purpose of Dermatology 2000, however, is the transformation of theoretical background knowledge into applied knowledge. Especially the interactive structure of the course supports the development of key competences which are essential in daily medical practise. At present, Dermatology 2000 is acknowledged in four out of five Bavarian medical schools. Successful participation is honoured by the issuance of certificates and credit points are awarded for the examinations at the respective home university.
Technical Aspects

At the end of the year 2001, Dermatology 2000 included five training units. Since the different modules are programmed in HTML, JavaScript, and Java, no special computer knowledge is required for the use of this Web site. Microsoft Internet Explorer 4 and Netscape Navigator 3 upward compatible to Netscape Communicator 4 are defined as Internet browser for Windows 3.x, Windows 95, Windows NT and UNIX. An on-line consultation per e-mail has been set up in case of technical problems and questions will usually be answered by the Web administrator within 24 h. The establishment of a chat room that allows participants to exchange their experiences and impressions is planned in the near future.
Course Description and Latest Results

The start page of Dermatology 2000 shows the course lessons available. Various function keys, e.g. an info button or a bookmark button, are present. If a short dermatological repetition is required during a lesson, the participant may use a well-illustrated index of all types of skin lesions. The feedback symbol allows the student to correspond with the lecturer, for example if suggestions for improvement should be required. Overall, the following 16 training units are planned for the Dermatology course 2000 with units 1, 2, 3, 4 and 6 already being available: (1) Anatomy of skin and dermatological examination of skin lesions; (2) Viral infections of the skin; (3) Sexually transmitted diseases; (4) Bacterial infections of the skin; (5) Allergology; (6) Atopic diathesis and atopic dermatitis; (7) Erythematous and papulous dermatoses; (8) Bullous dermatoses; (9) Collagenoses; (10) Chronic venous insufficiency (CVI); (11) Acne and acne-like skin diseases; (12) Hair diseases and epizoonoses; (13) Mycoses; (14) Blood vessel malformations; (15) Benign and malignant tumours, and (16) Pigmented skin lesions.

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Fig. 1. Case example for a typical sexual infection (see text for details). The student has to decide upon the correct questions. The image of the patients skin lesion can be enlarged by clicking on it (Screenshot of Dermatology Course 2000, chapter 3).

The first lesson covers basic dermatological knowledge (e.g. primary and secondary skin lesions), explains in detail the different ways of distinguishing between skin lesions and emphasizes the necessity of a full-body inspection during every physical examination for detecting suspicious lesions. In general, all 16 chapters are designed in an uniform pattern and each lesson starts with a short introduction in order to get the student interested in the subject. Additionally, a short overview about the courses content is given. On the following page, typical dermatological cases representing the selected group of diseases are demonstrated in a playful but always realistic manner (fig 1). The student has to construct the medical history of the virtual patient by choosing some of the anamnestic questions given. As just a few of the listed questions are useful for the process of correct diagnosing, the participant should only select the appropriate questions. After clicking on each necessary question the detailed image of the respective skin lesion appears and the student has to assess the correct diagnosis. After completion of this exercise the student may then enter the next pages which impart background information about the most important diseases of the chosen chapter. The use of video sequences, images, graphs and animations lends variety to teaching and represents the multimedia aspect of Dermatology 2000. At the end of each chapter the essential contents

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are summarized shortly. In order to obtain a certificate for the successful participation, the student has pass a final chapter test. The main purpose of the Dermatology Course 2000 is to stimulate students skills to apply theoretical background knowledge in daily routine and to increase the students learning curve regarding their practical knowledge in comparison to conventional training methods. Two factors are crucial for the successful establishment of a new teaching method: first students have to accept the new method and, second, the examination results achieved must be able to compete with those of conventional teaching. For this reason, a detailed statistical evaluation was set up in which the examination results of students taking part in the dermatology on-line course were compared with the data of students participating in conventional lectures. This evaluation showed that, at the end of the summer term 2000, Dermatology 2000 participants had a lower rate of mistakes compared with students passing conventional apprenticeship (17 vs. 27% mistake rate). Furthermore, figures showed that our on-line course was immensely accepted: 84.6% of the participants thought Dermatology 2000 to be a useful training method in addition to the conventional presentation of patients within conventional dermatological courses. 89.8% of the students felt motivated to learn more about dermatology and 86.8% were pleased to be able to work with a programme without any record of wrong answers. To examine the participants learning process, the required time for passing through the lecture scripts and the chapter tests at the end of each chapter are documented by a intern reporting system which also serves as a control system for the issuance of the certificates at the end of term.

Discussion

In recent years the importance of a new teaching method based on the use of case examples, the so-called cognitive apprenticeship [1], has been frequently discussed for several study courses. Above all, medical education is thought to profit from this kind of method, especially if diagnostic or therapeutic procedures will be studied [2]. In this context, early attempts like the Harvard-Model or a model introduced by the University of Maastricht were designed and these models have become the paragons of modern medical education. However, as cognitive apprenticeship requires a large number of patients and lecturers, the idea of creating a computer programme arose in order to reduce that outlay. Thus, already in 1989, a programme called PlanAlyzer was introduced [3]. In this programme, students had to find out the correct diagnosis for virtual anaemia patients. Another early programme for the diagnosis of radius fractures was developed by the Department of Surgery of the University of Heidelberg [4]. The evaluation of

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this computer-based training method showed 1520% better scores than the lecture, although 87% of the students stated that their experience with computers was limited or insufficient. The advantages of computer-supported learning with regard to better test results was also demonstrated by the evaluation of a programme for diagnosis and therapy of recurrent laryngeal nerve paralysis [5]. During recent years, many programmes have been established in different medical sectors, e.g. in pathophysiology [6, 7], anatomy [8, 9], radiology [10], dentistry [1113], dietetics [14], cardiology [15, 16] and surgery [17]. Naturally, multimedia programmes do not always represent the most successful teaching method. Modern textbooks, in particular, provide effective tuition as shown by an investigation which analysed the effects of the instructional resource Programmed Learning Sequence (PLS) [18]. One main result of this study was that the participating students did prefer the modern textbooks to the computer programme. A further point underlining the importance of multimedia programmes is their growing role in professional education in future. Experts estimate that although computer-based teaching methods only represent 2% of todays teaching methods in Germany but already 20% in the USA [19], they will climb to 20% in Germany and 40% in the USA until 2005. A good example for an already established on-line case-based learning module for continuing medical education is the melanoma lecture hall (melanoma.lecturehall.com). Harris et al. [20] could show a significant improvement in the participants knowledge of diagnosing pigmented skin lesions after completion of their on-line programme. With the planned establishment of additional modules for our courses for the medical education of both residents and dermatologists, we take part in this development. In future we plan an extension of this option as well as the integration of Dermatology 2000 in the medical curriculum so that successful students of the dermatology on-line course would not have to take the complete conventional final examination at the end of term. The long-term results of the on-line programme will be revised after 12 and 24 months, especially with regard to the question if the transformation of theoretical knowledge into applied knowledge of the students has been accomplished.

References
1 Collins A, Brown JS, Newman SE: Cognitive apprenticeship: Teaching the crafts of reading, writing and mathematics; in Resnick LB (ed): Knowing, Learning and Instruction. Essays in the Honour of Robert Glaser. Hillsdale, Erlbaum, 1989, pp 453494. Mandl H, Gruber H, Renkl A: Lernen und Lehren mit dem Computer; in Weinert FE, Mandl H (eds): Psychologie der Erwachsenenbildung. Enzyklopdie der Psychologie, D/I/4. Gttingen, Hogrefe, pp 437467.

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3 4 5 6 7 8 9 10

11 12 13 14 15 16 17 18 19 20

Beck JR, et al: Computer-based exercises in anemia diagnosis (PlanAlyzer). Methods Inf Med 1989;28:364369. Kallinowski F, et al: Computer-based training A new method in surgical education and continuing education (in German). Chirurg 1997;68:433438. Stehle A, Gross M: Interactive computer-assisted learning program for diagnosis and therapy of recurrent laryngeal nerve paralysis (in German). Laryngorhinootologie 1998;77:695699. Parker MJ, Seifter JL: An interactive, Web-based learning environment for pathophysiology. Acad Med 2001;76:550. Kofranek J, et al: GOLEM Multimedia simulator for medical education. Medinfo 2001;10: 10421046. Peuker ET, et al: Possibilities of multimedia online teaching in medical education (in German). Zentralbl Gynkol 1998;120:471473. Filler TJ, Jerosch J, Peuker ET: Live interdisciplinary teaching via the Internet. Comput Methods Programs Biomed 2000;61:157162. Frank MS, Dreyer K: Empowering radiologic education on the Internet: A new virtual website technology for hosting interactive educational content on the World Wide Web. J Digit Imag 2001;14(suppl 1):113116. Lechner SK, Thomas GA, Bradshaw M: An interactive multimedia solution to learning removable partial denture design. J Prosthodont 1998;7:177182. Schuhbeck M, et al: Development of an interactive multimedia-CBT program for dental implantology and using tests of a program prototype. Eur J Dent Educ 1999;3:3543. Mattheos N, et al: A virtual classroom for undergraduate periodontology: A pilot study. Eur J Dent Educ 2001;5:139147. Kolasa KM, et al: Teaching medical students cancer risk reduction nutrition counseling using a multimedia program. Fam Med 1999;31:200204. Julen N, et al: A qualitative model for computer-assisted instruction in cardiology. Proc AMIA Symp 1998, pp 443447. Petrusa ER, et al: Implementation of a four-year multimedia computer curriculum in cardiology at six medical schools. Acad Med 1999;74:123129. Konig S, Markus PM, Becker H: Teaching and learning in surgery The Gttingen curriculum (in German). Chirurg 2001;72:613620. Miller JA: Enhancement of achievement and attitudes through individualized learning-style presentations of two allied health courses. J Allied Health 1998;27:150156. Ziegler C: Auf der Suche nach dem neuen Lernen. Sddeutsche Zeitung, Feb 1999; 13/14, p V1/1. Harris JM Jr, Salasche SJ, Harris RB: The Internet and the globalisation of medical education. BMJ 2001;323:1106.

Wilhelm Stolz, MD, Clinic for Dermatology and Allergy, Hospital Munich-Schwabing, Klner Platz 1, D80804 Munich (Germany) Tel. 49 89 3068 2294, Fax 49 89 3068 3918, E-Mail wilhelm.stolz@kms.mhn.de

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5.3 Teledermatopathology
Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 201206

5.3.1

Teledermoscopy
Ralph P Braun, Jean-Hilaire Saurat .
Department of Dermatology, University Hospital, Geneva, Switzerland

In the last two decades a rising incidence of malignant melanoma has been observed [18]. Due to a lack of adequate therapies for advanced metastatic melanoma, the best treatment currently is still early diagnosis and surgical excision. Dermoscopy (also known as epiluminescence microscopy, dermatoscopy, amplified surface microscopy, Auflichtmikroskopie, Dermatoskopie) is a simple, easy-to-use in vivo method that has been described to be useful for the early recognition of malignant melanoma. The performance of dermoscopy has been investigated by many authors. Its use increases diagnostic accuracy between 5 and 30% over clinical visual inspection, depending on the type of skin lesions and experience of the physician [930]. It uses an immersion technique to render the skin surface translucent and has been shown to increase diagnostic accuracy for pigmented skin lesions, especially for malignant melanoma [12, 27, 3134]. This technique allows to visualize structures, so-called ELM criterias, which are not visible by clinical examination alone, and which facilitate the diagnosis of pigmented skin lesions [35, 36]. Dermoscopy and especially digital dermoscopy is based on twodimensional pictures and though ideal for telemedicine purposes. Since devices for digital dermoscopy become more affordable, we will try to provide a neutral overview of such devices which are currently commercially available. Basically everyone who owns a computer with Internet access and an e-mail account is potentially able to practice telemedicine and teledermoscopy. The simplest way to acquire digital dermoscopy images is to use a digital consumer camera (such as the Nikon Coolpix). Therefore, one can use special dermoscopy attachment with a built-in lens and light source (http://www.opticalneuhaus.com/, http://www.teachscreen.de). These attachments are available for

Light source

Optical signal

Electrical (video) signal

Skin

Camera chip Optical system

Frame grabber

Digital image

Camera

Computer

Fig. 1. Transmittance of an image using digital dermoscopy.

various consumer cameras. Recently there has been a new approach using a simple but efficient adapter which allows to take images by the means of a digital camera through a handheld dermatoscope (using the light source and lens of the handheld device (http://www.skinscan.de)). These devices all provide digital images of excellent quality but do not solve the problems of storage and retrieval and do not allow live examination of the pigmented skin lesion. A multitude of systems are commercially available which all look similar even though there are big differences between them. This might be confusing for the dermatologist. For this reason, we would like to start with a brief review of the technical principles of these systems: Basically all of them are composed of a video camera attached to a computer. The camera is one of the most important components of the system because it determines the image quality, and is the visible element for the patient. Its quality is one of the most important factors for the price of such a system. Inside the camera there is a light source (LED or halogen), an optical system (lens or optic with zoom), a camera chip (CD, CCD or 3CD) and a camera body (fig. 1). Almost all systems nowadays use LED light sources because of colour reproducibility and standardization purposes. The light source illuminates the pigmented skin lesion. Some systems use a polarization technique instead of immersion liquid. The advantage is that the use of immersion liquid is not necessary any more and that the examination is faster. We have the impression that this is true in some cases but that some structures are much

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harder to evaluate with polarization than with immersion liquid. The use of 90% ethanol as immersion liquid in a small plastic bottle (as used for the application of eyedrops) is almost as fast as the examination with polarization and in our hand the image quality seemed to be superior. The light is reflected from the skin and passes the optical system of the camera. In the majority of the cases a simple lens system is sufficient even though a zoom function is helpful in some cases (i.e. small lesions or precise evaluation of a part of a lesion). On the other hand, a zoom function increases the size and the weight as well as the price of the camera. The camera chip is the heart of every camera. This is an electronic element which transforms an optical signal (the light reflected by the skin lesions) into an electrical signal (video signal). This electrical signal is transmitted to the computer and transferred to a so-called frame grabber a black box which transforms the electrical (video) signal from the camera into a digital image. The frame grabber is the component which is very important for the quality of the final digital image. The best camera cannot provide digital images of good quality when a bad frame grabber is used and vice versa. Once the digital image is stored on the hard disk of the computer, a specific software has to be used to store and retrieve the images. All systems for digital dermoscopy offer the possibility of telemedicine and some of them even offer additional features such as computer-assisted diagnosis. The technical features vary from simple store-and-forward systems where images are sent attached to an e-mail to the consultant at distance for interpretation. This system is independent from any time schedules and can easily be done between different countries or continents. The disadvantage is that these systems do not allow direct interaction or discussion between consulting physician and consultant at distance. Some of the systems have built-in conferencing modules with a text or voice chat function which enables both partners to directly interact (Dermanet, Arpage AG, Reinach Switzerland). In some settings this might be a useful feature, but in our experience it was rather difficult to synchronize the time schedules of the consulting physician (dermatologist in private practice) and the consultant (university hospital) and that this feature requires an exact planning (and discipline from both participants). Colours are important in dermoscopy and the colour reproducibility is important for the diagnosis at distance based on dermoscopy images. Therefore, standardization and colour calibration of the digital images is suitable to assure the quality of the remote diagnosis. The absence of calibration and standardization renders the interpretation more difficult but not impossible. This problem is currently being solved and the latest generation of devices for digital dermoscopy such as the DermoGenius or the Microderm system have a built-in colour calibration.

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In alphabetical order we will give a brief overview over the characteristics of the different systems: The DermoGenius ultra (Rodenstock Przisionsoptik, Munich, Germany, http://www.dermogenius.com) is a standardized fully calibrated system which uses LED illumination, a 3CD camera which is very well designed and very lightweight. Teledermoscopy can be performed via a store-and-forward system (images attached to an e-mail). The system is designed for computer-assisted diagnosis and digital follow-up of pigmented skin lesions. The FotoFinder Medic (Teachscreen, Bad Birnbach, Germany, http:// teachscreen.de) and its Swiss versions (Dermanet, Arpage AG, Reinach, Switzerland, http://www.dermanet.ch) use a rather heavy camera with a built-in zoom optic allowing up to 70 magnification which also allows excellent macroscopical images. The Dermanet system is the only system with a built-in conference module which allows the live discussion of the same image by several participants. The Microderm system (Visiomed AG, Bochum, Germany, http:// www.visiomed.de) uses a well-designed calibrated camera with a sophisticated optical system with a zoom function. It has an e-mail-based store-and-forward system as well and a conference module for teledermoscopy. The system uses a CCD video camera and is designed for computer-assisted diagnosis. The MoleMaxII (Derma Instruments, Vienna, Austria, http:// www.derma.co.at) has two different video cameras for dermoscopy and macro images. It uses an e-mail-based store-and-forward system as well as a teleconsulting feature which is integrated in the software. It has been shown that teledermoscopy consultation is technically feasible [37], and that its diagnostic performance depends on the level of diagnostic difficulty and on the experience of the consultant at distance [38, 39]. Even though most of the technical issues such as standardization and calibration have already been solved or are currently being solved, there are still some important items which have not been addressed: This mainly concerns data safety, legal and financial aspects. Since patient data and images are transmitted during a teledermoscopy consultation, there is a need to protect these sensitive data. International standards such as encryption protocols remain to be defined. Another important issue is the legal aspect. It remains to be defined if the consultant at distance is responsible for the diagnosis or if this should be considered as a diagnostic aid and if the responsibility remains with the consulting physician (i.e. dermatologist in private practice) who is in charge of the patient (treatments and consequences). The last issue is the reimbursement situation for teleconsultations. Until now, teledermoscopy has been performed as a study or between friends or local

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networks of dermatologists who discussed cases without reimbursement. Since it has been clearly shown that the highest diagnostic accuracy can be obtained while consulting an expert, the reimbursement question for these expert consultations should be addressed.

References
1 2 3 4 5 6 7 8 9 10 11 MacKie RM: Strategies to reduce mortality from cutaneous malignant melanoma. Arch Dermatol Res 1994;287:1315. Schneider JS, Moore DH, Sagebiel RW: Risk factors for melanoma incidence in prospective follow-up. Arch Dermatol 1994;130:10021007. Bronzera SJ, Fenske NA, Erez IR: Epidemiology of malignant melanoma, worldwide incidence and etiologic factors. Semin Surg Oncol 1993;9:165167. Kelly JW, Yeatman JM, Regalia C, Mason G, Henham AP: A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Med J Aust 1997;167:191194. Elwood JM, Koh HK: Etiology, epidemiology, risk factors and public health issues of melanoma. Curr Opin Oncol 1994;6:179187. Kopf AW, Salopek TG, Slade J, Marghoob AA, Bart RS: Techniques of cutaneous examination for the detection of skin cancer. Cancer 1995;75(suppl):684690. Elder D: Human melanocytic neoplasms and their etiologic relationship with sunlight. J Invest Dermatol 1989;92:297S303S. Elwood JM: Recent developments in melanoma epidemiology. Melanoma Res 1993;3:149156. Kelly JW, Crutcher WA, Sagebiel RW: Clinical diagnosis of dysplastic melanocytic nevi. J Am Acad Dermatol 1986;14:10441052. Wolf IH, Smolle J, Soyer HP, Kerl H: Sensitivity in the clinical diagnosis of malignant melanoma. Melanoma Res 1998;8:425429. Argenziano G, Fabbrocini G, Carli P, De Giorgi V Sammarco E, Delfino M: Epiluminescence , microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Arch Dermatol 1998;134: 15631570. Kreusch J, Rassner G: Auflichtmikroskopie pigmentierter Hauttumoren. Stuttgart, Thieme, 1991. Stolz W, Braun-Falco O, Bilek P, Landthaler M: Farbatlas der Dermatoskopie, ed 1. Berlin, Blackwell Wissenschaft, 1993. Lorentzen H, Weismann K, Secher L, Petersen CS, Larsen FG: The dermatoscopic ABCD rule does not improve diagnostic accuracy of malignant melanoma. Acta Derm Venereol 1999;79:469472. Hartge P, Holly EA, Halpern A, Sagebiel R, Guerry D, Elder D, Clark W, Hanson L, Harrison C, Tarone R: Recognition and classification of clinically dysplastic nevi from photographs: A study of interobserver variation. Cancer Epidemiol Biomarkers Prev 1995;4:3740. Cascinelli N, Ferrario M, Tonelli T, Leo E: A possible new tool for clinical diagnosis of melanoma: The computer. J Am Acad Dermatol 1987;16:361367. Morton CA, MacKie RM: Clinical accuracy of the diagnosis of cutaneous malignant melanoma. Br J Dermatol 1998;138:283287. Grin CM, Kopf AW, Welkovich BA, Bart R, Levenstein MJ: Accuracy in the clinical diagnosis of malignant melanoma. Arch Dermatol 1990;126:763766. Kang S, Barnhill RL, Mihm MC, Fitzpatrick TB, Sober AJ: Melanoma risk in individuals with clinically atypical nevi. Arch Dermatol 1994;130:9991001. Stanganelli I, Bucchi L: Epiluminescence microscopy versus clinical evaluation of pigmented skin lesions: Effects of operators training on reproducibility and accuracy. Dermatology and Venereology Society of the Canton of Ticino. Dermatology 1998;196:199203. Kerl H, Wolf IH, Sterry W, Soyer HP: Dermatoscopy. A new method for the clinical diagnosis of malignant melanoma (in German). Dtsch Med Wochenschr 1995;120:801805.

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Lorentzen H, Weismann K, Petersen CS, Larsen FG, Secher L, Skodt V: Clinical and dermatoscopic diagnosis of malignant melanoma. Assessed by expert and non-expert groups. Acta Derm Venereol 1999;79:301304. Argenziano G, Fabbrocini G, Carli P, De Giorgi V Delfino M: Epiluminescence microscopy: , Criteria of cutaneous melanoma progression. J Am Acad Dermatol 1997;37:6874. Benelli C, Roscetti E, Pozzo VD, Gasparini G, Cavicchini S: The dermoscopic versus the clinical diagnosis of melanoma. Eur J Dermatol 1999;9:470476. Pehamberger H, Binder M, Steiner A, Wolff K: In vivo epiluminescence microscopy: Improvement of early diagnosis of melanoma. J Invest Dermatol 1993;100:356S362S. Stanganelli I, Seidenari S, Serafini M, Pellacani G, Bucchi L: Diagnosis of pigmented skin lesions by epiluminescence microscopy: Determinants of accuracy improvement in a nationwide training programme for practical dermatologists. Public Health 1999;113:237242. Steiner A, Pehamberger H, Wolff K: Improvement of the diagnostic accuracy in pigmented skin lesions by epiluminescent light microscopy. Anticancer Res 1987;7:433434. Schulz H: Auflichtmikroskopische Differenzierung maligner Melanome. Akt Dermatol 1991;17: 134136. Schulz H: Maligne Melanome in der Auflichtmikroskopie. Hautarzt 1994;45:1519. Schulz H: Epiluminescence microscopic characteristics of small malignant melanoma. Hautarzt 1997;48:904909. Ascierto PA, Satriano RA, Palmieri G, Parasole R, Bosco L, Castello G: Epiluminescence microscopy as a useful approach in the early diagnosis of cutaneous malignant melanoma. Melanoma Res 1998;8:529537. Binder M, Schwarz M, Winkler A, Steiner A, Kaider A, Wolff K, Pehamberger H: Epiluminescence microscopy. A useful tool for the diagnosis of pigmented skin lesions for formally trained dermatologists. Arch Dermatol 1995;131:286291. Menzies SW, Crotty KA, Ingvar C, McCarthy WH: An Atlas of Surface Microscopy of Pigmented Skin Lesions. Sydney, McGraw-Hill, 1996. Puppin D, Salomon D, Saurat JH: Amplified surface microscopy. J Am Acad Dermatol 1998;28: 923927. Bahmer FA, Fritsch P, Kreusch J, Pehamberger H, Rohrer C, Schindera I, Smolle J, Soyer HP, Stolz W: Diagnostische Kriterien in der Auflichtsmikroskopie. Konsensus-Treffen der Arbeitsgruppe analytische Morphologie der Arbeitsgemeinschaft dermatologische Forschung, Hamburg, Nov 17, 1989. Hautarzt 1990;41:513514. Fritsch P, Pechlaner R: Differentiation of benign from malignant melanocytic lesions using incident light microscopy; in Ackerman AB (ed): Massons Monograph in Dermatopathology. New York, Masson, 1998, pp 301311. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti Q, Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Dermatology 1998;196:299304. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R, DellEva G, Burroni M, Chimenti S, Kerl H, Soyer HP: Face-to-face diagnosis vs. telediagnosis of pigmented skin tumors: A teledermoscopic study. Arch Dermatol 1999;135:14671471. Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L, Ferrari A, Hofmann-Wellenhof R, Kenet RO, Magrini F, Mazzocchetti G, Pizzichetta MA, Schaeppi H, Stolz W, Tanaka M, Kerl H, Chimenti S, Soyer HP: Teledermoscopy Results of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6:132137.

Ralph P. Braun, MD, Department of Dermatology, University Hospital, 24, rue Michelis-du-Crest, CH1211 14 Geneva (Switzerland) Fax 41 22 372 9470, E-Mail braun@cmu.unige.ch

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5.3.2

Teledermatoscopy in Daily Routine Results of the First 100 Cases

B. Coras a, A. Glaessl a, J. Kinatederb, W. Klvekornc, R. Braund, U. Lepskia, M. Landthalera, W. Stolze
Department of Dermatology, University of Regensburg, Germany; b Private Practice, Bayreuth, Germany; c Private Practice, Gilching, Germany; d Department of Dermatology, University of Geneva, Switzerland; e Clinic of Dermatology and Allergology, Hospital Munich-Schwabing, Germany
a

Often, questions regarding the diagnosis of pigmented skin lesions could be clarified by consulting an expert. This consultation could be personal, i.e. by transferral of the patient to a clinic specialized in pigmented lesion, or by teledermatology. For dermatologists in private practice, who are interested in telemedicine, this type of expert consultation may present a favourable alternative. Dermatoscopy, dermoscopy, epiluminescence microscopy, and skin surface microscopy all refer to the same process of examining cutaneous lesions with an incident light magnification system and fluid at the skin magnifying lens interface. Since the development of a hand-held device [1], this technique has represented an improved approach for examination of pigmented skin lesions in daily routine practice besides conventional microscopy and macroscopic investigation. Two recent meta-analyses have shown that the employment of dermatoscopy results in improved diagnostic accuracy in melanocytic lesions, especially for physicians experienced in this field [2, 3]. Teledermatoscopy might present a solution for the problem of lower levels of sensitivity and specificity for inexperienced users [4]. A multicentre study by Piccolo et al. [5] evaluated the analogy between the direct clinical diagnosis and the telediagnosis of 43 cutaneous pigmented lesions using a digital photo camera. Their results confirmed that teledermatoscopy can be a reliable technique for the diagnosis of pigmented skin lesions but one that will depend on the expertise of the observer. To elucidate the possibilities of teledermatoscopy using a computerized dermatoscopy system with a video camera, we analysed the outcome of the first 100 cases in our teledermatoscopy approach. Since quality and

reproducibility of digital images are very important, all cases were digitized with a newly developed computer-aided dermatoscopy system (Dermogenius ultra) which fulfils all requirements for reproducible and objective image acquisition (illumination, gain control of camera, and shading correction).
Materials and Methods
Each of the three participating dermatologists in Bayreuth and Gilching, Germany, as well as Geneva, Switzerland, used the same technical equipment for the acquisition of digital images (Dermogenius ultra). The system consists of an ergonomic and easy-to-use hand-held 3-CCD camera (Dermogenius ultra, www.dermogenius.com, Rodenstock Przisionsoptik LINOS Co., Munich, Germany). The resolution of the camera is more than 700 TV lines with an actual pixel size of 512 512. The recording field is 11 11 mm, which corresponds to a magnification of 20 . The camera is calibrated on a daily basis prior to use for shading and colour corrections. The images were stored and processed using the Dermogenius Software Version 1.2 on a IBM-compatible computer (750 MHz Pentium 3 computer with 128 MB RAM, Matrox Meteor II frame grabber and Matrox G 400, graphic card, 56 K modem, high-resolution monitor). Based on the personal consultation of the patient including the medical history as well as the physical and dermatoscopic examination, participating experts with great experience in dermatoscopy established a diagnosis (diagnosis 1). Each of the three dermatologists in private practice sent their digital images via e-mail attachment including an anonymized identification to the Department of Dermatology, University of Regensburg. Corresponding patient data and medical history as well as informed consent were received via fax to assure high data security. The images were then evaluated by a physician experienced in dermatoscopy. The lesions were diagnosed (diagnosis 2) both based upon the digital images and the history of the patient (table 1). After a total duration of 16 months, the two different approaches were compared with the histopathologic diagnosis as golden standard. The histopathologic diagnosis of the majority of cases occurred at the Department of Dermatology Regensburg by one of the co-authors (M.L. or W.S.). Atypical melanocytic nevus was only diagnosed if one or two but not every feature of malignant melanomas were present [6].

Results

In 16 months, a total of 100 pigmented skin lesions were collected. The quality of digital images was sufficient in 90% of the cases. In 45 lesions, excision was performed because (a) of the diagnosis of a malignant melanoma/ atypical nevus, (b) a benign lesion was diagnosed but a malignant melanoma could not be entirely ruled out, or (c) of the patients request. According to our algorithm of dermatoscopy [7], melanocytic lesions were divided into benign (n 24), suspicious atypical melanocytic nevi (n 5), and malignant melanocytic skin lesions (n 16). Using teledermatoscopy, correct classification rate was 88.8% compared to 91.1% for face-to-face diagnosis (table 1).

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Table 1. Cases investigated Diagnosis 1 (face to face) Benign-melanocytic lesions (total) Melanocytic nevus Spitz nevus Other melanocytic lesions Suspicious lesions Atypical nevus (dysplastic) Malignant lesions (total) SSM/LMM ALM Total Correct classification rate (%) 23 ( 1 F) 15 6 ( 1 F) 2 5 13 ( 3 F) 11 ( 3 F) 2 41 ( 4 F) 91.1% Diagnosis 2 (teledermatoscopy) 22 ( 2 F) 14 ( 1 F) 6 ( 1 F) 2 5 13 ( 3 F) 11 ( 3 F) 2 40 ( 5 F) 88.8% Histologic diagnosis 24 15 7 2 5 16 14 2 45

F Incorrect diagnosis; ALM acral lentiginous melanoma; LMM lentigo malignant melanoma; SSM superficial spreading melanoma. Other diagnosis (collision tumours either seborrhoeic keratosis and melanocytic nevus or melanocytic nevus and blue nevus). Melanocytic nevus (also including dermal nevus, recurring nevus, congenital nevus, and papillary nevus).

Table 2. Overview for cases with discordant diagnoses Diagnosis 1 (face to face) Irritated melanocytic nevus Malignant melanoma Activated melanocytic nevus Melanocytic nevus Irritated seborrhoeic keratosis Diagnosis 2 (teledermatoscopy) Malignant melanoma Malignant melanoma Activated melanocytic nevus Junctional nevus Multiforme reaction Histologic diagnosis

Congenital nevus Spitz nevus SSM SSM Amelanotic malignant melanoma

Comparisons between histologic vs. teledermatoscopic diagnoses for malignant melanoma/atypical melanocytic nevus vs. melanocytic nevi revealed a sensitivity of 85.7% and specificity of 91.6%. The comparison of face-to-face diagnosis with teledermatoscopy for diagnosis of malignant melanoma/atypical nevi revealed a sensitivity 85.7 vs. 85.7% and specificity of 95.8 vs. 91.6%. In 5 cases our diagnosis could not be confirmed histologically (table 2). In 3 cases our diagnosis corresponded with the diagnosis of the dermatologists

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but could not be confirmed histologically: 2 cases were superficial spreading malignant melanomas both the dermatologists in private practice and ourselves supposed a melanocytic nevus as first diagnosis but malignant melanoma was the differential diagnosis and excision was suggested; in 1 case the clinical diagnosis was malignant melanoma but histology revealed an irritated spindle cell nevus. In both cases without confirmed histology the diagnosis of the dermatologists in private practice did not correspond with ours: in 1 case, the dermatologist diagnosed an irritated active melanocytic nevus, our clinical diagnosis was malignant melanoma but histology showed a congenital nevus, whereas in the second case, the dermatologist identified an irritated seborrhoeic keratosis, while we diagnosed a multiform reaction and histology revealed an amelanotic malignant melanoma.

Discussion

Dermatoscopy is a noninvasive method for both the differential diagnosis of pigmented skin lesions and the early diagnosis of malignant melanoma. The method itself is based on a two-dimensional picture and thought ideal for telemedicine purposes. Physicians using this method are accustomed to twodimensional pictures in comparison to other clinical examinations in dermatology in which the appreciation of the three-dimensional aspect of the lesions has an important impact on the diagnostic process [8]. The evaluation of pigmented skin lesions by dermatoscopy mainly depends on the experience of the physician, which can be increased with a formal training for just 2 half days [4]. Since dermatoscopy is a relatively new method, not every dermatologist has acquired that experience so that a consultation by teledermatoscopy might be beneficial [8]. Recently, Braun et al. [8] also evaluated diagnostic results of pigmented skin lesions obtained by teledermatoscopy and showed that picture quality was sufficient for diagnoses in more than 90% of the cases. They were able to identify each of the 9 melanomas in the study by teledermatoscopy. Piccolo et al. [9] demonstrated a concordance of 91% in 66 cases of pigmented skin lesions. The number of correct telediagnoses was lower but the difference was not statistically significant. The accuracy of telediagnoses was not related to the quality of the images but highly dependant on the level of diagnostic difficulty of a given pigmented skin tumour. The main purpose of a study by Provost et al. [10] was to determine if the clinical and dermatoscopic diagnoses and the dermatoscopic features of atypical melanocytic nevi and malignant melanoma are unaltered after telephonic

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transmission of their digitized images. Their data indicated that the images retain sufficient information for diagnostic purposes. Our results demonstrated similar sensitivity and specificity for teledermatoscopy and face-to-face diagnosis. Such positive results became possible because the reproducible colour-adjusted image acquisition was identical in all participating centres. While face-to-face diagnosis showed a sensitivity of 85.7% and a specificity of 95.8%, the teledermatoscopic diagnosis of our study demonstrated a sensitivity of 85.7% and a specificity of 91.6%. These figures point to the fact that the examined lesions sent by dermatologists with great experience in the field of dermatoscopy were difficult cases. This is further underlined by the absolute concordance in the two collision tumours, where both the dermatologists outside and inside diagnosed collision tumours between seborrhoeic keratosis respectively blue nevus with melanocytic nevi. Also there was high agreement in the diagnosis of the atypical melanocytic nevi and Spitz nevi. The use of teledermatoscopy for the diagnosis of pigmented skin lesions could contribute to a reduction in travel time and workload in dermatology clinics, could spare unnecessary distress for the patient and, ultimately, could save public money, while providing a faster and more efficient service [5]. The procedure of teledermatoscopy is simple with the images sent by e-mail. In the future, this service may be in high demand, if such high concordance between face-to-face diagnosis and teledermatoscopy can be demonstrated. A recent survey by Glaessl et al. [11] showed that a high proportion of dermatologists in private practice would be willing to use a teledermatoscopic service.

References
1 2 Stolz W, Bilek P, Landthaler M, Merkle T, Braun-Falco O: Skin surface microscopy. Lancet 1989;2:864865. Kittler H, Pehamberger H, Wolff K, Binder M: Accuracy of the clinical diagnosis for melanoma with and without dermoscopy: A meta-analysis of diagnostic test performance. Lancet Oncol 2002;3:159165. Bafounta ML, Beauchet A, Aegerter P, Saiag P: Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Arch Dermatol 2001;137:13431350. Binder M, Puespoeck-Schwarz M, Steiner A, Kittler H, Mllner M, Wolff K, Pehamberger H: Epiluminescence microscopy of small pigmented skin lesions: Short-term formal training improves the diagnostic performance of dermatologists. J Am Acad Dermatol 1997;36:197202. Piccolo D, Smolle J, Argenziano G, Wolf HI, Braun R, Cerroni L, Ferrari A, Hofmann-Wellenhof R, Kenet OR, Magrini F, Mazzocchetti G, Pizzichetta AM, Schaeppi H, Stolz W, Tanaka M, Kerl H, Chimenti S, Soyer PH: Teledermoscopy results of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6:132137. Clark W, Elder DE, Guerry D, Epstein MN, Greene MH, van Horn M: The precursor lesions of superficial spreading and nodular melanoma. Hum Pathol 1984;15:11471165. Stolz W, Braun-Falco O, Bilek P, Landthaler M, Burgdorf WHC, Cognetta A: Color Atlas of Dermatoscopy, ed 2 rev. Berlin, Blackwell Science, 2002.

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Braun RP, Meier ML, Pelloni F, Ramelet AA, Schilling M, Tapernoux B, Thrlimann W, Saurat JH, Krischer J: Teledermatoscopy in Switzerland: A preliminary evaluation. J Am Acad Dermatol 2000;42:770775. Piccolo D, Smolle J, Wolf IH, Peris K, Hofmann-Wellenhof R, DellEva G, Burroni M, Chimenti S, Kerl H, Soyer HP: Face-to-face diagnosis vs. telediagnosis of pigmented skin tumors: A teledermoscopic study. Arch Dermatol 1999;135:14671471. Provost N, Kopf AW, Rabinovitz HS, Stolz W, DeDavid M, Wasti Q, Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Dermatology 1998;196:299304. Glaessl A, Schiffner R, Walther T, Landthaler M, Stolz W: Teledermatology The requirements of dermatologists in private practice. J Telemed Telecare 2000;6:138141.

Wilhelm Stolz, MD, Clinic for Dermatology and Allergy, Hospital Munich-Schwabing, Klner Platz 1, D80804 Munich (Germany) Tel. 49 89 3068 2294, Fax 49 89 3068 3918, E-Mail wilhelm.stolz@kms.mhn.de

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5.3.3

HistoClinC: A Web-Based Telemedicine Application for Clinicopathologic Correlations in Dermatopathology

Werner Kempf, Serge Reichlin, Gnter Burg
Department of Dermatology, University Hospital, Zrich, Switzerland

Telepathology comprises a spectrum of applications of modern information technologies with the aim to transfer images of pathology specimens for diagnostic purposes between two geographically distant locations (for reviews, see Kayser et al. [1] and Rashbass [2]). Four major applications of telepathology can be distinguished, namely: (1) telemicroscopy; (2) online image atlases; (3) second-opinion/decision expert systems, and (4) clinicopathologic correlations. In most circumstances, telepathology means to transfer digital images of biopsy specimens from one pathology center to another remote center. Clinical data on patients history and laboratory investigations are helpful adjunctive information for diagnosis of most biopsies in surgical pathology, but clinical presentation is usually of minor diagnostic impact. In sharp contrast, diagnosis in dermatopathology essentially depends on information of clinical manifestation of the skin lesion which has been excised. This is mainly due to a considerable overlap of pathologic features in different skin disorders. The term look-alikes has been introduced for those pathologic conditions, where different disorders share the same pathologic features [3]. Look-alikes are a common and characteristic feature of dermatopathology and can be observed in inflammatory as well as in neoplastic skin disorders. For example, cutaneous lymphoid hyperplasia and low-malignant B-cell lymphomas share a variety of pathologic features such as nodular lymphoid infiltrates with formation of germinal centers. No single morphologic and immunophenotypic feature or molecular biologic findings allow to differentiate these two lymphoproliferative disorders with sufficient diagnostic

Parapsoriasis benign

Eczema ? Parapsoriasis ? T-cell lymphoma ?

T-cell lymphoma malignant

Fig. 1. Look-alike in neoplastic skin disorders: Identical histologic features with infiltrates of lymphoid cells in the upper dermis. Only correlation with clinical features allows to establish final diagnosis and differentiation between chronic eczema and early stages of cutaneous T-cell lymphoma.

accuracy [4]. The clinical manifestation and the course of the disease are crucial informations to establish final diagnosis. Similar problems are encountered in the differential diagnosis of benign, chronic inflammatory skin disorders like chronic eczema and malignant cutaneous lymphoma like early stages of mycosis fungoides (fig. 1). The majority of look-alikes concerns the large group of inflammatory skin diseases. For example, pityriasis rosea and eczema share most histologic features and can only be distinguished by combined evaluation of clinical manifestation and histologic findings (fig. 2). This correlation of clinical and pathologic findings is of crucial diagnostic and therapeutic importance to avoid unnecessary aggressive treatment in benign or self-limited diseases like pityriasis rosea and pseudolymphoma. On the other hand, early diagnosis of malignant processes such as cutaneous T-cell lymphomas may allow early therapeutic intervention to potentially prevent disease progression and fatal outcome. Dermatologists with training in dermatopathology are aware of the limitations of dermatopathologic evaluations of skin biopsies and the diagnostic value of correlation between clinical manifestation and histomorphologic findings. To overcome those limitations of histologic evaluation, photographs of the clinical features are occasionally submitted as hardcopies together with the biopsy specimens. Alternatively, digital images of the skin

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Pityriasis rosea Self limiting

Eczema/atopic dermatitis ? Pityriasis rosea ? PLEVA?

Atopic dermatitis Chronic recurrent

Fig. 2. Look-alike in inflammatory skin disorders: Pityriasis rosea and eczema share most histologic features and can only be distinguished by combined evaluation of clinical manifestation and histologic findings.

lesions are submitted in various forms, usually as images attached to e-mail messages. In cases, where skin lesions are disseminated or difficult to recognize on photographs or digital images, the patient is asked to come to the referral center where the skin biopsy has been evaluated so that clinicians and pathologists can discuss their findings and perform correlation of the skin lesions and the histologic findings. All these approaches are time-consuming for the involved parties, i.e. the patient, the dermatologist/clinician and the dermatopathologist. In particular, digital images of various size sent by e-mail via the Internet need first to be downloaded by the pathologist, are usually printed out to be available beside the microscope and often require additional modification (image size reduction, adjustment of colors, etc.) to be adequate for analysis. Personal experience shows that even a small number of digital images submitted in a non-standardized format can result in a time-consuming process which is often not feasible for routine work in common pathology laboratories. The aim of the HistoClinC (for Histologic and Clinical Correlations) project was to overcome these limitations and to create an Web-based application which should allow correlation of clinical and histologic features in a user-friendly way for both the dermatologist in private practice as well as for the dermatopathologist in the referral center. In this way, the system should enable the dermatopathologist to increase diagnostic accuracy of dermatopathologic evaluation.

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Upload of Dermatologist clinical images

Dermatologist Archive Dermatopathologist Clinicopathologic correlation

Second opinion

via Internet

Experts

Fig. 3. Schematic concept of a system for clinicopathologic correlations in dermatopathology.

HistoClinC

The technical goals of the system were to facilitate the handling, i.e. submission and retrieval of clinical images, respectively, and to have insight into the clinicopathologic correlation for both parties, the clinician/dermatologist and the dermatopathologist. The concept is schematically depicted in figure 3. A Web-based application accessible by Internet was chosen as a platform to enable easy and widely available access to the application. HistoClinC was programmed using cold fusion technology and is run physically on a Web server located at the Department of Dermatology, University Hospital, Zrich, Switzerland. One major technical issue was secure identification of the biopsy specimen and the protection of data, since the application can be accessed via the Internet. Access to the application is regulated by password and login, but no other security portals are required, since no personal data like the patients name are necessary for case identification. Thus, to avoid transfer of name the patients are identified by a number. Those numbers are generated by the dermatopathology center and printed on self-adhesive labels, which are sent out to the dermatologists in private practice. Each number is used only once in the system. The submitter of clinical images attaches the label with the identification number to the form sheet which is sent in together with the biopsy specimen. No personal data of the patients except for the date of birth and the gender are used throughout HistoClinC. After having shot digital images of the skin lesions, they can be uploaded into HistoClinC as jpg files by the dermatologist from his or her personal

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4 Fig. 4, 5. HistoClinC website Case documentation before (left) and after uploading images (right): Clinical images submitted by a dermatologist in private practice (upper row) can be correlated to the histologic findings (lower row). Note: Identification of the patient is achieved by a number and the date of birth, but not by name.

computer (PC). The application allows the upload of four clinical images at maximum and to add clinical description to the images. During the signingout process, those submission forms containing HistoClinC numbers are recognized by the dermatopathologist at the referral center who can access the clinical images by accessing the HistoClinC application via a PC beside the microscope. The correlation of clinical and histologic features is always performed by a dermatopathologist who is a board-certified dermatologist familiar with the clinical manifestation of skin disorders and who is moreover trained and experienced in skin pathology. After the correlation of clinical and histologic findings, digital images are created using a digital camera mounted on the microscope and connected to the PC, on which the HistoClinC application runs. This procedure requires minimal changes such as adjustment of light intensity on the routinely used microscope and can be done during or after the routine signing-out process. After the histologic images have been uploaded, a short description of histologic features and the final diagnosis

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are added. In addition, a final written report containing patients name and date of birth and a detailed description of the biopsy specimen is sent by mail to the dermatologist. In addition to the above-described function, HistoClinC allows to inform expert pathologists by e-mail asking them for evaluation of a case. The technical requirements for the participants are minimal to avoid high costs which could potentially limit the distribution and use of such an application. For the dermatologist in private practice, a digital camera and software (usually provided by the company who sells the camera) is required which should enable to store the clinical images in jpg format on his/her PC. For the dermatopathology center, a digital camera and software is required to save digital images of biopsy specimens in a sufficiently high quality by the simple and quick procedure described above. The HistoClinC project was started in December 2000. After only 10 months, HistoClinC went into the productive phase with four dermatologists in private practices and the Unit of Dermatopathology at the Department of Dermatopathology of the University Hospital in Zrich, Switzerland.

Discussion

HistoClinC is a Web-based application of telepathology which allows correlation of clinical and histologic findings in skin disorders. Thus it represents a unique project for the diagnostic process in dermatology where accurate diagnoses are often only achieved by an integrative synopsis of clinical and histologic features. The technical requirements for both parties, the case submitters as well as the dermatopathology center, are minimal and the costs are low compared to similar systems. A major advantage of HistoClinC is that the time-consuming process of downloading clinical images attached to e-mail messages and the handling of those images of various size using special software (e.g., Adobe Photoshop program) can be circumvented. In addition, one further advantage of this application refers to the use of numbers for the identification of patients and biopsy specimens, respectively, instead of patients name which would require more sophisticated data protection systems. Furthermore, HistoClinC images can be evaluated by other experts in the context of second opinions via direct Internet-based access to the cases, which represents a much faster procedure compared to the conventional way, i.e. sending of histologic slides to experts by regular mail. An inherent problem of histologic images used in telepathology is the fact that details selected by one pathologist may not be representative or misleading for

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another consultant expert. Ideally, digital images should provide an overview and depiction of details of the specimen which results either in images of high resolution and large size or multiple images of lower resolution and smaller size. Both approaches result in practical problems such as transfer time and critical quality of the images. However, despite these limitations, various studies using telepathology systems indicate that there is a high between in the diagnoses based on the evaluation of digital images and histologic sections [57]. In the future, reimbursement for the performance of clinicopathologic correlations has to be defined since the correlations require manpower and technical maintenance. In addition, legal aspects on data security as well as the impact of second opinions based on pre-selected images need to be clarified by national and international regulation schemes [8]. So far, the dermatologist who submitted the clinical images as well as the biopsy specimen, establishes and is responsible for the final diagnosis taking into account all available data. The scientific evaluation of applications like HistoClinC includes various aspects. First, it has to be shown in prospective studies that the quality of the clinical and histologic images provided on HistoClinC is sufficient for diagnostic purposes. Second, we have to show that there is a high concordance between the evaluation of digital clinical and histologic images and diagnoses based only on direct evaluation of histologic sections. In this case, HistoClinC would represent a cost-effective and reliable approach to substitute the conventional and time-consuming mailing of histologic sections to experts. A third point is related to the improvement in diagnostic accuracy by correlating clinical and histologic features of skin disorders which is the major goal of the HistoClinC application. In addition, such systems can be used for open and distance education [9]. In our experience, dermatologists using the HistoClinC system produce digital images of high quality allowing the dermatopathologist to recognize virtually all important features of the skin lesions such as distribution, size, surface structure and coloration. Most colleagues in private practice provide one or two clinical digital images, rarely three images per patient were uploaded. So far, correlation between the diagnoses based on the clinical images and the histomorphologic diagnoses seems to be good, but needs to evaluated in appropriate prospective studies which are currently ongoing. In summary, we assume that HistoClinC and other similar system will replace classic clinicopathologic correlation, which still requires the patient to be seen by the dermatopathologist in the referral center in most of the cases. HistoClinC represents an interesting and unique telemedicine application to improve diagnostic accuracy in the evaluation of skin biopsies.

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Acknowledgements
We are very grateful to Nicolas Miescher, Urs Hess, Rolf Sidler and Oliver Jschke for programming HistoClinC and to the dermatologists Dr. Petra Ellgehausen, Dr. Martin Grob, Dr. Norbert Hilty, and PD Dr. Ren Rdlinger for their timeless and kind collaboration during the installation and the tests of the HistoClinC system.

References
1 2 3 Kayser K, Beyer M, Blum S, Kayser G: Recent developments and present status of telepathology. Anal Cell Pathol 2000;21:101106. Rashbass J: The impact of information technology on histopathology. Histopathology 2000;36: 17. Ackerman AB, Chongchitnant N, Sanchez J, Guo Y: Histologic Diagnosis of Inflammatory Skin Diseases. An Algorithmic Method Based on Pattern Analysis, ed 2. Baltimore, Williams & Wilkins, 1997, pp 171172. Kempf W, Dummer R, Burg G: Approach to lymphoproliferative infiltrates of the skin. The difficult lesions. Am J Clin Pathol 1999;111(suppl 1):S84S93. Berman B, Elgart GW, Burdick AE: Dermatopathology via a still-image telemedicine system: Diagnostic concordance with direct microscopy. Telemed J 1997;3:2732. Dunn BE, Choi H, Almagro UA, Recla DL, Krupinski EA, Weinstein RS: Routine surgical telepathology in the Department of Veterans Affairs: Experience-related improvements in pathologist performance in 2,200 cases. Telemed J 1999;5:323337. Okada DH, Binder SW, Felten CL, Strauss JS, Marchevsky AM: Virtual microscopy and the Internet as telepathology consultation tools: Diagnostic accuracy in evaluating melanocytic skin lesions. Am J Dermatopathol 1999;21:525531. Dierks C: Legal aspects of telepathology. Anal Cell Pathol 2000;21:9799. Szymas J: Teleeducation and telepathology for open and distance education. Anal Cell Pathol 2000;21:183191.

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Werner Kempf, MD, Department of Dermatology, University Hospital, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 8733, 41 1 255 4403, E-Mail kempf@derm.unizh.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 222225

6.1

Teledermatology in North America

Hon Pak
San Antonio, Tex., USA

Background

The USA spent USD 36.7 billion in 1997 on dermatologic care which included approximately 33 million outpatient visits to the dermatologists [1, 2]. It is expected that the demand for dermatologists will only increase with our aging population. Interestingly, only 40% of skin conditions are being diagnosed and managed by dermatologists, even though there is evidence that dermatologists are more cost-efficient and better equipped to manage all skin diseases directly. Unfortunately, there has been a significant reduction of medical dermatologists in the USA, making direct access for all patients untenable. Given the current reimbursement by Medicare and managed care organizations, a significant number of dermatologists are performing more cosmetic and laser procedures leaving fewer dermatologists to manage patients with routine skin problems. This shortage of medical dermatologist in the USA is projected to worsen in the next several years.
Teledermatology in the USA

The number of teledermatology programs in the USA has been steadily increasing with the US military having the most store-and-forward (SAF) experience to date. Given the reimbursement limitations, most of the teledermatology programs in the USA with a few exceptions such as the US military and University of Arizona are utilizing interactive video teleconferencing systems (IAV) [3]. Recently, interest in teledermatology has increased due to the ongoing shortage of dermatologists in the USA with few viable alternative options. In the last few years, the number of published articles on teledermatology has increased substantially. Based on the available data from these studies and

our experience in the US military, there is sufficient evidence supporting the diagnostic equivalency (correlation) of teledermatology to a face-to-face evaluation with a dermatologist [415]. Although there are many studies (mostly from outside North America) alluding to the cost-effectiveness of teledermatology, outcomes studies are very few and those available are focused on IAV teledermatology and limited in scope. Led by Drs. Jim Grigsby and Anne Burdick, an outcomes study sponsored by the Center for Medicare and Medicaid Services (CMS, formerly HCFA) evaluating SAF teledermatology is currently underway. In addition, the author has received funding to perform a comprehensive outcomes study for SAF teledermatology in the military setting. Although most dermatologists who have used S&F teleconsultations would agree that teledermatology is a clinically effective method to deliver specialty consultation, there is debate on the final outcome (which includes clinical and cost outcome in addition to patients quality of life).

Barriers

Given the current shortage of dermatologists in the USA, many are now looking at teledermatology as one of few viable options to be able to meet the increasing demand and resolve the worsening shortage of dermatologists. Unfortunately there are many barriers which are inhibiting teledermatology from growing to its full potential: reimbursement, interstate licensing, credentialing and malpractice insurance. Although interactive telemedicine consultations are being reimbursed in the USA, only Hawaii and Alaska currently have pilot studies in which SAF teledermatology consultations are being reimbursed. The issue with interactive teledermatology, although more ideal for education, is that it is not optimal to handle a large volume of consults as seen in a normal outpatient dermatology setting. Interstate licensing is an issue fairly unique to countries with similar healthcare systems as the USA. The current state regulations do not permit physicians to provide services across state lines unless they have the appropriate state licenses, and thus only those healthcare organizations which serve populations across state lines are affected. However, by utilizing those dermatologists with the appropriate state licenses (whether they reside in that state or not), we can circumvent this issue. Of note, there is debate on a national medical license to practice telemedicine; however, the outcome of this effort is not clear. On the issue of credentialing, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently revised their Medical Staff Standards for its Comprehensive Accreditation Manual for Hospitals [16].

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The revision maintains that providers of telemedicine who diagnose and treat patients are subject to the credentialing privileges of the organization that receives the services. However, the new standard does allow the receiving facility to use credentialing information from another JCAHO-accredited facility. Most importantly, this decision to delineate privileges must be made at the receiving facility. Contrary to popular belief, the most difficult barrier is not credentialing, reimbursement or interstate licensing restriction. In the authors opinion, the most significant hurdle is in the area of malpractice insurance coverage. Before teledermatology can be utilized to its full potential, there must be significant reform. Although an increasing number of insurance carriers in the USA are covering telemedicine for those that currently have liability policies for their existing practices or hospitals, many carriers do not specifically cover telemedicine. In fact, there are very few carriers who will provide malpractice insurance just for telemedicine. Those that provide coverage will likely charge an annual premium with a minimal discount for part-time practitioners, instead of charging a fee based on the volume of consults. A retired dermatologist who has no desire of operating and maintaining an office or dermatologists with small children who choose to stay at home but want to keep up their skill using teledermatology will find it difficult or not profitable to obtain affordable malpractice insurance. Given the maldistribution of dermatologists in the USA, malpractice insurance reform to broaden coverage for teledermatologists would significantly enhance the growth of SAF teledermatology.

Conclusions

The author strongly believes that teledermatology will become a part of our daily practice of medicine. As evidenced by the increasing number of published studies, the use of teledermatology is increasing given its proven clinical efficacy. Furthermore, SAF teledermatology seems to be the better solution for the current shortage of dermatologists in the USA given its ability to handle a large volume of dermatology consults. Most experts feel that teledermatology will not replace dermatologists, but rather enhance our delivery of general dermatologic care to our patients. Most studies evaluating teledermatology show that patients benefit the most via an improved access to dermatology consultations. Technology for SAF teledermatology, although important, is no longer a barrier. In fact, there are many technology solutions for teledermatology. What is more important is our understanding the business process and training requirements for teledermatology and how teledermatology should be implemented. Teledermatology is no longer a futuristic concept. Given the current

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state of dermatology today, teledermatology will empower us to provide consistent, high-quality, cost-effective dermatologic care to our patients regardless of where they live.

References
1 Cherry D, Burt C, Woodwell, DA: National Ambulatory Medical Care Survey; 1999 Summary. Advance Data from Vital and Health Statistics: No 322. Hyattsville/Md, National Center for Health Statistics, 2001. Cherry D, Burt C, Woodwell, DA: National Ambulatory Medical Care Survey; 1998 Summary. Advance Data from Vital and Health Statistics: No 315. Hyattsville/Md, National Center for Health Statistics, 1999. Grigsby B, Brown NA: Survey of Teledermatology in the USA; in Wooton R, Oakley A (eds): Teledermatology. London, Royal Society of Medicine Press Ltd, 2002. Oakley AMM, Astwood D, Loane M, et al: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. NZ Med J 1997;37:398402. Phillips CM, Burke WA, Schechter A, et al: Reliability of dermatology teleconsultations with the use of teleconferencing technology. J Am Acad Dermatol 1997;37:398402. Lesher JL, Davis LS, Gourdin FW, et al: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. J Am Acad Dermatol 1998;38:2731. Lowitt MH, Kessler II, Kauffman CL, et al: Teledermatology and in-person examinations: A comparison of patient and physician perceptions and diagnostic agreement. Arch Dermatol 1998; 134:471476. Gilmour E, Campbell SM, Loane MA, et al: Comparison of teleconsultations and face-to-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Br J Dermatol 1998;139:8187. Kvedar JC, Edwards RA, Menn ER, et al: The substitution of digital images for dermatologic physical examination. Arch Dermatol 1997;133:161167. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 1997;133:171174. Whited JD, Russell HP, Simel DL, et al: Reliability and accuracy of dermatologists clinic-based and digital image consultations. J Am Acad Dermatol 1999;41:693702. High WA, Houston MS, Calobrisi SD, et al: Assessment of the accuracy of low-cost store-andforward teledermatology consultation. J Am Acad Dermatol 2000;42:776783. Barnard CM, Goldyne ME: Evaluation of an asynchronous teleconsultation system for diagnosis of skin cancer and other skin diseases. Telemed J E Health 2000;6:379384. Lyon CC, Harrison PV: A portable digital imaging system in dermatology: Diagnostic and educational applications. J Telemed Telecare 1997;3(suppl):8183. Krupinski EA, LeSeur B, Ellsworth L, et al: Diagnostic accuracy and image quality using a digital camera for teledermatology. Telemed J 1999;5:257263. Joint Commission on the Accreditation of Healthcare Organizations. Medical Staff Standards. Comprehensive Accreditation Manual for Hospitals. Available at http://www.jcaho.org/standard/ stds2001_mpfrm.html. Accessed March 17, 2002.

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Hon Pak, MD 1126 Beclaire, San Antonio, TX 78258 (USA) Tel. 1 210 916 0632, Fax 1 210 916 3103, E-Mail hpak@teledermsolutions.com

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6.2

Telemedicine Experience in North America

Abrar A. Qureshi a, Joseph C. Kvedar b
Partners Telemedicine, aBrigham and Womens Hospital and bMassachusetts General Hospital, Harvard Medical School, Boston, Mass., USA

History

The beginning of telemedicine in the USA dates back to the 195060s when Wittson et al. [1] provided the first telepsychiatry service in Omaha, Nebraska, followed by a separate group that organized the first teleradiology service in Montreal, Quebec. In separate endeavors in the 197080s, the National Aeronautics and Space Administration (NASA) and Massachusetts General Hospital provided telemedicine services via telephone lines and a microwave link respectively [2]. A collaborative effort by NASA and the Indian Health Services (IHS) was one of the first federally funded studies (STARPAHC), launched to document the efficacy of telemedicine services. In 1979, STARPAHC concluded that there were no consistent differences in quality of care rendered by sites with telemedicine systems compared to routine clinics staffed by physicians [3]. Since the initial phases of NASAs space program, continuous monitoring of environmental parameters has been a part of every space mission. In West Virginia, the first project began in 1985. At present, the West Virginia Medical Access and Referral System (MARS) has been expanded into a network called Mountaineering Doctor Television (MDTV) which links many facilities [4]. The Department of Veteran Affairs has a communications network that is composed of 23,000 miles of fiber-optic cables, connecting over 600 facilities, allowing rapid communication via live video-conferencing or storeand-forward technologies. The Center of Excellence for Medical Information Management was established in 1993 as the first step in creation of telemedicine services, by the US Department of Defense [5]. Prior to that, telemedicine

systems were used in Operation Desert Storm, using civilian communication satellites. Some of the initial thrusts in the Canadian distance health system were the establishment of a rudimentary network of fax machines and stillimage video transmission in Newfoundland, as early as 1983. This network was created to reach remote offshore sites such as oil rigs. A recent study was undertaken to evaluate the efficacy and reliability of teleobstetric ultrasonography services from an urban tertiary care center to a remote hospital [6]. These are just a few examples of telemedicine programs in North America. North American telemedicine programs have been developed to meet the changing demand for remote healthcare services. There has been tremendous progress since the first notion of delivering services over phone lines, however many of the programs that were started more than 20 years back have ended, mainly due to lack of financial support. The prevalent question being asked today is, why is telemedicine not playing a larger role in day-to-day healthcare delivery? More importantly, when will telemedicine adoption achieve the critical mass it requires to become a part of the healthcare-delivery fabric? The discussion that follows focuses on the current status, progress we are making in telemedicine research and trends that are emerging in North America. The themes prevalent in the discussion include limited patient awareness, increasing physician comfort and need for better revenue models for telemedicine sustenance.

Current Status

The demand for medical services to geographically remote areas and to unique markets such as prisons, warships or space shuttles, has resulted in targeted telemedicine programs that fulfill a specific need. Thus telemedicine programs in the USA have been niche-market oriented until recently, e.g. prison telemedicine. Rural telemedicine has been a practical way to deliver services to remote areas where there is physician shortage [7]. Specialty telemedicine is also called commercial telemedicine e.g. teleradiology or teledermatology [8] has helped reduce the distance between patients and specialty care. Both videoconferencing and store-and-forward consultations are commonly used modalities. Distance learning is fast becoming an integral part of many telemedicine programs in North America. Early initiatives were supported by grant funding from government institutions or investments from hospitals looking to expand their referral base. Hence, most programs are managed and run by academic institutions and hospitals, infrequently funded by industry. The initial strategy relied on creation of a hub-and-spoke infrastructure, with a central system based at a tertiary care hospital, reaching out to a surrounding population. Many programs need

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continued financial support to sustain themselves as the volume of remote consultations and distance learning is small. Programs funded and supported by governmental organizations have been successful in staying afloat, as the prime purpose of these programs is to provide service, irrespective of the revenue generated [9]. In large part, the services are free to individuals involved in governmental agency work. Of a total of 362 telemedicine programs that have been identified in the USA, 111 are at academic centers, 68 in hospital-based networks and 80 are federal (federal, military or Department of Veterans Affairs) representing 30 specialties in medicine, fulfilling a variety of service needs [10]. Based on an Agency for Healthcare Research and Quality report published in July 2001, the number of telemedicine encounters has increased steadily and evidence for diagnostic effectiveness is highest for the field of dermatology. The same study quotes consultations or second opinions as the most common telemedicine activity. The manner in which telemedicine services are offered to the population at large has taken a leap forward in the last year or so, with movement towards Webbased services. At least one time-and-place-independent system has been developed, as a browser-based, user-friendly service by Partners Telemedicine, Partners Health Care System, Inc., Boston, Massachusetts. This Web-based tool is dubbed Partners Online Specialty Consultation (POSC) accessible at http://econsults.partners.org. POSC allows both patients and the patients primary care physician to request a consultation from a Partners Health Care System specialist. The service is available to anyone, anytime, anywhere, as long as they have access to a computer with a Web browser. Another system developed by Healinx Corp., Emeryville, California, allows patients and providers to interact via e-mail that is encrypted, accessible at http://www.healinx.com. Patients pay a nominal co-payment and physicians are reimbursed via this system. A more recent website launched by the Cleveland Clinic Foundation, dubbed e-Cleveland Clinic can be accessed at http://www.eclevelandclinic.org.

Progress

We believe that forward motion in telemedicine will spring from outcomes research and technology development. There is need for high-quality clinical trials that can impact policy and practice of telemedicine. Thus far, few studies address cost-benefit issues effectively. Outcomes Research A number of methods have been used to evaluate the quality of telemedicine clinical trials including evaluation of access to care (utilization, barriers,

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mediators and outcomes), economic analyses (cost-effectiveness) and satisfaction studies (patient and provider) [11]. Studies comparing diagnosis between telemedicine encounters and real-time patient-provider encounters have conclusively shown comparable results in teledermatology and teleradiology. Bringing the physician and patient to adopt telemedicine requires both awareness of and comfort with the technology. Better outcomes studies are needed to convince patients and physicians that telemedicine is effective. Technology Development Advances in IT have facilitated better, faster and more accurate information to be transmitted cheaply across major distances. The Internet has played an important role in creating the infrastructure. The use of online tools for patient care is gaining popularity among physicians. A study shows up to 26% of physicians are communicating with their patients over the Internet [12]. With new tools emerging every day, telemedicine can become even more efficient and accurate. For example, tools that allow automated tagging of data with unique patient identifiers ensure that no patient data gets recorded in the wrong medical record. The tools can be tested in outcomes studies and data shown to future users as proof of efficacy.

Emerging Trends

A number of trends have emerged that will shape the adoption of telemedicine in North America. The trends are related to the economics of healthcare, development and deployment of emerging technologies and penetration of Internet-based technologies to physicians and the population at large. Privacy and Security The Health Insurance Portability and Accountability Act (HIPAA) is a Federal law enacted in 1996 to provide continuity of healthcare insurance coverage, and to prevent fraud. HIPAA provisions include security standards to protect data confidentiality and integrity. These security standards apply to any physician or allied healthcare professional transmitting healthcarerelated, financial and administrative information in an electronic format [see http://www.hcfa.gov/hipaa/hipaahm.htm]. Although privacy and security of information transmitted is an absolute must, there is a tradeoff: added cost and reduced access. Another aspect of any healthcare-related security implementation strategy needs to allow selective access to information pertinent to the needs or tasks of certain individuals. Despite customized security systems, skeptics will continue to doubt even the more robust security systems. The hope

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is that newer security measures will always be one step ahead of anyone attempting to compromise them. Provider Comfort, Consumer Awareness, Technology Adoption As a conservative estimate, more than half of the US population has access to and use the Internet. A recent survey has revealed that 47% of patients reported access to the Internet compared to 72% of nurses and 100% of physicians [13]. With such high degree of technology adoption, physicians can be convinced to come on board with telemedicine endeavors with solid outcomes research published in peer-reviewed journals, improved work flow and design. In 1998, of the 750,000 physicians in the USA, about 2,000 used telemedicine services. The most common application in the USA is teleradiology. In 1997, about 250,000 teleradiology studies were performed, and about 45,000 video and store-and-forward encounters were documented [14]. The most common specialty consultations were performed in psychiatry. For telemedicine to succeed, both patients and clinicians must accept the processes involved and embrace technology. It seems clear that technology advancement will move faster than its appropriate adoption. Strategies need to be in place to evaluate emerging technologies so that they may be utilized efficiently. For example, a more recent trend is evaluation of wireless technology for telemedicine purposes. The average Internet user seems to fit a very different profile than that of an Internet user with a medical problem. Most patients searching for answers to their questions have chronic disease or cancer. The informed patient prefers to visit multiple websites to confirm answers about their condition as compared to the average Internet user who prefers to stay with a few chosen, familiar sites. The quest for corroborating answers between more than two or more resources seems to allay apprehensions about a disease, its diagnosis or treatment. Increased patient awareness of telemedicine services will require improved user interfaces and marketing efforts. A high level of patient satisfaction with the services will enhance volume of telemedicine activity and allow long-term implementation. Before patients are approached with the notion of fee-for-service, it is imperative that those in the telemedicine arena develop an understanding of the value proposition. Economic Model, Healthcare Policy Impact Adequate reimbursement mechanisms have not been in place since telemedicine efficacy and safety had not been established until more recently. In the USA, telemedicine coverage by the Center for Medicare and Medicaid Services (CMMS, formerly HCFA), has been limited [see http://www.hcfa.gov]. Initially, coverage was provided for situations where patient-physician

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face-to-face contact was not necessary such as in radiology. After the Balanced Budget Act (BBA) of 1997, provisions were made for coverage of rural areas with shortage of health professionals, and for an interactive audio-video (videoconference) interaction between patient and physician. There was no provision for line charges or facility fees, and allied health professionals such as nurses, social workers and psychologists could not get reimbursed for telemedicine services. Store-and-forward technologies, pharmacotherapy, sleep studies, psychotherapy, and physical, occupational and speech therapy services are being targeted as the next in-line modalities to be reimbursed through third parties. Albeit slowly, there is a move towards cash-based services, with payment expected at the time of service rendered, hence free-market adoption. To get third-party payers involved with reimbursement of telemedicine services, quality clinical research is needed to evaluate the economic impact of telemedicine.

The Future

If telemedicine is both a method of healthcare delivery and a means of sharing medical knowledge, one can foresee a future where telemedicine is part and parcel of any brick-and-mortar healthcare delivery system. The role of telemedicine would be to support routine healthcare rather than replace it. In a supportive role, telemedicine adoption would be more palatable and less threatening. The eventual goal would be to eliminate the notion that technology drives telemedicine. Instead, the demand (from patient and provider) to deliver remote, rapid, accurate care via secure networks will become the driving force behind telemedicine and telehealth services.

References
1 2 3 Wittson CL, Affleck DC, Johnson: Two-way television group therapy. Ment Hosp 1961;12:2223. Brauer GW: Telehealth: The delayed revolution in health care. Med Prog Technol 1992;18: 151163. Berek B, Canna M: Telemedicine on the move: Healthcare heads down the information superhighway; in Hospital Technology Feature Report. American Hospital Association, 1994, vol 13, No 6, pp 165. Turner J, Brick J, Brick JE: MDTV Telemedicine Project: Technical considerations in videoconferencing for medical applications. Telemed J 1995;1:6771. Zimnik PR: A brief survey of Department of Defense Telemedicine. Telemed J 1996;2:241246. Reddy ER, Bartlett PJ, Harnett JDM, McManamon PJ, Snelgrove C: Telemedicine and fetal ultrasonography in a remote Newfoundland community. CMAJ 2000;162:206. Ricketts TC: The changing nature of rural health care. Annu Rev Public Health 2000;21:639657. Perednia DA, Allen A: Telemedicine technology and clinical applications. JAMA 1995;273: 483488.

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Mandl KD, Kohane IS, Brandt AM: Electronic patient-physician communication: Problems and promise. Ann Intern Med 1998;129:495500. Telemedicine for the Medicare population: Pediatric, obstetric and clinician-indirect home interventions: Evidence report. Technology Assessment (24 suppl):132. Roine R, Ohinmaa A, Hailey D: Assessing telemedicine: A systematic review of the literature. CMAJ 2001;165:765771. Von Knoop C, Lovich D, Silverstein M: Vital signs update: Doctors say e-health delivers. BCG Focus, Sept 2001. Jadad AR, Sigouin C, Cocking L, Booker L, Whelan T, Browman G: Internet use among physicians, nurses and their patients. JAMA 2001;286:14511452. Strode SW, Gustke S, Allen A: Technical and clinical progress in telemedicine. JAMA 1999;281:10661068.

Abrar A. Qureshi, MD Massachusetts General Hospital Associate Physician, Brigham & Womens Hospital, Two Longfellow Place, Suite 216, Boston, MA 02114 (USA) Tel. 1 617 724 5517, Fax 1 617 726 7530, E-Mail aqureshi@partners.org

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6.3

Teledermatology in Sub-Saharan Africa

Peter Schmid-Grendelmeier, Prosper Doe, Neil Pakenham-Walsh
Universittsspital Zrich, Dermatologische Klinik, Zrich, Switzerland

The probability of a child dying before age 5 is 10 times more likely in developing countries than in developed countries. Many countries of subSaharan Africa have less than USD 40 to spend on healthcare per person per year. Does telemedicine make sense for these countries under such conditions, and if so, how should it be delivered? And what about teledermatology in these areas, where skin diseases are abundant but almost neglected by many public health services? Under such circumstances, telemedicine is very different in the developing countries compared to that in the developed world. In Africa, many clinics and hospitals in many areas do not have regular access to modern ways of communication. Very basic needs such as power supply or telephone access cannot be taken for granted. Therefore, the sophisticated needs for telemedicine or even videoconferencing seem to be rather a toy or a dream that developing countries can ill afford at least at the moment. It is these and other questions regarding teledermatology in African countries that we want to discuss briefly. Our contribution is based on our personal experience with a teledermatological link between Tanzania and Switzerland.

Telemedicine in General in African Countries

Many developing countries have an acute shortage of doctors, particularly specialists. Sub-Saharan Africa has, on average, fewer than 10 doctors per 100,000 inhabitants. Several countries do not have a single radiologist, pathologist or dermatologist [1]. The specialists and services that are available are concentrated in cities. Workers in rural healthcare, who serve most of the population,

are isolated from specialist support and up-to-date information by poor roads, scarce and expensive telephones, and a lack of libraries. While there are still very few reports about teledermatology in Africa, there are already quite numerous reports about other telemedical activities in this and other areas with limited resources [27]. These reports contain a survey of telemedicine in 60 countries, half of which are from the so-called third world. Sub-Saharan Africa represents possibly the continent with the least developed network of transport, connections and also paths of digital communication and has to face the above-mentioned difficult conditions. Cheap and appropriate technologies and good ideas are mandatory to overcome these obstacles. As an example, the digital transmission of x-ray images needs such an unorthodox approach. Access to radiological expertise remains a challenge in developing countries. Digital radiology offers a potential solution but is expensive. Laser film scanners are very costly. Consumer image scanners are cheaper and can provide reasonable quality but are not suitable for full-size radiographs. Thus a suitable approach may be to photograph an x-ray image on a light box with a digital camera. This can provide adequate diagnostic quality in many cases and is becoming increasingly practical as cameras approach the ideal resolution for digital x-ray images of 2,048 2,048 pixels [8, 9]. Digital image compression techniques (wavelet compression) can reduce a file of highquality chest radiographs to a size suitable for e-mail (under 300 kB), thus enabling anyone with e-mail to consult a radiologist for an opinion. Such solutions have to be found and promoted by persons and organizations knowledgeable and actively involved with the needs and possibilities in areas with limited resources. Such expertise is more needed than just the knowhow about what is technically possible in industrialized nations. On the other hand, the fact that many technical features are possibly not accessible in areas such as sub-Saharan Africa should not inhibit the implementation of appropriated telemedical connections possibly on a technically lower level here. There are projects that focus on aspects of promoting telemedicine and the use of the electronic media in countries with limited resources. Two of them are Inmarsat and the Health Information Forum (HIF) International Network for the Availability of Scientific Publications (INASP). Both organizations are presented below in more detail.

Inmarsat

Inmarsat is a coordinating production of the ITU Report and is a participant in the European Telemedicine Corporation Group (ETCG). Inmarsat provides a satellite phone system capable of reaching virtually even the most

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remotest place on earth (http://www.inmarsat.org/index3.html). Inmarsats latest generation of satellite phones is the size of a laptop computer and can be purchased for less than USD 3,000 a unit. This is less than a tenth the cost of the terminals used more than a decade ago when the Inmarsat satellite system was first used for telemedicine delivery. (The cost of usage has also dropped, with rates for some voice and data services of under USD 3 per minute.) Conferences for telemedicine in developing countries are organized regularly. Representatives of the WHO, the ITU and the Midjan group are involved in these meetings. Reports from various African countries were involved in these meetings, such as reports about telemedicine in general, or partial aspects such as teleradiology. The nations involved so far include the Congo (telemedicine in emergencies and disasters), Kenya/Mali/Senegal (teleobstetrics, distance learning) and Tanzania.

International Network for the Availability of Scientific Publications (INASP)

INASP is a very useful organization for promoting access to information, both printed and electronic, in countries with limited resources. INASP is a cooperative network of partners working to improve access to information worldwide. Its health program, INASP-Health, works to strengthen and support the activities of organizations worldwide towards the common goal of providing universal access to reliable information for health professionals in resourcepoor countries. INASP-Health activities include: Advisory and Referral Network: INASP-Health promotes collaboration and sharing of expertise and experience through its advisory and referral network, which involves more than 750 organizations and individuals, North and South. Partners are kept up to date with current events in the field through the INASP Newsletter. Health Information Forum: INASP-Health runs regular thematic workshops, with guest speakers from developing countries and e-mail contributions from health professionals, publishers, librarians and information workers worldwide. The emphasis is to support and help those involved in health information work, North and South. INASP-Health Directory: INASP-Health publishes the directory of organizations working to improve access to reliable information for health professionals in developing countries. Available on the INASP website, the Directory serves as a networking tool for building professional relationships and sharing information, and as a reference for those in resource-poor settings who are seeking support.

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HIF-net at WHO is the e-mail discussion list dedicated to issues of health information access in resource-poor settings. Launched in July 2000 in collaboration with WHO, the list promotes cross-sectorial communication among providers and users of health information. It currently has over 500 participants, including health professionals, librarians, publishers, NGOs, and international agencies worldwide. More information is available under http://www.inasp.org.uk. The contact address is Neil Pakenham-Walsh at INASP_Health@compuserve.com. To join HIF-net at WHO, e-mail your name, affiliation and professional interests to INASP_Health@compuserve.com.

Teledermatology in African Countries Our Personal Experience with the Tanzania-Switzerland Connection

Dermatology is not a main focus of governmental as well as nongovernmental health policies in most of the countries with limited resources. Except leprosy and some infectious diseases affecting also the skin such as onchocerciasis, very little importance is given to dermatological problems in these regions. Overwhelming health problems due to major killing diseases such as malaria, tuberculosis and in the recent years the dramatic HIV/AIDS epidemic leave little space and money for the mostly non-lethal skin affections. Among others, the International League of Dermatological Societies (ILDS) of Dermatology has recognized this lack of skin care. Therefore, the ILDS developed the project UNIDERM to focus on providing healthcare to developing nations (www.who.int/ina-ngo/ngo/ngo090.htm) [9, 10]. Through the IFD (www.ifd.org) it currently operates two Regional Dermatology Training Centres (RDTC), one in Tanzania and the other in Guatemala serving rural community nurses. A third RDTC is under development in francophone Africa. The ILDS provides liaison and communication services linking dermatological societies throughout the world and assists sponsoring countries in the organization and programming of the quinquennial World Congresses of Dermatology [13]. As dermatology is not a primary focus of healthcare in the developing countries, there is also not much emphasis given to teledermatology in these areas. But teledermatology has been shown to be a useful tool to provide skin care to underserved populations such as in Canada or the Hawaiian islands [11], the Azores [12] or Taiwan [13]. Therefore, it offers also a great potential in an area like subSaharan Africa, which suffers a shortage of dermatologists as well as limited communications and transportation. Although the potential use and projects are discussed [27], reports about established teledermatological connections in this area are still rare. We describe here our experience with teledermatology

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Fig. 1. The RDTC located at the slopes of Mount Kilimanjaro.

Table 1. Steps towards the teledermatological link between Moshi and Zrich Jan. 1997 May 1997 June 1997 Aug. 13, 1997 Sept. 4 1997 Sept. 12 1997 From Sept. 1997 Oct. 25 1997 Since Dec. 1997 Mid Dec. 1997 Jan. 1998 Inauguration of the new RDTC building Opening of the new RDTC building Public telephone line at RDTC functioning First E-mail from RDTC sent by a local provider in Moshi First pilot videoconference with Switzerland Telephone line at RDTC disconnected (for false bill of Jan. 97) Temporary loss of the provider due to electricity shortage First live videoconference with Switzerland Digital histopathological transmission possible Termites destroy RDTC telephone lines Videoconferencing functional

made at the RDTC in Moshi, Northern Tanzania (table 1, fig. 1), which aims to promote knowledge for allied health professionals in dermatology, leprosy and STD [14]. Using the experience won in the Swiss Dermatologists Telenetwork (Dermanet/www.dermanet.ch), a complete hard- and software package was transferred to the RDTC (fig. 2; desktop PC Pentium 133 Hz, still digital camera, 28.8-kBaud modem) [15]. In a first step a telephone line had to be requested and established; the density of telephone lines in Tanzania was still about 3 per 1,000 inhabitants only in 1997. There was no possibility to use

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Fig. 2. The equipment used at the RDTC.

cellular and satellite phones at that time in Tanzania what has changed significantly in the meantime. Due to voltage instability and repeated power cuts, a unit for uninterrupted power supply had to be interconnected to avoid severe damage of the system. Here a mobile computing system based on a laptop would have been very beneficial compared to the desktop version. Still the camera used at that moment made the space and versatility of a desktop necessary. Using only dustcovers for protection, the system proved to be astonishingly resistant against heat and humidity. Repeated attacks from termites feeding on telephone and power wires were an unexpected challenge to be faced. Also theft proved to be a major risk which had to be prevented by multilockable doors and iron-protected windows. By means of a provider just starting up in the local town, we could finally establish the necessary access to the Internet. This proved to be very cost-saving and advantageous for the otherwise quite vulnerable telephone connections. Taking video pictures of patients required a relatively extensive counseling, as most patients were not all used to being photographed or even realizing the images of themselves on a computer screen. Challenging light facilities (sunlight or roof neon light) causing strong reflections on the mainly dark skin had to be managed before achieving pictures of sufficient quality. Finally, clinical pictures and later also digitized histopathological slides of either unclear or very interesting skin findings could be discussed through videoconferencing, which allowed interactive discussion with colleagues from Switzerland and in a later

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stage also from other countries. Expertise was also received by sending digitized pictures as e-mail attachments to colleagues for consultation. The speed of transmission was limited due to the locally available telephone connections (max. 19 kBaud), but sufficient to exchange the transmission of a JPEG-compressed picture within 12 min. The software used (Physicians Conference Network) allowed to be connected with colleagues all over the world having the necessary hardware and Internet access using a safe, password-protected way of exchange. Image transfer was done after consultation time due to time restriction. This was due to the fact that all the patients had to register before 9 a.m. to be seen the same day (rule given by the hospital authorities). Therefore, 100150 patients were often waiting outside the outpatient clinic to be seen for skin problems and sometimes there were only two or even a single dermatologist available to attend to all these patients. So there was little time left to take digital pictures of interesting cases. Also pictures initially could not be taken in the examination room. Using a camera linked with a cable to the PC, all the patients first had to be sent to the room with the PC/video equipment (which had to be safe-locked). Documenting the patients with digital images was therefore rather time-consuming in periods of sudden power cuts sometimes even a matter of a luck. Within the first year of the system being installed, images of about 30 patients (clinical or histopathological slides) were taken and saved, partly on the PC hard disk, partly on an external ZIP drive. Several cases were discussed during a total of four live videoconferences, but most cases were exchanged offline via e-mail attachment (store-and-forward principal) due to the fact that there was only a time difference of 1 h between Zrich (Switzerland) and Moshi (Tanzania). Thus, a common hour for a videoconference could easily be found at around 1 p.m. This time allowed also a rather fast exchange via the Internet, while in the evening when the Web was used by more and more people from Europe and especially North America the exchange speed rapidly declined in Moshi. The exchange of images had always to be agreed first, because any Swiss picture sent during the transfer of a picture from Tanzania just interrupted the transfer of the latter probably due to the much slower telephone lines. Also colleagues from Europe started to ask for expert opinions at the RDTC about their patients with dark skin or potentially tropical skin diseases. So a mutual exchange of knowledge could be started. This exchange is still ongoing 3 years after, although to a very limited extent. The software normally needs to be updated once a year. The technical equipment is still working after 3 years, although it suffered hard due to several severe crashes during massive power fluctuations and also a quite impressive termite invasion. The contact was and is of course also very dependent on the initiative and knowledge of some single individual participants of the RDTC.

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Several dermatologists may doubt if there is a necessity of having a teledermatological equipment for several thousand dollars while it is difficult to buy efficient drugs urgently needed for the treatment of skin diseases as frequent as scabies or superficial fungal infections. For the partner in the industrialized nation it needs an advanced knowledge of tropical skin diseases and a basic idea for the often limited possibilities and conditions in a developing country to make such an exchange (and not only the possession of the equipment) fruitful and attractive also for the partners on the side with the limited resources. Here an exchange between various areas with similar conditions, e.g. various centers in developing countries, would possibly bring a higher impact of teledermatology. A horizontal exchange might therefore be more beneficial than a vertical exchange in this aspect. But, on the other hand, this vertical teledermatological exchange can also be extremely beneficial if both partners do see the potency of learning and widening the understanding for each other. Nowadays there is an ongoing teledermatologic exchange between the RDTC and Switzerland, having expanded to dermatologists working in other African countries such as Uganda, Mozambique, Ghana and Senegal that have all access to the Internet. A more and more active exchange of e-mail-attached digital images has replaced the initially started ambitious videoconferences definitively more adapted to the local conditions.

Lessons We Learned: Technical Needs

As stated above, due to fact that skin findings can be discussed in most cases with still images, real online videoconferencing does not seem to be a crucial prerequisite. The exchange of digital images via e-mail offers a very useful and appropriate possibility of exchange. To develop reliable teledermatological communication possibilities, some basic requirements are nevertheless also mandatory in developing countries [16]. Briefly, these are: Computer Including Necessary Software Ideally a mobile computer (notebook), allowing temporary independence from locations and electric power supply or desktop system protected by UPS (unbreakable power supply). Speed of the CPU is less important than enough hard disk space to store the saved images. In the not too distant future the use of mobile phones allowing direct access to the Internet by new software such as GPRS may allow to transmit digital information without an additional computer. This would facilitate to a significant degree the exchange of electronic information in such areas too.

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Digital Image Source Modern digital cameras are small, robust, easy to use and cheap (USD 300800). They can create high-resolution images (1,900 1,400 pixels or better) that are adequate for dermatologic needs [17, 18]. With modification, this technique can be effective for telepathology and teleultrasound, enlarging the potential of digital image transfer significantly [1921]. Still images, especially for teledermatology but also teleradiology or pathology, are much more adapted than very data consuming live images. Software to compress the size of the images additionally is crucial. Mobile and cableless cameras are of much better use than desktop systems. A close-up function should be available. Devices for image storing should be replaceable. Software The software should be easy to use, fast learnable and stable. Whenever possible it should be usable in the mother tongue of the applicants. Software update should be possible via Internet or CD-ROM and not needing computer professionals possibly many hundreds or even thousands of kilometers away. Access to the Telephone Network and an Internet Provider The Internet is moving rapidly into Africa: whereas 3 years ago only 12 countries in Africa had Internet access, it is now available, at least in the capital cities, in 53 out of 54 African countries [22]. For example, there was no Internet provider in Tanzania in 1996, but there are several now including even Internet coffee shops located in the KCMC in Moshi, where we installed our teledermatologic link in 1997/98. Free online resources include various scientific journals. Many very reputed journals covering aspects of clinical medicine as well as research offer free online access immediately or a few months after release [23]. Additionally, several research databases and training courses are available [24, 25] (table 2). E-mail has many advantages in poor countries: it is cheap, hard- and software requirements are simple, and the information does not have to be transmitted in real time. These benefits have been shown by SatelLife [26]. Using a low earth orbit satellite and phone lines, it provides e-mail access in 140 countries, serving over 10,000 healthcare workers. These allow sending e-mail attachments such as image files, permitting a form of low-cost telemedicine. The patients findings are described in an e-mail, and digital photographs of the patient and their investigations, such as electrocardiograms and x-ray films, are attached. This store-and-forward telemedicine does not allow real-time interaction, but permits specialist support in the management of difficult cases and is economical. New technologies such as GPRS may additionally facilitate rapid digital exchange for text and images.

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Table 2. Some useful websites for telemedicine/teledermatology in sub-Saharan Africa (partly mentioned in the article) www3.sn.apc.org/africa www.freemedicaljournals.com African countries with Internet access List of medical journals that are available free of cost online immediately or several months after release of the printed issue Many links to the Supercourse, providing an overview on epidemiology and the Internet for medical and health-related students Homepage of Inmarsat International Network for the Availability of Scientific Publications (INASP) International League of Dermatological Societies International Foundation for Dermatology Homepage of Dermanet Homepage of the World Health Organization with plenty of links (among others, tropical diseases, teaching and training facilities and more than 40 links to telemedicine) One of the many networks of organizations for international cooperation in healthcare

www.pitt.edu/~super1

www.inmarsat.org/index3.htm www.inasp.org.uk/ www.who.int/ina-ngo/ngo/ngo090.htm www.ifd.org www.dermanet.ch www.who.int

www.medicusmundi.ch

Despite these fascinating new possibilities with their tremendous potential, it also has to be considered that a very limited part of the population in developing countries has access to these facilities. If a person earns around USD 50100 a month, a monthly rate of around USD 2030 the average for an Internet access in East Africa is just unaffordable. An alternative is offered by the free access to the Internet during a limited time during each day, which is offered free by various organizations, such as the UN or WHO. Therefore, international organizations, governmental authorities and military groups mostly use these systems. Electric Power Supply Taken as very natural in our setting, electricity can by far not be taken for granted in developing countries. Especially in rural and remote areas of developing countries there is sometimes no power supply at all. Here a petrol-driven generator may offer the only source of power if the user has no mobile computer system that can be charged at a regular frequency somewhere.

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In semi-rural or urban areas, power is generally available, but of a rather limited stability. Power cuts due to natural, technical and man-made problems can be frequent. In addition, the power current often fluctuates enormously. Therefore the existing power peaks and drops can be harmful to technical equipment such as computers, screens and digital cameras. In such areas, units warranting uninterrupted power supply are absolutely crucial. Sustainability Sustainability is one of the principal demands of all assistance directed to developing nations. In most countries healthcare is considered a public service. The provision of teledermatology or telemedicine services in general services meets an important social need to extend healthcare to remote and rural areas in developing countries. Pilot projects like our Tanzania-Switzerland connection may be a first step in demonstrating the benefits and also cost-effectiveness of telemedicine, but such projects should also be sustainable. Sponsors of such pilot projects must have a clear plan from the start about how the project can continue after the sponsorship comes to an end [27]. Some financial participation from the recipients should also be included from the beginning, according to their possibilities, as otherwise such a project risks becoming just a nice toy, which no one feels responsible to maintain. Also the sponsor has to care about sustainability, which does not only include a generous donation from the equipment in the beginning, but also a continuous support for hard- and software, technical assistance and teaching of users on a long-term basis. There are various investigations that can prove the cost-benefit and accuracy of teledermatology in industrialized nations. Such studies are even more needed in sub-Saharan Africa as in this region the limited resources have to be spent even more cautiously [2831]. Using Synergies in Telemedicine A Crucial Element in Areas with Limited Resources In the industrialized part of the world it may be possible to get individual facilities and equipment adapted to the different needs of each medical specialty, such as radiology, pathology, cardiology or dermatology. In areas with such limited resources as encountered in the health systems of many parts of sub-Saharan Africa, facilities for digital image transfer should be accessible for all disciplines. A simple digital camera with a sufficient image quality used by different colleagues and one central Internet/e-mail access may change the information exchange dramatically for an isolated hospital located hours or even days away from specialists such as radiologists, pathologists or dermatologists

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or any easy accessible library. Combined for example with histopathological images, teledermatology even offers a service just unavailable in many regions or even nations of developing countries. Ethical and Educational Aspects In developing countries the same ethical considerations for teledermatological exchange within and outside of the countries are also valid as in industrialized nations possibly in an even more profound way. Patients in these areas are rarely well informed about their rights. In areas where a classic photographic picture still is a rare event and an encounter with a computer is possibly the first in a patients lifetime, a digital image is sometimes just beyond the patients understanding. Religious customs also have to be considered among those who sometimes do not permit to be photographed. Therefore, the patient needs correct information and explanation so that he can really agree to this way of communication which is strange but beneficial for him in many cases.

Conclusion

Although the use of the electronic media and the exchange of digital information are still very restricted in sub-Saharan Africa, this is probably one of the regions that might benefit most from this technology; however, computers and mobile phones more so are also spreading rapidly in Africa. Also there is a tremendous lack of care and knowledge for patients with skin diseases in these areas. In our experience, teledermatology offers a high beneficial and efficient tool in the diagnosis and management of challenging dermatological patients at a consultant-hospital level in a country with limited resources such as Tanzania. Still, sustainability and basic requirements should be checked very carefully before investing in such facilities in a setting mentioned above. Not the most ambitious project regarding technical aspects is needed. The emphasis should rather be given to simple, easy-to-use and not too expensive technologies. Videoconferencing is feasible as shown by our experience, however a system based on e-mail and possible Internet access and a digital image source sending store-and-forward images will be sufficient at least for dermatology in by far most of the cases. A possible widespread use will by far outweigh the few advantages won by a videoconferencing system limited to a few centers linked together. Teledermatological exchange does implicate fun and professional enrichment but mostly it is also a simple necessity, especially for people working in

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remote or rural areas. So our emphasis should go to find means and ways to spread the tools for a reasonable and appropriate teledermatology in these areas. The exchange between the few colleagues caring for patients with skin diseases can doubtlessly be promoted by teledermatology. To improve the still very restricted care for patients suffering from skin diseases in these areas is the final aim. Teledermatology might contribute its small, but useful part to this aim. Telemedicine in general and teledermatology in particular on the African continent are probably a much greater challenge than in many other areas of our world but possibly also much more needed and beneficial.

Acknowledgments
We are indebted to Gnter Burg, Chairman of the Department of Dermatology of the University of Zrich, for continuously promoting and supporting a teledermatological link between Tanzania and Switzerland. We also thank Henning Grossmann, Principal of the RDTC in Moshi, for providing the facilities (such as a safe room and separate telephone line) to use the system. The computer equipment used in Tanzania was provided by Roche Pharma Switzerland and free software support given by Arpage Systems AG, Switzerland and Dermanet.

References
1 2 3 4 5 6 7 8 9 WHO advisory meeting on radiology education. Geneva, WHO, 1999. Fraser HSF, McGrath JD: Information technology and telemedicine in sub-Saharan Africa. BMJ 2000;321:465466. Strachan K: Health system trust. Telemedicine in South Africa: Bridging the gap (www. medicusmundi.ch/bulletin8207.htm). Wright D: Telemedicine delivery to developing countries. J Telemed Telecare 1997;3(suppl 1): 7678. Wright D: The International Telecommunication Unions report on telemedicine and developing countries. J Telemed Telecare 1998;4(suppl 1):7579. Wright D: Telemedicine and developing countries. A report of study group 2 of the ITU Development Sector. J Telemed Telecare 1998;4(suppl 2):185. Corr P: Teleradiology in KwaZulu-Natal. A pilot project. S Afr Med J 1998;88:4849. Whitehouse RW: Use of digital cameras for radiographs: How to get the best pictures. J R Soc Med 1999;92:178182. Buntic RF, Siko PP, Buncke GM, Ruebeck D, Kind G, Buncke HJ: Using the Internet for rapid exchange of photographs and x-ray images to evaluate potential extremity replantation candidates. J Trauma 1997;43:342344. Norton SA, Burdick AE, Phillips CM, Berman B: Teledermatology and underserved populations. Arch Dermatol 1997;133:197200. Goncalves L, Cunha C: Telemedicine project in the Azores Islands. Arch Anat Cytol Pathol 1995; 43:285287. Wu YH, Su HY, Hsieh YJ: Survey of infectious skin diseases and skin infestations among primary school students of Taitung County, eastern Taiwan. J Formos Med Assoc 2000;99:128134.

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Kopf AW: International Foundation for Dermatology. A challenge to meet the dermatologic needs of developing countries. Dermatol Clin 1993;11:311314. Donofrio LM, Millikan LE: Dermatologic diseases of eastern Africa. Dermatol Clin 1994;12: 621628. Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G: Teledermatology as a new tool in subSaharan Africa: An experience from Tanzania. J Am Acad Dermatol 2000;42:833835. Schmid-Grendelmeier P, Doe P, Milesi L, Kuehnis L, Burg G: Where the basics lack: Teledermatology in sub-Saharan Africa; in Wooton R, Oakley JM (eds): Teledermatology. Royal Society of Medicine press, London 2002, pp 231244. Vidmar DA, Cruess D, Hsieh P, et al: The effect of decreasing digital image resolution on teledermatology diagnosis. Telemed J 1999;5:375383. Krupinski EA, LeSueur B, Ellsworth L, Levine N, Hansen R, Silvis N, et al: Diagnostic accuracy and image quality using a digital camera for teledermatology. Telemed J 1999;5:257263. Johnson MA, Davis P, McEwan AJ, Jhangri GS, Warshawski R, Gargum A, et al: Preliminary findings from a teleultrasound study in Alberta. Telemed J 1998;4:267276. Kayser K, Szymas J, Weinstein R: Telepathology: Telecommunication, electronic education and publication in pathology. Berlin, Springer, 1998. Wright D: The sustainability of telemedicine projects. J Telemed Telecare 1999;5(suppl 1): S107S111. African internet connectivity. Accessible under www3.sn.apc.org/africa/ FreeMedicalJournals.com. www.freemedicaljournals.com The Global Health Network supercourse: Epidemiology, the Internet, and global health. www.pitt.edu/~super1 Groves T: SatelLife: Getting relevant information to the developing world. BMJ 1996;313: 16061609. Yellowlees P: Successful development of telemedicine systems Seven core principles. J Telemed Telecare 1997;3:215222. Wootton R, Bloomer SE, Corbett R, et al: Multicentre randomised control trial comparing realtime teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. BMJ 2000;320:12521256. Oakley AM, Kerr P, Duffill M, et al: Patient cost-benefits of real-time teledermatology A comparison of data from Northern Ireland and New Zealand. J Telemed Telecare 2000;6:97101. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42: 776783. Taylor P: An assessment of the potential effect of a teledermatology system. J Telemed Telecare 2000;6(suppl 1):S74S76. Yellowlees P: Practical evaluation of telemedicine systems in the real world. J Telemed Telecare 1998;4(suppl 1):5657.

Peter Schmid-Grendelmeier, MD Universittsspital Zrich, Dermatologische Klinik, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 3083, Fax 41 1 255 4403, E-Mail peter.schmid@hin.ch

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 247251

6.4

Telemedicine in Europe
Roger Kropf, Claudio Cipolat, Gnter Burg
Dermatologische Klinik, Universittsspital Zrich, Switzerland

The aim of this article is to give an overview about different telemedical projects and studies that have been conducted in Europe with the exception of Germany and Switzerland. Telemedical work in these two countries is presented in the next two chapters. The overview is divided into the various medical fields where telemedicine is already of increasing importance. The projects and studies presented here do by no means cover the whole area of what is currently going on in the field of telemedicine. They represent a selection made by the author. Many more articles would also have been suitable for presentation, but due to the limited amount of space and time for collection, this was not possible. The source from which the articles were obtained was the Journal of Telemedicine and Telecare, January 2000February 2002.

Telecardiology

Slovenia At the University Medical Centre of Ljubljana, a telemedical project involving the transtelephonic transmission of electrocardiograms was established and has been used on a regular basis since 1997. During the first year of service, 463 calls were received. The most common diagnoses made on the basis of the patients history and electrocardiogram were: acute myocardial infarction, angina pectoris, paroxysmal tachycardias and atypical chest pain. It was stated that with its use, time from onset of symptoms to initiation of treatment was shortened, which in turn reduced disability and mortality due to cardiovascular diseases and also improved cost-benefit [1].

Italy At six Italian hospitals, a telecardiology system was installed in order to evaluate the practical use of forwarding radiographic sequences of heart movements from patients and to discuss them with expert cardiologist using real-time teleconferences. It was found that this form of telecardiology was clinically viable and more efficient than the traditional method of delivering this data to specialists. The main drawback was the sometimes extremely long time for transfer especially when only one instead of three ISDN lines was used [2].

Teledermatology

The Netherlands A feasibility study in teledermatology was undertaken in the town of Groningen. General practitioners (GPs) were asked to send digital images as well as additional medical information by e-mail to the Dermatology Department of Martini Ziekenhuis. The dermatologists returned their responses by e-mail. Generally all persons involved (GPs, dermatologists and patients) were satisfied with the teleconsultations. Furthermore, the GPs reported that the teleconsultations were also of educational value [3]. Italy, Austria, UK, USA, Japan, Germany and Switzerland This multicentre study was conducted to evaluate the conformity of the direct clinical diagnosis and the diagnosis performed by sending digital clinical and dermoscopic images by e-mail to 8 dermatologists, 1 oncologist, 1 specialist in internal medicine and 1 GP. An average of 85% of the telediagnoses were correct when histopathology was used as golden standard, whereas faceto-face diagnosis by an expert dermatologist was correct in 91% of the cases. These results confirmed that teledermoscopy could be reliably used for the diagnosis of pigmented skin lesions. However, the degree of accuracy will depend on the expertise of the observer [4].

Teleneurology

Portugal A neurology teleconsultation network using standard teleconferencing software was established between the University Hospital in Lisbon and five nearby health centres in order to help GPs with the management of patients suffering from neurological disorders. The benefits, as described by the authors, consisted mainly of getting advice on patient medication and diagnosis.

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Additional benefits were the prevention of unnecessary laboratory and specialist examinations [5].

Teleophthalmology

Sweden A trial of teleophthalmology was conducted between a GP and an experienced ophthalmologist using desktop videoconferencing soft- and hardware over a 2-year period. The outcome stated by the two authors was that this form of teleophthalmology is reliable. It could possibly be a valuable alternative, especially in rural areas where physical distance between patient and specialist can represent a significant obstacle [6]. United KingdomSouth Africa A teleophthalmology service was established between a regional hospital in South Africa and an ophthalmology hospital in the UK in order to provide specialist advice in the diagnosis and treatment of difficult ophthalmology cases. Case discussions were conducted with the use of videoconferences using ISDN lines. No significant problems were experienced during the 12-month study period. Moreover, the medical officers at the South African hospital valued the educational benefits gained during this project [7].

Teleobstetrics

Italy In southern Italy a project was initiated which involved prenatal telemedicine by means of recording cardiotocographic information at peripheral locations with the use of remote data collection units. The data was then transmitted via modem to an operations centre, where it was analysed and a report faxed back to the peripheral unit [8]. United Kingdom In Northern Ireland a pilot study was conducted by means of supporting breast-feeding mothers with videophones at home. Potential problems were the poor quality of transmitted pictures, as well as sometimes a considerable delay of the streamed acoustic data. As outcome, the potential to save on hospital visits and home calls was recognized [9].

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Telepathology

United Kingdom In a collaboration between the Clinical and Biomedical Computing Unit at Cambridge University and the Department of Pathology at Leicester General Hospital, a telepathology network using standard videoconferencing technologies was established. The aim was to create a network of histopathologists not only throughout the UK, but also abroad. The main problems encountered were network restrictions due to firewalls, but which could be circumvented using a software system called webcam32. Further information can be accessed at http://tele.pathology.le.ac.uk

Telepsychiatry

United Kingdom At the Clinical Psychology Department of Dunain Hospital in Inverness, cognitive assessment of 27 patients with a history of alcohol abuse was performed. The patients were assessed using televideoconferences as well as traditional face-to-face consultations. After both trials the patients were handed a satisfaction questionnaire. The teleconsultations were significantly longer (mean 40.7 min, SD 6.4) than the face-to-face consultations (mean 33.0 min, SD 5.3). Most patients expressed high overall satisfaction with the teleconsultation as well as with video and audio quality in particular. This study showed that patient and psychologist do not have to be physically present in the same location for cognitive assessments to be carried out [10].

General Telemedicine

Croatia In Croatia a feasibility study was conducted by means of using real-time Internet conferencing between a GPs clinic in Selca on the island of Brac, and a team of specialists in Sveti Duh General Hospital, located in Zagreb on the mainland. In most cases this telemedical approach was successfully used to have patients diagnosed and treated on the island without the need to send them over to the mainland and therefore saving time and costs for travel. It was suggested that the formation of a permanent on-line specialist service would improve the access to healthcare, especially in rural areas of Croatia [11].

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Greece At the centre for Health Services Research at the University of Athens, an online antibiotic information database was developed to help non-specialist doctors in treating patients with infectious diseases. During the first 8 months of online service, 1,053 queries were received. The participants stated that the database served them for treatment of patients as well as for education about antibiotics. The continuation of the database was encouraged [12].

References
1 2 3 Gorjup V Jazbec A, Gersak B: Transtelephonic transmission of electrocardiograms in Slovenia. , J Telemed Telecare 2000;6:205208. Fogliardi R, Frumento E, Rincon D, Vinas MA, Fregonara M: Telecardiology: Results and perspectives of an operative experience. J Telemed Telecare 2000;6:S162S164. Van den Akker TW, Reker CH, Knol A, Post J, Wilbrink J, van der Veen JP: Teledermatology as a tool for communication between general practitioners and dermatologists. J Telemed Telecare 2001;7:193198. Piccolo D, Smolle J, Argenziano G, Wolf IH, Braun R, Cerroni L, Ferrari A, Hofmann-Wellenhof R, Kenet RO, Magrini F, Mazzocchetti G, Pizzichetta MA, Schaeppi H, Stolz W, Tanaka M, Kerl H, Chimenti S, Soyer HP: Teledermoscopy Results of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6:132137. Paiva T, Coelho H, Araujo MT, Rodrigues R, Almeida A, Navarro T, Cruz M, Carneiro G, Belo C: Neurological teleconsultation for general practitioners. J Telemed Telecare 2001;7:149154. Blomdahl S, Maren N, Lof R: Tele-ophthalmology for the treatment in primary care of disorders in the anterior part of the eye. J Telemed Telecare 2001;7:2526. Kennedy C, Van Heerden A, Cook C, Murdoch I: Utilization and practical aspects of teleophthalmology between South Africa and the UK. J Telemed Telecare 2001;7:2022. Di Lieto A, Catalano D, Pontillo M, Pollio F, De Falco M, Iannotti F, Schiraldi P: Telecardiotocography in prenatal telemedicine. J Telemed Telecare 2001;7:119120. Lazenbatt A, Sinclair M, Salmon S, Calvert J: Telemedicine as a support system to encourage breast-feeding in Northern Ireland. J Telemed Telecare 2001;7:5457. Kirkwood KT, Peck DF, Bennie L: The consistency of neuropsychological assessments performed via telecommunication and face to face. J Telemed Telecare 2000;6:147151. Ostojic V Stipic-Markovic A, Tudman Z, Zivkovic N, Cvoriscec B, Trajbar T, Donnelly CL, , Grgic M, Matek P, Lusic M, Iskra M: A feasibility study of real-time telemedicine in Croatia using Internet videoconferencing. J Telemed Telecare 2000;6:172176. Tountas Y, Saroglou G, Frissiras S, Vatopoulos A, Salaminios F: Remote access to an expert system for infectious diseases. J Telemed Telecare 2000;6:339342.

5 6 7 8 9 10 11

12

Roger Kropf, MD Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 3340, Fax 41 1 255 4403, E-Mail Roger.Kropf@der.usz.ch

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6.5

Telemedicine in Germany
Jrg Tittelbach, Peter Elsner
Department of Dermatology, Friedrich Schiller University Jena, Germany

In Germany the application of a modern communication infrastructure among healthcare providers is steadily increasing. The use of these technologies for the electronic prescription and the exchange of data between the different healthcare providers is in the centre of public interest. Besides the consideration in the public, a further application is the use of the new technologies in fields like teledermatology, teleradiology, telepathology, telesurgery and others. Different political conditions have proved to be an obstacle in the optimal application of a modern information infrastructure in the field of medicine. This will be the subject of the following paragraph.

Political Framework

In the last decade it has become generally accepted that the provision of technical resources is not sufficient for a sustained modification of the public health system. Besides the technical requirements, the creation of structures defining a legal, organizational and technological framework is necessary for a successful implementation and use of communication and exchange technologies. Therefore, issues of secure e-mail transmission, the availability, validity, security, verifiability and confidentiality of transmitted information must be clarified. In this context, the lack of an organizational structure leading the single players of the healthcare system has proved to inhibit necessary developments. Therefore, an interoperability of many players and providers cannot be guaranteed resulting in a diversity of solutions and approaches. To overcome these obstacles, the German Ministry of Education and Research has established an initiative called Telematikplattform (telematics platform) as an exchange platform for

the different players in the field of transmission and exchange of medical data and information. The aim of this initiative is the improvement of medical care, an increased effectiveness of financial resources, the use of all available empirical data in medical care and the creation of an infrastructure for planning, controlling and supply of research. A further hindrance for the introduction of modern data-exchange technologies is the allocation of financial resources. Those who will benefit from this introduction are not the same who have to take care of financing the new equipment needed [1]. In Germany no defined reimbursement is given for the implementation of information technologies for medical purposes. That is possibly why investment in such technologies is currently still limited to the institutions of each player. No common financial pool has been established. As an initiative to overcome these shortcomings, the initiative Aktionsforum Telematik im Gesundheitswesen (ATG) has been established, and will be discussed next.
ATG Forum for Telematics in Healthcare

The major aims of this forum are to intensify the interaction and interoperability of in- and outpatient care with the intention of cost-saving, avoiding disadvantages due to uncoordinated treatment and quality management. One of the most important and promising facts, supporting the thesis that this initiative can cause a sustained change in the healthcare sector, is the broad basis of this initiative among all players in Germanys healthcare system. The participants of this project are the German Ministry of Education and Research, the Ministry of Health, the Ministry of Economy and Technology, private and public health insurance providers, leading physician, hospital and pharmacy organizations as well as parts of the pharmaceutical industries, non-medical organizations and pension-insurance organizations. The main topics are managed in different work groups like electronic prescription, electronic medical letter, security infrastructure and European dimension [2].
Technical Preconditions

At present the various German healthcare providers are technically well equipped. In a recently published study it was shown that in Bavaria, 96% of dermatologists in private practice used a computer and 56% used e-mail on a regular basis [3]. However, some problems result due to a diversity of about 150 different software products for managing outpatient care and a broad variety of software solutions for clinics [4].

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Communication Standards

The HL7-standard is an international standard of the American National Standards Institute (ANSI) and part of the ISO standardization of the United Nations. A German user forum is adopting these specifications for the particular needs throughout Germany. This standard is mainly used for the data exchange between bigger institutions and clinics. Currently, further developments focus on the introduction of the XML schema. Outside the clinics, a set of standards (called xDT) is defined. These standards focus on the transmission of administrative data (KVDT, BDT), laboratory data (LDT), data acquired by technical devices (GDT) and others. A standard for the exchange of medical information between physicians has not been established. DICOM (Digital Imaging and Communications in Medicine) as a third important standard and is used for the exchange of medical images. This standard is implemented in large medical devices like radiology systems as well as in end-user devices. Therefore, it is used in teledermatology, telepathology and other systems.

Application and Examples

The previous paragraphs have described the general situation and use of modern telecommunication systems in the medical field. This paragraph will show certain projects as an example for the state-of-the-art use of telemedicine and teledermatology in Germany. One of the best known teledermatological resources in the German Internet is the website www.dermis.net, which is maintained by the Universities of Erlangen and Heidelberg under the leadership of Prof. Diepgen and Prof. Schuler. This site offers the visitor access to an online dermatology atlas of about 4,500 images, an atlas of paediatric dermatoses, an information portal of atopic dermatitis and skin cancer as well as case reports and dermatological lectures. Another very interesting dermatological resource is the teleteaching webpage www.derma2000.de, that is maintained by the University of Regensburg (Prof. Stolz). The aim of this project is the virtual reproduction of the situation of a patients consultation. The student is guided from the patients history, clinical examination and description of the clinical finding through the diagnostic process to the correct diagnosis. During the whole lecture the student has the option to ask for (computerized) advice and explanations. The results gained in the tests within this system are applicable for getting credit points.

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The webpage of the AWMF (workgroup of scientific medical societies) (http://awmf.net) as a collective forum of different medical sections has a broad impact on daily clinical practice. In addition to organizational and legal information and recommendations for quality management, one of the most used aspects are the guidelines for treatment that represent a common consensus for the therapy course of a broad variety of diseases. Furthermore, a very interesting initiative showing the wide application of telecommunication in dermatology is the project www.kids-inzell.de. Normally, the intermittent treatment of severe dermatoses in young patients can cause severe study disadvantages, ultimately leading to a retardation in comparison to classmates. The objective of this project is to enable these already dermatologically stigmatized children to continue their school education by use of the Internet to give them a positive occupational perspective. In general, the Internet is frequently used by both doctors and patients as a valuable resource of medical information. A large number of health Internet portals, medical databases and programs for CME (continuing medical education) is maintained by different interest groups like self-help associations, universities, companies and private persons. The presentation of all these initiatives would exceed the possibilities in this book.
Conclusion

In Germany the technical possibilities to use the Internet and telecommunication infrastructure for the exchange of medical data and expertise are relatively well developed. Today, different initiatives and projects show promising results but need further development and integration. The common initiatives of the different players in the healthcare sector have a key importance for establishing standardized interchange interfaces. This, in combination with building the political, ethical and legal framework for the application of these new media for the exchange of personal medical data, will provide a better interaction between the different healthcare providers. The intention is to guarantee a more cost-effective and quality-managed care of patients.

References
1 Debold P, Lux A: Kommunikationsplattform im Gesundheitswesen: Kosten-Nutzen-Analyse Neue Versichertenkarte und elektronisches Rezept. http://www.vdak.de/kpf/kna_bericht_v10a.pdf (28-11-2001). Debold und Lux Beratungsgesellschaft fr Informationssysteme und Organisation im Gesundheitswesen mbH, Hamburg. Aktionsforum Telematik im Gesundheitswesen. http://atg.gvg-koeln.de (28-11-2001). Gesellschaft fr Versicherungswissenschaft- und Gestaltung eV .

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3 4

Glaessl A, Schiffner R, Walther T, Landthaler M, Stolz W: Teledermatology The requirements of dermatologists in private practice. J Telemed Telecare 2000;6:138141. Jckel A, Schollmayer A, Dudek J: Einfhrung in die Chancen und Voraussetzungen von Telematikanwendungen im Gesundheitswesen; in Jckel A (ed): Telemedizinfhrer Deutschland 2000. Bad Nauheim, Deutsches Medizin Forum, 1999.

Jrg Tittelbach, MD Department of Dermatology, Friedrich Schiller University, Erfurter Strasse 35, D07740 Jena (Germany) Tel. 49 3641 937370, Fax 49 3641 937343, E-Mail tittelbach@derma.uni-jena.de

Tittelbach/Elsner

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Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 257260

6.6

Teledermatology in Switzerland
Claudio Cipolat a, Urs Bader b, Theo Rufli c, Gnter Burg a
a Dermatologische Klinik, Universittsspital Zrich, bPraxis fr Dermatologie und Venerologie, Zumikon, cDermatologische Klinik, Universittsspital Basel, Switzerland

Switzerland, as a highly developed country with an up-to-date healthcare system, is well suited for the development and the use of telemedicine. Although Switzerland is a small country in geographical size, its situation in the alpine mountains causes long travelling times for many patients, especially those not living in city centers. Therefore, distribution of access to healthcare is uneven, making the use of telemedicine even more useful. Telemedicine in Switzerland is mostly used by specialties, in which optical information is important, therefore radiology and dermatology have the most advanced telemedical systems. In the other specialties, e.g. internal medicine, modern information technology, especially the Internet, is used for usual information exchange, mostly containing text and sometimes images. Video teleconferences have also taken part between gastroenterologists and psychiatrist groups, but the expense not only on the cost side far outweighs the benefit, so that these projects run on a low level. In radiology, the most important task is the transport of virtual images between practices and/or hospitals. The problem is in image size, which makes transmission slow or dependent on special equipment such as glass fibers. With future technical development, these problems will be solved, with the limitation that technical development also increases size of image data, demanding faster equipment. Another limitation is data security for those large images; therefore, the Internet is not optimal for use which makes transmission again dependent on secured equipment. Also, firewall technology often limits size of passing data. This, on the other side, is actually more a political problem than a technical one.

Teledermatology in Switzerland

Because of the importance of optical information in the speciality, dermatology is ideally suited for the use of modern communication technology, especially the Internet. Therefore, an Internet-based teleconferencing system (Dermanet) was developed by a network of Swiss dermatologists, which now consists of 75 physicians, representing about 25% of all dermatologists in Switzerland. Each Dermanet participant has the following hardware (minimum requirements): (1) PC system, Pentium 133 MHz or faster, 32 MB RAM, 2 GB hard disk; (2) operating system Windows 95 or above/Windows NT; (3) graphic card 4 MB; (4) screen resolution 800 600 pixels, color depth true color (24- or 32-bit); (5) modem analog or integrated services digital network (ISDN), speed at least 28,000 bps, and (6) digital camera (video or still). The communication platform used by Dermanet is based on the Internet Protocol (TCP/IP). Participants forward their still images along with relevant data about the patient with interesting or difficult cases through Dermanet. Patient details are anonymous. The completed structured referral form includes a short history, relevant laboratory data, description of the localization and type of the lesions, and differential diagnoses. Digital pictures must be of excellent quality and should show or describe the localization of the lesion. To ensure reasonable transmission time, image files are JPEG (joint photographic evaluation group) format and do not exceed 300 kB. The image transmission time is 3050 s using ISDN. Data is archived in an electronic chart. It can be retrieved, edited, and used again for another teleconference. The images can be looked at off-line, with communication by e-mail, or the system has the possibility of a teleconference, where the pictures can be looked at real-time in a virtual conference room, where the mouse pointers of all participants logged in are shown, and communication is possible by chat room or telephone audio conference on-line. With the correct equipment (microscope with digital camera needed), even histologic pictures can be looked at real-time in a teleconference. At first, teleconferences were organized on a one-by-one approach between participants, and even with distant locations such as Tanzania [1] or a congress in the United States [2]. Now, teleconferences take place regularly, at which any member of the Dermanet group can participate: monthly teleconferences of the Dermatologic Clinics of the University Hospitals of Basel and Zrich; the monthly coin du practicien, organized by Dr. B. Tapernoux. The Dermatologic Clinic of Geneva has organized some teleconferences as well. The experience of the Basel-Zrich group is presented below. The system was also used for a study to demonstrate accuracy of teledermatologic diagnosis of nevi.

Cipolat/Bader/Rufli/Burg

258

Data Security

In general, proprietary systems such as Dermanet provide better security for patient data than the open, e-mail-based systems. In Internet-based telemedicine, data security is of uppermost importance, because access to unsecured data via the Internet is easy. Security measures built into the system also ease handling, because no additional encoding of data is necessary. Without adequate security, medical information may easily fall into the wrong hands, and the patient may not consent to telemedical activities. All services and transfers are password-, firewall- and software-protected by Arpages Security and Access System (ASAS) security software, which provides the following: (1) tunneling (through firewalls if needed) authentication (RSA, 1,024-bit and more); (2) data privacy (168-bit 3DES); (3) data integrity (MD5 hash/checksum); (4) support of all common transfer protocols; (5) end-to-end encryption; (6) access control on any user level and on any hardware resource, and (7) closed user groups. Authentication is achieved by keys of 1,024- to 2,048-bit (password or passphrase consisting of up to 256 characters). Encryption of data is based on DES3 with a 168-bit key. The data also is sent through a tunnel further preventing unauthorized access and misuse of the information. The development of the Dermanet system was supported by Roche Pharma (Switzerland) AG.

Experience with Monthly Teleconferences

In the pioneer group, monthly teleconferences in German language have taken place since November 1998, organized by the Dermatology University Clinics of Basel and Zrich, at which members of the Dermanet network can participate. The goals of these teleconferences are: (1) discussion of unclear cases; (2) confrontation of clinical pictures with histology (3), and presentation of interesting cases for teaching purposes. The further goals were to simplify communication among dermatologists, to improve the intellectual exchange among specialist physicians, and, very important, medical education. Also, service for patients and referring physicians is to be improved. Among the 75 members of the Dermanet working group, about 812 dermatologists participate in each conference. They belong to an active group of about 20 members which participate regularly. Experience showed that the maximum group size that is feasible for a single teleconference consists of 12 members; otherwise too many persons interfere with each other in the virtual telephone conference room. The conference is alternately chaired by the Dermatologic Clinic of the University Hospitals of Basel (Prof. T. Rufli) and

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Zrich (Prof. G. Burg, Dr. U. Bader, Dr. C. Cipolat). The duration of each conference is 3045 min, during which 24 cases can be discussed. During the sending time of the pictures, the patient is presented and then discussed in the group. If appropriate, histologic pictures can be discussed as well, either prerecorded off-line or real-time on-line. The equipment necessary is available in Basel for images off-line, for both possibilities in Zrich. Most practitioners do not have the equipment for photographing histologic pictures. In total, 37 conferences were organized until November 2001, during which 122 cases were discussed. In 23 cases, a diagnosis could be made. In 9 cases, diagnosis was uncertain even after the teleconference. In 22 cases, diagnostic steps were advised, in 21 cases, directions for therapy could be given. 48 patients were presented as teaching cases. To evaluate the benefits of the conferences, a questionnaire was sent to the members. The main benefit is seen in teaching and communication with the university center. Second follows benefit in assistance for diagnosis and therapy for a given patient. Problems also could be identified: technical limitations, such as sound and stability of the phone teleconference; the ease of use and stability of the program; long transmission times due to inadequate compression of pictures. The results of the questionnaire with identification of problems led to optimizing the technical aspects of the conferences, with updates of the program and the telephone system. The time point of the conferences could be optimized as well. In addition, participation in teleconferences is rewarded with CME (continuous medical education) credits. Therefore, the monthly teleconferences with the University Dermatologic Clinics of Basel and Zrich are a well-accepted tool for the Swiss dermatologists. As a consequence, since 2000, monthly teleconferences in French language under the name of le coin du practicien are organized by Dr. B. Tapernoux, Geneva.

References
1 2 Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G: Teledermatology as a new tool in subSaharan Africa: An experience from Tanzania. J Am Acad Dermatol 2000;42:833835. Braun RP, Meier M, Pelloni F, Ramelet AA, Schilling M, Tapernoux B, Thrlimann W, Saurat JH, Krischer J: Teledermatoscopy in Switzerland: A preliminary evaluation. J Am Acad Dermatol 2000; 42:770775.

Claudio Cipolat, MD Dermatologische Klinik, Universittsspital Zrich, Gloriastrasse 31, CH8091 Zrich (Switzerland) Tel. 41 1 255 2550, Fax 41 1 255 4403, E-Mail cipolat@der.usz.ch

Cipolat/Bader/Rufli/Burg

260

Author Index

Airaghi, G. 71 Albert, J. 191 Arnold, N. 195 Bader, U. 176, 257 Beglinger, C. 76 Boesch, H. 71 Bhm, K. 182 Brauchli, K. 102 Braun, R. 207 Braun, R.P. 201 Burg, A. 17 Burg, G. 2, 33, 176, 213, 247, 257 Burgdorf, W. 195 Christen, H. 102 Cipolat, C. 6, 33, 176, 247, 257 Coras, B. 172, 207 Demartines, N. 94 Denz, M. 2 Doe, P. 233 Dyson, A. 76 Elsner, P. 252 Ernst, B. 43 Esser, W. 191

Fischer, A. 76 Fischer, H.R. 76 Folkers, G. 43 Gabathuler, H. 39 Geiges, M. 6 Glaessl, A. 172, 207 Granlund, H. 158 Gruber, H. 195 Hffner, A. 12 Haller, U. 39 Hamm, H. 191 Hammack, G.G. 127, 148 Haroske, G. 102 Helfrich, M. 102 Hicks, L.L. 58 Hhn, H. 191 Isohanni, M. 132 Jundt, G. 102 Kempf, W. 213 Kinateder, J. 207 Klvekorn, W. 207 Kristiansen, I.S. 62 Kropf, R. 33, 247 Khnis, L. 154

Kurzynski, M.W. 83 Kvedar, J.C. 226 Landthaler, M. 172, 195, 207 Lepski, U. 207 Lichtsteiner, S. 43 Marincek, B. 87 Mielonen, M.-L. 132 Mihatsch, M. 102 Milesi, L. 154 Moring, J. 132 Mller, D. 76 Oberholzer, M. 102 Oberli, H. 102 Ohinmaa, A. 132 Olver, I. 121 Otto, M. 43 Pak, H. 222 Pakenham-Walsh, N. 233 Popal, H. 172, 195 Poulsen, P.B. 62 Qureshi, A.A. 226 Reichlin, S. 76, 213

261

Roesch, A. 195 Rufli, T. 257 Satava, R.M. 141 Saurat, H.-H. 201 Schmid-Grendelmeier, P. 233 Stauch, G. 102

Stolz, W. 172, 195, 207 Tachakra, S. 53 Tittelbach, J. 252 Tran, V . 43 .V Visnen, L. 132 Voellmy, D.R. 87

Whitten, P.S. 24 Wiegers, W. 182 Wittrup Jensen, K.U. 62 Zeevi, B. 115 Zelickson, B.D. 167 Zepter, K. 12

Author Index

262

Subject Index

Africa, telemedicine doctor shortages 233, 234 economic resources 233 ethics and patient education 244 Immarsat 234, 235 International Network for the Availability of Scientific Publications 235, 236 radiology 234 sustainability 243 synergy with industrialized world 243 teledermatology prospects 244 Tanzania-Switzerland connection 236240, 244 technical needs cameras 241 computers 240 electrical power 242, 243 Internet access 241, 242 software 241 Airlines, telemedicine use 10 Application Service Providing, advantages 188 Arpage Security and Access Services, security profile 74, 75 Authentication, see Security, medical data Cardiology, telemedicine cardiovascular disease epidemiology 115 congestive heart failure patient monitoring 118

electrocardiogram, transtelephonic clinical research 118 event recorders 117, 118 twelve-lead electrocardiograms 116, 117 historical perspective 116, 117 Italy experience 248 pacemaker monitoring 116 prospects 119 Slovenia experience 247 Case presentations, Internet access 36, 37 Climbers, vital signs monitoring core temperature 145 Everest Extreme Expedition clinic components 141, 142 costs 146 establishment 141 graphical interface 142144 performance of hardware 144, 145 Global Positioning System 144, 145 heart rate 144, 145 rationale 141 skin temperature 145 Compression, see Image and video compression Correctional telemedicine benefits 149 characteristics of prisons and healthcare provider risks 148, 149 cost-effectiveness 150, 151 development 149 standards for healthcare in prisons 148

263

Correctional telemedicine (continued) technology 150 Cost analysis, telemedicine classification of health consequences 62, 63 commercial influences on research 67, 68 correctional telemedicine 150, 151 cost-benefit analysis 63, 64, 66 cost-effectiveness analysis 63, 64, 66 cost-of-illness analysis 65 cost-minimization analysis 63, 64, 66, 67 cost-utility analysis 64 financing 68 marginal cost 54, 65 meta-analysis 65, 66, 69 net additional costs 68 prospects for study 69 teleoncology 124, 125 telepsychiatry via videoconference 136 willingness to pay 68 Cryptography, see Security, medical data Data compression, see Image and video compression Data protection, see Security, medical data Databases, Internet access 8, 9 Dermanet adaptation to other disciplines 157 database access 156 development 154, 155 digital image transfer 155, 156, 258 hardware requirements 258 Moshi station 156 prospects 156, 157 security 259 teleconferencing 156, 259, 260 Dermatology, telemedicine, see also Dermanet, Dermatology Course 2000, Dermatology online with interactive technology, HistoClinC, Teledermatoscopy advantages and limitations 29 Africa experience 236240 applications, overview 24, 213

clinicopathologic correlations, see HistoClinC European experience 248 evaluation studies of consultations diagnostic accuracy 161 management plan accuracy 161, 162 patient outcomes 163, 164 patient satisfaction 163 physician confidence 162, 163 real-time videoconferencing 158, 159, 164 store-and-forward teledermatology 158, 160, 164 Germany experience 254, 255 North America experience 222225 nursing homes, see Nursing home teledermatology prospects 29, 30 real-time teledermatology 2527, 158, 159, 164 research history 24, 25 store-and-forward teledermatology 2729, 158, 160, 164 survey of Bavarian dermatologists attitudes 172174 teaching tools, see also Dermatology Course 2000, Dermatology online with interactive technology application scenarios 34, 185, 186 architecture of telematics-based learning environment 185 case presentations 36, 37 course construction and tools 186, 189 databases 35, 36, 192, 193 digital archives 191, 192 interactive training programs 37, 38 learning objects 193 Learning Service Providing 188, 189 lectures 35 link collections 37 market for e-learning 183 rationale for use 3335, 182 resource lists 37 textbooks 36

Subject Index

264

Dermatology Course 2000 cognitive apprenticeship 198 outcomes 197, 198 overview 195, 196 prospects 198, 199 technical aspects 196 training units 196, 197 Dermatology online with interactive technology comparison with other training programs 180, 181 content 178 modules CyberLecture 177179 CyberNet 177, 179 CyberTrainer 177, 178 objectives 177 origins 176 participating institutions 177 prospects 180 technical aspects 179, 180 training applications 177 DermoGenius ultra, teledermatoscopy 204, 208 DICOM, image standard 88 Economics, see Cost analysis, telemedicine Electrocardiogram, transtelephonic clinical research 118 congestive heart failure patient monitoring 118 event recorders 117, 118 twelve-lead electrocardiograms 116, 117 Entropy coding, image and video compression 2123 Error frame, image and video compression 19 Europe, telemedicine cardiology 247, 248 dermatology 248 general telemedicine 250, 251 Finland telepsychiatry, Oulu experience advantages and limitations 138, 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137, 138

project origins 133 prospects 139, 140 requirements 137 responsibility area 134 Germany, see Germany, telemedicine neurology 248, 249 obstetrics 249 ophthalmology 249 pathology 250 psychiatry 250 survey of Bavarian dermatologists attitudes 172174 Switzerland, see Switzerland, telemedicine Family practice, telemedicine consulting 8486 general telemedicine experience Croatia 250 Greece 251 patient monitoring 84, 85 skills required of doctors 83 TelFam system 8486 FotoFinder Medic, teledermatoscopy 204 General Packet Radio Service, patient monitoring in primary care 80 Germany, telemedicine ATG forum 253 communication standards 254 political framework 252, 253 technical preconditions 253 teledermatology 254, 255 Global Positioning System, climber monitoring 144, 145 Gynecology, telemedicine Italy experience 249 training at University Hospital of Zrich advantages and disadvantages of videoconferencing 41, 42 prospects 4042 rationale 39 teleconferencing from 1997 to 2001 39, 40 United Kingdom experience 249

Subject Index

265

H.263, image and video compression 17, 19 High-speed networks, development 1315 HistoClinC advantages and limitations 218, 219 functions 216218 implementation 218 legal aspects 219 look-alikes in dermatopathology 213, 214 overview of system 216 rationale for development 214, 215 reimbursement 219 scientific evaluation 219 technical issues 216, 218 I-frame, image and video compression 20 Image and video compression entropy coding 2123 formats 17, 18 goals 17 lossy vs lossless algorithms 17 prediction 1820 preprocessing 18 quantization 21 transformation 20, 21 Information Society evolution 12, 13 high-speed networks 1315 internet-based computerized patient records 15, 16 multimedia 13 International Network for the Availability of Scientific Publications advisory and referral network 235 health directory 235 health information forum 235 HIF-net at WHO 236 Internet-based computerized patient record, development 15, 16 iPath, telepathology 103, 104, 111 Joint Pictures Experts Group, image standard 89 Learning Service Providing, advantages 188, 189 Lectures, Internet access 35

Microderm, teledermatoscopy 204 Mobile extranet infrastructures, development 77, 80 MOEBIUS, patient monitoring in primary care 80 MoleMaxII, teledermatoscopy 204 Mosaic, Web browser origins 8 MPEG, image and video compression 17, 19, 21

National Aeronautics and Space Administration, history of telemedicine 9, 10 Neurology, Portugal experience with telemedicine 248, 249 Nurse, telemedicine satisfaction survey 5861 Nursing home teledermatology components and system requirements 168, 169 rationale 167, 168 specialist visits to nursing homes 167, 168 study of store-and-forward system 169, 170

Oncology, telemedicine applications 121, 122 assessment clinician satisfaction 123, 124 patient satisfaction 122, 123 definition of teleoncology 121 economic evaluation 124, 125 equipment 122 medicolegal issues 125 prospects 125 Ophthalmology, telemedicine clinical applications 128, 129 effectiveness 129 pilot projects 127 prospects 129, 130 Sweden experience 249 technology 128 United Kingdom-South Africa connection 249

Subject Index

266

Paramedic, telemedicine satisfaction survey 5861 Pathology, telemedicine aims 102 architecture of system 103, 110 consultation active consultation 107 passive consultation 107110 steps 105 database 105 expert module 104, 105 hardware modules 104, 105, 111 iPath software 103, 104, 111 model 102, 103 modular design 111, 112 United Kingdom experience 250 Pharmacology, telemedicine training by Swiss Center of Pharmaceutical Sciences contact with students 48 design 44, 45 integration into curriculum 4850 origins 43, 44 pnn development of online courses 45, 46 teamwork 48 TELEPOLY videoconferencing system 4547 Top Class 46, 47 Vireal Lab 48 Virtual Laboratory 47 Web-Based Training 45, 47 Psychiatry, telemedicine definition of telepsychiatry 132 United Kingdom experience 250 videoconferencing with patients advantages 132 historical perspective 133 Oulu experience advantages and limitations 138, 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137, 138 project origins 133 requirements 137 responsibility area 134 prospects 139, 140

Quantization, image and video compression 21 Radiology, telemedicine Africa 234 applications 87, 88 implementation economic challenges 90 legal issues 90 security 90, 91 system integration 90 interaction types 89, 90 prospects 91, 92 technical requirements hardware 89 image size 88 image standards 88, 89 Resource lists, Internet access 37 Seafarers, telemedicine use 10 Security, medical data Arpage Security and Access Services security profile 74, 75 confidentiality 71 cryptography 73 Dermanet 259 identification and authentication 71 integrity 72 intranets 77 radiology data 90, 91 regulatory requirements for Internet data 71 rules for data transfer 72 Security Onion and layers of security 7274 United States law 229, 230 SENTIMED, archives 192, 193 Space medicine, history of telemedicine 9, 10 Surgery, telemedicine conferences 95, 96 consultation 95 interactivity 96, 97 mentoring 97 prospects 100 requirements 94 robotics and telesurgery 97, 98

Subject Index

267

Surgery, telemedicine (continued) telepresence 97 transmission rates 94, 95 virtual reality 98, 99 Switzerland, telemedicine applications, overview 39, 43, 94, 102, 115, 154, 176, 201, 213, 233, 257 Dermanet, see Dermanet gynecology training at University Hospital of Zrich advantages and disadvantages of videoconferencing 41, 42 prospects 4042 rationale 39 teleconferencing from 1997 to 2001 39, 40 pharmacology training by Swiss Center of Pharmaceutical Sciences contact with students 48 design 44, 45 integration into curriculum 4850 origins 43, 44 pnn development of online courses 45, 46 teamwork 48 TELEPOLY videoconferencing system 4547 Top Class 46, 47 Vireal Lab 48 Virtual Laboratory 47 Web-Based Training 45, 47 teledermatology, Tanzania-Switzerland connection 236240, 244, 245 Tagged image file format, image standard 89 Teaching, see Training Technician, telemedicine satisfaction survey 5861 Teledermatoscopy color reproducibility 203 consultations 203, 204, 210 ELM criteria 201 image acquisition 201203 outcomes study 207211 performance analysis face-to-face diagnosis comparison 11

histological analysis comparison 207, 209, 210 visual inspection comparison 201 reimbursement for consultations 204, 205 systems DermoGenius ultra 204, 208 FotoFinder Medic 204 Microderm 204 MoleMaxII 204 overview of features 203 Telemedicine, see also specific countries cardiology, see Cardiology, telemedicine cost analysis, see Cost analysis, telemedicine data protection, see Security, medical data definition 2, 6, 76 dermatology, see Dermanet, Dermatology, telemedicine, Dermatology Course 2000, Dermatology online with interactive technology, Teledermatoscopy disciplines for applications 2, 3, 78 family doctors, see Family practice, telemedicine growth of field 95 historical perspective 610 impact on future healthcare 4, 5 nursing homes, see Nursing home teledermatology obstacles ethical and legal considerations 4 funding 4 organizational resistance 3, 56 psychological barriers 3, 56, 57 technical and logistic restraints 3 oncology, see Oncology, telemedicine ophthalmology, see Ophthalmology, telemedicine paramedical personnel satisfaction survey 5861 pathology, see Pathology, telemedicine patient expectations attitude to change 55 cost control 54, 55 focus group 53

Subject Index

268

quality control 55 rationalization of care 53, 54 patient monitoring in primary care 7880 prisons, see Correctional telemedicine psychiatry, see Psychiatry, telemedicine radiology, see Radiology, telemedicine surgery, see Surgery, telemedicine training, see Dermatology, telemedicine, Dermatology Course 2000, Dermatology online with interactive technology, Gynecology, telemedicine, Pharmacology, telemedicine, Training, Web-Based Training TELEPOLY, videoconferencing system 4547 TelFam, features 8486 Telstar, telemedicine origins 2, 5 Textbooks, Internet access 36 Therapist, telemedicine satisfaction survey 5861 Top Class, pharmacy student training 46, 47 Training, see also Dermatology, telemedicine, Dermatology Course 2000, Dermatology online with interactive technology, Gynecology, telemedicine, Pharmacology, telemedicine, Web-Based Training Application Service Providing 188 demands on telematics-based learning environment 184 Learning Service Providing 188, 189 market for e-learning 183 medical applications of telematics-based teaching 183, 184 rationale for telematics-based teaching 182 Transformation, image and video compression 20, 21 United States, telemedicine consumer awareness 230 economic model 230, 231 historical perspective 226, 227 outcomes research 228, 229 privacy and security 229, 230

prospects 231 provider comfort 230 services and applications 227, 228 technology adoption 230 technology development 229 teledermatology barriers 223, 224 credentialing 223, 224 economics 222, 224 military experience 222, 223 prospects 224, 225 Universal Mobile Telecommunications System, patient monitoring in primary care 80

Video compression, see Image and video compression Videoconferencing gynecology training at University Hospital of Zrich advantages and disadvantages 41, 42 prospects 4042 rationale 39 teleconferencing from 1997 to 2001 39, 40 historical perspective 133 psychiatry, Oulu experience advantages and limitations 138, 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137, 138 project origins 133 prospects 139, 140 requirements 137 responsibility area 134 TELEPOLY 4547 Virtual Laboratory, pharmacy student training 47 Virtual reality, surgery applications 98, 99 Vital functions climber monitoring, see Climbers, vital signs monitoring

Subject Index

269

Vital functions (continued) monitoring over networks 78, 79 Web-Based Training course construction and tools 186, 187 dermatology training 182, 186, 187 pharmacy student training 45, 47

World Wide Web access evolution 12, 13 data protection, see Security, medical data database access 8, 9 medical resource limitations 8 origins 79

Subject Index

270