Telemedicine and Teledermatology

Telemedicine and Teledermatology Current Problems in Dermatology Vol. 32 Series Editor G. Burg Zürich Telemedicine and Teledermatology Volume Editor G. Burg Zürich 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, Günter. II Series. RL72.T45 2003 616.5–dc21 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, CH–4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel ISSN 0070–2064 ISBN 3–8055–7463–0 ..... R......... G.. Cipolat.. 33 Kropf........................... IX Burg. C............................................. 17 Burg....) 2 Teleteaching 2............ (Zürich) 1............................2 The History of Telemedicine ....Contents Preface ...................................................................... K........1 The Communication Revolution Goes On – Global High-Speed Networks: Setting the Pace for Future Multimedia Applications ...3 Teledermatology Delivery Modalities: Real Time versus Store and Forward ............ Zepter...... C...................... Mich......................... P.................................. 24 Whitten. Burg..... (Zürich) 1.... (Zürich) 1.......................................1 Teleteaching Tools in Dermatology on the Web ............2 Image and Video Compression: The Principles Behind the Technology . Denz............... (East Lansing.............................. (Zürich) 1 Telemedicine in a New World 1......... G.................3 Technology 1.................................3.........1 The Telemedical Information Society: Doctors’ Playground or a Contribution to the Evolution of Healthcare? .......................... 12 Häffner... M....3........ G.. A............ M.......... Cipolat............... Burg. (Zürich) 2 6 V .......... A..............3............S. Geiges........................ (Zürich) 1. . (Basel)..... Airaghi............. (Zürich) 3 Teleconsulting: Legal............ (Zweibrücken). B.L.............. 71 Boesch. (Odense) 3..............S............. Müller....... (Basel) 4.........3 Towards a Virtual Education in Pharmaceutical Sciences: An Innovative E-Learning Approach ..........) Contents VI ....................5 Potential of Telemedicine in Primary Care ..................... Christen..... Mo......... G........................ (Odense)........ 121 Olver......2............ S.. Fischer.. (Zürich) 2. 87 Voellmy......R.................... I..................... H.......................................... Oberli........3 Economic Aspects – Saving Billions with Telemedicine: Fact or Fiction? ......... C............ 39 Haller................4 Secure Transfer of Medical Data over the Internet: From Regulatory Data Protection Jam to Framework-Based Requirements .................4 Modern Telepathology: A Distributed System with Open Standards . S..2 Teleradiology .... Brauchli.....) 3.. 102 Oberholzer..... G...................................B.. K.... Stauch....... (Columbia................V Folkers........... Jundt.. (London) 3..... 94 Demartines........ V .......... (Honiara).................................. (Adelaide......... H.. (Basel)..U.. S............ Beglinger.............................. Poulsen. M.......................... S.... Lichtsteiner......... L....... A..................... .... Gabathuler.......... 76 Reichlin. B. B...... D........ D................ G..... I.. Ethical and Consumer Aspects 3........ Helfrich.. M......... Haroske.. Mihatsch. (Kolding)... (Küsnacht/Zürich) 3.......................... (Dresden)......... (Zürich) 4..................................... K.............. H..............2 Telemedical Training at the Department of Gynaecology. Fischer. P........................... Ernst.................. Wittrup Jensen.......................... M.. 83 ⁄ Kurzynski.... M................... (Wroc law) 4...... Marincek.. Dyson...... H....2 Satisfaction of Paramedical Personnel ...................................... (Aurich)............... University Hospital Zürich ....1 Telemedicine for the Family Doctor ......................R...................3 Telemedicine Applications in Surgery ............. 43 Tran............... 58 Hicks....................... (Schaffhausen) 4................5 Telecardiology ..1 Changes Patients Expect to Result from Telemedicine ............. (Zürich) 4............. A... (Basel) 4 Fields of Application of Telemedicine 4...... G.... 115 Zeevi.......W.... N......... Otto................ H..................... M..A..........6 Telemedicine in Oncology .... 53 Tachakra....... 62 Kristiansen... U.. G.. ............ 182 Böhm.... (Geneva) Contents VII .. K.... L..7 Telemedicine in Ophthalmology ..... Isohanni.....1 Dermanet® – A Tailor-Made Tool for Teledermatology… ............ Conn........................G.................................2............ G..2 Teledermatology-Teaching 5.. 127 Hammack..3 Image Archives.............. Väisänen... C.... W................ Audio...... U..1... (Oulu) 4... M...............) 5 Teledermatology 5.M................. Esser... Stolz........3 Teledermatology in the Nursing Home ...................... (Regensburg) 5..... Wiegers..... G..and Video-Sequences for Teleteaching ... Tex... (Regensburg). Burgdorf.... Cipolat........... B.................................. Minn........ Hamm.......2 Telematics-Based Teaching in Dermatology .................. M.. (Munich) 5..... H.. 167 Zelickson. (Hamburg)................4 Dermatology Course 2000: An Interactive Multimedia Dermatology Course for Students Programme Description and First Results ......... H......-H..1.. A...... 132 Mielonen..............) 5. (Darmstadt) 5... Gruber.....1 Teledermatology in Clinical Use 5.. J....... H.8 Implementation of a Telepsychiatric Network in Northern Finland ..................... (Galveston.1 Dermatology Online with Interactive Technology (DOIT) ....... L.... J. 141 Satava.. 195 Stolz........ A...3... H....D....... W....-L....... R............. 191 Höhn...3 Teledermatopathology 5........) 4................... 154 Kühnis..... 172 Glaessl................ M..... 201 Braun........ J.. 176 Bader...2 Aspects of Quality: Face-to-Face versus Teleconsulting ...1.......... N. (Galveston....G......9 Telemedicine and Real-Time Monitoring of Climbers ....... (Reinach) 5.. (Würzburg) 5...........4...10 Telemedicine in Corrections ......1.... G.... Ohinmaa... H..... (New Haven..... Burg........................ Roesch... M..... W............................... (Regensburg).... L........ (Minneapolis... Landthaler................. B......... A.... Coras.. (Zumikon)...........) 4...... Albert............. W.....2... (Regensburg).........4 A Survey among Dermatologists in Practice about Teledermatology ........ W............1 Teledermoscopy ...................... (Munich).... Tex....... Saurat..... (Mainz).......................P....... 158 Granlund............2........... 148 Hammack............. Popal....... (Zürich) 5......2...... Landthaler.. Milesi... Arnold. Popal................. H............................ (Helsinki) 5....................... R.. Moring........ .2 Teledermatoscopy in Daily Routine – Results of the First 100 Cases ..3 Teledermatology in Sub-Saharan Africa ...... 213 Kempf... S...) 6. Burg... C.......... T............................ R........ Rufli........ (Zumikon)......................... Klövekorn..... (Geneva)......... (Bayreuth)..... 247 Kropf..................... (Zürich) 6 Global Telemedicine 6............. M............ B.. P. Pakenham-Walsh.......... (Zürich) 6. 226 Qureshi..... (Boston............................. J.............................A. R.................. Landthaler............ H............... J................................ Kinateder............................. 252 Tittelbach...................... Doe.........4 Telemedicine in Europe .. Glaessl.................................. W............................... Burg.................. 207 Coras................................ Braun......... W.......................... 263 Contents VIII ..........1 Teledermatology in North America ...... Burg. U............. Reichlin...C........ G... U.... Kvedar..... N...6 Teledermatology in Switzerland ................. J............. Stolz........ P.............. A.... (Munich) 5......... (Jena) 6....... (Zürich) 6....................5 Telemedicine in Germany ..... (Basel)........ (Regensburg)..3 HistoClinC: A Web-Based Telemedicine Application for Clinicopathologic Correlations in Dermatopathology ......... G....3.. (San Antonio........... (Gilching)...........) 6..3... Mass.5....... C.....2 Telemedicine Experience in North America ....... 257 Cipolat.............. 261 Subject Index ........ G...... (Zürich)............ (Regensburg). (Zürich) Author Index ........................ P................. A. Lepski......... Elsner............. 233 Schmid-Grendelmeier.... Bader.. 222 Pak.......... W............... Cipolat... Tex........... Preface Telemedicine holds great potential to revolutionize medical and paramedical services. Disease monitoring will become another telemedical application for patients with heart disease. Telemedicine is defined by the World Health Organization (WHO) as ‘the practice of healthcare using interactive audio. This includes healthcare delivery. metabolic diseases. etc. consultation and treatment as well as education and transfer of medical data’. namely radiology IX . Telemedicine. store-and-forward or other hybrid technologies. 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. diagnoses. but rather offer better healthcare at the same price. The reliability of telemedical procedures and the cost-effectiveness of face-to-face vs. different logistics may be implemented. refers to a more stringent definition of e-health. visual and data communications. those medical disciplines that rely heavily on imaging techniques are suited especially well for telemedicine. however. Considering this definition. The implementation of these modern forms of healthcare will probably not save costs. telemedical care will have to be compared and evaluated by appropriate studies. and high blood pressure. including real-time. Depending on the local requirements and geographical distribution of the partners in a telemedical network. not only for primary care physicians in remote areas but also for teaching students and for continuous medical education. consulting and asking for second opinions will be the gold standard of medical care. In the future. including telemedicine. and the fields of application in the context of various disciplines. Each article provides a brief overview rather than comprehensive information on details. otorhinolaryngology. indirect costs such as time and effort for the patient will be reduced. insurance companies and healthcare providers. ophthalmology. Liza Anyawike of S. the general population. telemedicine will be an established part of modern healthcare. The articles were kept relatively short so that various aspects could be covered. Quality will be improved without saving direct costs. My thanks are also due to Mrs. patients. and many other specialities. dermatology. telecardiology. I wish to thank the contributors to this volume. teleconsulting relating to legal. psychiatry. pathology. There is no doubt that within 3–5 years. politicians. will proceed. The evolutionary process. However.and related disciplines such as surgery and orthopaedics. to the publishers for their excellent cooperation. Telemedicine will certainly add a new dimension to the medical and paramedical healthcare services. diabetology. including technology. however. This book covers part of the broad spectrum of telemedical applications with special emphasis on teledermatology. providing a tremendous benefit for the patient in a modern healthcare system. ethical and consumer aspects. including physicians. Susanna Ludwig and Mrs. Günter Burg. Telemedicine still encounters some resistance on various frontiers. Karger Publishers for their help and courtesy. neurology. teleteaching. Zürich Preface X . oncology. MD. 1 Telemedicine in a New World . Michael E. The World Health Organization (WHO) defines Telemedicine as ‘the practice of healthcare using interactive audio.Burg G (ed): Telemedicine and Teledermatology. radio signals and television programs.1 The Telemedical Information Society: Doctors’ Playground or a Contribution to the Evolution of Healthcare? Günter Burg. consultation and treatment as well as education and transfer of medical data’. but today is in almost everyone’s mouth. People watching TV were aware that they were experiencing an innovation that would change our society. Karger. This includes healthcare delivery. the telecommunication satellite ‘Telstar’ began to transmit international phone calls. visual and data communications. . Basel. vol 32. According to this definition. both amongst the competent and the incompetent. Universitätsspital Zürich. Switzerland On July 10. 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. and pushed by healthcare organizations seeking new methods to enhance health services and the high-tech industry who scented a lucrative market. promoted by worldwide electronic networking and the dizzying progress of information technology. orthopedics. Curr Probl Dermatol. 10 years ago was rarely discussed. disciplines that rely heavily on imaging techniques are especially suited for telemedicine: (1) radiology and related disciplines such as surgery. and (3) dermatology. Telemedicine was fostered by the needs of seafarers and the raw emergencies of battlefields. De Bakey was also revolutionizing open-heart surgery. Martin Denz Dermatologische Klinik. Currently. and others. 1962. His operations were transmitted live by television using ‘Telstar’ as a relay. pp 2–5 1. (2) pathology. 2003. In those days. diagnosis. several hundred pilot projects are underway to test the possibilities of applying information technology to medicine. (9) psychiatry. There are. however. 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. And still. no matter whether a consultation is done face-to-face. need highspeed connections in order to provide a reasonable transfer rate of data. (3) Psychological barriers: We refer to subjective arguments preventing the acceptance of telemedicine by both patients and physicians. (2) Organizational resistance: Looking at the reality of hospitals and healthcare institutions.However. The Telemedical Information Society 3 . However. 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. The compatibility of software programs also is an essential prerequisite for the widespread use of telemedicine in the future. other disciplines that need to transfer medical data at a distance can also benefit from the new technology: (4) telecardiology. many obstacles hindering the triumphal progress of telemedical applications: (1) Technical and logistical restraints: High-resolution images. such as those used particularly in radiology. New data transfer media and potent new programs for data compression are still being developed. while many questions as to liability remain to be clarified. Nevertheless. (8) otorhinolaryngology. studies have shown that if telemedicine can be explained in the appropriate terms. fax or telemedicine. pathology and dermatology. (7) oncology. responsibility lies with the physician caring for the patient. There is almost no area of medical or paramedical care in which the implementation of telemedicine could fail to offer some procedural improvement. Patients do esteem a tangible improvement in the quality of healthcare. while user-centered telemedicine projects are blocked by endless discussions about the lack of evidence for their return on investment. astonishment? We watch as huge misinvestments are poured into administrative-oriented IT systems. and many other specialties. such as the fear of a deterioration in the doctor-patient relationship. patients are indeed very ready and willing to accept it. These barriers are mainly caused by a lack of awareness of the potential positive impact of telemedicine. at best. (6) neurology. 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. (5) diabetology. the exponentially growing need for storage capacity will be an ongoing challenge. via phone. As long as insurance companies persist in refusing to reimburse expenditures for telemedical activities. but will become available worldwide wherever needed. Telemedicine by itself will not revolutionize any future healthcare system. healthcare Burg/Denz 4 . the use of telemedicine as a further tool in healthcare will decisively contribute to the optimization of processes. Neither private health insurers nor governmental health authorities have yet agreed to reimburse expenditures for telemedical consultations. as global networking makes data and knowledge available independent of time and location. Therefore. Access to specialized. legal systems will have to evaluate telemedical procedures as they become standardized. However. whether on the part of the consultant or on the part of the physician requesting the second opinion. but also a significant reduction in costs. money. is growing at the impressive rate of about 20% per year. Last but not least. 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. it is highly encouraging to realize that the use of telemedicine applications. Without doubt it will contribute to increased competence in all institutions that provide healthcare. On a macro-economic scale. in-depth knowledge on certain medical issues will no longer be restricted to a limited number of experts. telemedicine does have the potential to improve the quality of healthcare for all patients in the future. Nevertheless. Reciprocally. (5) Ethical and legal considerations: Any technology may be helpful or dangerous. Ethical principles in medicine are timeless. but they must evolve according to the challenge of previously nonexistent technological possibilities and societal developments. telemedicine could provide not only an improvement in quality. in their many different facets. the purposes for which patients’ data may be collected and the ownership of such data has to be clarified. 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. the application of telemedicine will be limited to the small number of pioneers who are prepared to invest time.(4) Lack of reimbursement: A major issue limiting the use of telemedicine in medical practice is the lack of economical incentives. Presuming that patients. depending on the users’ sense of responsibility. ideas and energy in this new technology [1]. Telemedicine will neither make face-to-face consultations superfluous nor devalue the physician-patient relationship. From a local perspective it will provide helpful practical solutions but probably not reduce costs. Report available: http://www. this goal is within our reach.1338. Universitätsspital Zürich. enabling and sometimes also impeding communication.FF. Television gives us an example of how information flow was enhanced. Rhein-Sieg Verlag. As a society. Fax 41 1 255 4403. 2001. MD. writing and arithmetic.com/ ER/Research/Report/Summary/0. Looking back to the 1960s with the satellite ‘Telstar’ and De Bakey’s TV transmission of open-heart surgery. The introduction of any new technology has always been accompanied by a structural and behavioral change in society [2]. E-Mail burg@derm. citizens. an awareness of the responsible and appropriate use of telemedicine tools and methods is gradually evolving in the field of medicine. In the same way. Dermatologische Klinik. References 1 2 Forrester Research 2000: Why doctors hate the net. 41 1 255 2550.ch The Telemedical Information Society 5 .professionals.unizh. medicine evolved and began to integrate the methods of information and communication technologies into its daily routines. so that in the future telemedicine will be able to take its rightful place in the instrumentarium of modern healthcare. St Augustin. Gloriastrasse 31. CH–8091 Zürich (Switzerland) Tel.forrester. Günter Burg. economists and politicians will strive in common for the further development of telemedicine in healthcare.html Nefiodow LA: Der sechste Kondratieff – Strategien zum Strukturwandel in Wirtschaft und Gesellschaft.9114. 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 ‘r’s’ of reading. vol 32. and the speed of information transfer.2 The History of Telemedicine Claudio Cipolat. Technological advances of the last five centuries have allowed healthcare providers to transmit greater amounts of information at exponentially increasing rates. thereby improving care and the quality of life [3]. To deliver treatment. it includes the whole range of medicine including diagnosis. Michael Geiges Dermatologische Klinik. The decline in computing cost coupled with a rise in . Hence. With new communications technology – the telegraph in 1844 and telephone in 1876 – patients were able to summon physicians quickly and inexpensively. Provider and recipient of healthcare had no longer to be at the same place [2]. Physicians could come to their patients – or patients to their physicians – with greater ease and in a shorter period of time. further shortening the time constraint on healthcare. the distance barrier was diminished. Curr Probl Dermatol. Johannes Gutenberg’s invention of the printing press in 1451 allowed healthcare providers to disseminate information en masse [1]. resulting in decreased costs and increased quality of care. Karger. distances involved. pp 6–11 1. As the speed of land transportation increased.Burg G (ed): Telemedicine and Teledermatology. and later with the automobile in 1896 and airplane in 1904. Switzerland Telemedicine is the delivery of healthcare and the exchange of healthcare information across distances. patients and providers had to be co-located. treatment and prevention of disease. continuing education of healthcare providers and consumers. facilitating collaboration and expanding their mutual knowledge base. In addition. The roots of telemedicine can be traced back centuries. Universitätsspital Zürich. and research and evaluation. Advances in transportation and communications soon followed. 2003. As a result. first with the steam engine in 1825. Basel. healthcare was limited by the need to relocate people and equipment. distance between patient and physician played a large role in driving the costs of healthcare and the volume of healthcare delivery. when medical care was limited to the radius in which the physician was available. performed when distance is an issue. physicians could now easily confer with one another. as well as clinical practice. Telemedicine is still a relatively new area of interest. the World Wide Web and Internet. this seldom seems to be translated from the initial project leader to other clinicians. Five regional supercomputer centers around the US were connected to form the backbone of the Internet. high-powered computers. Each computer sent its message to adjoining computers until it reached its destination. Birth of the World Wide Web The US military developed the idea for a national network of computers in the late 1960s. 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]. there is a lack of training given to clinicians before they use videoconferencing or other telemedicine technologies [11]. user or outcome focus. it is still the human factors that tend to determine the success or failure of telemedicine projects. 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. The Internet stands at the forefront of telecommunications in medicine. ARPAnet was designed to function even if one or more of its computer sites were destroyed. With this purpose in mind. The relatively short history of telemedicine from the 1960s onwards is characterized by many different types of systems. While it is true that most telemedicine systems are becoming increasingly user-friendly. each member university and research facility paid for its own connection and service. the advent of fiber-optic cable. and while the technology is rapidly evolving. it is also still true that many clinicians and other users remain rather fearful of the technology [10]. While there is generally high-quality clinical ownership of most telemedicine systems in the first instance. teaching. relatively few have endured beyond a few years [5–7]. as a long distance telecommunication network [12]. In general. or not used at all. and research. ARPAnet’s successor was created in the 1980s by The National Science Foundation (NSF). higher speed access methods are offering a range of new services such as real-time video and voice communications. Along with the growth of the Internet.computing power. Lack of planning tends to lead to one outcome: the equipment simply sits there and is not used appropriately. Medical education. will be affected in numerous different ways by these advances. The History of Telemedicine 7 . and few systems seem to have a real consumer. To minimize costs. changing and fascinating. and satellite communications now permit transfer of specialized medical information at high speeds [4]. In view of the cost of these systems. anyone could move around the Net easily and access its vast resources without knowing complex computer languages. Telecommunications on the Internet are standardized by a set of communications protocols. problems with storage space and required computer power may arise.This cost-sharing helps make the Internet inexpensive to use. and quality control can pose challenges for professionals. and can be used for students as well as a reference image atlas for physicians [15]. but also to view graphics. MEDLARS. With the increasing accessibility of the Internet has come a collection of information. Quality is a major problem.. sharing images and text on the Internet has great potential. Complicated and cumbersome. In 1991. To expedite research for ongoing projects at CERN Laboratories in Geneva. For the visually oriented specialty of dermatology. Each document was given a unique address. In 1992. The basic problems of medical resources on the WWW can be classified into three areas: scholastic quality. easy-to-use Web browser that accesses hypertext documents in a point-and-click environment. the TCP/IP protocol suite. The resources pertaining to the field of dermatology include a large palette of options. For example. the first graphical. an image database is available through the WWW. AIDSLINE. but its lack of formal organization. it can be a valuable resource. photographs and videoclips online with the click of a mouse button. videoconferencing. multimedia mail. The Internet allows anyone with hardware and a connection to ‘publish’. and ease of access. such as MEDLINE. payment is needed. clubs. or URL (Universal Resource Locator). etc. atlases. compression and color depth of the image must be optimized to enable fast access and offer acceptable image quality. the early Internet needed fine tuning. Mosaic made it easy not only to locate and retrieve documents on the Internet. relevance. was created. these resources may vary in their quality. databases. textbooks. associations. etc. The Internet is also a medium for accessing various databases. 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). Finally. and a great deal of material appears to be posted without editorial oversight or peer review. The WWW. Switzerland (European Laboratory for Particle Physics). journals. mailing lists. A person can figuratively jump from one computer to another and pursue information by following hypertext links. however. standards. Mosaic. The resolution. that describe routing of messages over the Internet. When a high resolution is chosen. Berners-Lee’s program – the World Wide Web – was introduced on the Internet [14]. True. or ease of access [16]. and image databases facilitate applications of digital images in a visually oriented discipline. relevance. consulting software engineer Timm BernersLee [13] developed a system to link documents stored on various computer systems and make the Internet’s huge knowledge base easily accessible. MEDLINE is the most used Cipolat/Geiges 8 . allowed ground controllers to analyze basic physiological parameters (e.g. Also. an integrated suite of equipment that measured several health parameters for the crew at critical mission stages and transmitted them back to Earth [19]. and heart rate and were near real-time delivered to Mission Control Center with less than a 2-min delay. in-orbit crews with pre-flight medical training are usually able to respond to unexpected events. In-orbit astronauts have reported a wide range of medical events [18]. balance disturbance. Due to the recent technical achievements in computing. and environmental health has always been an integral part of the NASA’s operations [17]. telemetry of flight suit data. flight controllers on the ground are able to evaluate specific health criteria. With the consultation assistance of ground controllers.medical database by healthcare professionals. synchronous phonocardiography. The Remote monitoring of crew. blood pressure. ECG. we are now able to access instantly resources around the world. Temperature.. this facilitates a huge and increasing free flow of information between specialists worldwide. During the beginning stages of the Space program. may change not only the way of accessing information. in conjunction with voice communications. A new addition for the Apollo project (1968–1972) was the biosensor harness. and was adapted to the computer for the first time in the 1960s. CO2 production. The advantage of MEDLINE is the possibility of using Medical Subject Headings (meSH) search and the reliability of the indexed sources. Since the first days of suborbital flight. ECG data). Project Gemini (1965–1966) astronauts served as test subjects for studies in sleep patterns. pulse. spacecraft. telemedicine has been transformed by the increasing complexity of space operations. These data included O2 consumption. The Internet has altered the paradigm of scientific communication and. History of Telemedicine in Space Medicine The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine research and applications. they were not downlinked real-time during the mission. and nutritional changes. Although these data were collected and recorded. In addition. In the Space Shuttle program (1981 until today) a tracking and data relay satellite system provides real-time communication of The History of Telemedicine 9 . in the near future. ventilation. and agree upon medical protocols. but medical practice itself. consult with onboard crew medical officers. 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. telemedicine capabilities go far beyond monitoring healthcare. Today. ventilation. a significant step for modern telemedicine. Royal Society Medicine Press. At the same time. In this decree. pp 6–18. Wootton R. In 1935. London. Zajtchuk R. the terrestrial validation of telemedicine technologies to bring healthcare to remote locations provides feedback. In 1950. Telemedicine for Airline Passengers and Seafarers Airline passengers and seafarers are different examples of people who can benefit from telemedicine [20]. Saunders. Craig J: Introduction to Telemedicine. 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.biomedical information from Shuttle crews to mission control. 1929. Monthly Labor Rev 1996. Unless a doctor is flying on the same aircraft.45:200–261. References 1 2 3 4 Garrison F: History of Medicine. the care of the patient is entrusted to the onboard personnel [21]. 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. the Italian government established the CIRM as a foundation by means of a legislative decree. Airplanes are always in contact with an air traffic control center by radio. Dis Month 1999. Cipolat/Geiges 10 . Virtual reality. and enhancement of the space program. and nanotechnology promise a new stage in the evolution of telemedicine. In case of a medical emergency. pp 1–207. Gilbert GR: Telemedicine: A new dimension in the practice of medicine. G. Philadelphia. haptic feedback. the air traffic control center can act as a communications bridge between the aircraft and healthcare staff on the ground. As missions have increased in complexity. The NASA effort to monitor and maintain crew health. An example of distance between patient and healthcare provider is the passenger on board an airplane who requires medical treatment. immersive environments. Warnke F: Computer manufacturing: Change and competition. Prof. with the purpose of offering shipmasters free radio medical assistance. 1999. improvement. NASA telemedicine capabilities have grown apace. Guida in Rome established the International Radio Medical Center (CIRM). and environmental integrity in space flight is a sophisticated and coordinated program of telemedicine combining cutting-edge engineering with medical expertise. system performance. with a medical staff of 10 physicians and 49 specialist consultants providing radio medical assistance 24 hours a day [22]. Hosp Community Psychiatry 1992. Huntley A: Dermatology on the Internet.37:641– 647. seafarers and islanders. Roy SA: Evolution of telemedicine in the space program and earth applications.84:71–79. Brown FW. J Telemed Telecare 1996. 41 1 255 2550. Bagshaw M: Telemedicine in British Airways. Universitätsspital Zürich.99:32– 40. Healthcare Inform Manage 1995. Allen A: Analysis of telemedicine from an organisational perspective. Rizzo N: Organization and activities of the International Radio Medical Center (CIRM). Sitaru C: Dermatology resources on the Internet: A practical guide for dermatologists. Bull Med Libr Assoc 1996.28:135–144.159:437– 438. Diepgen TL: Development of a dermatological image atlas with worldwide access for the continuing education of physicians. Doarn CR. Carvalho M.4:19–30. Bittorf A. Fax 41 1 255 4403. Telemed J 1995.1:45–53. Semin Nucl Med 1998. Fulvio S. National Aeronautics and Space Administration. CH–8091 Zürich (Switzerland) Tel. A source of clinical and scientific information. Krejci-Papa NC. Biagini M.9:13–16.2(suppl 1):36–38.13:1– 4. Telemed J E Health 2001. Rizzo N. Technol Rev 1996.5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Preston J.2:125–131. Hartley B: Using telemedicine to improve health care in distant areas. Merrell RC: Applications of telemedicine in the United States Space Program. Dauri A. Telemed J 1998. J Telemed Telecare 1996. J Telemed Telecare 1997. 2000 (unpubl data). 1975–1997. J Telemed Telecare 1995.4:207–224.3(suppl 1):7–9. Whitten PS. Int J Dermatol 1998. Glowniak J: History. Telemed J 1995. Elford R: Telemedicine activities at memorial University of Newfoundland: A historical review. Dermatologische Klinik. Gloriastrasse 31.usz. J Dermatol Sci 1996. Med J Aust 1993.1:19–30. MD. Dauri A: Telemedicine for airline passengers. structure and function of the Internet. E-Mail [email protected] The History of Telemedicine 11 . Claudio Cipolat.7:1–15. Amenta F.24:122–125. Yellowlees P. Krejci-Papa NC. McCoy WT: Telemedicine – A health care system to help Australians. applications and impact on librarianship. Allen A: The role of the consultant in telemedicine. Telemed J 1998. Nicogossianc AE. Zundel KM: Telemedicine: History. Über DF.43:25–31. Camerucci S. Longitudinal Studies of Astronaut Health. Bashshur RL: On the definition and evaluation of telemedicine. The Web Maestro: An interview with Tim Berners-Lee. Bittorf A. Nicogossian AE. was revolutionary. the telephone.1.1 The Communication Revolution Goes On – Global High-Speed Networks: Setting the Pace for Future Multimedia Applications Andreas Häffner. These developments were also accompanied by rapidly increasing interconnectivity of the various tools. At the beginning of the last century. however. publicity and communication have always been intrinsic aspects of human expression and of society. writing and printing. So. In the last few decades. 2003. 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). and on their decisions [1–7]. as the new . radio. not only because of its accessibility. Later. a revolution has occurred in the instruments available for those seeking to collect. Switzerland The Information Society Information. but also because it offers access to virtually unlimited amounts of information and in addition. vol 32. Karger.3. The personal computer is thus now the center of a global electronic network of appliances and systems. The Internet. Karoline Zepter Dermatologische Klinik. processing and communication of information. basic communication tools were speaking. interacting to offer unprecedented possibilities for the collection. using them in combinations for various purposes. pp 12–16 1. Curr Probl Dermatol. cinema and television were major steps forward in distributing information. awareness. more rapid means of communication. being directly within reach for a major proportion of our societies.3 Technology Burg G (ed): Telemedicine and Teledermatology. Basel. Universitätsspital Zürich. process and distribute information and this revolution has had a profound effect on the interaction between the various actors in society. it may incorporate multiple sources of various media spatially or temporally.information technology and its networks advance and becomes more pervasive. usually government-owned companies controlled all equipment. By the 1980s. They could also opt to pay for better TV service by subscribing to cable. Consumers became more influential with regard to their telephone equipment. In the 1990s. communicate and process a variety of information in an integrated manner. Recent advances in key enabling technologies. In telephony. multimedia systems allow the end user to share. in modern business systems. a handful of networks and the governments that supported them dominated. text. economic operations and activity in general are becoming increasingly knowledge-based and directed by information. can be summarized under the term multimedia – the blending of images. entertainment and manufacturing sectors. And High-Speed Networks Twenty-five years ago. In television. such as groupware. graphics. the networks and the various levels of government and people. is called The Information Society. and the scope in which knowledge is expressed is becoming global. the interrelationship between this information. videotext and other information within a human interface that uses capabilities to access and present information. This global knowledge-based community. mobile technologies became affordable and ubiquitous. sound. Uses Multimedia Core technologies. however. the integration of various types of media such as data. graphical user-interfaces have raised the demand for multimedia applications and thus also for an ever more advanced network infrastructure. speech generation. tariff models became more diverse and telephone lines began to be used for data transmission as well as voice. Essentially. In a distributed environment. graphics. retailing. with its increasingly dominant information and communications networks. things were changing. Similarly. services and prices. empowering these new information societies. The Communication Revolution 13 . consumers had little choice. voice. voice and full video has gained significant impact considering the current applications of computers in education and training. for example. animation. the new technology they use and the information they pass on. Cable and satellite networks.Internet Access Evolution Dial-in (POTS) Dedicated Line Service Modem. 1.048 Mbit/s 1.90) 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. The seeds of a broadband revolution are seen in how today’s networks are evolving to deal with these limitations. and. while two-way. 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. which rendered them ineffective wherever interactivity and two-way communications were required. available network speeds reach up to 34 Mbit/s today. Changing uses of existing networks inevitably exposed fundamental flaws and limitations. Internet access evolution: while few kilobit connections were the standard only 10 years ago. though fast. were inherently one-way. POTS (V. 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.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. because these networks relied on dedicated connections. were too slow for high volumes of data.544 Mbit/s ISD Fig. Cable networks are being enhanced with new two-way controlled equipment that enables interactive TV xD SL Häffner/Zepter 14 . Copper-based voice networks. particularly those with chronic diseases. It is the exception rather than the rule for a patient to receive medical care from only one provider. To Transport Increasingly Vital Information Aside from professional and entertainment use. as by a recognition that networked computers offered a better – or even the only way – to meet the basic challenge of medical informatics. Consumers are beginning to actively influence and participate in the broadband revolution. local and medical independence. they also create it. making the explicit recording of this information less critical than is currently the case. Satellite services are being enhanced with two-way strategies that make them more useful. Informed consumers ever more recognize that they not only consume content. The seeds of a broadband revolution are dispersed not only with new technologies. unknown so far. For this reason. Hence. One example is the concept of an Internet-based computerized patient record (iCPR). but also in the new models of interaction that open the doors for new forms of consumer-controlled services. that is to provide comprehensive information at the right place and time. 1). content is about them and they are part of it. was not so much driven by the underlying technology which made it possible to do something new. With an elevated life expectancy and accustomed to international traveling. medical care is fragmented even for those who are not geographically mobile. Today. unlike some applications of computers in medicine (NMR scans. Not only was the volume of information lower in previous generations. notably raise their demands on availability and accessibility of personal medical data and documents. 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. ‘lifestyle’ activities. including the use of information systems to gain or enable medical advice. for example). enter the stage of these new product/service classes. and interesting to a wider range of users (fig. people. cost-effective. the concept of the iCPR. an extensively documented and continuously updated health record will become more and more important and provides a novel.and internet-based services. continuity of medical care was more often maintained through enduring patient-physician relationships. 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 15 . and how content is delivered. Love PED: Current and future directions of multimedia technology in business. Finally. for the storage and administration of health data from heterogeneous sources. Katharine Sharp Review.ch Häffner/Zepter 16 . not just speed. but much more about content. The problems surrounding the iCPR make clear that the real broadband revolution is not so much about speed. how content is protected. and new computing appliances. Archival and Information Studies. but think content. The transition to the computer-based patient record has only begun. Electronics Commun Jpn 1998.11:75–90. E-Mail ach5@derm. and as the basis of a significant amount of clinical research. enhanced quality of service. Papavassiliou S: Network and service management for wide-area electronic commerce networks Int J Netw Manage 2001. they are enabling higher transmission speeds. As broadband technologies evolve. MD.19:105–120. In spite of the grossly unmanageable state of the paper medical record. 4 5 6 7 Andreas Häffner. new models of content storage.pharmaceutical prescriptions.1:141–163. it remains the repository for the overwhelming majority of actual clinical data. Gloriastrasse 31. 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. It is the need to define how content is gathered. Kimura H: A study on structure and quality of multimedia network systems for education using satellite interactive communication. University of British Columbia. CH–8091 Zürich (Switzerland) Tel. 41 1 255 2550.unizh. Gendreau T: A broadband revolution? Yes. www. The European Commission: The Information Society and Development (2001) ER/04 Economic Analysis. References 1 2 3 Margaritidis M. Summer 1996 (ISSN 1083–5261). McFarland D: Multimedia in higher education.pdf Gunasekaran A. Polyzos GC: Adaption techniques for ubiquitous Internet multimedia.mindport. Fax 41 1 255 4403. valued. Int J Inform Manage 1999. But these technologies are only the enablers of the broadband revolution – not the revolution itself.81:355–365. 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. Dermatologische Klinik. Wirel Commun Mob Comput 2001. School of Library.com/ factsheets/BBRevolution. No 3. organized. Universitätsspital Zürich. vol 32.2 Image and Video Compression: The Principles Behind the Technology Andreas Burg Zürich. The most generally used compression schemes for the transmission of life video data (such as MPEG-2. At the receiver the compression procedure needs to be reversed to restore the original data stream. Basel.263 and MPEG-4 [3]) are based on the same principle ideas and algorithms. H. This procedure is called decompression. Karger. 2003. Curr Probl Dermatol. the transmission of multimedia streams has remained a major challenge. as opposed to lossless algorithms which are typically used for text. 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]. Table 1 summarizes the required bit rates for the transmission of raw video data for some typical applications. . Their structure is shown in figure 1. pp 17–23 1.) As a consequence. 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. (These schemes are classified as ‘lossy’ compression algorithms. Nevertheless. The required data rates to transmit the raw video streams data exceed by far the capacity of modern networks. programs and other data. the original data stream cannot be perfectly restored at the receiver.Burg G (ed): Telemedicine and Teledermatology.3. Switzerland Image and Video Compression: The Principles Behind the Technology The capacity of telecommunication systems has grown rapidly in recent years. Most of today’s 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]. The Y component defines the brightness of the pixel. Preprocessing In the preprocessing stage the frames that arrive from the video source are first converted into the so-called YUV color space. Required bit rates for the transmission of raw video data for some typical applications Application Format Bit rate. 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. while U and V determine its color. With this measure the overall amount of data of the incoming frames is already reduced to two thirds or to one half respectively. In this representation. 1. As the human visual system (HVS) is much less sensitive to the latter. 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 (128–256 Kbits/s) UMTS (144 –384 Kbits/s) Preprocessing Prediction Transformation Quantization Entropy encoding Postprocessing Reconstruction Inverse transformation Inverse quantization Entropy decoding Fig.Table 1. each picture element (pixel) is represented by its luminance (Y) and its chrominance (U and V). In this context the term ‘redundant’ describes a piece of information Burg 18 . Video compression. Prediction The goal of the next step(s) is to remove redundant information from the video stream. 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. 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. This is necessary to allow the receiver to reconstruct the original image (fig. 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. and (2) most pixels in a frame are very similar to the pixels in their vicinity. it is impossible to start a sequence at an arbitrary time. 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. 2). which themselves also depend on even older frames. 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.263. The simplest form of prediction assumes that two subsequent frames are identical. 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). Only the difference between the guess (predictor) and the actual frame (the error frame) is transmitted. A much more complex. however also more efficient scheme is the so-called motion estimation and compensation. However. in reality. This technique is used in most of today’s video compression algorithms such as MPEG-2/4 and H. The predictor is again subtracted from the region in the current frame and the resulting error is transmitted together with the corresponding motion vector.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. and (3) if an abrupt scene change occurs there might be very little correlation Image and Video Compression 19 . The better the predictor matches the actual frame. 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. Its displacement is called a motion vector. To exploit this. 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. a frame is partitioned into multiple square (MPEG-2/H. The predictor for each frame is simply the preceding frame.263) or arbitrarily shaped (MPEG-4) regions. This is done by making a guess about the current frame using only information from previous frames together with a set of rules. the smaller is the remaining amount of actual information that needs to be conveyed. (2) if an error occurs during the transmission of a frame it will propagate into all subsequent frames. Moreover. independent of any previous frames. 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. it is not suitable for a real application as it requires knowledge on the statistics of the image which is not a priori available. The frequency of these I-frames depends on various parameters such as the type of scene or the quality of the transmission channel. Burg 20 . While it achieves theoretically the optimum performance. most of the redundancy caused by inter-frame correlation has been removed.Fig. between subsequent frames and no suitable predictor might be found for a frame. 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. The two most common transforms are the Wavelet and the 2D Discrete Cosine Transform (2D-DCT ). To counter these problems. These frames are as opposed to the predicted D(ifferential)-frames encoded by themselves. 2. Motion estimation. modern algorithms introduce so-called I(ntra)frames in regular intervals. 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. The best possible transformation for this purpose is the so-called Karhunen-Loeve transformation. Transformation After the prediction step. 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. 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. This is achieved through the use of algebraic transforms which have the ability to remove correlation. This is exploited by simply applying more coarse quantization steps to the higher than to the lower frequency AC components.The former is. it introduces a degradation in the image quality. This step is the place where the trade-off between compression ratio and quality is performed. This means that a data stream that has been compressed at the transmitter can be fully restored at the receiver. H. no quality degradation has been caused so far. Therefore. while the other elements represent the horizontal and vertical AC components. no actual compression has been performed yet. This transformation is still lossless and reversible. currently only being used for still images (for example in the new JPEG-2000 standard) and is not further discussed here. The first element in the top left corner represents the DC component. The decompressed data will be 100% identical to the original data and no further information will be lost. All entropy-coding algorithms [5] by themselves are lossless data compression algorithms. Thereby each coefficient is quantized using a predetermined step size. 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. Without the described preprocessing schemes these algorithms are the same that are used for the lossless compression of text documents. Entropy Coding While after these preprocessing and transformation steps the amount of correlation and information in the frames has been greatly reduced. 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. The result of the transformation of such a block is a new block of the same size in the frequency domain. As the quantization cannot be reversed at the receiver. due to its higher complexity.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. software or databases. At this point. Their theoretical principles were first described by Shannon. Quantization In the frequency domain representation a quantization step is applied to the transformed image data. This is only done in the Entropy-Coding step. The latter is part of all three major video compression systems (MPEG-2. who found that the amount of information in any kind of message (or data stream) could Image and Video Compression 21 . exploits the fact that after the previously explained preprocessing steps most of the data in the stream consists of zeros. However. and (4) prefix codes. The last step is the prefix coding. In general.be quantified and in order to do this it would be necessary to know the probabilities of all symbols within the message. (3) run-length codes. Different variations of this basic idea are in use. The name comes from the fact that each code word starts with a prefix which might vary in the number of bits. it does not yet define how this bound can actually be reached in practice. 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. prefix-coding schemes achieve compression by representing symbols with a high probability of occurring with shorter code words. Various techniques are known to construct such codes with Burg 22 . The first two (LZW coding and arithmetic coding) do not play a major role in the encoding of multimedia streams. Entropy-coding algorithms aim at reaching this limit as close as possible. are always followed by one or many zeros. The essence of the generic run-length coding algorithm. While Shannon’s theorem puts a lower bound on the achievable compression ratio. the so-called zero-run-length coding. the much simpler run-length coding and the so-called prefix-coding schemes are used in most of today’s standards to perform the actual data compression. They simply encode every non-zero symbol with the symbol. This is mainly due to their complexity and due to their problems of recovering from transmission errors. while longer code words are used for less frequent symbols. for example that a non-zero number. since the discovery of these information theoretic principles. Instead. a number of compression algorithms have been developed which can be loosely categorized as: (1) LZW codes. Some algorithms. These can easily be found by counting the number of their occurrences and by dividing it by the overall message length. (2) arithmetic codes. run-length coding is always applied first. If both algorithms are used. It collapses runs of subsequent zeros into a single zero followed by the number of zeros in the run. 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. 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 determines the length of the code word. It is the theoretical minimum number of information bits that is required to store its entire content. followed by the number of subsequent zeros. 1993. Mitchell JL: JPEG Still Image Compression Standard. Diss. Proc IEEE 1998. Nguyen-Phi K: Contextual coding and data compression. References 1 2 3 4 5 Ebrahimi T. Haldenstrasse 14. Vienna 1997. Proc IEEE 1998.ch Image and Video Compression 23 . CH–8124 Maur (Switzerland) Tel.86: 1342–1382. IEEE Multimedia 1999(Oct–Dec):74–83. Van Nostrand. Pennebacker WB.86: 1109–1125. E-Mail apburg@iis. It achieves the highest possible coding efficiency that can be realized with this kind of algorithm. Fax 41 1 632 1194. Casalino F.ee. Tech Univ. Andreas Burg. Battista S. Hanzo L: Bandwidth-efficient wireless multimedia communication. One of the most widely known is the so-called Huffman code.different properties.ethz. Lande C: MPEG-4: A multimedia standard for the third millennium. 41 1 632 6095. Kunt M: Visual Data Compression for Multimedia Applications. New York. and to improve the quality of care. Other pioneering projects sought to assess the accuracy of teledermatology. as well as to diagnose and prescribe therapy for patients located at a different physical location. Projects such as the one conducted between Jackson Memorial Hospital. East Lansing. Important to document are the current projects comparing outcomes between teledermatology and traditional care. the goals of teledermatology are to reach out to people residing in underserved areas. 5]. Whitten Department of Telecommunication. Basel. Mich. black and white bidirectional interactive television was installed at Logan Airport in Boston and Massachusetts General Hospital. 2003. Wootton et al. The dermatologist uses telecommunications equipment to evaluate clinical and laboratory data. to decrease the costs of providing some health services. Michigan State University. Curr Probl Dermatol.Burg G (ed): Telemedicine and Teledermatology. [6] found that there were no significant differences in clinical outcomes between teledermatology and conventional outpatient dermatology care in a project conducted in . More recent evaluation efforts in this field have certainly focused on accuracy [4. Simple feasibility of teledermatology was an important first question. Researchers reported that in almost all cases diagnoses made over the system were equivalent to diagnoses made in person [2]. Karger. and prisons in Florida demonstrated that a two-way microwave link could be employed by a dermatologist to assess a patient [1]. pp 24–31 1. 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]. In general.3 Teledermatology Delivery Modalities: Real Time versus Store and Forward Pamela S. Research in the field of teledermatology has examined an array of issues. vol 32.. a major teaching hospital of the University of Miami School of Medicine. USA Teledermatology is the delivery of dermatologic patient care through telemedicine technologies. In 1972. In another early study.3. single chip video camera to a tripod mounted. Real-Time Teledermatology The delivery of teledermatology services is through one of two means: store-and-forward. In real-time teledermatology. digital lines are usually preferred (e.Northern Ireland. as part of a multitelemedical service to institutional patients. and any personnel (typically a nurse or general practitioner) co-located with the patient presenting the patient/images. a look at important research conclusions for both approaches. three sensor chip camera. While live video images can be transmitted through analog phone lines. This modality enables a dermatologist to see and hear a patient through this video connection.. Though studies appear to consistently document positive outcomes in relation to teledermatology. the actual delivery technique varies dramatically among the two approaches. a patient. one cannot have a complete grasp of this field without understanding the two categories of teledermatologic care. namely real time and store and forward. sought to compare live two-way interactive video examinations with Teledermatology Delivery Modalities 25 . Either system may have a dermatoscope (skin scope) and a microscope camera as additional features. Thus. videoconferencing equipment is employed to allow for synchronous activity between two or more parties. Maryland. is highly reliable in relation to diagnostic and management accuracy and well received by patients. However. Diagnostic procedures and therapeutic interventions can be recommended through both approaches. For example. This facilitates a direct interaction in real time between a dermatologist. motion handling is improved therefore decreasing the amount of motion artifacts. The medical aspects of dermatology can be achieved for the most part with either approach. 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. computer-based systems and real-time. and a discussion of the advantages and disadvantages for each. A number of projects have documented the success of real-time teledermatology.g. videoconferencing systems. and expectations of peak use [8]. a project conducted within the Baltimore Veterans Affairs Medical Center in Baltimore. T1). Bandwidth requirements are typically determined by the size and resolution of images sent. these images are traditionally slower and of poorer quality. Another study conducted in Hong Kong [7] concluded that teledermatology. This chapter seeks to document this difference through a brief explanation of both. ISDN. required turn around time. Opinions differ regarding whether real-time video is required for teledermatology or if digital images will suffice. By increasing bandwidth. In general. In another project launched by Tripler Army Medical Center in Hawaii. However. However. physicians tend to display greater comfort with their in-person diagnoses than their videoconferencing diagnosis [10]. 19]. almost universally accept real-time teledermatology.traditional in-person exams in regard to diagnostic agreement and patient/ provider satisfaction [10]. efficacy and user satisfaction. health providers sought to address challenges faced by uniquely remote service providers stationed on Republic of Marshall Islands. a dermatologist can ask a patient a direct question or ask to see something from a different angle. 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]. Project researchers concluded that patients were equally satisfied with both modalities. One of the overriding goals for this project was to reduce costs associated with transporting shackled patients with armed guards to hospitals for care. A project employed in the Highlands of Scotland demonstrated a high degree of both patient and physician satisfaction with teledermatology real-time consultations. 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. 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]. For example. A number of other real-time teledermatology projects have been launched to meet specific health system goals. This delivery modality possesses several documented advantages and disadvantages. Whitten 26 . Research in the field of real-time dermatology has also demonstrated high degrees of patient and provider satisfaction [18. Proponents of real-time teledermatology argue that it creates a more effective communication interaction by enabling three-way discussions between a patient. In a synchronous event. Realtime teledermatology services have proven a welcome solution for clients residing tremendous distances from providers [22]. and physician diagnostic agreement was quite high between the real-time teledermatology and in-person visits. most of these studies assume that in-person consultations are the gold standard that is always correct. The largest studies examining teledermatology have employed the use of videoconferencing equipment to provide real-time diagnoses and clinical management [11]. projects employing real-time teledermatology have demonstrated diagnostic accuracy. on the other hand. Such studies have documented a range of diagnostic accuracy from 54 to 80%. general practitioner and dermatologist. comprising 60 atolls in the center of the Pacific basin. physicians preferred in-person examinations. Patients. A variety of studies have evaluated the diagnostic accuracy of videoconferencing [12–17]. In this project. Other documented advantages suggest that real-time. Critics of this mode of delivery argue that a significant disadvantage lies in its lack of cost effectiveness for services provided over short distances. It is often difficult to coordinate the schedules of specialists. More sophisticated systems provide software that allows for additional patient details such as a short case history. live videoconferencing is pragmatic for monitoring treatments over great distances and is a cost-effective solution for long-distance services [11].Another advantage relates to the increased amount of available information. the technologies employed to provide teledermatology are increasingly asynchronous. there is a greater amount of clinical information potentially available compared with store-and-forward solutions. 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. image-based files. Typically a digital camera is employed to capture still digital images on a digital monitor. storage. Initial teledermatology projects typically relied on such synchronous systems. literature reports that providing dermatological services via real-time videoconferencing is a feasible solution in regard to quality of care and acceptance. 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. Computers used to transmit these images need to have the capability to deal with large. Yet another advantage relates to new educational opportunities that arise. However. A specialist is able to provide spontaneous and interactive education and training to a generalist while a consult is happening. when there is a technical problem. As with real-time videoconferencing. In summary. Because many images Teledermatology Delivery Modalities 27 . patients and a provider to present the patient at the remote end. expensive medical time is wasted. Simply put. and many continue to employ this solution. It is to a discussion of these store-and-forward solutions that we now turn. PACS facilitate the capture. And. The main parameter impacting the quality of display on a digital monitor is the number of pixels and the number of bytes per pixel. store-and-forward solutions must also take into account transmission speeds for images. 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. retrieval and display of digital pictures. Among its strengths is the fact that it is an inexpensive and effective means of providing diagnosis and management plans. Store-and-forward dermatology projects have popped up in a number of unique contexts. It may also prove to be faster than a traditional referral. It is commonly accepted that the future of teledermatology will focus primarily on store-and-forward techniques [11]. the flexibility inherent in this asynchronous solution often allows for slower transmission speeds to meet providers’ needs.280 1. store-and-forward solutions also possess both advantages and disadvantages [11]. 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.are quite large. Most studies published to date for this technique have employed lower resolution. Accuracy has been demonstrated to be reliable in a number of studies. However. Other studies suggest that a range of digital store-and-forward systems are feasible [28–31] and can provide cost-effective teledermatological services to rural residents [28. Some dermatologists report that the time needed to complete the evaluation is often less than that of the live interactive teledermatology consultation. a web-based. Several hundred consults have been performed for outlying military primary care clinics. In another project. High et al. Another study conducted in the UK [24] concluded that use of a video camera to store digital images allowed for a reasonably accurate diagnosis. 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]. since the social formalities between the doctor and patients are absent [32]. never having to make a trip to see their dermatologist in person [27]. Whitten 28 . lower cost solutions. store-and-forward teledermatology system has been in place at Walter Reed Army Medical Center since 1998. Though considered the delivery alternative with the most potential by many. The authors of this study determined that digital image consultations and clinic-based examinations were of comparable diagnostic reliability. [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. a large amount of bandwidth is required if the image must be received in a short amount of time. More than 50% of the patients had their condition treated at the primary care facility. [25] employed a digital camera capable of taking images of resolution 1. Whited et al. However. 31]. A great number of images can be reviewed in a single sitting which may convenient for dermatologists.000 pixels to study 168 skin images from 129 patients. 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. Finally. there are also generic disadvantages that must be addressed for both delivery modes. However. it appears that management plans are just as effective as those in traditional consultations. even when the primary care provider possesses low confidence in the correct diagnosis and treatment plan for a condition. Some patients will always require an in-person visit for a wide range and often unpredictable reasons. time off work) are decreased for patients [11]. whether real-time or store-and-forward technologies are employed.The reported disadvantages of store-and-forward dermatology often revolve around communication shortcomings.g. there are a number of generic advantages.. Providers are often resistant to change. equipment costs are falling while image quality is simultaneously improving. that primary care providers in general are reluctant to refer patients with skin conditions. many dermatologists report that this is a repetitive and boring way to practice their craft [11]. For example. teledermatology could facilitate shorter waiting lists for specialty care. [33] report. 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. Teledermatology levels the playing field by facilitating equitable services between urban and remote areas. Despite the shortcomings of store-and-forward as well as real-time teledermatology. the researchers found that the installation of a teledermatology system dramatically increased the number of patients referred for a specialist evaluation. A number of studies indicate that patient costs (e. security and privacy concerns must be addressed on an ongoing basis to prevent liability issues from looming too large. In addition. Finally. The asynchronous nature of store and forward also limits educational opportunities with primary care providers which is an option in real-time teledermatology. In general. both modalities exhibit a promising future. First. Teledermatology Delivery Modalities 29 . however. Ultimately. Perednia et al. In their Oregon-based study. They concluded that teledermatology may improve the practice of referring appropriate cases for specialty review. travel time. the specialist is unable to communicate directly with the patient or referring physician to gather information. Some dermatologists report a loss of patient rapport. 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. Corbett R. 1974. Poropatich RK: Tricare region 3 teledermatology: Clinical consequence. Athanassiu A. Allen MH. Woo J. feasibility and satisfaction with both solutions. the future looks bright for both real-time and store-and-forward technologies.105:833–835. Beaty NB. Telemed J 2000. Astwood DR. Corbett R. Macdonald A. Jeedy DJ. Bloomer SE. et al: Effect of camera performance on diagnostic accuracy: Preliminary results from the Northern Ireland arms of the UK Multicare Teledermatology Trial. Pujals JS.2:7–9. Murphy RLH Jr. Hjelm M: Teledermatology in Hong Kong: A cost-effective method to provide service to the elderly patients living in institutions. et al: Reliability of telemedicine in evaluating skin tumors. Hayes HA. Dec 1976.139:81–87. Johnson MLT: A model for televised remote dermatological consultation. J Telemed Telecare 1998. Arch Dermatol 1997.110:51–53. Dingbaum AM. Initial evidence points to acceptable levels of accuracy. Homan L: Teledermatology in the nursing home. vol 1: Executive Summary. Keough GC. Loane MA. Bloomer SE. Corbett R. Mathews C. Vidmar DA. Loane MA. Telemed J 1998. Wooton R: Teledermatology: A review.4:95–100.144:696–707. D’Alton ME: Effect of ISDN bandwidth on image quality for telemedicine transmission of obstetric ultrasonography.38:27–31.133: 171–174. Results from the Northern Ireland arms of the UK Multicentre teledermatology Trial.39:774–778.Overall. Chrichton C. Telemed J 1998. Campbell SM. Gilmour E. Loane MA: Multicentre randomized control trial comparing real-time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis.134:471–476. Sanders J: Final report: An evaluation of the impact of communications technology and improved medical protocol on health care delivery in penal institutions.4:36–40. Telemed J 1999. J Am Acad Dermatol 1998. Mease AD. Corbett R. J Telemed Telecare 1998. Kessler II. Fitzpatrick RB. Davis LS. BMJ 2000. Chan WM. Loane MA. Loane M. Br J Dermatol 1998. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Whitten 30 . Wootton R. Gore HE. Nore J.2:83–88. Snow J: Teledermatology in correctional healthcare. Loane MA. Unpubl report. Jones DH. Eedy DJ. Bloomer SE.6:122. Journal of Telemedicine and Telecare 1998:4(suppl 1):3–5. et al: Accuracy of dermatologic diagnosis by television. Gore HE. Malone FD. Hicks N. J Telemed Telecare 1997. Oakley AMM. Br J Dermatol 2001. Hsieh P. Int J Dermatol 2000. Phillips C. Steele K. Whitlock WL.8:188. et al: Patient satisfaction with real-time teledermatology in Northern Ireland. Kauffman CL. Hooper FJ. Gourdin FW. Selickson BD. Arch Dermatol 1972.4:5–9. Bloomer SE. NSF grant GI39471. References 1 Sassmore L. Eedy DJ: Preliminary results from the Northern Ireland arms of the UL Multicenter Teledermatology trial: Is clinical management by realtime teledermatology possible. J Telemed Telecare 1996. Loane MA. Siegel E. Lesher JL. Burnett JW: Teledermatology and in-person examinations: A comparison of patient and physican perceptions and diagnostic agreement. Archives of Dermatology 1998. Lotery HE. Lowitt MH.5:375–383. et al: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. et al: Diagnostic accuracy and clinical management by realtime teledermatology. Cruess D. et al: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. et al: Comparison of teleconsultations and face-to-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Telemed J 2000.320:1252–1256. et al: The effect of decreasing digital image resolution on teledermatology diagnosis.4:161–165. NZ Med J 1997. et al: Teledermatology in the Highlands of Scotland. Chan HHL. Burke WA. Corbett R. Burdick AE. Marchionda L. Campbell E.22 23 24 25 26 27 28 29 30 31 32 33 Norton SA. Welch M. Phillips CM. Shannon GW (eds): Telemedicine: Theory and Practice. Springfield. Stud Health Technol Inform 1999.3:227–233. Tait CP.5:41. Telemed J 1997. Harris D. Houston MS. Hall RP. Watson HW. Calobrisi SD. Arch Dermatol 1997.133:197–200. Western Australia.64:179–184. J Am Acad Dermatol 2000. PhD. pp 290–293. Poropatich R: Web-based teledermatology consult system: Preliminary results from the first 100 cases. Bartlett M. Department of Telecommunication.133:171–174. et al: Telemedicine for dermatology care in rural patients. Taylor P.144:328–333. 409. Whited JD. Drage LA. J Telemed Telecare 2000. Zelickson BD. Whitten. Julius CE. Burgiss SG. Hon SP.42:776–783. Medinfo ‘98: Proceedings of the Ninth World Congress on Medical Informatics. Telemed J 1999. Thomas 1997. E-Mail pwhitten@msu. Perednia DA. East Lansing. MI 48824–1212 (USA) Tel. Gibson A.41:693–702. Homan L: Teledermatology in the nursing home. Wallace J. Br J Dermatol 2001. in Bashshur RL. 1998. Burdick AE. Bergmo TS: A cost minimization analysis of a real-time teledermatology service in Northern Norway. Sander JH. Michigan State University. Pak HS. Fax 1 517 355 1292. pp 225–247. McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. High WA. Poropatich RK: The impact of the web-based store-and-forward teledermatology consult system in the national capital area. J Am Acad Dermatol 1999. Barkley A: Evaluating a telemedicine system to assist in the management of dermatology referrals. Arch Dermatol 1997. Pamela S. Welch ML.40:190–193.6:273–277. Australas J Dermatol 1999. Simel DL. Murray K. et al: Reliability and accuracy of dermatologists’ clinic-based and digital image consultations. Berman B: Teledermatology. Berman B: Teledermatology and underserved populations. Morrisey M: The effect of a teledermatology program on rural referral patterns to dermatologists and the management of skin disease. 1 517 432 1332. Clay CD: Pilot study of store-and-forward teledermatology services in Perth. Goldsmith P.edu Teledermatology Delivery Modalities 31 . 2 Teleteaching . 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.1 Teleteaching Tools in Dermatology on the Web Roger Kropf. Loss of coordination and the apparent lack of interactive teaching programs are further facts to contribute to the problems of many universities.Burg G (ed): Telemedicine and Teledermatology. however certainly appropriate at the time of planning and construction. the option of teleteaching medical information to students. now tend to become increasingly crowded and sometimes truly overfilled. Karger. Additionally. there are also more and more sub-disciplines to emerge especially from the fields of natural sciences. 2003. vol 32. pp 33–38 2. Universitätsspital Zürich. Switzerland At the beginning of the era of the so-called information society. 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. The number of front lectures professors are required to give is also rising as science advances. 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. Curr Probl Dermatol. As a result of scientific achievements. a whole new way of making relevant medical information available to persons in need of it is introduced. Basel. graduates and postgraduates becomes more and more an important issue. often once designed for quite a limited number of students. Just imagine the current situation which many universities around the world are confronted with. There is no longer the need to attend lectures . Claudio Cipolat. Günter Burg Dermatologische Klinik. Campuses and auditoriums. g.and courses by being physically present at the place and time they are held. the advantages of multimedial learning are improved visualization of otherwise hard to show or explainable processes. • resource lists. animation sequences. 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. • electronic textbooks. interaction. sounds. The use of computer technology in teleteaching opens completely new ways of learning and will alter the overall appearance of education. graphs. The freeing of personal resources. simulation. and • interactive training programs. • online databases with various elements of multimedia (e. the student will learn independently for himself.). These forms mainly consist of texts. Most of the information delivered this way is constituted of various forms of multimedia. films. Instead the learner can access the information he is in need of directly from home or computer rooms at the campus. because the number of illnesses and dermatological conditions to be presented to students is Kropf/Cipolat/Burg 34 . as well as the independence of a firmly structured time schedule as is the case with most curricula. speeches. video media. and function as message transmitters between author and user. campus space and in the long run reduction of educational costs. postgraduates and practicing doctors profit from the availability of up-to-date information through the internet. etc. which are often criticized. three-dimensional representations. slide collections. In general. The advantages are quite obvious. • case presentations. Instead of the many front lectures. 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. etc. images. and/or in small groups. • link collections pointing to further resources. easy and fast investigation and of course the possibility to learn over distance. Also. audio media. Teleteaching in Dermatology In dermatology there is a special need for teleteaching tools. Lectures over the Internet Lectures in dermatology over the Internet are a useful way of teleteaching important aspects of dermatology like skin efflorescences. Virtual Hospital. systematic dermatology as well as frequent and rare dermatological diseases and pharmacotherapy. are crucial points of the overall quality of the online lecture. it can be also a valuable source of information for clinicians and practicing doctors. the construction of large databases.html username and password required Introduction to Basic Dermatology. 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.limited by the number of patients visiting the hospital and the diseases they suffer from. is also an import way of teleteaching.ch/vorlesung/index. After having established a diagnosis. 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. then is presented randomly selected images with the diagnosis masked by asterisks. Most of the image or slide databases display thumbnail images with an additional zoom function which is an extremely important feature in regard to Teleteaching Tools in Dermatology on the Web 35 . presenting primarily dermatological images and to some extent other types of multimedia like video sequences and speeches commenting medical procedures or diagnoses. Naturally the use of multimedia. the correctness of one’s assumption can be checked. med. but when rather rare and complex dermatological cases are presented. rare dermatological diseases. The primary focus is on students. as well as intelligent and well-planned navigation interfaces to quickly retrieve the required information. while others do this to a lesser degree or even lack these important features. Dr. Prof. like xeroderma pigmentosum. University of Iowa. G. Some have also a kind of quiz mode where one can first choose the region of the body.html Online Databases Especially in dermatology. Some feature wellplanned navigation and information retrieval interfaces. University Hospital Zürich. 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. Switzerland http://www-usz.vh. are hard if not impossible to show to students and other clinicians as real cases. especially the use of high-quality dermatological images. On the other hand.unizh. USA http://www. which a doctor sees only a few times if at all in all his years of clinical practice. Frequently occurring dermatological diseases can easily be presented. In the following section.org/Providers/Lectures/PietteDermatology/BasicDermatology. Burg. 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. The learning potential can be very high according to the form in which the cases are presented. USA http://www.emedicine. University of New York. Nevertheless.com Electronic Textbooks Electronic textbooks about dermatology are an additional way of teleteaching dermatological knowledge. Another drawback is that most of these textbooks lack interaction with the user. to establish a diagnosis and/or differential diagnosis and finally to choose the appropriate treatment.net Dermquest – A Resource for Dermatologists and Dermatology Residents http://www. 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 Electronic Textbook of Dermatology. 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. the doctor can be required to ask questions about the case.htm Dermatology Textbook at Emedicine. electronic textbooks also represent a valuable source of dermatological information when properly done.dermis.muni. to order virtual laboratory data and other examinations.org/stamford.cz/atlases The Comprehensive Online Dermatology Information Service for Health Care Professionals http://www. Therefore.com http://www. An Comprehensive Internet Atlas of Skin Histopathology http://www. to have a look at the clinical picture. to formulate a hypothesis.com/derm/contents. Kropf/Cipolat/Burg 36 .telemedicine.download time and establishing a correct diagnosis.dermquest. For example. Since the use of textbooks or scripts represent a standard for education. 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.htm Case Presentations The online presentation of dermatological cases with varying degrees of difficulty. it lies near that these textbooks are also made available online. co.asp?FilterField Subject_Area& FilterValue Dermatology Dermatological Resources. Also for undergraduates it is helpful to know that these resource lists exist and can be accessed. University of Iowa. Interactive Dermatology Cases http://apps. but they do not present the information itself.dermatology. The main target group are postgraduates and clinicians seeking further knowledge or doing research on a certain topic.pathology. There are quite a few on the Web now. They should also be updated regularly to keep up with the latest advances in the field of dermatology.uk/calreviews/summaries. 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.edu/medyear3/derm/ Virtual Dermatology.uiowa. USA http://tray.iupui.htm Interactive Training Programs From a didactical point of view. College of Medicine.nz/~jfung/dermatology/links. interactive programs constitute certainly the most promising and important teleteaching tools in dermatology.edu/cases/dermcases/dermcases. Cambridge Clinical Reviews – Dermatology http://axis.edu/#Dermatology Link Collections Link collections are a quite a traditional way of presenting information. If hyperlinks to further medical resources are provided. Teleteaching Tools in Dermatology on the Web 37 .cbcu.ucla. 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. USA http://erl. It is therefore important to look through link collections on a regular basis.cam. which means the source is no longer there or the contents have been removed or relocated from the WWW.ihug. Another problem with hyperlinks is that unfortunately all too often they are dead.medsch. but their quality of teaching needs to be assessed to insure a rewarding e-learning experience. Sicklehut Medical Links http://homepages.ac.cfm Resource Lists The display of resource lists is also a valuable way of presenting relevant dermatological information. They simply point or hyperlink to the source.Cases presented in this form contain a high level of interaction and encourage the user to act like in the real situation. the solving of such cases represents an extremely valuable form of teleteaching. University of Indiana. These interactive programs consist mainly of parts of the teleteaching items that were just presented.derma2000. basic facts about viral infections such as epidemiology. laboratory findings. etc. however the contents of these applications need further adaptation in order to provide full learning benefits and acceptance. Gloriastrasse 31.Kropf@der. Roger Kropf. 41 1 255 3340. To give an example: Dermatological cases of a certain topic (e.usz. University of Regensburg. MD. Germany http://www. 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. are introduced to the user as background information. The main problem with interactive programs is also that they must be updated regularly and extended to cover the entire field of dermatology. CH–8091 Zürich (Switzerland) Tel. clinical picture. viral infections) are presented and while trying to solve the case. Concepts and programs as they can be found on the WWW are promising. Dermatologische Klinik.de/ Conclusion Dermatology is well suited for teleteaching by using computer technology. Fax 41 1 255 4403.ch Kropf/Cipolat/Burg 38 . E-Mail Roger.g. Universitätsspital Zürich. Dermatological Practice 2000. pp 39–42 2. Gynaecology and Endocrinology) moved into the new building ‘Nordtrakt I’ of the University Hospital of Zürich. Karger.Burg G (ed): Telemedicine and Teledermatology. Universitätsspital. The question then arose as to whether a transmission into other lecture rooms would solve the space problem. our colleagues from the canton of Wallis asked for a teletransfer of these advanced training session to Brig. Zürich. In 1996. These well-organized. Switzerland Starting Position (from 1978 to 1996) Since the Department of Ob/Gyn (consisting of the clinics for Obstetrics. vol 32. to Basel and Brig. Even physicians from neighbouring cantons and from nearby countries came to Zürich. Curr Probl Dermatol. with experts and referees from Switzerland and other countries. originally organized for the gynaecologists of the local area. or if it might be better to make use of modern teleconferencing technology and transmit these advanced training seminars externally as well. Heinz Gabathuler Departement für Frauenheilkunde. Teleconferencing from 1997 to 2001 Participants that came from far away travelled up to 6 h to attend a seminar of 3 h.2 Telemedical Training at the Department of Gynaecology. 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. and in time the lecture hall seating 300 was often completely full. became well known. Our Ob/Gyn Department. Neonatology. decided therefore to transmit these seminars. advanced training sessions. . Basel. At this time came the same request from the gynaecologists in Basel. University Hospital Zürich Urs Haller. together with TV-Uni. 2003. Teleconference transmission in gynaecology and obstetrics. St. Next year.2002 Multipoint Basel St. In 1997. 1. the concept was prolonged with a new provider and Switch. Basel upgraded the system to three lines with a total of 384 kbit/s in 2000. the telemedical training was carried on in 2001 with great success (fig. the transmission was organized with an ISDN line (128 kbits/s) from Zürich to Basel. 1). While Brig kept on using one single ISDN line. and in 1998 a multipoint system to Basel and Brig was set up. projected slides and especially the display of videos. Gallen Zürich Zürich live USZ es lin N /s bit SD 3I 4k 38 Aarau Thun 38 Be lli Brig 1 IS DN line 128 kbit /s nzo na 3 4 D IS kb N it/ s es lin 200-300 Teilnehmer 8 x / Jahr Meran In-house: IP Switch Fig. Due to irregularities from the side of the provider. Perspectives for 2003 The number of groups interested in transmission of our sessions of continuing medical education continues to increase. 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. With a multipoint transmission via the canton of Ticino. The desired quality could not be generated for moving objects. transmission coverage is Haller/Gabathuler 40 . each with an ISDN line organized via a provider who was responsible for the routing. Gallen and Bellinzona installed a system with three lines. At the same time. the use of ISDN videoconferencing has the following advantages: (1) cost-efficient technology. Thun and Meran. In the meantime the technology at the University Hospital of Zürich is set up to utilize the IP technology at least in the hospital itself. 1). and (3) guaranteed bandwidth. These possibilities are now being tested and improved within the technical departments of the University Hospital and TV-Uni (fig. Advantages and Disadvantages of ISDN Videoconferencing Based on our experiences. a combined ISDN/IP technology can be offered. Telemedical Training 41 .IP-Codec 1 IP-Codec 2 Chair control terminal (Web) IP-Codec 3 IP-MCU IP-Codec n External ISDN-Codecs IP-ISDN USZ Gateway. Alternatively. if they have the adequate set-up at their disposal. 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. planned for the following new sites: Aarau. (2) internationally widespread technology. 2. 2). Combined ISDN/IP technology: USZ 2002/03 with IP-MCU and IP/ISDN Gateway. This has the advantage that external conference sites can be offered the same technology. each with three ISDN lines (384 kbits/s) (fig. Gatekeeper USZ intranet External ISDN-Codecs ISDN-WAN Fig. haller@fhk. (3) in-house routing. Urs Haller. which should be initiated by the organizer or by the external users. and (5) interactivity with use of multipoint is hardly used.The following disadvantages can be listed: (1) limited resolution. CH–8091 Zürich (Switzerland) Tel. Future Prospectives and General Problems of Videoconferencing Concerning the technology. (4) mixed use of multipoint 128/384 kbit/s is error-sensitive. 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).usz. One of the main problems is the fact that the funding of advanced training courses is not explicitly organized. MD. Fax 41 1 255 4433. the new provisions and effects of the anticorruption laws of the new medicament laws have to be taken into account. In this case.ch Haller/Gabathuler 42 . Departement für Frauenheilkunde. we expect the following developments for the IP future: (1) mixed ISDN IP technology. (2) IP technology will substitute the mixed use. 41 1 255 5200. (3) presentations sometimes have to be filmed → down-converter → VID. E-Mail urs. Universitätsspital Rämistrasse 100. or the participants themselves? Another interesting possibility might be sponsoring. and (4) videostreaming: post-production for Internet use of the advanced training. (2) adaptation of movements dependent on the amount of ISDN lines. 3 Towards a Virtual Education in Pharmaceutical Sciences An Innovative E-Learning Approach Van Van Trana. vol 32. Beat Ernst b. For the degree of a Federal-certified pharmacist.g. 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. A special emphasis is put on finding and investigating new therapeutical and diagnostical methods. bUniversity of Basel and c pnn AG. The goal is to qualify pharmacists for expanded responsibilities in healthcare services and provision of rational drug therapy. After 4 academic years. Within this framework. and from their application to the effects on the patient. Curr Probl Dermatol. e.Burg G (ed): Telemedicine and Teledermatology. Imparting basic knowledge about cognition of drugs. the Institute of Pharmaceutical Sciences at the ETH in Zürich and the Department of Pharmacy at the University of Basel established in May 2000 a Center of Pharmaceutical Sciences. from drug discovery. pp 43–51 2. Karger. Salome Lichtsteinerb. The Pharmaceutical study is dedicated in its first 2 years to natural sciences and pharmaceutical fundamentals. Thereby students learn in lecture. to their reabsorption and transport in the body. Gerd Folkers a a ETH Zürich. Basel. 2003. The aim of this ‘Pharma Center’ is to achieve a worldwide leading position in pharmaceutical education. Marc Otto c. students graduate with a diploma. the education aims for optimally safe and qualitative drug handling. The first step towards this target is implemented in Pharmaceutical . laboratory and seminar about different aspects of drugs. Switzerland The new curriculum of pharmaceutical science at the ETH Zürich and at the University of Basel is designed to educate a scientifically and technically competent pharmaceutical scientist. The following 2 years especially focus on the whole spectrum of the ‘drug’. conventional types of media such as text. This allows a real-time discussion of complex data and supports much more efficient and constructive teamwork. As a result. 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. This progress demands new teaching technology in order to properly represent the complex data. new mechanisms of drug interactions and other biomedical items are estimated to be published every year. rather than being told what it is and simply asked to remember it [1]. This is important since students understand a subject better if they construct it themselves step by step. In the last decades. as well as the mechanism of drug effect and the relationships between the chemical. 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.000 papers about new impacts in drug discovery. Computer-based media and high-tech communication roomware are tools to enable these requirements. physicochemical properties and the biological activity. the density of information for a professor to teach and a student to learn grows rapidly. 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. Obviously. sophisticated scientific technology has enabled accurate investigation of complex data at a molecular level. Analyzing the Problem – Developing a Solution For a deeper understanding of biomedical sciences. structural. both the receptor and the ligand are better represented in real-time 3D. overhead and blackboard are not sufficient anymore. Where could this be done better than in virtual space? Further. This is one reason why computer-based media are integrated into the curriculum. manipulation and simulation of a structure are actually more essential for a deeper understanding. 80.Chemistry in which scientific emphasis is put on structures and properties of organic medicinal and pharmaceutical compounds. Since the goal of every teaching institution is to provide Tran/Lichtsteiner/Ernst/Otto/Folkers 44 . Although a high qualitative three-dimensional (3D) visualization of a structure can definitely improve one’s understanding. For example. students should have the option to observe and manipulate these objects at a molecular level by themselves. 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 phenomenon is a real challenge for teaching institutions. the type of knowledge and data which are supposed to be taught has changed tremendously. In addition. new indications. Integration of these new teaching technologies into the curriculum improves education to a level which meets the demands and standards of the modern society. 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. immense expenditure is made to implement new teaching technologies for their quality assurance. The reference scenario offers a quick search for short definitions and explanations. The update scenario assumes that the user is already experienced in a certain field and that he is interested in an Towards a Virtual Education in Pharmaceutical Sciences 45 . Hence. this concept should guarantee the constant availability of the newest results of research. The study scenario allows more detailed learning. pnn is dedicated to develop online courses for the education of healthcare professionals (CME. healthcare professionals are expected to attain continuous education in order to handle the extreme increase of knowledge. update and study. named pnn. since on one hand. Nowadays. Healthcare professionals need new ways of education. it will be an important contribution to the quality assurance in healthcare education. even less time is available due to a planned shortage of lecture. To meet these requirements we have founded a spin-off company of the Swiss Federal Institute of Technology Zürich. traditional forms of professional education are very expensive and on the other hand the standards to be met are constantly rising. Web-Based Training (WBT). Learning Homepage. 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. employees in life science sectors are also targeted by computational teaching technologies. However. Secondly. And finally it should train students in self-studying as well as in collaborating within a team. New media like TELEPOLY (videoconferencing system). Online courses can offer cost-efficient education that complement traditional forms of face-to-face courses. pnn has identified three education scenarios: reference. this is only provided if its potential is exploited and intelligently applied. an enhanced teaching strategy has to be developed in order to support students to obtain the most possible of what is available. How can these problems be solved? Definitely. Aside from educational institutions. Firstly. Virtual Laboratory and high-tech Communication Roomware are major factors in achieving this purpose (see below: State of the Art).the newest results of research to the students. As it can be seen from other institutions and companies. continuous medical education). The students’ acceptance of TELEPOLY was strongly influenced by the quality of the course. their motivation and two variables of interaction. In the update scenario the time spent with a course is very short. It has therefore developed different frameworks of courses to offer pedagogically standardized frameworks for the update scenario. Averaged over the whole sample. robust and simple to avoid any distractions from the material to be learned. The simultaneous transmission of several channels of high-quality video and sound enables a synchronous and interactive teleteaching in pharmaceutical chemistry between the ETH Zürich and the University of Basel. To acquire that update the user would probably invest about 10–20 min to study a focused course or information. 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. It contains Tran/Lichtsteiner/Ernst/Otto/Folkers 46 . Top Class: A Learning Homepage Simultaneously. the participants demonstrated an almost neutral position towards TELEPOLY compared to the traditional lecture mode [2]. Top Class – a learning homepage – was initiated to provide students a support of the lecture of pharmaceutical chemistry. 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.update of the latest developments. extensive visualization and mechanisms to individualize the learning experience. able to guarantee stable and undisturbed transmission. the applied technologies ensure that all course material is suited for the small band internet. The results of this evaluation showed that TELEPOLY proved to be a very reliable technology. State of the Art TELEPOLY TELEPOLY is a videoconferencing system jointly developed by the two Swiss Federal institutes of Technology in Zürich and Lausanne in 1995/96. pnn courses use interactive elements. Initiating TELEPOLY was the first step in integrating new media into the pharmaceutical education. Hence it is essential that the user interface is self-explanatory. 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. In order to make up for the disadvantages of learning from an anonymous computer. pnn believes that this update scenario covers a big part of the professional training. To lower entry barriers. TELEPOLY combined with WBT allows the professor to hold lectures for both classes at the same time and to teach fundamentals. Compelled to this situation. the TELEPOLY as well as Top Class. Experience shows that this goal is difficult to reach with conventional teaching techniques. biological properties. a Virtual Laboratory is being set up. the development of a new learning environment is necessary to support student’s self-studying. In addition to this freedom. receptor interactions and drug development for clinical trials will help students to understand the complex interdisciplinary process of drug research. By using WBT and the learning homepage. The aim of this learning homepage is to support the active and self-managed learning of the students. In the Virtual Laboratory. molecular models will bear their calculated or experimental properties mapped on their surfaces and will change those properties during manipulation. students can use virtual molecules to experiment the chemical structure of a drug. 3D visualization of complex data may certainly provide better understanding compared to 2D visualization or verbal explanation. are not able to present contents of a lecture in a pedagogically high level for self-studying. it allows interactivity with the data and third. These three advantages point out WBT as a very valuable pedagogical medium. their pharmacokinetic and pharmacodynamic properties. it enables 3D visualization of complex biochemical data that is otherwise difficult to explain in words. Self-studying will become more and more crucial yet.handouts with learning objectives of all topics taught in the lectures and overheads which can be printed out. pictures. Hence. For example. it gives the students the opportunity to study at their own pace. Test questions to control one’s standard of knowledge and an e-mail system to contact the professor or other students are further services. space filling and configuration analysis. It allows the representation of contents using text. WBT offers three more advantages: first. students can learn the details by themselves and study wherever and whenever they like. animations and sounds to support a better understanding of complex data. But the ability to integrate and apply the knowledge in different practical situations can only be acquired through simulation exercises. second. 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. Towards a Virtual Education in Pharmaceutical Sciences 47 . Exercises including synthesis suggestion. As mentioned above. The Necessity of New Teaching Media In both approaches. Web-Based Training is an appropriate medium. partly due to the shortage of face-to-face lecture hours but also to the necessity of lifelong learning. More seminars or meetings can be organized. Therefore. Interactive tables and white boards with built-in electronic devices provide easy access to the Internet. To prepare students for this working situation. proper high-tech communication tools are crucial for high-level teaching and research. the concept of combining all advantages of each medium creates an ideal curriculum for the students. By shifting lecture contents to the Web. teamwork is and will remain very important – all modern research in life sciences has switched to teamwork. This approach creates a completely new type of synchronous and asynchronous interactive collaboration in practical work. Aside from self-studying. However. linked together worldwide. This kind of direct interaction is not substitutable by any media since the interpersonal emotion. seminar teaching and research meetings. the contact and interaction between students and professors can actually be improved. Therefore. Due to these reasons. databases and local computer network. such as a professor’s 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. professors will get more time for direct interaction and contact with their students. This so-called Vireal Lab (virtual-real-Lab) will be located in the library of the Institute of Pharmaceutical Sciences at the ETH in Zürich [3]. where students and professors discuss interactively about several issues or questions. traditional teaching cannot absolutely be substituted by online learning.Most people consider a general flaw of WBT or e-learning to be the lack of social contact between the students and professor. Our Aim – Optimal Integration of New Learning Media One of the most important roles of an academic education is to prepare each student for ‘tomorrow’s challenge’. The book ‘The Digital University’ [4] supports this view of the significant role for asynchronous collaboration within higher education. it is important to stimulate one’s interest and motivation. Nowadays the abundance of knowledge Tran/Lichtsteiner/Ernst/Otto/Folkers 48 . there is a plan to establish a completely new scientific environment which combines virtual worlds with the real world of a library. are able to create real breakthroughs in basic and medicinal sciences. However. Using high-tech communication roomware. this lab will stimulate interactive teamwork. Only big teams. 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. Laboratory experiments and skills are further examples that cannot be practiced and learned on the computer. aiming to enhance and guarantee the quality of the education. glossary. will combine to create a more appropriate curriculum. technical and socially competent students. laboratory experiments and seminars are combined in order to build a ‘newly considered’ curriculum. glossary and many other services. A new concept: An approach to combine traditional education with new educational technology. Obviously. learning objectives.Table 1. As such. being complementary. For each learning objectives the best appropriate learning mode is specified. Towards a Virtual Education in Pharmaceutical Sciences 49 . As a starting point. but more importantly the way we teach. At the Institute of Pharmaceutical Sciences at the ETH Zürich and the Department of Pharmacy at the University of Basel. Subsequently. 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. WBT. etc. These abilities allow students to be up to date and in line with today’s information-science society. forum and chat. searchengine. 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. a pedagogical analysis has been made to determine learning objectives for each topic of the curriculum. a project is running to create such a new concept of education. Appropriate learning modes including lectures. lecture documents. A consistent virtual attendance and a learning homepage will support students with help. it can provide more independent. a new educational strategy has to be implemented to raise the standard of education to a more flexible and up-todate level. an approach is presented in table 1 in which new teaching technology with its enormous interactive potential and traditional education. new teaching technologies will be accordingly adjusted to the curriculum. this approach is very unique. By using new educational technology the primary intention is to improve education and not just to be ‘à la mode’. Although the technology of e-learning is in the limelight. The whole curriculum will be pedagogically reanalyzed in order to find a more appropriate teaching strategy. (3) classification of each scientific learning objective according to the six grades of Bloom [5] which includes knowledge. Unfortunately. and post-doctors as peer reviewers. Its success is not likely to be obvious until its implementations occur and considered evaluations are accomplished. The pedagogical analysis will involve: (1) reconsideration of the importance and up-to-dateness of all topics. Pavel Pospisil and Juliana Chen for their valuable comments and advice. presentation techniques and time management. Consequently.g. synthesis and evaluation. comprehension. Acknowledgements Especially. e. Clearly. assistants. previous lecture outlines and notes are not just transposed to the Web to be ‘online’.This concept will be implemented in collaboration with pedagogy experts and under contribution of a group of students. (4) determination of basic knowledge needed to achieve each learning objective. the converse process where the curriculum is tried to be adjusted to new teaching technologies has been observed very often. (2) determination of scientific and nonscientific learning objectives. we would like to thank Leonardo Scapozza. communication and interpersonal skills. pedagogical concepts have the most impact on the quality of teaching and learning. and accordingly (5) choosing of appropriate teaching method. Based on this pedagogical analysis. 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. Tran/Lichtsteiner/Ernst/Otto/Folkers 50 . analysis. Work is now in process for developing successful application and integration of this concept into higher education. application. medium and examination mode. Springer.ch Towards a Virtual Education in Pharmaceutical Sciences 51 .pharma.tran@pharma. 1976. No 40217.vireal. Hailes S. Wilbur S (eds): The Digital University.pharmacenter. 1999. www.ch URL: www.ethz.ch URL: www. New York. ETH Zürich 2001.References 1 2 3 4 5 Stokstad E: Reintroducing the intro course. Winterthurerstrasse 190. Bloom BS: Human Characteristics and School Learning.ch URL: www.93:1608–1610. CH–8057 Zürich (Switzerland) E-Mail vanvan. Diss.pharma. URL: www.unibas.anbi.ch Van Van Tran. Kunz P: New information and communication technologies in education: Evaluation of the videoconferencing system TELEPOLY. ETH Zürich.ethz.ch Hazemi R.ethz. McGraw-Hill.ethz. Science 2001. Berlin.pnn. 3 Teleconsulting: Legal. Ethical and Consumer Aspects . Basel. pp 53–57 3. 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. Central Middlesex Hospital.Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. If there were any uncertainties. Karger. The facilitator stressed the need to consider the changes that would occur.1 Changes Patients Expect to Result from Telemedicine Sapal Tachakra Accident and Emergency Unit. what patients will expect of telemedicine in the future. More primary care would be required to deal with the bulk of the consultations for which patients are referred to specialists. but bureaucrats are a little more cautious. London. vol 32. telemedicine would be available for advice. Patients and planners need to know what is likely to be possible and more importantly. UK Telemedicine is an exciting new technology that is highly thought of by some governments. 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 greater use of nurse practitioners would mean that general practitioners would have the opportunity . Its Views The group felt that the following changes would occur. 2003. The size of the district general hospital (DGH) would shrink and the role of the specialist would also change. Fewer tertiary care centres were envisaged because it was felt that patients would be prepared to travel considerable distances if it were absolutely essential.to specialize in one field and call themselves specialoids. This would mean fewer more centralized tertiary centres. would have all the cases related to his/her speciality referred to him/her. More home care will be required by an ageing population. they will go along with it when it becomes inevitable. basic codec and connected through a plain old telephone line. The great advantage of telemedicine is its great educational potential. 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. Patients will be able to demand telemedical consultations and the dismissive attitude of doctors and nurses will have to change. if the person had a TV set-top camera. 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. Newer and different healthcare facilities which are custom-built for the changing environment of provision of healthcare. This would remove the cost of time and transport of community nurses. and if practising in a group. Although some specialists will be uncomfortable with such change. More accountable doctors and nurses as patient power increases due to the use of telemedicine. 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. Control of Costs Change of DGH use would occur because of the large amount of work performed by general practitioners and specialoids. DGHs will be destabilized by groups of general practitioners who will dictate the configuration of services. 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. 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. Tachakra 54 . 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. Less shroud waving is inevitable as patient groups refuse to accept the standards set by professional organizations. The use of the Internet is already having a profound impact in some areas. All patients will expect a certain standard of treatment and this can only be possible with protocols. Knowledge which was a premium commodity will be so easily accessible that the professional role will change. Discussion The Business Week issue of October 17. With the disadvantage of distance. Some entrenched attitudes are being broken down. Attitude to Change More open doctors will be the result of lessening of the awe in which doctors are held. Such groups already understand that they are not well represented by the professional organizations of doctors and nurses. the changes will be permanent. in the long run. 1994. there are enough groups finding out that patients are asking more questions when telemedicine is used. Less bluff and bluster are likely to be the result of doctors and nurses seeing themselves on a screen. There will be squeals about individual clinical freedom but they will not work with a wellinformed patient population. make it easier for official bodies to gauge the performance of a doctor or a service by the better information-gathering that will ensue.Multiskilled personnel will ensue as telemedicine will allow many professionals to undertake a greater variety of work than before. many others will follow. Permanence of the change process is certain because the information revolution has only just begun. Checks and balances: The use of telemedicine will. they will enter into a dialogue about the risk-benefit analysis of certain restrictive practices. arrogant doctors will be drummed out of the system as patients start seeing healthcare as just another service. Condescending. had a feature entitled ‘Rethinking Work: Is America Ready?’ The theme centred on the problems of Changes Patients Expect to Result from Telemedicine 55 . 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. Less hierarchical organizations are highly likely because of the need of multiskilling and efficiency. but like in previous social and industrial revolutions. The economic trends of a decline in wages. In healthcare. Jeff Goldsmith [2]. All these factors are likely to be even more relevant with video-conferencing in healthcare. a decline in unionization rates and poorly implemented technological changes will create jobs with such hazards. having been employed by the organization for several years [10]. This change has already started in Europe. Many factors are likely to increase the growth of telecommuting. Much of the focus on changing the work environment has been on virtual companies. More than a decade ago. the explosion in telecommunications and computer technology in recent years [7. Major corporations have tried the virtual corporation philosophy and are only slowly solving some of the problems. mobile phones and video-conferencing in common areas. and the social change that demands a balance between work and family life [9]. a move away from manufacturing base.a changing work dynamic and its effects on social and political networks. 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]. are the federally mandated programs designed to decrease air pollution by reducing commuting [4–6]. They replaced offices and desks with computers. in the USA. 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]. 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. Attention to psychosocial hazards in the work environment should become an increasingly important component of occupational safety and health interventions. other studies indicate that although the levels of comfort in the use of technical equipment were reported to be only moderate Tachakra 56 . However. Research findings have linked a number of measurable psychosocial characteristics with negative psychological. Among them. a rather traditional industry. a noted futurist. increased hours of work. Such changes may also have a bearing on medicine. Some companies reject the use of such agreements because they would violate the basic climate of trust that they have for their employees [11]. all is not as rosy as it seems [12]. 8]. such changes have not occurred because of the forces of conservatism. However. physical and physiological consequences. 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. on entry to the nursing workplace.9:9. Goodrich JN: Telecommuting in America. Radiol Technol 1998. today.10:50–56. etc. Consultant and Clinical Director. Dagen CD: Telecommuting policies that work.10:6. Grey B: Telecommuting: The time is now. Nurses. Cauldron S: Working at home pays off.Tachakra@tinyworld. Cahill J: Psychosocial aspects of interventions in occupational safety and health.35:50–52.11:52–55.11:45–50. There should be a similar experience among doctors. Ross R: The telecommuting imperative. Acton Lane. London NW10 7NS (UK) Tel.21:6–14.71:40–49. Hum Resources Mag 1990.29:308–313. Conclusion There are unique opportunities that will be available with telemedicine. PC World 1993. Mich Nurse 1995. 44 20 8453 2250. pharmacists. Henricks M: The virtual entrepreneur. Foley J: Pacific Bell works long distance. Fax 44 20 8453 2507. Park Royal. Sullivan N: Yesterday. Harv Bus Rev 1989. Bellinger A. radiographers. Central Middlesex Hospital. are liable to be the big winners if they are open to change. References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Gibbs M: Workplace changes affect nurses. La Van H: Telecommuting: Has its time come? Home Office Comput 1992. Bus Horiz 1990. tomorrow: The evolution of the home office.33:31–37.. Success 1993. Goldsmith J: A radical prescription for hospitals.40:41–44.35:50–52. Pelletier D: Diploma-prepared nurses’ use of technological equipment in clinical practice. Home Office Comput 1992. Am J Ind Med 1996. Farrah BJ. Bailey DS.uk Changes Patients Expect to Result from Telemedicine 57 .co.67:367–368. Home Office Comput 1993. E-Mail Sapal. The most heartening perspective is of Nancy Fagan [14] who advises ‘Make workplace changes work for you’. subjects rapidly acquired high levels of comfort in relation to equipment handling [13]. Hum Resources Mag 1993. Sapal Tachakra. Fagan NQ: Make workplace changes work for you. MD. Pers J 1992. J Adv Nurs 1995.89:107. USA Satisfaction of Paramedical Personnel The structure. Karger. job satisfaction often decreases. These changes result in increased accountability. Mo. since it is impossible for individuals to anticipate and predict all consequences associated with the changes. Telemedicine is another change agent that can have conflicting impacts on the workers in the healthcare industry. and inadequate numbers [2. technology and knowledge of the healthcare industry is currently experiencing substantial changes. in turn. It is the uncertainty associated with the risk that creates much of the stress among employees in the healthcare sector. many rural systems lack resources to be able to cushion the consequences of the changes that occur.. Curr Probl Dermatol. The rapidity and magnitude of these changes are creating increased stress for individuals working in the healthcare industry. Individuals working in rural areas also often experience increased stress because of the inherent characteristics of the rural practice environment. lack of flexibility in staffing patterns. University of Missouri. This stress results because these changes create risk and uncertainty. limited access to technologies. 2003. 3]. lower and compressed salary scales. In addition. financing. The stress-inducing characteristics exacerbated in rural practice include: isolation.Burg G (ed): Telemedicine and Teledermatology. heavy workloads. Columbia. vol 32. Hicks Department of Health Management and Informatics. and the stress often reduces job satisfaction. As stress increases. pp 58–61 3. lack of continuing education and career opportunities. leading to increased staff turnover and poorer performance. loss of autonomy. the diversity of skills needed. Telemedicine has the potential to decrease stress associated with many of the characteristics of rural practice: reduce feelings of isolation. increase diversity . Basel.2 Satisfaction of Paramedical Personnel Lanis L. improve continuing education opportunities. an emphasis on outcomes and constraints on resources [1]. which. increases training costs and disrupts the continuity of care received by patients [4]. speech). dental) and allied professionals (paramedics. telemedicine can also increase the complexity of delivering care in rural communities. and 91 by workers in the other sites (a 56. pharmacy.5% response rate). Method The paraprofessionals included in the study were nurses (registered nurses. The organizations included were hospitals. This chapter examines levels of satisfaction and perceptions of impacts that changes in the healthcare industry are having on rural health paraprofessionals. The 30 Likert-scale questions were adopted from a previously validated instrument. changes and communications. and technicians (laboratory. therapists (physical. 209 by workers in nursing homes (a 45. radiology. county health departments. the career satisfaction questions focused on the general satisfaction with the career the individual had selected. and 104 by other paraprofessionals. The study was conducted among direct patient care paraprofessionals (non-physicians) in six rural counties in Missouri. clinical social workers. and 26 other sites. 9 background questions.1% response rate). The questions on the survey were clustered into satisfaction with job and career. nursing homes. only 2 nursing homes declined to participate in the study. There were 256 surveys returned by workers in hospitals (a 53. impacts of changes in health industry on work. On the survey. There were 359 responses returned by nurses.108 surveys were distributed to workers in the 44 organizations participating in the study.in skills available and increase access to sophisticated technology. of these. respiratory. medical. nutritionists). nursing home and other ambulatory care sites). home health agencies. The survey included 30 Likert-scale questions involving satisfaction.2%). therapists. clinics and provider offices in the counties. and 556 completed surveys were collected (a response rate of 50. In the sample. certified nursing aids). Response rates for paraprofessionals cannot be calculated because the profession of the non-respondents is not known. there were 6 hospitals. Satisfaction of Paramedical Personnel 59 . 14 nursing homes. and an open-ended question on the effects of technology on the respondent’s job. Alternatively. 1. Results During August 1998. 93 by therapists.1% response rate). the job satisfaction questions focused on the current work situation of the respondent. rehabilitation. global issues impacting work and communications among providers. licensed practical and vocational nurses. the Work Life Survey [6]. These levels and perceptions are examined by type of paraprofessional (nurses. other direct patient care allied health professionals) and by work site of respondents (hospital. occupational. In this survey. thereby creating pressures and stress for workers in healthcare [5]. if given the opportunity to select again. communication among staff appears to be better. only 67. Managed care was viewed as having a large impact by 38. therapists and other paraprofessionals regarding their level of satisfaction with jobs and careers. Telemedicine was not viewed as having a large impact (only 19.5% indicated they would recommend their career to others. to 40.4% indicated that communication between staff and administration was very adequate. Communication between staff and administration appears to be an issue. although their levels of satisfaction were still relatively high.0% of other paraprofessionals.2% indicated it as having a large impact). and another 28. The range among type of professional was from 50. it is obviously impacting the perceptions and stress levels of the rural health services labor force. while those employed in hospitals had the lowest levels of satisfaction.0004.3% of respondents. However. as reflected by only 8. Poor communication between administration and staff increases uncertainty about what is occurring. 12. There were significant differences by type of organization on career satisfaction and administrative communications (p 0. since telemedicine was not widely available in rural Missouri at the time of the survey. Only 20. 46. In the series of questions regarding factors impacting the healthcare industry.1% indicating it was inadequate and 27.5% of respondents indicated that technology in healthcare was having a large impact on their work.0% of other paraprofessionals. 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. While these numbers are not large. and 28.0% indicating it was only somewhat adequate. There was not a significance difference among nurses. In addition.2% indicated that the government was having a substantial impact on their work. to 46. 35. These findings were consistent with the results from Hicks 60 . Telemedicine offers an opportunity to improve communications.9% of therapists.6% of therapists. which can improve job satisfaction among workers.2% indicating it was moderately adequate. paraprofessionals employed in other settings had the highest levels of satisfaction with job and career. In addition. Computers and other information technology were also viewed as having a large impact on their work by 32. with 33. with 18.1% indicating that it was somewhat adequate.6% indicated they would not choose their current career. Alternatively. Kruskal-Wallis test for both).1% of nurses. and increases stress among workers.3% indicating that communication was inadequate. this result is expected. while managed care has not made noticeable inroads into rural areas of Missouri. but only 22.6% of nurses.the paraprofessional respondents were generally satisfied with their job and with the careers they had selected. In addition. In general.9% indicated that their current work situation was a source of major frustration. 31. Blegen MA: Nurses’ job satisfaction: A meta-analysis of related variables. additional studies evaluating its impact on levels of satisfaction among paraprofessionals is needed. Bruce TA: Professional preparation for rural medicine. J Rural Health 1990. As telemedicine is implemented. J Rural Health 1990. Cecil G.6:527–533. while not a solution for all contributors to stress and dissatisfaction. University of Missouri.6:523–526. Nurs Res 1993. Physician Work Life Survey.edu Satisfaction of Paramedical Personnel 61 . Mitchell J. J Telemed Telecare 2000.missouri. may alleviate some of the factors directly by reducing isolation and improving continuing education opportunities. Hudson ST. the lower job satisfaction is. Geligns AC: Improving health: The reason performance measurement matters. In general. Webb W: An evaluation of satisfaction with telemedicine among health care professionals. 6 Lanis L. Sheps Center for Health Services Research.42: 36–41. Hicks LL. Discussion The findings in this survey are similar to earlier studies of health professionals: while their work is personally rewarding. 324 Clark. Madsen R. Koenig S. the larger the change occurring. leading to substantial amounts of dissatisfaction with current jobs and careers. Boles KE. This occurs because of uncertainty and the stress associated with that uncertainty. SGIM Career Satisfaction Study Group. Tracy J. E-Mail HicksL@health. The introduction of telemedicine. Pickard MR: Education of nurses for rural practice. MD Department of Health Management and Informatics.17:26–29. Columbia. 1997. Kling B. Fax 1 573 8826158. 1 573 8828418. References 1 2 3 4 5 Their SO. and indirectly by improving communications within and among organizations and professionals. the amount of stress is high. MO 65211 (USA) Tel. Hicks.6:209–215.hospital-based paraprofessionals indicating larger impacts by many factors in the healthcare sector. Health Aff 1998. and the conclusion is opposite. University of Southern Denmark.e. fall into one of nine types (table 1. Kolding. Kim U. telemedicine is dominated. or offering existing services in a way that is more convenient to the patient or the doctor. Economic evaluation aims to estimate resource use (i. Curr Probl Dermatol. A–I) depending on costs and health consequences. it would imply that we have dominant strategy in favour of telemedicine. medical programmes. the second presents a review of economic studies of telemedicine. telemedicine is ‘costsaving’ and ‘dominant’ and should definitely be chosen. Health Economics Research Unit. The first section presents briefly basic principles of economic evaluation. Karger. Basel. A core assumption in economic theory is that resources are scarce.3 Economic Aspects – Saving Billions with Telemedicine: Fact or Fiction? Ivar Sønbø Kristiansena. Whether the costs are smaller and benefits greater is an empirical question that needs . 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. The aim of this paper is scrutinize such statements. If telemedicine has lower costs and greater health benefits than alternative modes of care (table 1. Peter Bo Poulsenb.Burg G (ed): Telemedicine and Teledermatology. Devoting resources to one intervention or programme means that some other alternative programme cannot be implemented. Wittrup Jensena a Institute of Public Health. If costs are greater but benefits smaller (table 1. C). It would be a bonus if such technologies also ‘save billions’ [1] as have been claimed in the past. This means that use of resources always means loss of opportunities and loss of (health) benefit elsewhere (‘opportunity cost’). In principle. including telemedicine applications. Odense. and bMuusmann Research & Consulting. Denmark Telemedicine is a fascinating example of how new technologies can offer new medical diagnostic and therapeutic services. When advocates of telemedicine claim that it can ‘save billions’. G). vol 32. 2003. pp 62–70 3. while the third provides a general discussion of the cost-effectiveness of telemedicine technologies. CUA cost-utility analysis. Medical interventions are said to be ‘cost-effective’ if the additional health benefits justify the additional costs. However. 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.Table 1. CBA implies that we put a money value on health benefits. In table 2 we have outlined the different types of economic evaluation. one can make priorities by choosing those interventions with the lowest cost per unit of benefit. but this term does not necessarily imply that interventions are cost-saving. real cost-benefit analyses are very rarely undertaken. 2–4]. If the costs are greater. Here. because ‘saved healthcare costs’ are used as the only valuation of benefits [e. Economists would therefore hesitate to classify an analysis as CBA unless health benefits are accounted for. By comparing the cost per life year gained or cost per cancer detected. The term ‘cost-benefit analysis’ (CBA) is frequently misused in the medical literature. in economics. because health benefits often are of a greater value to the individual than just the saved healthcare costs. cost-effectiveness analyses (CEA) are employed. 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. Instead. Here. it is assumed that two or more types of Economic Aspects 63 . A special version of the CEA is the cost-minimization study.g. thorough analysis. In the context of healthcare. 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. we measure the benefits in life years gained or some other natural unit such as for example ‘breast cancer detected’. 5 million. the marginal cost of the orange is 2 dollars. It should be noted that. The lower the cost per unit. 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’.Table 2. In order to make comparisons across different programmes or interventions easier. the marginal benefit were 1. the marginal cost is 0. If the radiology programme costs 3 million and the traditional mode of care costs 2.5 million.000 correct diagnoses with the telemedicine programme and 8. A programme is recommended if the benefits are greater than the costs healthcare programmes have the same health outcome. etc. Interpretation Health programmes are ranked according to their cost per unit of health benefit. 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. except for CBA (which is rarely undertaken). avoided heart attacks. and choose the programme with the lowest cost. The lower the cost per unit.500 with the alternative mode. symptom-free years. health benefits can be measured as so-called quality adjusted life years (QALYs) in cost-utility analysis (CUA). the higher the priority Health programmes are ranked according to their cost per QALY. By marginal (or incremental) cost we mean additional costs compared to something else. This simple Kristiansen/Poulsen/Jensen 64 . If an apple costs 1 dollar and an orange 3 dollars. If the benefit were 10. 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.500 correct diagnoses. Then one needs only to estimate costs. Methods To review the economic evaluation of telemedicine applications.example illustrates two important issues. A telemedicine application may be more or less costly than other modes of care. ‘telepsychiatry’. The first search was conducted by Ohinmaa et al. This is the reason why this type of analysis is not included in table 2. Often. The reason for this is that COI is not a comparative analysis as no alternatives are considered. Thereby COI does not provide the decision-maker about the opportunity costs and marginal use of resources. [5] and resulted in 784 hits until November 1998. In the third search the same search terms were used. Second. However. depending on what is chosen as comparator. This review included 29 studies of which 19 presented some economic data or a full economic evaluation. To review publications after November 1999. only 11 studies with economic data and some sort of comparison group were included. Additionally. this type of analysis is not useful for priority setting because it does not account for health benefits from the use of resources. but only Medline and NHS Economic Evaluation Database (NHS EED) were searched. but only the total costs to society in relation to a disease without considering the benefits. we need solid evidence on the health consequences of the alternative programmes. This is when the cost-of-illness (COI) analysis is carried out. Ohinmaa’s 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’. the electronic databases described above were searched using the terms ‘telemedicine’ and ‘cost’. The 19 economic studies in the Ohinmaa review [5] and 11 studies of the Kristiansen et al. Valid economic evaluation therefore requires a proper comparison group. the introduction of a therapy or health technology. First. is advocated on the basis of the burden of illness that can be avoided. the alternative (‘comparator’) is crucial. ‘economics’ and ‘cost-effectiveness’ [6]. when discussing the costeffectiveness of telemedicine. The two first searches were quite similar in that they encompassed Medline. ‘evaluat’. we used three searches in electronic databases. [6] review are summarized as tables 3 and 4 in the latter review [6]. the database of INAHTA (International Association of Health Technology Agencies) was searched. ‘teleradiology’ and ‘teleconsult’ combined with ‘assess’. This resulted in 137 hits. but excluded studies without any control group. This additional search resulted in 404 hits of which 40 studies were selected for detailed scrutiny on the basis of the Economic Aspects 65 . but after exclusion of studies not meeting quality and content criteria. Health Star. Additionally. preferably in a randomized controlled trial. ‘feasib’ and ‘pilot’. such as telemedicine. we searched Medline (December 1999 to September 2001) and NHS Economic Evaluation Database (1999–2001) using the same search strategy as in the review by Kristiansen and Poulsen [6]. Embase and CINALH using the terms ‘telemedicine’. They included evaluative studies of telemedicine. while 7 studies concluded that Kristiansen/Poulsen/Jensen 66 . For 44 of the studies. Twenty-nine studies included costs covered by hospitals or clinics while 40 included costs to other sectors of the healthcare system. In many of the studies it was difficult to judge whether the comparison to telemedicine was realistic or correctly analysed. implying that one parameter is varied at a time. based on uncertainty. When performed. Thirty-four of the 55 studies covered transport costs. but only in 6 cases patients were randomized to mode of care. just like clinical practice. while depreciation of capital investments was performed in 20 additional studies of the 55 economic evaluations. In 18 studies the results indicated that telemedicine might be cost-saving given some minimum of patient throughput. Only 7 studies had a broad societal cost perspective including costs covered by other sectors or by patients. only the simple ‘one-way’ sensitivity analysis used. but did only use saved costs as the measure of benefit. the alternative mode of care was explicitly described. Five studies explored indirect costs (production gains or losses). 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. Of the 40 studies. Seven of the studies did state that they intended to perform a CBA. None of the studies measured and valued health benefits in terms of QALYs. One study used avoided patient transfers (assuming that this represent a health benefit). Only one of the studies used a direct measure of health benefit in terms of life years gained. These studies have been classified as cost-minimization studies in this study. This means that in total 55 (19 11 25) economic evaluations of telemedicine are considered in this chapter. while the remaining 25 were included in this review [2–4. 7–28]. Discounting of future costs and benefits was performed in 6 analyses. but were in fact performed only in 23 of the 55 studies included. Results Of the included studies.404 abstracts. 4 were CEA and 51 were cost-minimization studies. Such analyses ought to be performed in every economic evaluation. 15 were not real economic evaluation or lacked a comparison group. Economic evaluation is. one used successful examination and one used blood pressure reduction in mm Hg. The 4 CEA had different measures of health benefit. 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. While this clearly might be the case. there is a great concern about commercial Economic Aspects 67 . geography.telemedicine would incur higher costs than alternative modes of care. however. should be seen against the background of the methodological problems in this area. Unfortunately. These savings will however depend on the patient volume. Most authors seem to assume that patients prefer medical services in their local area rather than travelling to remote facilities. Telemedicine technologies typically have high capital costs that may be offset by avoided time and transport costs. type of patients and type of economic analysis. Such interactions are necessary as well as legitimate. clinical setting. The economics methodology is most often fairly simple with cost-minimization as the clear dominant approach. The rest of the studies had unclear conclusions. A thorough and time-consuming study will tend to be outdated once it is finished. Currently. few studies report results where it is clear that telemedicine in routine practice is compared to a proper alternative practice. Discussion The number of economic evaluations of telemedicine applications is still somewhat limited. but may impact the conduct of research as well as presentation of results. it is frequently difficult to judge whether the publications report real routine use or an ideal telemedicine service run by enthusiasts. Rapidly changing technologies and prices will soon make a good study irrelevant. Rather. and the researchers are ‘aiming at a moving target’. but clearly increasing. Very little is known about patients’ preferences for telemedicine versus traditional modes of care. some patients may prefer to get a greater medical centre where they may believe the expertise is higher. First. 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. The published studies are heterogeneous with respect to type of application and technology. some of the studies may leave the impression that the authors aim to ‘prove’ that their application is cost-saving. Some general conclusions might nevertheless be justified on the basis of the review. This harsh critique of the literature. Measuring true costs to society might be difficult in an area of monopoly pricing or public services free of charge to the patient. and only 6 studies randomize patients to avoid bias in the results. The development of telemedicine technologies requires collaboration between medical and commercial interests. Technologies are rapidly developing. there are few signs that the quality of the economic analyses is improving over time. For the reader of studies. cannot be judged from the published literature – simply because many of the studies are not designed to address this issue. Also. [8] in 2000 is a nice example that still-image telemedicine actually saves costs. when its introduction is considered. if the travel distance for the patient is long enough or the number of patients in an area is large enough. It is clear from the published literature. that telemedicine in many cases incurs net additional costs. Are Telemedicine Services Cost-Effective? The answer to this important question has to be seen in the context of the published literature. for example by measuring patients’ willingness to pay (WTP) for telemedicine. there is little doubt that these costs can – partly or fully – be offset by savings in other areas such as transport. 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. and guidelines for disclosure of conflicting interests have been adopted by major journals (ref. Interestingly. Telemedicine should be judged on a broader basis than simply costs and health benefit. however.e. it is not obvious that the decision-maker will opt for telemedicine even if it is preferable from a societal standpoint. Kristiansen/Poulsen/Jensen 68 . Therefore. together with a full societal economic evaluation. Unfortunately. None of the studies reviewed has measured patients’ WTP for the telemedicine alternative. This was the case in 18 of 44 Norwegian municipalities included in Bergmo’s study. To the extent patients prefer telemedicine despite equal health outcome. If telemedicine services are paid by one organization. Even though telemedicine services incur additional costs. a variety of technologies have not undergone economic evaluation. JAMA statement). Policy-makers should ideally consider all costs. The study by Bergmo et al. benefits and preferences when choosing between telemedicine and traditional services. a separate analysis exploring which budgets are influenced by telemedicine services ought to be carried out. but may be preferred by patients due to convenience or better health outcome. many societies place a great value on geographic equality (‘equal medical service in all geographic areas’). this issue is seldom raised although there exist exceptions [7]. and telemedicine services may certainly overcome geographic barriers. and second the quality of most publications is poor to fair rather than good. Whether the telemedicine technology is then cost-effective (i. First. Organization and financing of healthcare may represent barriers here. such preferences should be accounted for in the economic studies. resources cannot generate more health benefit elsewhere). and avoided transport cost are saved by another. only 6 studies reported on commercial sponsoring of all studies we have identified.influences on research. It is time to stop talking about saving billions through telemedicine. et al: Multicentre randomised control trial comparing real-time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis.com. Kristiansen IS. J Telemed Telecare 2000. Wootton R. 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. Second. Ref type: Report. Bergmo TS: A cost-minimization analysis of a real-time teledermatology service in northern Norway. http://www. Dagens Næringsliv (newspaper). most of the studies only pay attention to the cost side of the economic evaluation leaving out assessment of health outcome. Corbett R. First. Hailey D. Corbett R. The scientific literature in this area leaves little doubt that telemedicine services can be cost-saving. Loane MA. Oct 16.120:2305–2311. Pedersen S: Will the use of still image electronic referrals save costs? (in Norwegian) Tidsskr Nor Lægeforen 2000. General principles and a systematic review.143: 1241–1247. Third. Sixth. 1999. Roine R: The assessment of telemedicine. While a 1995 Lancet editorial concluded that ‘the economic benefits of telemedicine have yet to be proved’ [29].320:1252–1256. many studies do not employ basic standard methods such as discounting or sensitivity analysis. J Telemed Telecare 2000. Hicks N. and rather spend time and effort on high-quality evaluation of an interesting and promising group of technologies. quality and design of published economic evaluations in the area of telemedicine still are not as good as one would wish. Fifth. 3 4 5 6 7 8 Economic Aspects 69 . 99. Br J Dermatol 2000. some of the studies do not describe a clear comparator to the telemedicine application. BMJ 2000. it is not often clear whether the studies describe long-term routine use of telemedicine or some demonstration project. the perspective of most of the studies is fairly narrow in that only hospital costs are considered. References 1 2 Grytås G: Saving billions from telemedicine (in Norwegian). et al: A comparison of realtime and store-and-forward teledermatology: A cost-benefit study. Patel T: A cost-benefit analysis of the effect of shipboard telemedicine in a selected oceanic region. Bloomer SE. Eedy DJ. but we lack a sound basis for more general conclusion about its cost-effectiveness.6(suppl 1):S165–S167. Fourth. a recent BMJ review states that telemedicine ‘is immature in that relatively little information exists about its cost-effectiveness’ [30]. Poulsen PB: Saving billions with telemedicine – Fact or fiction? (in Norwegian) Tidsskr Nor Lægeforen 2000.120:1777–1780. Lotery HE. Bloomer SE.6:273–277. Oslo. Hicks N.inahta. Bergmo TS. Breivik E. Lotery HE. Eedy DJ. the lack of randomized designs makes the studies subject to bias in assessment of costs and in particular health outcome. Ohinmaa A.Conclusion We conclude that the number. J Telemed Telecare 1999. Sanders J.sdu. J Telemed Telecare 1999. Woo J. Lamminen H.9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Brownsell SJ. Doolittle GC: A cost measurement study for a home-based telehospice service. J Glaucoma 1999. Catlin P. Dorman T. et al: Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: A health technology randomized assessment. Viikinkoski P: Patient referral by telemedicine: Effectiveness and cost analysis of an Intranet system. Telecare 2000. Moring J. Fax 45 65 918296. BMJ 2001. Williams G. Tuomi ML. Doszpod J: Cost-effectiveness of home telemedical cardiotocography compared with traditional outpatient monitoring. 28:3925–3931. Danish Institute for Health Services Research. Corbett R. Telemedicine: Fad or future? Lancet 1995.5:220–230. Harno K. Evans C. 19 Winslow Park. Jenckes M. Loane MA. J Telemed Telecare 2000.7:167–173.6:102–107. Hicks N. Carlson C. University of Southern Denmark.345:73–74. Hailey D. Ruohonen K. Torok M. Johnston B. Carlier J: Future systems for remote health care. Bragg R. Eedy DJ.6(suppl 1):S69–S70. Tuulonen A. Bowering R: A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland. Beltrami CA: The economics of telepathology – A case study.6(suppl 1):S193–S195. et al: A randomized controlled trial assessing the health economics of real-time teledermatology compared with conventional care: An urban versus rural perspective. Jones G. Alanko HI. Lamminen J. Mielonen ML. Carlson C. Ghandi M. Viikinkoski P: Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics. Paavola T. Elford DR. Della MV Cortolezzis D. Health Economics Research Unit. J Telemed Telecare 2000. J Telemed Telecare 2000.6:152–157. Lamminen H. Cohen D. Urness D. Doze S. Wheeler L. Uusitalo H: A cost study of teleconsultation for primarycare ophthalmology and dermatology. Thompson A. Dawson A.8:367–373. Ivar Sønbø Kristiansen. Toppinen E: The application of teleophthalmology in examining patients with glaucoma: A pilot study. et al: Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care.39:774–778. Jacobs P: Evaluation of a routine telepsychiatry service. Neece A: Financial analysis of telecardiology used in a correctional setting.9:40–45. Dixon L.7:219–225. Ohinmaa A. E-Mail isk@sam. Kovacs F.6 (suppl 1):S155–S157. Deuser J. Hampton CL. J Telemed Telecare 2000.7:73–81. Arajarvi E. Candelier C. White H.dk Kristiansen/Poulsen/Jensen 70 . 2002. St John K. J Telemed Telecare 2001. J Telemed Telecare 2001. Wootton R: Recent advances: Telemedicine. DK–5000 Odense (Denmark) Tel. J Telemed Telecare 2001. 46 65 503843. J Telemed Telecare 2001. Lamminen J. Maddigan B. Uusitalo H: A feasibility study of real-time teledermatology in Finland. Ohinmaa T. Juutinen A. Arch Fam Med 2000. Isohanni M: Psychiatric inpatient care planning via telemedicine. J Telemed . Zhang N. J Telemed Telecare 2000. Hjelm M: Teledermatology in Hong Kong: A cost-effective method to provide service to the elderly patients living in institutions. Kildemoes HW: Reduced delay of thrombolytic therapy for patients with acute myocardial infarction: A health economic study (in Danish). Hyytinen P. Chan WM. Paavola T. MD.6:385–391. Harno K. Rosenfeld BA.6:320–329. Malloy W.7:90–98. Bloomer SE. Simpson J. Bradley DA.6(suppl 1):S168–S169. Fisk KJ. J Telemed Telecare 2001.7:108–118. Crit Care Med 2000. Sousa KH: Outcomes of the Kaiser Permanente Tele-Home Health Research Project. J Telemed Telecare 2000. Institute of Public Health. Pronovost P. Yellowlees P: A community-based approach to evaluation of health outcomes and costs for telepsychiatry in a rural population: Preliminary results.5:141–152. Kennedy C. Chan HH. Breslow MJ. Telemed J E Health 2000. McCue MJ. Int J Dermatol 2000. Copenhagen.323:557–560. and second. the secure electronic data transfer strikes on three main aspects: Confidentiality: Confidentiality relates to keeping secrets. pp 71–75 3. therefore requiring a higher degree of protection against abuse.Burg G (ed): Telemedicine and Teledermatology. From the point of view of cryptography. Increasing Internet communication is a trend also in healthcare. Gianluca Airaghi Arpage AG. patient and healthcare data in general are considered sensitive. Küsnacht/Zürich. Wiley. 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. two specific facts engender skepticism about this trend: first. 2001). New York. the Internet is basically insecure. Basel. 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. They answer the following questions: Who is the origin of the data transfer and how can they prove their identity? . Curr Probl Dermatol. Among others. Digital Security in a Networked World. 1. Switzerland The Internet has become a common communication medium. vol 32. the data protection authorities have issued specific guidelines. Various regulatory bodies have therefore promulgated specific requirements regarding the transfer of medical data over the Internet. However. Karger. It answers the following question: Have unauthorized persons gained knowledge of the transferred data? Identification and authentication: Identification and authentication relate to digital identity.4 Secure Transfer of Medical Data over the Internet: From Regulatory Data Protection Jam to Framework-Based Requirements Hannes Boesch. 2003. which is moving fast towards Internet-based communication. 14 key exchange algorithms dealing with identification/authentication and 2 algorithms dealing with integrity. still remain basic. Rule B: Whenever medical data are transferred over the Internet.ch/d/themen/gesundheit/uebertragung. the ceremonial for securing Web traffic supported by almost all Web browsers and Web servers. Specific algorithms have been conceived in connection with each of them. Take the Secure Socket Layer protocol. 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. Internet security can be conceived as an onion with a kernel surrounded by several layers (fig.edsb. 2. Since anonymization and pseudonymization are very hard to handle in daily life. In order to reduce complexity. The aspects of confidentiality. Following Bruce Schneier. Rule B impedes both useful and usable Internet data transfer. Boesch/Airaghi 72 . they shall be anonymous or at least pseudonymous. And after all restrictions. models are necessary. then there is no need for restrictions! 3. 1). encountered above. All these restrictions do not correspond to the needs of efficient healthcare reality. 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. then technical security standards shall apply. the concrete approach chosen by data protection regulators (see for example www. Rule C: If there is no alternative to the transfer of non-anonymous or nonpseudonymous medical data over the Internet.Integrity: Integrity relates to modifying transferred data. 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. This approach has significant limits. Data protection aims to restrict Internet-based communication in healthcare: Rule A renders Internet use subsidiary to other media. However. Let us therefore shift the focus from Internet use restrictions to technical security standards. SSL supports not less than 9 different encryption algorithms dealing with confidentiality. unlawful use of data. 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. Dealing with security from a technical point of view means dealing with high complexity. identification/authentication and integrity.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. Specific security goals are not achieved through cryptography and security protocols alone. Networked computers build networks: network security deals with preventing all kinds of attacks like. 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. with controlling the access to and the use of data and software available on computers. Specific goals are for example the exchange of encrypted data over the Web. cryptographic algorithms cover all of the aspects mentioned above.Network security Networked computer security Computer security Protocols Cryptography Fig. Cryptography is a branch of mathematic science dealing historically with specific algorithms conceived for keeping data confidential (encryption). The Security Onion. The kernel of Internet security is made of cryptography and security protocols. Data Security Over Internet 73 . 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. but in general through the interaction with the remaining layers of the onion. Computer security deals. Today. among others. 1. the identification of a person accessing confidential resources or the authentication of the author of an e-mail. Applying the above scheme to the ASAS technology leads to the overview as per table 2. Firewalls are designed for granting network security. but also to examine existing security technologies and infrastructures in healthcare. The security onion is a reasonable model allowing not only to design rough Internet security profiles. Take for example a computer on which a firewall software runs.Table 1. access control on resources Firewall. integrity Security protocols (S/MIME. e-mail security. according to a very basic axiom. Table 2 shows that the ASAS security onion is rather complete. uninterrupted power supply. 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. then the almost complete lack of computer security reduces remarkably the security level of the whole system. identification/ authentication. A basic scheme such as the security onion helps because. the Arpage Security and Access Services. However. physical access protection Filters. 4. 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. 5. Concrete security systems are always based on a preliminary decision about the general security level to be achieved. The Health Info Net (HIN) is the Swiss nationwide secured Extranet platform for healthcare professionals and institutions. other for example. there is nothing such as ‘absolute security’. if the access to the computer on which the firewall software runs is not restricted (let us say: no password required). blocking or modifying intended communication. HIN is based on a technology called ASAS. Security layers and relating issues Layer Cryptography Protocols Computer security Networked computer security Network security Security aspects and issues Algorithms for confidentiality. tunneling. online/offline certificate distribution methods Rights management. malware detection. virtual private networks. engendering unintended communication and granting not allowed access to data and resources. SSL/TLS). Only malware detection is not covered. intrusion detection. 6. Security technologies such as ASAS and infrastructures such as the Swiss HIN show that a broad coverage of security requirements can be implemented Boesch/Airaghi 74 . 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, Zürichstrasse 64, CH–Küsnacht (Switzerland) Tel. 41 1 910 6674, Fax 41 1 910 6686, E-Mail [email protected] Data Security Over Internet 75 Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 76–81 3.5 Potential of Telemedicine in Primary Care Serge Reichlina,b, Anthony Dysonb, Daniel Müller b, Andreas Fischer b, Hans Rudolf Fischer c, Christoph Beglinger c a c Department Innere Medizin, Kantonsspital Basel; bMedgate AG, Basel and Abteilung für 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 patient’s 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. Potential of Telemedicine in Primary Care 77 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 4–5 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 Reichlin/Dyson/Müller/Fischer/Fischer/Beglinger 78 Patient Medical contact centre Centre of competence General practitioner Fig. 1. Networked healthcare. the results from the patient to the general practitioner’s 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 Potential of Telemedicine in Primary Care 79 Reichlin/Dyson/Müller/Fischer/Fischer/Beglinger 80 . the contact centre and the medical competence centre is assured. the treating physician. The mobile extranet used in these trials was based on General Packet Radio Service (GPRS). 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.medical competence centre is established by different means using a mobile extranet as well as a conventional or mobile telephones. To get there we will need to be open to all possibilities technology can offer. Two different clinical trials are testing two different groups of patients to gain experience in networked healthcare. we must carefully and critically evaluate the outcomes from a medical as well as economic point of view. forming the cornerstone of integrated primary care. new solutions. Due again to the modular infrastructure. This implies that technology is seen merely as a tool used in a comprehensive framework of healthcare delivery. Both patient and data triage are facilitated. ensuring that the right patient receives the right level of care at the right time. Patient as well as data triage will be facilitated. 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. such as Cellular IP and Universal Mobile Telecommunication System (UMTS) can be adopted as soon as they become available. as it was the most attractive mobile data transfer technology available. The first trial is tackling cardiac risk factor management in young obese patients. supported by MOEBIUS technology. On the other hand. Clinical as well as technical feedback to patients and doctor-to-doctor dialogue is provided. Other medical sensors could easily be ‘plugged in’ to the modular infrastructure. and the second trial is testing the system in a group of elderly people monitoring their oral anticoagulation. 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: 37–40. Roine R, Ohinmaa A, Hailey D: Assessing telemedicine: A systematic review of the literature. CMAJ 2001;165:765–771. Wootton R: Recent advances: Telemedicine. BMJ 2001;323:557–560. 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;134:1024–1032. Wu J, Kessler DK, Chakko S, Kessler KM: A cost-effectiveness strategy for transtelephonic arrhythmia monitoring. Am J Cardiol 1995;75:184–185. 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;130:1361–1365. Koschinsky T, Heinemann L: Sensors for glucose monitoring: Technical and clinical aspects. Diabetes Metab Res Rev 2001;17:113–123. IST – Information Society Technologies: IST homepage. Retrieved 2001 at URL: http:// www.cordis.lu/ist 9 10 11 12 Christoph Beglinger, MD, Abteilung für Gastroenterologie, Universität Basel, Petersgraben 4, CH–4031 Basel (Switzerland) Tel. 41 61 2655175, Fax 41 61 2655352, E-Mail [email protected] Potential of Telemedicine in Primary Care 81 4 Fields of Application of Telemedicine Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 83–86 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 [1–3]. 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 doctor’s 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 patient’s health. The range of the family doctor’s 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, children’s diseases and many other specializations. Telemedicine Services for the Family Doctor Practices According to the above characteristics of a family doctor’s 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 patient’s therapeutic actions. For the diagnosis of difficult cases, a general practitioner sometimes needs a specialist’s 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 100–200 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 doctor’s workstation and the patient’s home units. Kurzynski 84 Department of Family Medicine and Regional Teaching Unit Wal⁄ brzych 60–100 km Legnica 60–100 km Wrocl⁄aw 0–80 km Jelenia Góra 100–130 km Zielona Góra 120–200 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 patient’s and doctor’s station using the ISDN telephone communication network, which makes fast digital communication possible. The doctor’s workstation is equipped with a microphone, speakers and videocamera. The patient’s 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 patient’s biological signals are transmitted to the doctor’s 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. Telemedicine for the Family Doctor 85 278:152–159. the functional specifications of a telemedicine system for family doctor practices have been outlined. et al: Real-time monitoring of patients. etc. Park SH.2:36–37. (2) Transmission: In the next phase the document must be sent to the consultation partner. In summary. circles. Proc MIE Conf.pwr. Division of System and Computer Networks. Wyspianskiego 27. Puchala E: System of telemedicine services designed for family doctors’ practices: Telmed J E Health 2000. ⁄ Marek W. E-Mail kumar@zssk. Kuperman GJ. which means that during cooperative work on for example an image file. Wozniak M: The project of the telemedicine system for family doctor practices. Both partners can discuss about the multimedia document in the WYSIWIS mode. a sound file can give the ECG signal interpretation. the system can be configured with regard to different priorities of documents (e. has also been presented. which has many interesting advantages (the possibility of sending any data. Fam Med 1998. Staniszewski A. Med J Aust 1997. 48 71 3203792.6:449–452. non-urgent messages can be sent later at a tariff suitable time. X-ray or USG images. Wroc law University of Technology. Steciwko A. the prospective partner need not be present in order to receive the message. Yellowlees PM. References 1 2 3 4 5 6 7 Doughty K: Telemedicine. Proc 20th Conf IEEE/EMBS. both partners have the same documents on line and the teleconsultation can begin. Fax 48 71 3202902.A patient’s document consists of several files of various nature. reducing transport cost)). pp 1038–1041. an image file can include microscopic. for example. Puchala E. Hong Kong 1998. et al: Electronic communication with patients. Proc 23rd Conf IEEE/EMBS. Puchala E. Jaffrey F. Istanbul 2001. For this purpose in the TelFam the electronic mail system is used.166:262–265. a text file can contain results of a patient’s examinations. Evaluation of distance medicine technology. polygons. text) to the discussed images and they can be seen from the partner immediately after the action. PL–50370 Wroc law (Poland) Tel. 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. Faculty of Electronics. Wozniak M: TelFam – A telemedicine system for the family doctor practices. Kurzynski. it is possible to point with the mouse an anomaly on a medical image. to add different annotations (lines. Kurzynski MW.g. Bujnowska-Fedak MM. (3) Consultation: After the transmission phase. Eng. ⁄ Wyb. JAMA 1997. Hannover 2000. pp 1321–1324. The TelFam system.wroc. Balas EA.pl Kurzynski 86 . Jeong T. Ryu SH. Kennedy C: Telemedicine: Here to stay. pp 1131–1135. and robot surgery planning can only be performed with the transfer of digital radiological images [1]. and all telecommunication within radiology. Borut Marincek Institute of Diagnostic Radiology. remote radiological services. University Hospital Zurich. Voellmy.2 Teleradiology Daniel R.Burg G (ed): Telemedicine and Teledermatology. Karger. especially radiology. New applications like preoperative simulation. Curr Probl Dermatol. . Numerous modern visualization techniques have been developed in cooperation between information technology and medicine. the need for digital radiological images in other medical disciplines is stronger than ever. vol 32. where the correct report may be created only when all previous exams are at hand. Switzerland Radiology has always been a mediator between medical and technical sciences. In a narrow definition. pp 87–93 4. images are acquired in facilities with general radiologists or emergency physicians. teleradiology also comprises transmission of image demonstrations. information about radiological exams. intraoperative visualization. In a wider sense. 2003. radiological reports. Today. but with no experts for specific radiological subspecialties. Images are transmitted to the experts for remote reporting. Teleradiology Scenarios Transmission of previous exams: Transmission of previous exams to the investigating radiology institute is important especially in long-term patients. and organizational tools like remote scheduling. exam requests. Basel. teleradiology includes transmission of radiological images. 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. Relatively new DICOM features are wavelet compression and data encryption. It is inversely proportional to the image compression ratio and the communication bandwidth. DICOM is rapidly evolving. Reference image databases are tools to share radiological knowledge. Voellmy/Marincek 88 . The objective is to save imaging costs and/or to share images among health networks. an average CT scan selection with 40 uncompressed images has a size of about 18 MB. and services.In cooperative reporting. Losslessly compressed images may be used for primary reporting without quality problems. Digital images can be compressed without loss of information. the use of image acquisition resources and reporting personnel is optimized [2]. Lossy compression results in compression ratios of up to 1:20 or more. acquisition parameters. bit depth and number of images. resulting in decreasing image quality. Technical Requirements Image Size Image size depends on the image modality. Images are transmitted from decentralized imaging units to reporting units with high-qualification. Economically. Remote image processing is performed on cutting-edge technology workstations and software. Transmission time is proportional to image matrix. It can be used for result communication or image demonstration purposes. high-availability radiologists [3. including data dictionaries and data formats. Some healthcare companies send images to radiologists in other countries to save reporting costs. An advantage over other image standards is the great amount of information about the image context (patient. Image Standards in Radiology DICOM is a comprehensive standard for medical images. In remote image archiving. resulting in typical compression ratios of 1:2 to 1:3.). images are transmitted to a central storage provider instead of being stored at the acquisition site. etc. 4]. including a high-level communication protocol usually based on the TCP/IP protocol. As an example. it is favorable to keep advanced imageprocessing resources in a few specialized centers. modality. It defines information objects. The best-known example in Europe is the Eurorad database with over 600 international contributions [5]. dedicated peer-to-peer reviewing systems.024 pixels is sufficient. CRT brightness. for primary reporting of chest or bone images. patient confidentiality. For image reviewing. Web distribution in e-health environments is another special case of asynchronous transfer. Storage. investigations showed that diagnostic motion imaging is possible [7]. For the storage of transmitted images. Minimal requirements for computer equipment as well as image annotation. radiological images are transferred to the remote site for later review. a standard cathode ray tube (CRT) color monitor or a flat screen with a resolution of 1. but it contains no specific information about the image context. high-luminescence CRT or flat screen grayscale monitors are required. There are teleconferencing systems with or without radiological add-ons. Interconnection. Transmission time for an average CT scan selection is about 38 min with an ISDN connection or 72 s with a DSL connection. Monitors Modern off-the-shelf personal computers are sufficient for most teleradiological purposes. e. affordable data subscriber line (DSL) or cable modems with bandwidths up to 2 Mb/s are available. like FTP or DICOM. a two-monitor configuration with high-resolution. It allows image compression from lossless to about 1:20. inexpensive devices like network-attached storage cabinets are available. However. and image compression are defined in the guidelines of the American College of Radiologists (ACR) [8].280 1. Computers. Types of Teleradiological Interaction Systems with display synchronization allow interactive remote image interpretation. An authentication mechanism is provided to protect unauthorized Teleradiology 89 . JPEG (joint pictures experts group) is used primarily for image transmission in the Internet environment. eventually with previous images.TIFF (tagged image file format) is less complex than DICOM. Even with lower bandwidths. workstation functionality.g. for image reviewing and even for primary reporting [6]. In the asynchronous approach. and remote demonstration systems with special discussion tools. The images can be transferred by any standard protocol. in a physician’s office. To connect a physician’s office to teleradiology service providers. which has to be provided by the teleradiology application separately. Images are transferred to Web servers for later retrieve and review. The partners do not necessarily have to use the same application for display as long as the images are transferred in a standard format. Integration into PACS also helps to unambiguously associate images and reports. 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]. Additionally. planning. and non-repudiation mechanisms require a comprehensive security concept. access control. Authentication. The lack of EMR standards makes EMR integration a challenging issue. Some Web implementations have plug-ins to display full resolution DICOM images. billing rule restrictions do not allow telemedical diagnostics or consultations to be adequately charged. confidentiality. Legal responsibility after remote diagnosis and the copyright of images are other questions that have still to be resolved in most countries. Security Teleradiology. it is therefore important to implement standardized electronic medical records and standardized communication formats to interchange patient records [11]. is always present during the patient’s examination. Legal Issues In many countries. in many countries. For further propagation of teleradiological applications. even a nonradiologist. teleradiology services could increase revenues by enhancing reporting volume [12]. Political efforts to change the funding rules have to be enforced. However. data integrity. waiting. This legal restriction could be overcome by teleradiology contracts between hospitals where at least one medical doctor. Economic Challenges Teleradiology has the potential to lower cost of film output. The solutions are Voellmy/Marincek 90 . retrieving and reporting times. most of the radiologists wait for the – paper-based – patient record to be available before reviewing or reporting images. the radiologist has to be physically present during a patient’s examination. film-posting expenses. like all telemedical activities. needs a high security level [13]. Most of the picture archiving and communication systems (PACS) provide a web interface for Internet browser access. Telemedical applications should therefore be seamlessly integrated into PACS or electronic medical records (EMR) [4.access. 10]. Since most of the images can only be interpreted with the clinical information available. which is an important security requirement. they will have access to the complete original image series. as well as the maintenance of the specialized know-how to operate the equipment. external clinicians will expect radiology reports to be enriched with a selection of relevant images. Integrity checking and nonrepudiation mechanisms are other features of PKI. especially on a transnational basis. endoscopy. The secure hypertext transfer protocol (https) can be used to encrypt images for web distribution. or intraoperative photography will be combined for a more comprehensive clinical visualization. pathology. archiving and image distribution will be standard for every hospital. Computers containing images should be separated from public networks by firewall systems. high-qualification specialists. The aggregation of healthcare institutions to healthcare networks will enhance the need for teleradiological solutions. Empowered by decreasing information technology (IT) costs. Therefore. This will lead to a concentration of radiological experts to a few centers with high-availability. Trans-disciplinary teleimaging will establish as a completely new field: images from radiology. as adequate payment will be established. internal digital image management. They will compare their images to reference images in publicly available image databases. A public key infrastructure (PKI) solves all the issues mentioned above. Future Developments In a few years from now. Images will be available on mobile image display devices. PACS implementations will have standardized and secure wide area network expansions. Teleradiology 91 .available. Access can be restricted to those who have the corresponding key. this may be a solution to the confidentiality problem in Web environments. Consultations will be more frequent. Existing consultation services will expand. IT security infrastructure will be a commodity. exact anatomic measurement for implant sizing or operation result visualization. access control and confidentiality. Special niche players will provide visualization services like 3D operation planning. the capital-intensive equipment for these services. the conditions for a successful development for teleradiology applications will improve. Images can be signed digitally. will be concentrated in a few centers. Virtual private networks (VPN) are adequate solutions for authentication. On request. but they require a minimum of users’ and system administrators’ compliance [14]. Patients will want to access selections of their images as well. Combined with a strong authentication mechanism. For economic reasons. AJR Am J Roentgenol 1999. Strickland NH: Can PACS make a radiology department more competitive? Eur J Radiol 1999. teleradiological solutions must be an integrated part of the standard workflow in the radiological practice.eurorad. Bowers GH. Integrated health platforms [15] will render teleradiology a standard procedure of the clinical routine.Conclusion Basic teleradiology technology. Fabbrini F. Weisser G. Pinck D. Carter SJ. which means to implement an EMR.acr. The remaining challenges are mostly of a non-technical nature. Rowberg AH: Application of the advanced communications technology satellite to teleradiology and real-time compressed ultrasound video telemedicine. Teleradiology can be seen as a mandatory element of the ideal medical information system that provides secure and instant access to clinical data. To ease their use. Cramer U. In some countries. Br J Radiol 2000. Valentino D: Update on digital image management and PACS. 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Bartolozzi C: Teleradiology in Europe. Ratib O. Pysher L. Steiner E. Bandon D. Remote consultation and image-processing services are beginning to establish.org/departments/stand_accred/standards/ pdf_standards/toc. J Digit Imaging 1999.pdf Buxton PJ: Teleradiology – Practical aspects and lessons learnt. therapy planning and monitoring. including images. Eur J Radiol 1999. Baert A. Reimann C. Stewart BK. Caramella D. References 1 Walz M. the legal basis for teleradiology is not certain. is available and cost-effective today. Frija G.10:1472–1482. Eur J Radiol 2000. Wein B. Reponen J. 2 3 4 5 6 7 8 9 10 11 12 13 Voellmy/Marincek 92 . Bolte R. http://www.12:68–76.52:81–91. http://www. Int J Med Inf 1998. Ashcroft RE. Goddard PR: Ethical issues in teleradiology. Abbe BS. Haimerl M. 32:113–115. The solution of the remaining challenges is in progress. ACR: ACR Standard for Teleradiology. and billing rules are missing. Kalman M: Implementing teleradiology in a private radiology practice: Lessons learned. http://www.13:145–156. Daniel R. Fax 41 1 255 8987.14 15 16 Eng J: Computer network security for the radiology enterprise. Gould RG: Computers in imaging and healthcare: Now and in the future. Rämistrasse 100.html#k1c Arenson RL. E-Mail daniel. Radiology 2001. Universitätsspital. Avrin DE. DMT Direktion. Andriole KP.usz.de/forschung/studien/telematik/ telematik_1.voellmy@dmr. Voellmy. Bundesministerium für Bildung und Forschung: Telematik im Gesundheitswesen – Perspektiven der Telemedizin in Deutschland. J Digit Imaging 2000. 41 1 255 2165.iid.220:303–309.ch Teleradiology 93 . CH–Zürich (Switzerland) Tel. Burg G (ed): Telemedicine and Teledermatology. as images play a major role. laparoscopic surgery. University Hospital Zürich. is ideal for surgical demonstration. Transmission through ISDN lines appears to fulfill most of these requirements. 4]. this configuration allows teleconferencing with the best price/quality ratio. a technique based primarily on pictures. acceptable quality of animated pictures. The use of 6 ISDN lines at an information rate of 384 Kb/s resulted in 93. These results confirm our own investigations where an off-site diagnosis using teleconferencing was made in between 85 and 96% of cases [5]. telementoring. pp 94–101 4. and 60% recognition of fine structures [6]. published in 1995. education and practical teaching. to that of direct clinical examination [3. Telemedicine as a surgical application is supported by works that indicate off-site diagnosis for surgical patients can be performed with a similar sensitivity. the telematic system must be easy to manage. For example. rapid transmission of medical files. Good transmission quality is achieved with a high information transmission rate. EUR 260 (USD 275). vol 32. the use of virtual reality for teaching and operation planning [2] and robotics. Teletransmission technology for surgical purposes should provide highquality. The word ‘telemedicine’ applied to surgery includes the use of various new technologies of communication and covers many topics beginning with videoconferences. describing 28 different specialties. Switzerland Telemedicine is used in most areas of medicine as demonstrated in the other chapters of the present book. In addition.3% recognition of organ structure. Currently. including veterinary medicine [1]. good audio quality. to be used regularly by surgical teams. and low . and a Europe-USA link. Curr Probl Dermatol. 2003.3 Telemedicine Applications in Surgery Nicolas Demartines Department of Visceral and Transplantation Surgery. The cost for 1 h of videoconferencing at 384 Kb/s for a Europe-Europe link amounts to EUR 180 (USD 190). varying between 78 and 98%. and as previously showed in a review. assuming highquality image transmission. reliable and inexpensive. Basel. Karger. It means telemedicine needs further proper scientific evaluation [6]. by radio. for medical teleconferences.447 3. However. 1).4. Teleconsultation implies a consultation from a distant site. Evolution of the number of publications listed in Medline about ‘telemedicine’.082 546 27 88–92 117 93–95 1996 1998 1999 2000 2001 Fig. the use of modern telecommunication technologies allows the advanced transmission of complex documents for special or challenging problems [11. 2). a comparison between 1. Based only on the transmitted documents. the experts have to judge and evaluate the Telemedicine Applications in Surgery 95 .02) [7]. An important aspect in the introduction of new technologies in surgery is the scientific evaluation prior to large clinical application. rate of artifacts. On the other hand.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]. the need for accurately transmitted clinical documents is greater and technical requirements become more important (fig. Twenty years ago. and teleconferences allow real-time consultations.649 2. by telephone or using telematics [9]. This increase in number of publications does not however give information about the real value of telemedicine. Teleconferences have become routine in industry and in the business world. A lower transmission rate using 4 ISDN lines at 256 Kb/s induces 12% artifact. and the cost. Telemedicine became popular in the last decade.907 1. This is of special importance regarding the quality control. 12]. as demonstrated by the exponential increase in publications listed in Medline (fig. and allow participants – who may be hundreds or even thousands of kilometers apart – to carry out discussions that include sound and images. 1. Let us define a few specific terms [8]. compared with only 3% at 384 Kb/s (p 0. but more on the increasing general and scientific interest on this topic. The opportunity for interactive discussion thus significantly improved the level and quality of clinical information available. this hypothesis needed to be validated by scientific evaluation. Interactivity: Videoconferences offer the opportunity to discuss complex cases in real time over distance. Tools used for ISDN-based videoconference in surgical application. thus increasing the value of teleconsultation in real time. case and advise the best treatment based on the clinical information transmitted. This was performed during a surgical teleconference program running between six European University hospitals between 1996 and 1999 [6].001) [6]. complementary data was provided live by the surgeon in charge of each case. confirming preliminary studies from the Mayo Clinic and NASA showing teleconferencing satisfaction levels of between 80 and 90% [13]. Our own works show surgical participants in teleconferences have an 86% level of satisfaction [6]. During the interactive discussion. Out of 271 clinical presentations of surgical cases. specialty training and the opportunity to exchange information allow the emergence of new concepts in tele-education and teleconsultation. 2a–c. The initially available clinical information was judged adequate in 55% and inadequate in 45% of the analyzed cases. significantly increasing the number of cases having adequate information to 95% (p 0. 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].a Camera Video unit b ISDN Control c Fig. However. Demartines 96 . 60 cases were analyzed in order to judge the value of the interactivity between the expert and surgeons presenting the case. Multidisciplinary teleconferencing continues to expand: teaching. The concept was further developed when Marescaux et al. Telemedicine Applications in Surgery 97 . thoracic and vascular surgery. the concept dates from some 50 years ago where radioactive isotopes were manipulated using telecommands [21]. Telementoring: The next stage extends beyond the discussion of therapeutic and diagnostic tactics. 24. 25]. a microscope. 3). a Surgeon in New York.g. from a distant site. with the use of a robot (Marescaux Nature). 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. Thus. The patient was located in Strasbourg. 3. These findings highlight a need for real-time interactivity [16]. In telementoring. USA (fig.. 2001. an endoscope or a surgical manipulator and to thus physically perform some task without actually being present [19. France. Telesurgery and Robotics involve the use of robotics and the actual operation is performed by robots commanded from a distant site [23]. Telepresence dictates an action from a distant site. Clinical applications are currently in operation in Belgium where telelaparoscopy is quite frequent [26]. France. Telementoring has been performed and tested successfully during several different invasive procedures [17–20]. b Patient in Strasbourg.a b Fig. and laparoscopy [19. First robot-assisted transatlantic laparoscopic cholecystectomy performed by the team of Jacques Marescaux. The importance of interactive case presentation is confirmed by others. [27] performed the first transatlantic laparoscopic cholecystectomy on September 7. and the surgeon in New York. telepresence is the first step introducing telesurgery and robotics. and includes obtaining off-site assistance for a therapeutic step. a videorecorder. suggesting that this is a key benefit of telemedicine [14]. 84% of participants in rural telemedicine in the USA reported using interactive video sessions [15]. Preclinical experiments have been performed in microsurgery. and assists him/her step by step in real time during the procedure. e. Telepresence allows a consulting expert to maneuver. 22]. University of Strasbourg. [2. Virtual reality: The use of virtual reality applied to liver surgery will have fascinating repercussions of assisted surgical strategy and surgical simulation on tomorrow’s surgery. 4). For clarity. by Marescaux et al. ergonomics. The potential advantages of telesurgery (robotic) are the mini-invasive approach. An interesting pioneer work was performed at the European Institute of Telesurgery in Strasbourg. i. degree of freedom. Demartines 98 . a better possible view with possible magnification. France.e. 4a–c. http:www/eits.a b c Fig. a highly fine motion movement and the ergonomics for the operating surgeon (fig.org]. an increased degree of freedom of the instruments. better view. fine work. The term ‘telesurgery’ is occasionally wrongly used to describe a videoconference on a surgical subject but it means telesurgical robotics. one should definitively distinguish between these two. Potential advantages of telesurgery. Using virtual reality concepts (navigation. Telemedicine Applications in Surgery 99 . A computer interface was developed to manipulate the organ and to define surgical resection planes according to internal anatomy. providing the organ with real-time deformation computation. training and teaching for complex surgical procedures may be possible. Validation studies are currently being performed (fig. The first step of surgical simulation was implemented. a realistic threedimensional image was created. and the external envelope. The three-dimensional anatomy of the liver can be clearly visualized. 5). the tumor. 5. surgical planning. including the envelope and the four internal arborescences. Virtual reality applied to liver surgery. The simulation allowed the deformation of a liver model in real time by means of a realistic laparoscopic tool. Using data from the National Library of Medicine. interaction and immersion).7 8 2 Tumor 3 5 4 6 Virtuals Fig. The virtual organ can be manipulated and a resection defined depending on the anatomic relations between the arborescences. the quality control and the cost-benefit relationship for the surgical patients. Ferrer-Roca O. with an easier access to expertise. Vogelbach P. Mutter D. Swiss Surg 1999. et al: Telemedicine in vascular surgery: Feasibility of digital imaging for remote management of wounds. References 1 2 3 4 5 6 7 8 9 10 11 Perednia DA. Trippi JA. The major benefit is in teaching and education. Mutter D. Tassetti V et al: Virtual reality applied to hepatic surgery simulation: . Clark W. thus allowing a better definition of the surgical strategy. Harder F: Telemedicine: Application. Mil Med 1996. 273:483. Athanassiou A. Otto U.13:729.4:161. thus allowing direct active guidance for advanced procedures. et al: Telemedicine and remote clinical diagnosis in surgery: A comparative study.4:161. Malone FD. methodolgy and users’ guide. Kopp G. Application of robotics allows the realization of operations over a distance. Esteves M. Demartines N. J Am Coll Cardiol 1996. Demartines N. Fisher JB. Ann Surg 2000. Berdusis K. Clement JM.228:627. N Engl J Med 1975. Alboliras ET. Bonnano R. Nelson D. et al: Assessment of telemedicine in surgical education and patient care. Marescaux J. The development perspectives are in the semiautomatic recognition of structures with development of an interface with the robot. JAMA 1995.135:849. Eisner L. Willememain T. Vix M. Mutter D.131:1225. Allen A: Telemedicine technology and clinical applications. Arch Surg 2000. Walters TJ: Deployment telemedicine: The Walter Reed Army Medical Center experience.161:531. Gomez E: The environment for telemedicine in the Canary Islands. J Telemed Telecare 1998. Edwards RA.27:1748. Moore G.Conclusion Telemedicine applications in surgery are various.27:1089. Martin A. Webb CL: Rapid identification of congenital heart disease by transmission of echocardiograms. Reconstruction using virtual reality should increase the feasibility and safety of complex surgical procedure by better visualization of the preoperative anatomy. 12 Demartines 100 . Demartines N. J Vasc Surg 1998. Nores J.231:282. Kovacs R: Emergency echocardiography telemedicine: An efficient method to provide 24-hour consultative echocardiography. thus opening the door to a semiautomatic robot-assisted complex surgical procedure. Lee KS. Wirthlin DJ. beginning with teleconsultation and telementoring – real-time remote assistance during the course of an invasive procedure. D’Alton ME: Effect of ISDN bandwidth on image quality for telemedicine transmission.5:73. Ann Surg 1998. Buradagunta S. It is important for the surgeons to be part of these developments to manage the emergence and the application of these new technologies. The next revolution. This application is of great importance for education and teaching as well. and to ensure a proper scientific evaluation to assess the indications. Moglienicki P: Comparison of television and telephone for remote medical consultation. Marescaux J. Am Heart J 1996. Telemed J 1998. Margossian H. Gaumer G. J Am Med Inform Assoc 1997. Nature 2001. Vice Chairman. Lesher JL Jr.71:329. Bowersox I: Telepresence surgery. Falk V Walther T. Johnston S. Butner SE. Shah A.16:367. Obes Surg 1999. Davis LS. Durlach N. Trapp MA.115:470.38:27. Hassol A. Jensen J. Janetschek G. J Am Acad Dermatol 1998. Diegeler A.8:69. Panser LA.2:35.83:466. Department of Visceral and Transplantation Surgery. Puskin D: Rural telemedicine data/image transfer methods and purposes of interactive video sessions. Nicolas Demartines. Gagner M. Urology 1999. 1995. Campbell M. Saleh W. Mohr FW: Robot-assisted minimally . Thompson WO: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. Rubino F. invasive solo mitral valve operation. MD. Autschbach R. CH–8091 Zürich (Switzerland) Tel.13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Kottke TE. Marescaux J. Lee BR. Franken EA Jr. Fax 41 1 255 89 42. English D.11:1001. Mayo Clin Proc 1996. Initial clinical experience. Grigsby J. Surg Endosc 1997. Falcone T. Rämistrasse 100. Br J Surg 1996.Demartines@chi. Gourdin FW.23:281. Mintzer C. Moore RG.usz. Mavoras A: Virtual Reality: Scientific and Technological Challenges. Cordts PR. University Hospital Zürich. Battellini R. Cadiere GB. Vertruyen M. Garcia-Ruiz A. World J Urol 1998. J Thorac Cardiovasc Surg 1998. E-Mail Nicolas. Bishoff JT.9:206. Urology 1998. J Laparoendosc Adv Surg Tech A 1998. J Vasc Surg 1996. Smith MK: Transatlantic robot assisted telesurgery. et al: Robotically assisted laparoscopic tubal anastomosis in a porcine model.ch Telemedicine Applications in Surgery 101 .52:17. Irvin C. Bowersox JC. Bowersox JC. J Telemed Telecare 1996.53:892. Green PS: Vascular applications of telepresence surgery: Initial feasibility studies in swine. Kavoussi L: Telesurgical mentoring. Little Finger L. Billica R: Endoscopic surgery and telemedicine in microgravity: Developing contingency procedures for exploratory class spaceflight. Vix M. Jones JA. Novotny PJ: The Pine Ridge-Mayo National Aeronautics and Space Administration Telemedicine Project: Program activities and participant reactions. Mutter D. Berbaum KS: Subspecialty radiology consultation by interactive telemedicine.413:389–391.4:36. Breitenbach C. Schulam PG. et al: A novel method of surgical instruction: International telementoring. Washington. National Academy Press. Himpens J. Favretti F: The world’s first obesity surgery performed by a surgeon at a distance. Hill J. Leroy J. Cornum RL: Remote operative urology using a surgical telemanipulator system. 41 1 255 23 89. Miles B. Docimo SG. University of Basel. a distinction of subgroups in telemedicine [1–14] is no longer absolutely indicated.4 Modern Telepathology: A Distributed System with Open Standards Martin Oberholzera. intraoperative frozen sections). Germany. Because images are also diagnostically relevant in many other disciplines in medicine as pathology. Germany. Gerhard Stauchf. telepathology) can be justified. Basel. Kurt Brauchlia a Department of Pathology and bUniversity Computing Centre. Basic Model of Telepathology The user of a telepathology system wants a system to be available unlimitedly. vol 32. 2003. Michael Mihatscha. Solomon Islands. Städtisches Klinikum Dresden-Friedrichstadt. telepathology is mainly concerned with the exchange of information contained in images. Heinz Christenb. Dresden.Burg G (ed): Telemedicine and Teledermatology. Karger. dTechnical University Kaiserslautern. Switzerland. and (2) to deliver primary diagnostics to patients who are treated in hospitals without resident pathologists. Aurich.g.g. Gunter Haroskec. pp 102–114 4. Gernot Jundta. All diagnoses in pathology are based on images. cInstitute of Pathology. Zweibrücken. Hermann Oberlie. Curr Probl Dermatol. Therefore. e National Referal Hospital. Honiara. and fInstitute of Pathology. 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 pathologist’s working team. Markus Helfrichd. the distinction among subdisciplines of telemedicine (e. 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 . It can really be that the diagnostically relevant images can only be created by means of specific procedures (e. Taking care however (i) of the conditions in which images are generated and (ii) of the therewith linked special processing. ch) [18]. the expert(s) answer(s) the question. and optionally a small software module controlling the specific imaging facilities of the actors.unibas.net. and (iv) optionally a module for remotely controlling the microscope. All these prerequisites are fulfilled in the modular client-server system iPath (http://telepath. images can be uploaded manually using a Web page. and (iv) the partners must have the possibility to generate images in a simple way. looked at or retrieved from the server. 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). information of any source (images. text files. (ii) used via an easily accessible universal network. Methods The software modules of iPath are available as free software under http://ipath. Alternatively. 1): (i) a module for generating the images (capturing or microscope control). Modern Telepathology 103 . The non-expert asks a question. sourceforge. with the own microscope. (ii) a module for filing of images or other information on the server (filing). (iii) the partners must have a free as possible access to the server. The partners and the server are linked with each other via a network. (ii) all actions of each partner have to be communicated to the server. Architecture of a Modern Telepathology System A widely available telepathology system should include four basic modules as single system components operating independently (fig. All the tools (modules. or another ‘manipulator’ (‘microscope control’). this module has been written in Java. 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. Telepathology has three supporting legs: two partners and a server with a database. in the own office). audio) are stored.computer.patho. The ‘expert module’ (realized as Web application) controls the access to the database and contains the module ‘microscope control’. The technological precondition mandatory for the clients is a Web browser being able to execute Java applets [15–17]. (iii) a module for the function of the expert (‘expert module’). and (iii) used spontaneously to contact any expert – without special software. On the server. The images can manually or automatically (in combination with the module ‘microscope control’) be inserted in the database. The server software is running on a Pentium II Personal Computer with Windows NT 4. CGI: common gateway interface-programs. Basic concept of iPath. iPath consists of five basic (main) software modules (capturing.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. if the module ‘microscope control’ of the non-expert(s) is linked with the server. (Intranet is a local area network (LAN). The hardware modules are demonstrated in table 1. iPath works also with scanning tables of the company Märzhäuser (Wetzlar. or on an independent computer (server) located in the Internet. One such Internet server can serve hundreds of users and many simultaneous connections. The module ‘server with database’ is installed on the computer of the expert (in Basel) for the intranetto-intranet application (for Samedan). filing.0. e. expert.g. Germany). an intranetto-intranet connection has been installed between the University Hospital Basel (Basel. Switzerland) and the Ospidel Circuitel d’Engadin’Ota (Samedan. 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. and database) which are distributed on the three ‘legs’: non-expert. 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. Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 104 . a server (Pentium II. For telepathology via the Internet.) – We have concretely realized both possibilities. 1. Basel. Switzerland). of a hospital. and server. expert module. microscope control. too) is located at the University Computing Centre. The ‘expert module’ allows access to the database on the server and to all microscopes. The server software (see fig. presently we are using ‘Postgresql’ [19] on our Internet server. 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. If the expert establishes contact with any microscope registered at the server. A case corresponds to a concrete query of a non-expert to one or several experts. The quality of the video image and the video image transfer rate can be regulated interactively. The main unit of the iPath database is the ‘discussion group’. 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. opinion. 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. 2). diagnosis. 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 video image is transmitted in regular periodic intervals (actually 1–2 s). The database is based on an SQL (structured query language) database server. and (iv) the formulation of the answer(s) of the expert(s) to the non-expert.Table 1. Modern Telepathology 105 . (iii) the presentation of images or documents to the expert(s). 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. 3). The ‘expert module’ can be called up via conventional Web browsers (Netscape Navigator or Internet Explorer). Each ‘case’ is stored in a discussion group. 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. additional question) into the field ‘comment’ of the database. 2) and is stored directly in the JPEG format in the database at the server. All users are attributed to a ‘discussion group’. A single case can have any number of comments (fig. Telemicroscopy.or macroscopical) is shown in the left upper corner. The expert can also communicate with the non-expert via the chat function. 2. On the screen of the expert the actual video image (micro. Record of a case (frozen section analysis) in the database of iPath (see text).Fig. These digitalized images are already stored in the database. The module ‘microscope control’ is the tool for telemicroscopy. 3. On the right side the already captured high-resolution images are shown. Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 106 . A chat function as discussion platform is also available for each case. Fig. 98 Effic 0.00 0.92 1.85 0.94 Spec 0.92 0. a system was used which consisted of two Macintosh computers. we observed 6.73 0.8% was found in conventional frozen section diagnoses [22].95 0. The efficiency of frozen section diagnoses as we observed was in the range of that published by other authors [23–25].93 0. Heidelberg (Germany) has used iPath successfully for 12 months for purposes of passive consultation.81 Virtual frozen section analysis. Effic efficiency.90 0. The number of nonconclusive cases ranges in the literature for frozen section diagnosis made by telepathology between 2.96 PPV 0. Passive Consultation: Some Examples The main use of the new system iPath [18] is the passive consultation. iPath is in use via ISDN and with two B-channels (128 kbit/s) between Basel and Samedan.98 NPV 0. Timbuctu® was used as a data transfer protocol. Active Consultation: Frozen Section Diagnosis Intraoperative frozen sections have been performed for the Ospidel Circuitel d’Engadin’Ota (Samedan. Value for [5]. The working group ‘Bone Tumors’ at the German Center for Cancer Research. Validity of telepathology n 139 93 117 128a 151a a Author Present study [1] [2] [3] [4] Sens 0. min minimal value for [ – 2SE (min)].6 and 7. 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 3.90 0.00 0. a picture-instrument manager and a relational database (Omnis 4®).Table 2. Modern Telepathology 107 .93 0.89 0. In a large-scale study a portion of nonconclusive cases of 3.0% [23–25]. The system is a very good platform for the discussion of morphological findings (pathology and radiology).93 1. NPV negative predictive value. Until 2001. Switzerland) for 10 years [20.96 0.87 0. PPV positive predictive value. For 2 years this service was also offered to the Regional Hospital Burgdorf (Burgdorf. Spec specificity. 24]. as network the Integrated Services Digital Network (ISDN) with one B-channel (64 kbit/s).5%. 21]. The same holds for the values [22. Since half a year.88 min 0.78 0. Sens sensitivity. Switzerland). In connection with the interpretation of a heart biopsy after a heart transplantation.5 6. He confirmed the grading made by M. iPath was used for answering the questions of the pathologist (fig.6 3.) had installed a small histological laboratory there and trained the technicians of the hospital in the preparation of histological sections. The question was if the rejection therapy which had to be reduced because of severe side effects can be maintained. in order to receive a second opinion of a specialist at the Center for Heart Transplantations of the University of Hannover (Germany). iPath developed to a very important key element of help to self-helping. 12 h after the query in his comment to the case.028 6a 8 9 % 6. By the end of August 2001.O. Within 10 min the problem was solved (registration and administration inclusively). technical dysfunctions happened: the reasons were dysfunction of the ISDN (twice) and of the microscope (once).B. 4).] [2] [3] [4] Conventional frozen section [review.Table 3. In this case the pathologist was the non-expert and the surgeon the expert. iPath was used spontaneously by M. In Honiara. The collaboration with the hospital in Honiara (Solomon Islands in the South Pacific) proved to be very successful.O.0 2.8 a In 3 additional cases. [unpubl.8 7. 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. n Nonconclusive or false n Steffen et al. 1] 93 117 128 155 118. 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. one of the authors (K. Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 108 . Anamnestic and clinical key information and the images of the biopsy before and after the reduction of the therapy were stored in iPath. The histological images could be transferred via a laptop computer and the sole Internet connection of the hospital to the iPath server in Basel. Nonconclusive cases for telepathological frozen section diagnosis between Basel and Samedan Author Total. An old Nikon microscope was at disposition on which a digital camera could be installed. Histology required?)’. Macroscopic images (fig. Specialist consult and advice would be very much appreciated. and M.H. One day later the diagnosis of breast cancer was made and transmitted to the server by M. No dermatologist in the country. 24 years.g. recurrent episodes of generalized psoriasis. Images of any kind (e. 2001. Can you offer any alternatives? Skin biopsies were taken.O. also macroscopic findings of patients or of organs or radiographs or electrocardiograms) can be ‘shown’ worldwide to experts. Cyclosporin A is better (2–5 mg/kg body weight). 5) were stored in the database with the following description: ‘(2001-11-01 04:48: Female patient.M. because M.O.5 mg every 2 weeks. Another problem arose in Honiara in connection with treating a patient with psoriasis. since relapses very often occur sometimes with a tendency to pustular psoriasis. was at that time on vacation in this village. 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. Recently. in an Internet café in Elunda (East of Crete).O. Discussion on the correct orientation of a specimen of breast tissue (see text). methotrexate in children (or young women) is not recommended.’ The system finds another application by the authors M. on October 7. to demonstrate contributors the histological and cytological findings of their cases. 4. At dermatological problems the macroscopic findings are stored in the database Modern Telepathology 109 . Within the same day the diagnosis was confirmed by a second pathologist in Dresden (G.O.’ – 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.). Cortisone is not recommended.Fig. In this way a histology of a trucut biopsy of a woman was presented telepathologically by H. histology is being processed in our lab right now. treated by the physicians with methotrexate 2. prednisolone 20 mg daily was added. Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 110 .Fig. 5. by the non-experts. 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. Active consultation. The pathological-anatomical findings are then added to the case by the expert. iPath cannot only be used in pathology but in all disciplines of medicine (see text). (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. 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, 26–31]. 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) [16–18]: 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 Modern Telepathology 111 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 expert’s remote microscope control and the microscope on the non-expert’s 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. Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 112 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. Fröscher for the competent editorial collaboration. References 1 2 3 Bhatia RS: Telepathology: Advantages and problems. J Assoc Physicians India 2000;48: 456–457. 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;21:161–167. 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Martin Oberholzer, MD, Department of Pathology, University of Basel, Schönbeinstrasse 40, CH–4003 Basel (Switzerland) Tel. +41 61 265 2525, Fax +41 61 265 3194, E-Mail [email protected] Oberholzer/Christen/Haroske/Helfrich/Oberli/Jundt/Stauch/Mihatsch/Brauchli 114 Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 115–120 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 20–50% 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 This article will focus on telecardiology applications at home. Some of the telecardiology applications are conducted in high-tech hospital-based telemedicine rooms (echocardiograms. cardiac catheterization. Most telecardiology applications. 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. with the exception of transtelephonic electrocardiograms. dizziness.000 of these receiving cardiac monitoring services during 1996. X-rays. 4]. Transtelephonic pacemaker follow-up monitoring is used mostly in the USA. are limited to their utilization mainly because of the high cost of the equipment and absence of reimbursement. cardiac catheterization) but most of the telecardiology applications can be performed from a patient’s home. heart sounds and multiple vital signs to monitor cardiac patients from their home or office. echocardiograms. individuals with pacemakers appear to make up the largest group receiving transtelephonic cardiac monitoring services. MRI. or the pre-warning of Zeevi 116 . At present. presyncope and syncope. and is capable of detecting pacemaker generator malfunction. echocardiogram).applications in telemedicine have generated the most widespread interest among providers and patients. battery depletion. as the need for monitoring the first generation of implanted pacemaker patients led to the development of single-lead transtelephonic electrocardiograms. with approximately 140. Transtelephonic Electrocardiogram Twelve-Lead ECG Transtelephonic 1. Shortening the time interval between initial chest pain and appropriate intervention is a critical factor in immediate and long-term outcome for cardiac patients. They recommend use of transtelephonic 12-lead electrocardiograms for fast diagnosis and intervention. and lead failure [3. Industry sources suggest that the US pacemaker population included an estimated 680. Telecardiology originated more than 30 years ago. CT. Telecardiology programs are not only connected to the consulting services but provide interpretations (ECG. and for remote consultation between cardiologists.to 12-lead ECG has been used for many years in evaluating patients with chest pain and symptoms suggesting possible arrhythmia such as palpitations. home health services and continuous patient and physician education. as well as between general practitioners and cardiologists.000 patients. Telecardiology now uses state-of-the-art telecommunication and image compression technologies to manipulate ‘tele-data’. These include electrocardiograms. in many cases. Telecardiology 117 . 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. An agreement reached regarding a management strategy can. the looping memory recorder which is used mostly for pre-symptoms and the non-looping recorder for post-symptoms. offer instant remote diagnosis in emergency situations and can organize mobile coronary care units for fast intervention. different autotrigger functionalities for the detection of asymptomatic arrhythmias. and can also optimize healthcare costs in terms of reduced emergency room visits. 6]. hospital admissions and usage of additional diagnostic tests [11. as the appropriate strategy for pre-hospital intervention [5. 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. Event Recorders Transtelephonic event recorders have been used to diagnose cardiac patients for more than 30 years. with rapid technological advances. Decreasing mental stress of patients and their family improves their quality of life. usually staffed by teams of critical care unit (CCU) nurses and cardiac technicians supported by consultant cardiologists. they can eliminate false alarms which otherwise may have required unnecessary use of CCU resources. In parallel to the development of mobile emergency services. 12].and post-event times. 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. the loop recorder has become smaller and more sophisticated.receiving hospitals based on confirmed pre-hospital diagnosis. Such systems. thus significantly reducing the time to treatment. a longer programmable memory. Such a service also has the potential to reduce the cost of medical care through a reduced number of emergency room visits [9. Two main types of cardiac event monitors are available. and most recently. Similarly. 8]. obviate the need for patient referral. Correspondingly. 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. Such telecardiology services have demonstrated reduced patients ‘decision time’ from 3 h to 44 min when calling the service provider. 10]. Telecardiology facilitates real-time discussion and useful support between general practitioners and cardiologists. programmable pre. During the last 10 years. and now features 1–3 ECG channels. Cardiac event recorders are used for the diagnosis of palpitations. Many studies have demonstrated a marked improvement in the patients’ functional status. dizziness. which is staffed by trained nurses and ECG technicians. 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. automated reminders for medication compliancy. involving the management of sizeable patient groups and large amounts of data. Patients were pleased and comfortable with the use of this equipment [18–23]. thus lowering medical costs. and accounts for a large proportion of medical care expenditures. Re-hospitalization following heart failure admission is also common. From the fall of 2002 the FDA will only accept ECG data collected for clinical trials in digital annotated format. of whom 45% are re-admitted within 6 months.Patients usually wear these loop recorders for 2–5 weeks. It is the most common indication for hospitalizations in Medicare populations. 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 [13–17]. daily self-monitoring of weight and vital signs (blood pressure. however their use in the rest of the world is limited. Thus using 12-lead transtelephonic digital ECG for clinical research combined with central reading of the tracing is now mandatory for the CROs. pre-syncope and syncope. particularly for the elderly. programs were developed to optimize outpatient treatment and prevent hospital re-admissions. a more timely and cost-efficient process. especially during intermittent symptoms. Zeevi 118 . These multidisciplinary programs consist of patient education. Cardiac event recorders are mostly used in the USA where reimbursement for their usage exists. reduced emergency room visits and hospital admissions. Additionally. The patient transmits the recording for diagnosis to a monitoring center. CROs are continually seeking ways to make the clinical trial phase. the looping memory writes the ECG into stored memory including the pre-symptomatic ECG. SpO2) for the detection of deterioration. Upon patient activation. most other drug evaluations require ECG monitoring of cardiovascular side effects. syncope and pre-syncope. As a result. and 24-hour telephone access to the healthcare provider. More than 50% of these tests are geared to the evaluation of cardiovascular and respiratory drugs. ECG. Home Monitoring for Patients with CHF CHF is a major health problem. Twelve-Lead Digital ECG for Clinical Research Pharmaceutical companies use Clinical Research Organizations (CROs) to test the safety and effectiveness of their products. and chest pain. dyspnea. Eur Heart J 1996. Cheng A. Hammond K. Am J Cardiol 1995. Europe. Domenighine D.1:43–46. 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 Cardiol 1997. Zanelli E. Lamov Z. Chakko S. J Telemed Telecare 1996.2:7–13. et al: Cardiac event recorders yield more diagnoses and are more costeffective than 48-hour Holter monitoring in patients with palpitations.66:214–219. Neil A. Ruggerio C. Benaminovitz A. Heart and Stroke Facts. Karlsten R.79:207–208. Shanit D. Kim KY.6: 140–145.138:633–640. Gibler B. Kinlay S. Herling V Vishlitzki V: The impact of a new cardiac emergency service on subscribers .13:58–66. Prystowsky E: Utility and cost of event recorders in the diagnoses of palpitations.June:61–64.6:1–7.123:835. 2001. Eur Heart J 1995.It is likely that telecardiology will grow and its usage will expand around the world in the coming years. Am Heart J 1992. Roth M. Platt S. Congest Heart Fail 2000. Nanevicz T. Clin Cardiol 2000. Fogel R.19:2089–2098. Am J Cardiol 1999. Cardiologia 1999. Pontinen M. Frost & Sullivan. J Telemed Telecare 2000. References 1 2 3 4 5 American Heart Association. presyncope and syncope. et al: Utility of patient-activated cardiac event recorders in general clinical practice. Am Heart J 1999.79:371–372. et al: Transtelephonic monitoring for pacemaker follow-up 1981–1994. et al: Use of telemonitoring to decrease the rate of hospitalization in patients with severe congestive heart failure. Zimetbaum P. Ann Intern Med 1996. Telecardiology will mature sufficiently as its advantages are realized for enhancing patient care at a lower cost. Piette J. et al: Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope. Am J Cardiol 1997. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Telecardiology 119 . Zipkin D. Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology: Acute myocardial infarction: Pre-hospital and in-hospital management. Sjoqvist BA: Telemedicine and decision support in emergency ambulances in Uppsala. Lintzer M. Furman S. Japan. Pritchett E. et al: The feasibility of a telecommunications service in support of outpatient congestive heart failure case in a diverse patient population. Leitch J. 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. requests for medical assistance: Characteristic and distribution calls. et al: Telecardiology community: A new approach to take care of cardiac patients. Carthy Z.23:271–276.75:184–185. Massie B. Cardiovascular Monitoring Equipment Markets: USA. Kessler D. Greenbaum RA: Telecardiology: Supporting the decision-making process in general practice.124: 16–20. Scalvini S. Organization for Economic Cooperation and Development. Program cuts CHF hospitalizations up to 84%. Roth N. Cordisco ME. PACE 1996. CHF Dis Manage 2000. Kereiakes DJ. Heidenreich P. Am J Emerg Med 1995. 1998. Ho KKL. et al: A cost-effectiveness strategy for transtelephonic arrhythmia monitoring. 1999. Martin LH. Wu J. Am J Cardiol 1990.16: 129–133.84:860–862. et al: Effect of a home monitoring system on hospitalization and resource use for patients with heart failure. et al: Potential reduction of costs and hospital emergency department visits resulting from prehospital transtelephonic triage. Gross J. Evans J.44:921–924. Am Heart J 1999. et al: Prevention of hospitalization for heart failure with an intensive home-monitoring program.22 23 Johnston L. Wheeler J. Rheinweg 7. Arch Fam Med 2000. Fax 41 52 632 0051.9:40–45. Benjamin Zeevi. MD Vice President Business Development 8. CH–8200 Schaffhausen (Switzerland) Tel. et al: Outcomes of the Kaiser Permaente Tele-Home Health Research Project. Medical Director. Ruggiero C. Deuser J. Card Guard AG.com Zeevi 120 .138:633–640. Der E. 41 52 632 0050. Shah N. E-Mail bzeevi@cardguard. vol 32.. A second model is clinicians videoconferencing with remote patients and their referring clinician or nurse who provides details of the physical examination. the link can be used for any patient support measure or educational activity. Range of Uses A common model for teleoncology is real-time videoconferencing. pp 121–126 4. The patient’s case is presented and the interaction is enhanced if the patient’s radiology and pathology can be presented and discussed. Once in place. Curr Probl Dermatol. These interactions can occur hospital to remote hospital. or to a home or community to home. treatment and follow-up based on the transfer of video images of clinicians and patients and data including pathology and radiology images.Burg G (ed): Telemedicine and Teledermatology. Basel. Cancer Centre. This provides a second opinion for the remote clinician. hospital to community center. Here the teleoncology link is between clinicians. Even within this model there are several possibilities. It enhances peer review and is part of quality assurance. S.A. University of Adelaide. 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]. which cannot be done by telemedicine [1]. 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. Karger.6 Telemedicine in Oncology Ian Olver Royal Adelaide Hospital. 2]. 2003. . The opinions of a multidisciplinary cancer team can be provided to rural and remote centers that may only be served by generalists [4]. graphics and text [1. such as prostatic biopsy can be performed [6]. subject to cancellation Olver 122 . while a PC equipped with a camera is the cheapest equipment for digital videoconferencing [7]. often internationally for second opinions which can be digitally returned [2]. The cost of ‘roll-away’ units. 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. Since often a major aim is to export multidisciplinary oncological expertise to a rural or remote area. has fallen dramatically over the past decade to be affordable by most hospitals. Patient Satisfaction One of the early studies of patient satisfaction with teleoncology was from the University of Kansas where outreach clinics.A further use for teleoncology is to obtain second opinions by storing all the patient’s data. Equipment At the top of the range. More specialized uses of teleoncology equipment include the data transfer for CT-based remote 3D radiation oncology treatment planning [5]. and conferences can be recorded on videotape. which can be used in any room equipped with an ISDN. the equipment required is a purpose-built telemedicine theater at a tertiary center for staging multidisciplinary meetings. These use ISDN (integrated systems digital network) lines. 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. pathology and including multimedia educational facilities. including case notes. Evaluation of Teleoncology Evaluating teleoncology is difficult because of the many models used. personal computers can be equipped with small cameras for Internet-based conferencing while a videophone is cheap and simple to install in patients’ homes. then forwarding them to experts. Experts from a distance can direct endoscopies in remote centers and selected surgical techniques. imaging and pathology digitally. with the capability of demonstrating radiology. These systems require less bandwidth and do not require the sender and receiver to be in convenient time zones. 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. Using the ordinary telephone system. Clinician Satisfaction The Kansas teleoncology project reported a survey of their tertiary-based clinicians who were conducting videoconferencing clinics with rural cancer patients. 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. The total patient population surveyed was 39. which suggested general satisfaction [11].when the oncologist was unable to travel due to bad weather. who found the equipment easy to use. The isolated clinicians felt better supported and the tertiary clinicians reported improved communications over Telemedicine in Oncology 123 . patients saw convenience of access as a self-evident advantage of teleoncology [10]. In a subsequent study in Kansas using semistructured interviews. Just over 18% anticipated that telemedicine would have a large effect on their work [12]. recorded similar satisfaction. were supplemented by a videoconferencing link [8]. They considered the videoconference better than a phone call but gave no reasons for this. all found it useful [4]. Patients also expressed concern about the reliability of a nurse as a proxy examiner. In our Australian evaluation of videoconferencing between 20 clinicians in a tertiary and remote center. we reported a teleoncology model of remote clinicians presenting patient data to a tertiary center multidisciplinary team without the patient being present. 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. Similar patient satisfaction with initial interviews was recorded in a teleoncology evaluation in Scotland [9]. They used a 12-question survey with 5-point scales and were able to compare onsite and telemedicine consultations. 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 doctor’s end. although in subsequent experience only 3 of over 250 patients have declined to use the videoconference [1]. There were some problems scheduling all the participants to be together at the same time. but surveyed the remote patients to assess their level of satisfaction [4]. Physicians and surgeons in the Scottish study. Levels of satisfaction with the telemedicine consultation also correlated with the oncologist seen. In Missouri. In Australia. The teleoncology consultation compared favorably to onsite visits except following onsite consultations where patients described more difficulty in being candid in a videoconference. 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. 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]. We hold all our multidisciplinary meetings in the teleoncology theater. 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 Olver 124 . The remote clinicians valued the input of a multidisciplinary team and cited educational and peer review activities as strengths of the system. and Whitten et al. and lack of a reimbursement for a videoconference. Hakansson and Gavelin’s [14] literature survey found only 16% telemedicine publications mentioned economics. 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 can be difficult because a doctor while traveling also loses the opportunity to consult with patients in that time [17]. 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. 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. 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]. The prior data can be sent in hard copy or digitally depending on what equipment is available. Even then. Decreased clinician traveling time was also seen as an advantage. It can for example be used for educational purposes and revenue generated from that [18]. Economic Evaluation There is a paucity of data on the cost-effectiveness of teleoncology and indeed of telemedicine generally.the use of a telephone only. The difficulties with teleoncology were grouped into technical issues such as breakdowns. Costing the equipment should allow for the future decreases in these equipment costs [17]. One of the problems of assessing cost-effectiveness is the need to identify a comparator to the teleoncology link. Occasional face-to-face visits can decrease the impersonality of the teleoncology link. [15] found that most studies were inadequately designed or conducted and was unable to perform a meta-analysis. telemedicine should not disrupt normal practice. Most importantly. Once the telemedicine equipment is purchased it can be put to multiple uses. Ball C. Any electronic information on the Internet or directly transmitted should be accurate.62:275–277. it will become a more attractive candidate for solving the problems of access to multidisciplinary specialist care for rural and remote communities [4]. could a remote clinician be liable for not using it? The Future As teleoncology equipment becomes more sophisticated in the quality. Stud Health Technol Inform 1999.97:38–42. Bauer JJ: A telementored transrectal ultrasound-guided prostate biopsy. Med J Aust 1997. but it may not be apparent to the patient if there are people off camera at one end of the link. Wisc Med J 1998. Summerfield AB. Telemed J 2000. Allen A: Practising oncology via telemedicine. Eur J Cancer 1990. Chissov V Danilov A. . Any record made of the consultation should be confidential. 1999. References 1 2 Doolittle GC.6:213–218. Kretschmer R (eds): The Impact of Telemedicine on Health Care Management. 3 4 5 6 7 Telemedicine in Oncology 125 . 20].into a decrease in the average length of stay of 8. This may be more confused if the teleoncology link crosses state or international boundaries. for video network in medicine (Moscow Information Network for Teleoncology).166:262–265. if a teleoncology link exists to improve the quality of remote specialist care. in Nerlich M. Stitt J: A system of teleoncology at the University of Wisconsin Hospital and Clinics and Regional Oncology Affiliate Institutions. Purkable TL. Obviously there are the same issues of privacy and confidentiality as with any consultation. Yellowlees PM. pp 119–125. Watson JP: Digitised video and the care of outpatients with cancer.26:1025–1026. Moscow. . J Telemed Telecare 1997. Olver IN. here to stay. Selva-Nayagam S: Evaluation of a telemedicine link between Darwin and Adelaide to facilitate cancer management. Medicolegal Issues The medicolegal issues with telemedicine are not unique but shared by other distant communications and medical consultations [4. Vorozhtcov G. Kazinov V Sokolov V Frank G: Perfect DiViSy technology . yet becomes cheaper. Also. IOS Press. Kennedy C: Telemedicine. particularly in direct consultations with patients who have a clinician with them to report on the physical examination. Liability for an opinion may be problematic. Lipsedge M.35 days and that is the data around which our cost analysis can be built [4]. Future uses may encompass everything from education utilizing virtual reality to remote guidance of nanotechnology therapeutic devices.3:63–70. quantity and speed of information transfer. Fax 61 882 322148. Sanders JH.1: 196–201.3(suppl 1):20–22. Haycox A. MD. Gavelin C: What do we really know about the cost-effectiveness of telemedicine? J Telemed Telecare 2000. Med Today 2001. pp 249–264. Allen A. 1997. Loeffelholz P.4:113–119.edu.6:209–215. in Bashshur B. Ian Olver. Hakansson S. Koenig S. J Telemed Telecare 2000. Boles KE. Allen A. Kunkler IH. Springfield.1:34–37. Foreman D: A pilot study of teleoncology in Scotland. Hudson ST.6(suppl 1):38–40. 61 882 225577. Harmon A. Whitten P. Wittman C. Kling B. J Telemed Telecare 1995. E-Mail ian. Grigsby J: Results of a meta-analysis of cost-benefit research: Is this a question worth asking? J Telemed Telecare 2000. Rafferty P. Telemed J 1999. Kingsley C. Shannon GW (eds): Telemedicine Theory and Practice.6(suppl 1):4–6. Hill D. Mair F. Tracy J. J Telemed Telecare 2000. J Telemed Telecare 2000. Telemed J 1995. Madsen R. Henry M. North Terrace. Royal Adelaide Hospital. Whitten P.1:41–46. J Telemed Telecare 1997. J Telemed Telecare 1995. Allen A.au Olver 126 . Carlson E: A cost analysis of a teleoncology practice.6(suppl 1):33–36. Brahams D: The medicolegal implications of teleconsulting in the UK. SA 5000 (Australia) Tel. Zollo S.1:81–83. Hayes J. Webb W: An evaluation of satisfaction with telemedicine among health-care professionals. Williams T: A review of telemedicine cost-effectiveness studies. University of Adelaide. Mitchell J.5:291–301. Mair FS. Hicks LL. Cancer Centre. Mair F. Doolittle G: Teleoncology. Thomas. J Telemed Telecare 1997. May C. Williamson SK. Doolittle GC. Sebille S: Telemedicine to Iowa’s correctional facilities: Initial clinical experience and assessment of program costs. Doolittle GC: Patients’ perceptions of a telemedicine speciality clinic.olver@adelaide. Olver IN: Telemedicine: Prospects and realities. Boysen CD.6:36–40.8 9 10 11 12 13 14 15 16 17 18 19 20 Allen A. Adelaide. Wittman C: A pilot study of the physician acceptance of teleoncology. Williams A. Sadasivan R. Kienzle M. Hayes J: Patient satisfaction with teleoncology: A pilot study. May C. Preliminary evaluation of remote evaluation of diabetic retinopathy has been done [8]. Tex. Pilot Projects Ophthalmology has been evaluated in a significant number of telemedicine pilot projects over the past 10 years. Ophthalmology is a frequently evaluated discipline in telemedicine. evaluated in the USA. included ocular imaging equipment [15]. 2003.7 Telemedicine in Ophthalmology Glenn G. A specially designed space medicine pack for NASA. Hammack Health Informatics and Telemedicine. University of Texas Medical Branch in Galveston.Burg G (ed): Telemedicine and Teledermatology. pp 127–131 4. the USA [4] and India [5]. In Australia. The British military has evaluated tele-ophthalmology in the field [9]. There are few medical disciplines in telemedicine that have had this diversity of application and experimentation. due to its status as a frequent referral need of the primary care practitioner. Ophthalmology was included in a telemedicine evaluation in the Azerbaijan Republic [13]. vol 32. In Israel. Karger. primary care ophthalmology via telemedicine has been explored [10]. Basel. ophthalmology via telemedicine has been piloted in the prison population [7]. Triage of ocular emergencies via telemedicine has been tested in Australia [11. Curr Probl Dermatol.. USA Ophthalmology has frequently been included in discussions of the promise of telemedicine and its impact on medical care [1. Teleophthalmology was identified in a study of telemedicine challenges and a framework to overcome them [6]. 12]. 2]. and a telemedicine link between Hawaii and the Kwajalein Atoll in the Pacific included ophthalmologic consults [14]. . Complete overviews of the topic have recently appeared in ophthalmologic literature in Great Britain [3]. 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. Store-and-forward images were e-mailed from Cuba and Romania to the USA for evaluation. and also provided ophthalmic consult capabilities for servicemen in Kuwait [18]. The alternative to store and forward imaging is real-time video. Applications in remote screening with telecommunications via satellite have Hammack 128 . Some applications require a camera for imaging the external eye and adnexa as well. Clinical Applications Telemedicine has been applied to diverse clinical challenges in ophthalmology.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. real-time video has been used in ophthalmology education to support an international conference [19] and live telementoring of surgery [20]. and in the clinical applications noted below. Comprehensive management of diabetic eye disease has been undertaken [23]. Real-time video was found to be effective in allowing remote consultations between a general practitioner and ophthalmologist [24]. Use of telemedicine in diagnosing strabismus was evaluated [21]. In addition to patient use. Another evaluation found telemedicine diagnosis of strabismus accurate with the exception of small vertical deviations [22]. developed for the consumer camcorder industry. This technology was used to image the eye during spaceflight to evaluate spacecraft air quality [17]. Store and forward uses electronic still images as the examining technology. This modality requires connectivity of sufficient bandwidth to support moving video. usually 128 kbps or more. and the method was found to be effective. Typical devices required for ophthalmic telemedicine are (1) a video-equipped slit-lamp biomicroscope and (2) a digital fundus camera. There are two commonly used strategies in ocular telehealth for sharing of ocular examination images. This technology was utilized in many of the ophthalmology telemedicine clinical pilot projects noted above. These images are captured and then are electronically shared between the patient location and specialist for evaluation. The availability of these new devices since 1990 has enabled the development of ophthalmic telemedicine. Specific digital image formats for ophthalmic images have been proposed [16]. The charge-coupled device (or CCD) color camera. revolutionized digital ocular imaging instruments. been successful [25]. Some studies show a high reliability of ocular telemedicine consults. In addition. It remains unclear whether ophthalmic care is suitable for the medium of telemedicine. 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]. There was high agreement between the accuracy of the telemedicine examinations and the conventional examinations [37]. Effectiveness of Telemedicine in Ophthalmology The clinical impact of ophthalmic telemedicine programs is not consistent. Telemedicine has provided innovative developments in clinical teaching. Clinical and technical protocols were found to be key in maintaining diagnostic confidence with a telemedicine system. 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. significant interdisciplinary education efforts have been supported by ocular telemedicine [32]. in South Africa. and there is little similarity to the evaluation methods between studies. Telemedicine has been used for post-operative follow-up of corneal transplant patients [29] and also evaluated for early diabetic retinopathy screening [30]. and operational success was limited due to the cost of the digital ocular imagers needed and the skilled personnel required to operate them [36]. through the development of an integrated computer multimedia system for ocular teaching and collaboration [31]. A Finnish study found ophthalmic telemedicine to be cost-effective only when more than 110 patients per year were seen using the system [34]. A significant study compared ocular examinations conducted via telemedicine and by conventional methods to a reference standard. a combination telemedicine system that provided ophthalmology services demonstrated decreasing use over time due to technical and organizational concerns [33]. Conclusions There have been a significant number of ophthalmic telemedicine programs developed and implemented. 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. Recently. Others indicate that the costly ocular imaging equipment and skilled personnel required at the patient site prevents Telemedicine in Ophthalmology 129 . J Telemed Telecare 1998. Telemed J E Health 2001. Kilbey JH. Nagpal PN: The impact of information technology on the practice of ophthalmology.4(suppl 1):97–99. Ramani V Hart CJ. with consistency in study design and evaluation techniques. J Am Assoc Pediatr Ophthalmol Strab 2001.7: 261–265.ophthalmic telemedicine from being effective. Williams A. Henderson C. Levy BJ. Rosengren D. Tennant MT. Kelly G. Murrillo S: Teleophthalmology: Rationale.5:291–296. J Telemed Telecare 1999.4: 375–377. Naranjo R. Gogolitsyn Y. Bursell SE. Kelly GJ. Trasler M: The first telemedicine link for the British Forces. Delaplain CB. Norton SA. Blackwell N. 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Constable IJ: Working toward a portable tele-ophthalmic system for use in maximum-security prisons: A pilot study.5(suppl 1):17–20.67:423–428.67:1080–1085. Birkmire-Peters D. Hernandez L: Telemedicine: Strabismus e-consultation. Greve MD: Tele-ophthalmology via stereoscopic digital imaging: A pilot project. Definitive clinical and economic successes have yet to be documented. Billica RD: A field trial of the NASA Telemedicine Instrument Pack in a family practice. Lindborg CE. J R Army Med Corps 1998.144:125–130.44:61–72. Lifshitz T. Papakostopoulos S: Evaluation of . Ophthalmology 2000. Baker RS. Klein SA.4(suppl 1):1–2. Telemed J 1999. Hinz BJ. Dean-Hart JC: Comprehensive standardized ophthalmic telemedicine. Barry CJ.4(suppl 1):42–43. Standardized evaluation of transmission modalities.107:1999–2005. Kraft SP. J Telemed Telecare 1998. Dodson K. March GA. More study is required. Kanagasingam Y. Br J Ophthalmol 1999. Hawaii Med J 1993. Macarthur C: Strabismus examination by telemedicine. Ogle JW.83:1254–1256. Rodriguez RE: Real-time telementoring in ophthalmology. Lamminen H. Aviat Space Environ Med 1996. Crump WJ. Dodson K. Yamada J. Flowers CW Jr. Helveston EM. Lenton L. Nagpal M. References 1 Morin JE.29:642–648. and ophthalmology. Stud Health Technol Inform 1996. Aiello LM: Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hammack 130 . Aiello LP. Ann Med 2001.33:222–228. Clermont AC. Orge FH. Med J Aust 1997. Cavallerano AA. Gupta SC: Introduction of new . Mehl DC. current issues. Papakostopoulos S. Everingham M. Giladi R. J Telemed Telecare 1998. Shanit D. Scott C. Samedov RN: An Internet station for telemedicine in the Azerbaijan Republic. Cohen KL: External ocular hyperemia: A quantifiable indicator of spacecraft air quality. Glastonbury J: The use of telemedicine to treat ophthalmological emergencies in rural Australia.3:43–52.52:338–339. Papakostopoulos D. Cavallerano JD. Gimbel HV Cuzzani O. Telemed J 1997. Aviat Space Environ Med 1996. Papakostopoulos D. Hyytinen P.24 25 26 27 28 29 30 31 32 33 34 35 36 37 Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy. Zhu N. Bailey JE. Shimmura S.3: 141–157. and telecollaboration: Design considerations and prototype construction. Murdoch I.5:38.6(suppl 1):96–98. Telemed J 1997.64: 173–178. Wynchank S: Telemedicine in South Africa: Success or failure? J Telemed Telecare 2001. telemedicine. Maren N.hammack@utmb. Berger JW: An intelligent. Tang RA: Telemedicine enters eye care: Practical experience. E-Mail glenn.7(suppl 1):25–26. Rendall J: Postoperative evaluation of patients following ophthalmic surgery.7:167–173. Lamminen J. Smith L. Briggs R. J Telemed Telecare 1997. Shinozaki N. 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Marier RL: Reliability of telemedicine examination. Cuypers M. Eikelboom R.28:129–132. Tang R: Collaborative telemedicine between optometry and ophthalmology: An initiative from the University of Houston. Stud Health Technol Inform 1999. Glenn G. Lof R: Tele-ophthalmology for the treatment in primary care of disorders in the anterior part of the eye. Nitzkin JL. Barry C. Constable IJ. Stud Health Technol Inform 1999.3:227–228. Bainbridge J. Ohinmaa T. Jitskaia L: Tele-ophthalmology screening for retinal and anterior segment diseases. Schiffman JS. Yogesan K. Suite 718. J Telemed Telecare 2000. Hariprasad R. Clin Exp Ophthalmol 2000.62:124–129. J Ophthal Nurs Technol 1998. J Am Optometr Assoc 1998. 1 409 7472601. Director of Health Informatics and Telemedicine. TX 77555–1006 (USA) Tel. Taylor P. Blomdahl S. Burns J. Cuypers M: Fred Hollows lecture: Digital screening for eye disease. Fax 1 409 7472603. Li HK. Galveston. Fukagawa K. Lamminen H. Eddy C.7(suppl 2):47–49. 8 Implementation of a Telepsychiatric Network in Northern Finland Marja-Leena Mielonen.Burg G (ed): Telemedicine and Teledermatology. it is rapidly increasing as a means of daily patient care . Juha Moring. University Hospital of Oulu. Because videoconferencing saves travelling. Curr Probl Dermatol. making the expert’s help and the transfer of patient information to the right place possible regardless of where the patient or the relevant information is actually located. Basel. Arto Ohinmaa. The principal telepsychiatric communication method is videoconference. Matti Isohanni Department of Psychiatry. Leena Väisänen. The only university hospital of this area is located in Oulu. Another possibility is to exploit modern technology in treatment. trouble and expenses. 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]. In this way it is possible to enhance regional equity. 2003. 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. which can replace the customary consulting hours whenever the patients and their families live a long distance away from the doctor. pp 132–140 4. which permits simultaneous sound and image connections between two or more consultative parties. Telemedicine also involves consultations and supervision between professionals. time. Karger. supervision and teaching by medical staff. control visits and treatment are possible through the use of telecommunications. One of the advantages of using videoconference contacts is that the expert knowledge can be attained when and where it is needed. Telepsychiatry refers to interactive psychiatric communication through a telematic network. consultation. Our aim is to use videoconferencing and its applications in Northern Finland and describe this implementation here. vol 32. The application of telemedicine means that the examination of a patient. 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].and staff training in Finland. there is not yet sufficient evidence about the cost-effectiveness of videoconferencing in psychiatry. As a precursor of videoconference equipment. ease of use. and the equipment was also used for surveillance of other connections. PC-based equipment and reductions in the cost of telecommunication. A detailed description of the project has been published elsewhere [6–8]. fast and relatively inexpensive method to offer psychiatric services across long distances [6–9]. It was first used experimentally in conditions such as internal TV transmission in the hospital. and to create a reliable infrastructure (sufficient resources. the quality of both sound and picture improved. a videophone was developed in the USA in 1964. Interactive videoconferencing provides an easy. family therapy. The novel Telpsyko project for the years 2001–2002 aims to set up an integrated distribution system for public health service facilities (the best expertise available at the time. 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. Videoconferencing has subsequently been employed successfully for many purposes in telepsychiatry.g. accessibility). counselling. Experimentation continued subsequently in different parts of Canada and the USA [3–5]. The results so far have been promising. Videoconferencing in Telepsychiatry 133 . teaching and administrative negotiations. e. compatibility and confidentiality). However. quickness. Below. the cost of videoconferencing decreased substantially owing to the development of low-cost. At the same time. In the 1990s. cost-effectiveness) and to improve the quality of shared information both in data production (reliability. treatment cooperation. 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. we will present some preliminary practical conclusions based on this project. patient negotiations. confidentiality. 000. 9]. Responsibility Area Oulu University Hospital is responsible for the demanding specialized medical care of a population of approximately 720.Norway Sweden 60 miles (n. 24% for occupational supervision. serving the whole of Northern Finland. but a greater proportion of the consultations and discussions were done by videoconferencing [8. Oulu University Hospital (fig. the need for psychiatric community services has increased markedly at the expense of hospital treatment. 1). The overall number of consultations did not increase in this region. 40% of the on-line time was used for teaching. Connections from Oulu University Hospital’s Department of Psychiatry. 16% for consultations and patient negotiations and 20% for training. In this area. Mielonen/Väisänen/Moring/Ohinmaa/Isohanni 134 . the Clinic of Psychiatry had a total of 600 h of telepsychiatric connections.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. The supervision and training that the health service staff needed were mostly obtained from the Department of Psychiatry. 1. During 2001. 12]. Technically. patients. but not in all. for example. the connections could be established nearly in every time. videoconferencing is equated to conventional telephone consultation. many health organizations use the new technology in their distance-caring practice. Furthermore. under the requirements of a mental health act. The patients and their families have been less negative about videoconferencing than expected. if one must settle the (legal) responsibility issues? The consulting doctor can never take full responsibility for a patient. how does one estimate the patient’s suicide risk on the basis of a videoconference. Nowadays.Practical Experiences The experiences in patient care have been positive. such as shaking hands and touching. It is important to discover the possible shortcomings in the examination that might affect treatment via videoconferencing. The videoconferencing treatment sessions are entered in the patients’ case records. Participants in family therapy and supervision generally want to continue with videoconferences. The participants were satisfied with the quality of the audio. the quality of the video. performed an assessment of a patient who has been confirmed to be mentally ill by a magistrate [10. Legally. The participants were seldom unhappy after videoconference negotiations. and the general quality of the videoconferencing interaction. Written consent for treatment is recommended. At the beginning of the videoconference. The current Finnish legislation does not recognise the use of videoconference systems in treatment. and the legal responsibility is therefore at the site where the patient is. The participants in a videoconference should know each other beforehand. Cases have been reported from Australia in which a specialist working through telepsychiatry has. the content of the meeting should be explained. In our previous study [6]. especially to first-time patients and relatives. The significance of these factors has not been properly evaluated yet. relatives and other social and healthcare staff who had participated in videoconferences were given a user survey questionnaire after the sessions. It is not possible to sense smell. Videoconferencing in Telepsychiatry 135 . the personnel. The doctor or other specialist always needs to assess the suitability. acceptability and legality of the decisions concerning a patient reached via videoconferencing. For example. can we equate a videoconference with a face-to-face consultation? In most clinically relevant aspects we can. The workers who carried out family therapy sessions and supervision pointed out. This helps to structure the interaction. The normal physical contact is lacking in a videoconference. that the participants have to take turns to speak in a videoconference and cannot speak simultaneously. as normally in a family session. The attitudes of the staff have become more positive along with the increase in participation and user experience. among other things. Oulu University Hospital. 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.e. assuming that 30% of the transmissions from the Department of Psychiatry and 60% of those from the health centres are between these sites. and then the only significant cost of telepsychiatry in videoconferencing is the salary costs of the participants [8]. cost-saving compared to the conventional practice. The lease for the gateway needed for a multipoint conference (i. both primary and special care personnel. In the Department of Psychiatry of Oulu University Hospital. it takes an entire working day to travel to a psychiatric meeting in the Oulu University Hospital. The price range of the videoconferencing equipment available in Finland is wide. The installation costs of the ISDN lines were about EUR 330 per line. Videoconferencing can improve the quality of psychiatric care and increase cooperation between primary and secondary care units. patient care planning negotiations are arranged with the psychiatric personnel of the primary care units and the relatives in the municipality. the cost of the PC-based videoconferencing equipment and three ISDN lines was approximately EUR 15. Negotiations via videoconferencing are. The lease for one ISDN line was about EUR 20 per month. in the long run. The health centres used similar equipment. According to our feasibility study [8]. 90% were satisfied with the quality of the communication via videoconferencing [8]. 9]. a conference connecting more than two sites) varied (1–3 ISDN) from EUR 40 to 60 per site when the system was used for domestic and district calls. The cost-saving can be obtained with a relatively small number of meetings (25–30) per year. the prices varied within EUR 12. the distance being about 200 km (fig.000–50. At the moment. The costs of videoconferencing were half of the costs of conventional negotiations. However. Of the respondents.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. Mielonen/Väisänen/Moring/Ohinmaa/Isohanni 136 .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]. In 2001. relatives and patients assessed the quality of both technical factors and the negotiation itself to be good. 1). efficient use of the videoconferencing equipment lowers the fixed costs per transmission.000. The cost of a 1. For a Kuusamo health centre doctor. At the Department of Psychiatry. even cheaper equipment alternatives are available [8.000 (1 EUR USD 1. The cost of a videoconference is 6 times the cost of a telephone call.8). The most important reason for the primary care personnel to arrange the negotiation by videoconferencing was the costs. User training will be necessary for professionals. but acquire more skills along with increasing experience. What Should Be Taken into Account in Preparing a Videoconference? It is important to notice the basic things that improve the quality of videoconferencing. According to our experience. A good videoconferencing situation demands very much from both the user technology and the environment (table 1). angle of view and audibility). and these have impeded communications. We always assess the use of the videoconference system in psychiatry from the point of view of different user parties. The videoconference room should be situated in or near the admission area. operation. when videoconferencing is started. one should seek to avoid cancellation of previously agreed appointments with the patient. nurses and other workers personally contact others via videoconferencing.e. The compatibility of the equipment should be guaranteed by standardization. Beginners make a lot of mistakes (light. compatibility problems have occurred from time to time. It has turned out that the people who only use the equipment occasionally tend Videoconferencing in Telepsychiatry 137 . The videoconferencing room must be peaceful and soundproof for professional secrecy. The goal is to make each professional able to act independently in an on-line situation. and many doctors. it is necessary to give written instructions and to provide staff training.Table 1. productivity and acceptability as well as effectiveness. one can avoid making mistakes with technical situations. three ISDN lines (i. Using a checklist. The participants’ experience of videoconferencing and familiarity with the equipment increases the likelihood of a successful videoconference. Each situation should be planned beforehand. Naturally. However. consultation and therapy (table 2). 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. because videoconferencing is a fairly demanding technique. and the special features possibly involved in it should be borne in mind [6]. we were sometimes unable to establish a contact because either the sound or the image did not transfer adequately between the conference points. 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. 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 patient’s 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 one’s organization and one’s 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 [10–12]. Mielonen/Väisänen/Moring/Ohinmaa/Isohanni 138 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 patient’s 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 people’s 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. Videoconferencing in Telepsychiatry 139 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;16:99–100. Preston J, Brown FW, Hartley B: Using telemedicine to improve health care in distant areas. Hosp Commun Psychiatry 1992;43:25–32. Dongier M, Tempier R, Lalinec-Michaud M, et al: Telepsychiatry: Psychiatric consultation through two-way television: A controlled study. Can J Psychiatry 1986;31:32–34. Dwyer TF: Telepsychiatry; psychiatric consultation by interactive television. Am J Psychiatry 1973;130:865–869. Mielonen ML, Ohinmaa A, Moring J, Isohanni M: The use of videoconferencing for telepsychiatry in Finland. J Telemed Telecare 1998;4:125–131. 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;6:152–157. 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):66–68. Werner A, Anderson LE: Rural telepsychiatry is economically unsupportable: The Concorde crashes in a cornfield. Psychiatr Serv 1998;49:1287–1290. Yellowlees P: The use of telemedicine to perform psychiatric assessments under the Mental Health Act. J Telemed Telecare 1997;3:224–226. 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;1:79–85. 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;1:79–85. 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;104:223–226. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Marja-Leena Kuusimäki Mielonen, MD, Department of Psychiatry, University Hospital of Oulu, PL 29, FIN–90229 Oulu (Finland) Tel. 35 88 3152011, Fax 35 88 336169, E-Mail marja-leena.kuusimä[email protected] Mielonen/Väisänen/Moring/Ohinmaa/Isohanni 140 Burg G (ed): Telemedicine and Teledermatology. Curr Probl Dermatol. Basel, Karger, 2003, vol 32, pp 141–147 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 Satava 142 Diagram of the telecommunications pathway from the individual climber back to the conference room at Yale University School of Medicine (author: B. Camp 1. Crossing a deep crevasse on the Khumbu Icefall. Wyo. Jackson. Everest (E399) Satellite Climber wearing sensors. 2. Fig. 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.). demonstrating the trail and location of an individual climber.. One small excursion slightly beyond Telemedicine and Real-Time Monitoring of Climbers 143 . The large concentration of data points in the upper left is at Camp 1. Climbing Team Leader. USA). using ladders roped together (courtesy of James Williams. where the climbers established camp and remained overnight. 3.H.Real-Time Physiologic Monitoring From Mt. and on the right are the individual climber’s vital signs (courtesy of Dr. 4. and then retransmit the entire data from the last successful transmission. Tom Blackadar. Inc. Wellesley. Whenever there was a loss of transmission. USA). 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.. with the numbers representing the locations of the four camps. there is a large skew of 1 climber position due to malfunction (most likely miscalculation of GPS satellite signal capture). In addition. Clicking on any of the climber boxes reveals the detailed individual vital signs screen which provides specific overall information as well as the chronological. with the exception of 1 climber whose heart rate monitor functioned 78% of the time.. The data was monitored in real time and then was stored on both the receiving computer and the wearable datalogger. high-fidelity presentation of the data points which were acquired in real time and plotted every 5 min. The heart rate varied from a minimum of resting at 86 to strenuous exercise of 164 beats per minute (bpm). The laptop computer screen. Camp 1 for purposes of photographic documentation can be noted heading diagonally to the upper left corner. On the left is the terrain map of Mount Everest with the overlay of the climbers’ position. The climbers had different baseline heart rates Satava 144 . the datalogger would continue to store the data. The VSM functioned for 95–100% of the time. depending upon activity. showing the intuitive graphical interface. Fitsense Technologies. The inset in the lower left corner is a reference graphic representation of the vertical ascent which is usually taken to the summit. PhD. Mass.Fig. 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. however after a short time the system became erratic in location acquisition and then totally failed. and there were a few times when skin temperature trended in the inverse of core temperature. There was no direct proportionality between the skin and core body temperature. 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 reliability of acquiring location on the two functioning GPS systems for continuous monitoring was 100%. often (but not always) correlating to rapid increase in the actigraph. 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 1–3°C) in pill temperature. The skin temperature sensor functioned extremely well with the maximum variability of skin temperature of 22. The GPS location functioned well in 2 of the 3 climbers. especially in those individuals with chronic disease states. and fluctuated only 1–3°C over the duration of a climb. Unfortunately. In April 1999. Discussion One direction of the future of telemedicine seems to be pointing to continuous monitoring of health status. activity level. 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 Telemedicine and Real-Time Monitoring of Climbers 145 . skin temperature and even a gradual and persistent increase in core body temperature.6°C. One VSM initially had an excellent functioning. though there were numerous intervals of 10–20 min when a sudden dramatic increase in heart rate was accompanied by a rise in actigraph level.7–39. The Sherpa had a lower baseline (86–100 bpm).before the ascent.1–34. while the two other systems continued to function perfectly well at the same time and place. All of the climbers had increase of heart rate to the 150 range. but was usually within 4–7°C of core body temperature. skin temperature and core temperature was not consistent. usually in the 100–120 range after acclimatization. The VSM had a loss of transmission rate from 3 to 12%.3°C (usually 5–10°C over the duration of a strenuous climb of 6–9 h) and was much greater than the core temperature variation of 36. The correlation between heart rate. The core temperature pill was extremely accurate. episodic model utilized today (with): Intelligent wearable sensors. however the entire system provided a continuous update upon the location and health status of climbers under extreme duress.. There seems to be a consensus that wearable. which can then lead to the development and implementation of the same systems for daily living to improve the health of every person. the E3 demonstrates that continuous remote monitoring of an individual is possible.migrate to a more proactive. in non-extreme circumstances. However. wireless transmission of health data is commonplace. it will become cost-effective to wirelessly ‘plug in’ a VSM system to the existing infrastructure. high-cost.25: 229–236. preventative model rather than reactive. Yale. routine vital sign monitoring can become routine. this expedition was very expensive. trend analysis tools. the cost could be justified. deep-sea activities or high-profile expeditions. initial concept and feasibility of a new technology begins with proof under extraordinary circumstances. even on a global scale. pp 322–337.Y. Coburn B. USA. NASA Commercial Space Center for Medical Informatics and Technology Applications. N. and the Saint Charles Hospital. mass-produced devices. 1997. Inc. nursing homes and assisted-living communities become more high-tech with built-in information systems infrastructure. Comput Biol Med 1995. Willard/Ohio. 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. predictive algorithms…’ [5]. 1998. New York. As the hospitals. Port Jefferson. Villiard Books. Under certain circumstances. On a daily basis. References 1 2 3 Krakauer J: Into Thin Air. Satava RM: Virtual reality and telepresence for military medicine. however there are no documented reports of continuous real-time monitoring of vital signs on an ambulatory person in truly remote or hazardous conditions.. such as the battlefield. In addition. As always. one-of-a-kind device to the commercial sector for affordable. Acknowledgements Support for this research was provided through a grant from Olympus America. Satava 146 . National Geographic Society Press. The NASA is legendary for technology transfer from experimental.. Beshears D: Everest: Mountain Without Mercy. such as the E3. Conn. not only the equipment but also the telecommunications costs. pp 76–87. space exploration. 1 203 7649069. Int J Radiat Oncol Biol Phys 1991. Sathiaseelan V Rademaker AW.be.edu Telemedicine and Real-Time Monitoring of Climbers 147 .cua.4 5 Mittal BB. ingestible telemetric temperature sensor for deep hyperthermia applications. CT 06510 (USA) Tel.htm Richard M. E-Mail richard. Herman W (eds): Workshop on Home Care Technologies for the 21st Century: http://www. 40 Temple Street. MD.hctr. Yale Endolaparoscopic Surgery Center.edu/ hctworkshop/HCTr_F. in Winters J. Warren S: Smart healthcare systems and the home of the future. Dighe A. Satava. Brand WN: Evaluation of an . Suite 3-A.21:1353–1361. Fax 1 203 7649066. Johnson PM. New Haven. Pierce MC.satava@yale. such as medication administrations or simple treatments. Karger. rivaling and in some cases exceeding levels available to the general population.Burg G (ed): Telemedicine and Teledermatology. Today in many nations healthcare provision to the incarcerated is greatly improved.10 Telemedicine in Corrections Glenn G. Aspects of care not typically monitored in free-world ambulatory healthcare. Curr Probl Dermatol. vol 32. litigation forced many changes and set minimum standards for inmate healthcare [1]. pp 148–152 4. Hammack Health Informatics and Telemedicine. Many of these include mandatory on-site review and accreditation. Standards for correctional healthcare provision are now established at national and international levels [2–4]. University of Texas Medical Branch in Galveston. In the USA. are carefully logged. In the USA. USA Delivery of healthcare is an expected component of incarceration.. As recently as the 1970s. The incarcerated population is proving to be a concentration point for several important infectious diseases [5]. The quality of healthcare delivery within correctional settings such as prisons. correctional healthcare was primitive. a litigious atmosphere results in correctional healthcare receiving several levels of internal and external oversight and procedural compliance monitoring. 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). with prison or jail inmates to providing healthcare services to one another in some cases. . Basel. Tex. jails and other detention facilities has been an issue of human rights concern. Attention is being focused on the public health risks posed as inmates are released back into the general population after incarceration [6]. 2003. the initial remote prison site was used as a ‘telemedicine hub’ to which inmates were transported for care. These applications provided specialist consultations to the inmate population. They also endure an increased risk of physical assault due to the nature of the patients they serve. Internet Protocol (or IP) is now emerging as an alternative to ISDN telecommunications for videoconferencing. The hub location is chosen such that transport of the inmates to the hub is less distance than to the consultant location. Telemedicine in Corrections 149 . Inmate patients have reported high acceptance of telemedicine care [9. usually a medical college or university. 16]. with still image store and forward being utilized in some cases. All studies noted improved access (reduced wait times) to specialist care using telemedicine compared to physically transporting inmates outside of the correctional environment. correctional telemedicine programs are being developed in many states. The Internet has been used for store and forward inmate healthcare [13]. In Ohio. additional telemedicine hubs are implemented [9. Development of Correctional Telemedicine Correctional care was included in some of the earliest expectations for telemedicine [7]. In the USA. Correctional telemedicine has also obtained high use satisfaction ratings from consulting specialists and remote site presenters [9. ISDN-based telemedicine networks provide live continuous bidirectional audio and video [12]. 95% of the telemedicine consults saved one or more trips to an external clinic for outpatient specialty services [9]. correctional telemedicine is credited with reducing the costs of providing inmate medical care by lessening or eliminating the need for additional security guards. Correctional healthcare providers have increased exposure risks for these serious and nuisance conditions. 11]. and HIV are critical needs in correctional care. The close proximity and isolation of the incarcerated population also make nuisance conditions spread quickly. After analysis of the effectiveness of the initial location. 15. The earliest efforts occurred in the 1990s as pilot or demonstration projects [8–10]. In Texas.Qualified specialist management of hepatitis. tuberculosis. Benefits of Correctional Telemedicine Reduced inmate transport has been reported as a benefit of correctional telemedicine. vans and chase vehicles [14]. 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. 14]. In most studies. Currently. a nurse or physician extender will act as remote presenter for primary care-oriented visits. In East Carolina. IP-based systems are gaining slowly in popularity as cost and data security concerns are addressed by the telecommunications industry. Correctional telemedicine has most frequent use in access to specialty disciplines for referrals. and may have additional imaging tools. Cost-Effectiveness of Correctional Telemedicine Cost-effectiveness of telemedicine has been documented. gastroenterology [8]. neurology [20]. the presenter will perform needed physical examination or imaging techniques. Clinical routine for the presenter will include pre-visit preparation of chart summaries and pertinent chart documents for faxing. In contrast. In the correctional setting. and laryngoscopy. Typically. with varying levels of impact.Correctional Telemedicine Methods Most correctional telemedicine systems provide bidirectional video and audio between the provider and the patient. At the patient location. 20]. Copy-stand type document imaging cameras with adjustable lighting are used to provide remote viewing of photographs or documents. ISDN-based systems comprise the majority of these systems. 18]. and professional-quality video monitor for viewing the patient image. In most ISDN-based telemedicine systems. This individual can be a nurse. a 90% cost reduction [8]. eliminating the need for faxing. facsimile (fax) transmission provides sharing of the written medical record between the patient location and provider location. and will assist with the patient interview and encounter documentation. providing otoscopy. Additional medical video cameras are utilized. Other medical telepresence technologies such as digital telestethoscopy are used. or physician. fundoscopy. physician assistant. The provider site is equipped with a camera to image the provider. a presenter is used to provide remote examination services. telemedicine is used for chronic care provision rather than acute care. radiology [19]. Many of these are equipped with backlight (lightbox) to allow remote imaging of radiographic films. The remote (patient) site is similarly equipped. A later review of the same correctional telemedicine program using a return-on-investment (ROI) Hammack 150 . Specific medical disciplines noted as being successfully provided via telemedicine include dermatology [17. Some correctional systems are using electronic medical record systems to share medical information. initial consults and post-operative consults. Physicians are most likely to present on specialist consultations. the cost to transport a patient 160 km from prison was estimated to be USD 700 per visit. and ophthalmology [12. the cost of a telemedicine consultation was estimated at USD 70. At the time of videoconference. cardiology. 48 per visit. Records of the United States Court of Appeals. a savings of USD 14 per encounter [24]. USA. This same study reported a cost per medical consult at USD 255. World Health Organization: Healthy prisons – A vision for the future.analysis yielded a more conservative 4-year ROI for the telemedicine system [21]. Transport savings totaled USD 35.640 and medical care savings USD 21. Conclusions Correctional medicine has characteristics that make it amenable to telemedicine.78:236–240. Ill. UK. aff ’d in part and rev’d in part. A similar study from Iowa placed the break-even point at 275 telemedicine visits per year [11]. Department of Public Health. Liverpool. 679 F 2d 115 (5th Cir 1982). 103 S Ct 1438. 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. Chicago. Lanham.51 for a face-to-face encounter. High security and transport costs are associated with bringing the incarcerated patient out of prison and into the traditional clinic for care. a savings of USD 8. The operating costs of the telemedicine system totaled USD 42. 1996. As volume increased.123. References 1 Ruiz v. 460 US 1042. telemedicine service cost savings were USD 46 per visit. 688 F 2d 266 (5th Cir 1982). American Correctional Association. Estelle. 1996. amended in part and vacated in part. 503 F Supp 1265 (SD Tex 1980).19 per visit for telemedicine versus USD 263. Analysis of telemedicine cardiology services showed a varying benefit dependent on use [22]. Report of the First International Conference on Healthy Prisons.277. 75 L Ed 2d 795 (1983).486 for 165 visits over 7 months [23]. March 24–27. National Commission on Correctional Health Care. Telemedicine has provided improvements in access to specialty care for this population. Initial visit volumes of 25 per year resulted in telemedicine services costing USD 45 per visit more than traditional clinical encounters. cert denied. 2001 Accreditation Standards. An integrated analysis of both patient transport and medical care costs for HIV care in Virginia reported a real cost savings of USD 14. Telemedicine has proven cost-effective in correctional care. Geneva. 2 3 4 5 Telemedicine in Corrections 151 . Patient. USA. Md. WHO/ Liverpool. 2001 ACA Accreditation Standards. J Urban Health 2001. and consulting provider satisfaction ratings have been high. University of Liverpool. Hammett TM: Making the case for health interventions in correctional facilities. 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]. referring provider. edu Hammack 152 . Fisher EJ.2:25–35. Balch D: Development of a telemedicine and distance learning network in rural eastern North Carolina. Slipy SM: Telemedicine and interconnection services reduce costs at several facilities. Kesler C. Kanagasingam Y. Jones BE. Fisk KJ: Cost-minimization analysis: A follow-up study of a telemedicine program. Barry CJ.42:26–30.2:17–24.78:214–235. Telemed J 1996.133:197–200.2: 139–143. Telemed J 1998. Prison and health system partner with Ameritech. E-Mail glenn. Health Manage Technol 1995. Anonymous: Prison telemedicine gets an enthusiastic thumbs up – from the inmates. Youngblood B: The University of Texas Medical Branch – Texas Department of Criminal Justice Telemedicine Project: Findings from the first year of operation. Hammack. Fisher E. Barry CJ. Marks TK. Brunicardi BO: Financial analysis of savings from telemedicine in Ohio’s prison system.183:1123–1136. Zincone LH. Hampton C. 36–37. Kienzle M. Suite 718 Galveston. Burdick AE. prisons and the health of urban populations: A review of the impact of the correctional system on community health. 55. Hampton CL. McCain T: An Ohio telemedicine system for prison inmates: A case report. Malloy WN. Mekhjian H. 32–34. MD. 2201 Market Street. Gailiun M. Zollo S. Laing VB. Burdick AE.3:11–17. Bonnin A: Medical tele-imaging: A good chance for the future (in French). Neece A: Financial analysis of telecardiology used in a correctional setting. Telemed J 1997. Gray CL. Parpart F. Telemed J 1997.5:291–301. Telemed J 1996. Dixon L. Mekhjian H. Loeffelholz P.3:61. Peterson C. Yogesan K. Constable IJ: Working toward a portable tele-ophthalmic system for use in maximum-security prisons: A pilot study. Doty E. Turner JW. Bull Acad Natl Med 1999. Director of Health Informatics and Telemedicine. Telemed J 1999. McCain TA: Patient satisfaction with telemedicine in a prison environment.3:247–255.7(suppl 2):63–64. Warisse J. J Urban Health 2001. Gailiun M. Henderson C. Telemed J 1998. J Telemed Telecare 1995. Berman B: Teledermatology and underserved populations [erratum appears in Arch Dermatol 1997. Hampton CL. Norton SA. J Telemed Telecare 2001. Telemed Virt Real 1998. Ostomy Wound Manage 1996.5:55–61. Brecht RM. Gustke S: Dermatology teleconsultations to Central Prison: Experience at East Carolina University.6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Freudenberg N: Jails. Krick RS: The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia. Telemed J 1996.4: 323–327. Arch Dermatol 1997. Telemed J E Health 2000. Phillips CM.16:52. McCue MJ. Fisk KJ. Balch DC: Financial analysis of telemedicine in a prison system. University of Texas Medical Branch in Galveston.7: 261–265. Constable IJ: Online eye care in prisons in Western Australia. Fax 1 409 7472603. Burke WA. J Telemed Telecare 1999. Malloy W. Mahmud K.1:178–182. Telemed J E Health 2001. Phillips CM.hammack@utmb. Balch D. 72. Mazmanian PE. 1 409 7472601.4:49–54.133:819]. Marks TK. Sebille S: Telemedicine to Iowa’s correctional facilities: Initial clinical experience and assessment of program costs. McCue MJ. Jenkins DP: Telemedicine: Caring for patients across boundaries. McCue MJ. Parpart F. TX 77555–1005 (USA) Tel. Mazmanian PE. Henderson C.6:385–391. Murphy R. Glenn G. 5 Teledermatology . held each year. in 1995. Laura Milesi Dermanet Reinach.1 of the dermanet communication suite software was ready for marketing in 1998. Curr Probl Dermatol.roche-pharma.1 Teledermatology in Clinical Use Burg G (ed): Telemedicine and Teledermatology. 2003. Switzerland A Bit of History… Dermanet is a completely integrated total solution for the everyday routine of dermatology in practices and hospitals (fig. and the utilization of potential synergies. pp 154–157 5. Karger. In such a context. Version 2. It was clear from the outset that the project could be achieved only by intensive cooperation between an array of experts. cost effectiveness. vol 32.2 of the software was completed . optics. The basic idea goes back to the early days of the Internet age.ch) decided to set a development goal in this direction. 1). a group of Swiss dermatologists in cooperation with Roche Pharma (Schweiz) AG (www.1 Dermanet® – A Tailor-Made Tool for Teledermatology… Lorenz Kühnis. but also from applications software. Two years later. and by means of regular written and verbal questionnaires. The user-friendliness and functionality of the software was optimized in various workshops. version 2. 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. For this reason. the key parameters are quality assurance. and imaging. French and English. not only from dermatology. The requirements for the use of a platform of this kind were defined at a start-up workshop.5. 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 first prototype of the dermanet communication suite software version 1. Basel. The system was practice-tested to make it increasingly practiceperfect. system safety.0 became available in 1997 in German.1. g. including those required to deal with adaptation to the year 2000. We should like to take this opportunity of thanking once again all those who helped. In addition. e. all the university hospitals in Switzerland (Basle. various special adapters were developed that are now used in many dermatology practices. Today.dermanet. The program also constantly imported improvements from standard consumer-level developments to obviate dependence on outdated expensive and complicated specialist technology. Geneva.ch for details. with various adjustments and expansions. 1. a digital Dermanet 155 . 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. Dermanet – see www. Based on the Nikon Coolpix 900 digital camera line. Lausanne and Zurich) are linked to the dermanet platform and make their specialist services available on it. Bern. An abiding concern throughout the whole development period was to be compatible with the most important standards and open to future requirements and developments. 25–30% of independent Swiss dermatologists use dermanet in their work with colleagues and centers of excellence. their precision and their knowledge. so that these could be incorporated and made available rapidly and efficiently.Fig. to make dermanet into what it is today. with their presence. org. printed or e-mailed for further opinion. spoken communications). It is then readily available for retrieval. Its prime purpose is to accelerate access to second opinion. The resulting digital image material – whether clinical. as well as up-to-date information on the Swiss dermatology scene. inter-university continuing medical education (CME) forums for dermatologists are held several times each month. As well as the secure and anonymous exchange of data via the Internet (data. May 2000. histologic or dermoscopic – is archived simply and unambiguously by the patient administration program within the dermanet communication suite software.eblue.ch). The most remote dermanet station is in the Kilimanjaro Christian Medical Centre’s Regional Dermatology Training Centre in Moshi. Vol 42. An increasing number of dermatologists from regional quality assurance groups are now using this function for monthly virtual seminars. In addition. the dermanet system also provides an interactive teleconferencing function. images. and a slide adapter for digitizing existing slides. It has created huge new opportunities Kühnis/Milesi 156 . 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. on-line journals and Medline services. allowing simultaneous consideration and diagnosis of digital image material regardless of location.arpage. etc. No 5. reassessed.ch) and give dermanet the status of a high-quality secure Virtual Private Network (VPN). This has proved a constant source of fascinating image material for Swiss university dermatology departments. enabling the individual specialist to offer state-of-the-art advice and treatment informed by consultation with colleagues and centers of excellence. Tanzania (www. thereby optimizing patient care and satisfaction.ch) offering access to all databases of dermatologic interest. The Moshi station represents the epitome of knowledge transfer across continents. physically located on the server of the FMH. dermanet. Completing the array of services available through the dermanet system platform is an Internet portal tailored to dermatologists’ needs (www.dermoscope for epiluminescence microscopy. The expert structure and constant updating of the database add strength to the doctor-patient relationship. a digital microadapter for histopathology. … 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. cultures and economic environments and has been operating superbly for several years. Part 1. skin site. diagnosis. the Swiss Medical Association (www. compared. p 833). whether searched by patient. Within seconds it can be displayed. ASAS® (www.hin. Dermanet was developed and tested in Switzerland. who are developing it further and who are a part of it in their daily work. into the modular structure of its software design.ch Dermanet 157 . And. in conclusion. This means that it was optimized for an area with dense medical care and a high level of accessibility to all current telecommunications technologies. Fax 41 1 991 18 38. seamlessly and cost-effectively. Dermanet is a community of medical professionals who use it. i. where imaging modalities are of major importance. while it may function slightly faster or slower depending on the infrastructure available. E-Mail infoderma@dermanet. it will always function. However. This is where dermanet benefits from the fact that it is based on normal consumer level technologies and products.for specialist communication which are still far from being exhausted. in other words. it has already become clear on many occasions that the use of dermanet may be of vital importance in other countries too. Future developments. notably in telecommunications and biometrics. it is these people. CH–4153 Reinach (Switzerland) Tel. 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. with all their knowledge. Dermanet was optimized for Dermatology. It is essentially visual. to whom we would like to offer once again our formal thanks! Dermanet. Postfach. This means that it could also be adapted to all other disciplines which are image-based. can readily be integrated. 41 1 991 18 38.e. their commitment and their readiness to place their own knowledge at the service of (tele)medicine. And finally: dermanet is not just a bundle of software and hardware. Basel. Recent years have produced an increasing number of publications which have thrown light on all these aspects of quality. 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. There are. vol 32. situations when FTF consultations are not easily achieved. concerning both RTV (table 1) and SAF (table 2) consultations. When switching from FTF consultations to telematic consultations.2 Aspects of Quality: Face-to-Face versus Teleconsulting Håkan Granlund Department of Dermatology. In these situations we would benefit from a possibility to perform consultations at a distance. There are several aspects of quality that have to be fulfilled: accuracy of diagnoses. consultations in dermatology are difficult. Telematic technology offers distant communication and rapid exchange of images. patient satisfaction. Curr Probl Dermatol. . Unfortunately. a long distance to a specialist or regional lack of specialists. consultations in dermatology are preferably performed face-to-face (FTF). Meeting patients in our office is also the familiar way we have practised medicine for decades. Store-and-forward (SAF) technology has gained popularity in the USA. Helsinki University. whereas real-time video-conferencing (RTV) has been more used in Europe.e.Burg G (ed): Telemedicine and Teledermatology. accuracy of management plans. Without images. however. 2003. i. Patients appreciate in-person contacts with the physician and physicians are more certain about their judgements when having seen the patient [1].1. i. a realistic concern is how to maintain quality of medical service.e. visual impressions of a skin condition. Helsinki. and physician’s confidence. Karger. pp 158–166 5. and two types of telematic consultation have been introduced into dermatology. Finland Whenever convenient. 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. GP general practitioner. Published studies evaluating quality aspects of RTV consultations Study Year of Design publication Patients. 1 Quality Aspects 159 .Table 1. RTV to FTF Comp. n Diagnostic accuracy. RTV to FTF Comp. to FTF ? Comp. 74% were more confident with FTF. 2 Percentage of patients considering RTV as good as FTF. to SAF 51 60 104 83 60/36 126 139 351 107 334 204 96 C Consultant. to FTF Comp. 3 Kappa statistic. needing referral 50 77 75 78 and 94 59 80 67 59 63 71 72 64 0. RTV to FTF Comp. % Accuracy of Satisfaction with RTV . % inter-observer intra-observer patient physician Outcome of RTV % . management % satisfied plan.473 85 51 44 46 45 692 97–100 C 80. to FTF Open Comp. % 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. 801 81–89 77 90 87 96 69 RTV SAF 90–100 90 Outcome of SAF. % Accuracy of Satisfaction with SAF. to FTF Comp. to GP Comp.441 67 92 194 70 84 76 vs. management % satisfied plan.? Comp. to FTF Comp.Table 2. to FTF Comp. to FTF 18 29 100 12 129 Agreement with histological findings. to FTF Comp. Published studies evaluating quality aspects of SAF consultations Study Year of Design publication Patients. n Diagnostic accuracy. to FTF Comp. to FTF Comp. Granlund 160 . % inter-observer intra-observer patient physician 83 88 94–95 90 71 87 75 404 1. Accuracy of the Diagnoses A prerequisite for a consultation of good quality is that it offers a possibility to make a correct diagnosis. 5]. 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. but disagreement has been about 6% in published studies [2. Most of the other published studies. For some diseases. The disease groups that can be evaluated in this way are unfortunately few. Accuracy of the Management Plan Clinical examination alone seldom ends up with a definite diagnosis. but if true it could be attributed to a better image quality in SAF. seldom a correct diagnosis to refer to. This is of course not true. Interestingly. 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%. however. repeatability or reproducibility) [2] using the FTF diagnosis as referendum. The accuracy of a management plan based on a teleconsultation is an essential part of the quality of the consultation.or intra-observer diagnostic reliability (also referred to as diagnostic precision. Two dermatologists may arrive at Quality Aspects 161 . During this time the used technology has developed and probably influenced the quality of images. but needs reassurance with further examinations and tests before a treatment plan is created. as if it were a correct diagnosis. In lack of a true standard most evaluations of telematic consultations refer to the FTF diagnosis as the standard goal. When interpreting results about diagnostic reliability it must also be realized that the studies span over a period of 5–6 years. like tumours. 3]. Actually only two published studies use histology as the referendum [4. we can use histopathology as a reference standard and as an equivalent to a correct diagnosis. The number of studies is too small to allow strict conclusions. have in fact measured inter. but quite satisfactory. The intra-observer reliability has been evaluated in fewer studies. This is not optimal. although stating that they have measured diagnostic accuracy. The agreement about the diagnoses between two observers in FTF has not been studied thoroughly enough. the diagnostic reliability has been higher for SAF (87–95%) than for RTV consultations (63–71%). There is. and must be remembered when evaluating results from studies comparing diagnostic concordance. A management plan of good quality can actually save a false diagnosis. i. in the same study all FTF examinations were satisfactory. The quality of a management plan can also be judged from its influence on costs. better technique. Quality in Terms of Physicians’ Confidence Consulting dermatologists involved in teledermatology studies have expressed a positive attitude towards this new type of medical service. Image quality affects confidence also in SAF consultations [7]. 2). This could have reflected a uncertainty with the teleconsultation. On the other hand. We found no difference in the number of referrals and the number of patients recommended further investigations. data]. 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. but RTV consultations resulted in more treatment instructions [unpubl. Our conclusion is that a RTV consultation does not seem to increase the consumption of healthcare services. There is surprisingly again a difference in favour of SAF consultations. Examples of variables used to measure concordance of management plans are the number of referrals. gave more confidence to the consultation. 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. 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. 81% of physicians giving RTV consultations were satisfied with their ability to examine the skin. [4]. Both aspects can be used separately to assess accuracy between two types of consultations. but their management plan can be the same or similar enough to make the diagnosis of lower importance. When evaluating results from published studies it must. Many consultants prefer FTF consultations because they feel more confident with their judgements when based on conventional in-person examinations [6].different diagnostic decisions. the proportion of suggested biopsies.e. Granlund 162 . It was also noted that higher bandwidth. however. The management plan consists of recommendations for both further evaluations and for treatment. In a study by Lowitt et al. and the ratio between suggested systemic and local treatments. dermatologists who are less experienced with information technology can harbour a strong negative attitude for nonrelevant reasons based on suspicions and fears. especially blurred motion pictures. We asked the patient questions about their present status.Confidence is important. however. Quality in Terms of Patient Satisfaction The ultimate goal of medical care is of course a satisfied patient. A ‘wrong’ initial diagnosis corrected with the contribution of a ‘right’ management plan can give a satisfied patient in the end. 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]. data]. Improvement in the quality of technology is the base for better confidence. Most clinical interventions on usefulness of teleconsultations have measured at least patient satisfaction. be realized that patients confronted with new technology tend to be enthusiastic and to overestimate their immediate satisfaction with its use. Younger patients seem to accept teleconsultation better than older people [4]. Long-Term Aspects of Quality The question of quality in medical service is not answered until we ask: ‘What really happened to the patient?’. where patients have felt uncomfortable or embarrassed [9]. we made a follow-up survey 6 months after the initial consultation by sending the patients a structured questionnaire. In a study were RTV and FTF consultations were compared. The immediate satisfaction of the patients has scored very high (tables 1. It must. It influences the level of agreement in diagnoses and thus diagnostic quality [4. whether they had been urged to make a new visit to a physician and how pleased they were with the consultation [unpubl.e. 2). causing a positive bias [8]. If patients have expressed dissatisfaction. During the lapsed Quality Aspects 163 . but better exchange of information is needed. On the other hand. 7]. This suggests that teleconsultations will be even more accepted in the future. where affordable equipment still is hampered by weaknesses in image quality. 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. i. This applies specially to RTV consultations. SAF technology already enables sufficient image quality. it has most often concerned the arrangement of the RTV consultation. Probably a combination of digital images and real-time communication by an ordinary phone call could increase confidence. Discussion Teleconsultation in dermatology has been produced in two ways. 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. Drugge RJ. English D. although of mandatory importance [10]. Grichnik JM. Stechuchak KM. The decrease in satisfaction is no surprise. but is hampered by the lack of real-time conversation with the patient and/or the GP. Wootton R: Teledermatology: A review. Gourdin FW.41:693–702. Patients express high immediate satisfaction with the teleconsultation. Thompson WO: Telemedicine evaluation of cutaneous disease: A blinded comparative study. RTV consultations also need participation of several people and time has to be arranged for them all. J Am Acad Dermatol 1999. Whited JD. is however not optimal. Nineteen and 31% in the respective groups had been referred to the consulting hospital for further evaluation. i. Foy ME. The image quality.5 in the FTF group.e. Br J Dermatol 2000. either by SAF or by RTV technology. Davis LS. Myers SA. Measured on a visual analogue scale graded from 0 to 10.4 4.2 3. This clearly decreases the quality of history-taking. had had to revisit their GP because they still had problems with their skin condition.6 months. In our experience the outcome of standard and teleconsultations seems to be comparable. 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. References 1 2 Eedy DJ. Hall RP. These differences were not statistically significant. SAF technology enables good image quality. but it is encouraging to notice that there was no difference between convention and teleconsultation. by –1.7 in the RTV group and by –1. Despite the shortcomings it is surprising how high reliability in terms of diagnostic accuracy and management plans has been achieved in published studies. 3 Granlund 164 .28:27–31. Simel DL. 44 and 46% of the patients in the RTV and FTF groups. respectively.144:696–707. Horner RD: Reliability and accuracy of dermatologists’ clinic-based and digital image consultations. J Am Acad Dermatol 1998. 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 overall satisfaction with the consultation decreased in both groups. Lesher JL. Sime D. Wootton R: Diagnostic accuracy and clinical management by real-time teledermatology.4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Lowitt MH. Wootton R: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. Gore HE. BMJ 2000. Stone D. Gustke S: Reliability of dermatology teleconsultations with the use of teleconferencing technology. Crichton C. Phillips CM.6:121. Balch D. Esmail A. Kessler II.110:51–53.37: 398–402. Reeve P: Practising dermatology via telemedicine. Gilmour E. Loane M.139:81–87. Eedy DJ. Siegel E. Loane MA. Loane MA. Eady D. Wootton R: A comparison of real-time and store-and-forward teledermatology: A cost-benefit study. Loane MA. Telemed J 1999. Gore HE. Drage LA. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. Corbett R.4:5–9. Mathews C. Pos O: Diagnostic correlation: Store-and-forward teledermatology versus in-person evaluation. Menn ER. Bloomer SE. Lyon CC. Griffiths CEM. Loane MA. Gilmour E. Parry EJ. Steele K. Astwood DR. Corbett RO. Mills BJ. Duffill MB.320:1517–1520. Lewis K. J Telemed Telecare 1998. J Telemed Telecare 1998. Whitten P: Systemic review of studies of patient satisfaction with telemedicine. Steele K. Zelickson BD. Hicks N. Steele K. Toms J. teledermatology for unselected skin lesions. J Telemed Telecare 1998. Methews C. Oakley AM. Gore HE. Grichnik JM. Jones DH. Br J Dermatol 1999. J Am Acad Dermatol 1997.22:163–165. Philips CM. Manning D. Hicks N. Welch ML. McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation.5:S85–S86. J Telemed Telecare 1997. Duffill MB. Macdonald A. Mathews C. Loane MA.4:36–40.5:357–366. Rademaker M.134:471–476. Drugge RJ. Mathews C. Harrison PV: Digital imagining and teledermatology: Educational and diagnostic applications of a portable digital imaging system for the trainee dermatologist. Loane MA: Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis. Brendish L: The Cornwall dermatology electronic referral and imagetransfer project. Telemed J 1998. Arch Dermatol 1998. J Telemed Telecare 1999. Harrison PV Kirby B.4:31–32.4: 95–100. Allen MH. Roland MO.143:1241–1247. NZ Med J 1998. McKinley J: Teledermatology in the Highlands of Scotland.133: 171–174.111: 296–299. J Telemed Telecare 1998. Griffiths CEM: Digital . Wootton R: Comparison of teleconsultations and face-toface consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Mills W. Baradagunta S. White H. Cruess D. Burke WA. Bloomer SE. NZ Med J 1997. Corbett R. Br J Dermatol 2000. Potts S. Bloomer SE. Lotery HE. Simel DL: A pilot trial of digital imaging in skin cancer. Wilson JL: Reliability of telemedicine in evaluating skin tumors.4:108–112. Mathews C. Homan L: Teledermatology in the nursing home. Kvedar JC.320: 1252–1256. Houston MS. Corbett R. Paisley J. Kauffman L. Mair F. Smulders-Meyer O. Burnett JW: Teledermatology and in-person examinations. Eedy DJ.2:7–9. Clin Exp Dermatol 1997. Harrison PV Patefield S. Calobrisi SD. Gonzalez E: Teledermatology in a capitated delivery system using distributed information architecture: Design and development. Hall RP. Steel K. Corbett R. Telemed J 2000. Stone D. Br J Dermatol 1998. Wootton R. Whited JD. Eedy DJ. Hooper FJ. Wootton R: Patient satisfaction with real-time teledermatology in Northern Ireland. Paisely J.3:83–88. Shechter A. Steele K. Quality Aspects 165 . Harden D. Burke WA.141(suppl 55):43. J Am Acad Dermatol 2000. Campbell SM. et al: Effect of camera performance on diagnostic accuracy: Preliminary results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. Steele K. Gould D. Lotery HE. Arch Dermatol 1997. Gore HE.42:776–783. Bloomer SE. High WA. BMJ 2000. Dickinson Y. Oakley AM. Mathews C. J Telemed Telecare 1996. Pak HS. Corbett R. Bloomer SE. Schofield R: Teledermatology – High technology or not? . Eedy DJ. Dickinson Y. 441 patients. Barkley A: Evaluating a telemedicine system to assist in the management of dermatology referrals. Goldsmith P. E-Mail Hakan. 358 9 471 96186271. JEADV 1999. Taylor P.26 27 Harrison PV: Teledermatology in Morecambe Bay – 5 years’ experience in 1. Murray K. Central Hospital. Meilahdentie 2. Helsinki University.fimnet. Fax 358 9 47186561.fi Granlund 166 . Br J Dermatol 2001. Håkan Granlund. Harris D.12:S96.144:328–333. MD.granlund@pp. Department of Dermatology. FIN–00250 Helsinki (Finland) Tel. 3 Teledermatology in the Nursing Home Brian D. vol 32. or practicing dermatology at a distance.. The primary reasons for these failures appear to be lack of sustainable funding. can be a very useful tool given the right clinical setting. pp 167–171 5. University of Minnesota. lack of physician adoption and/or lack of need. Basel. This chapter will evaluate the use of teledermatology in one clinical setting – the nursing home. skin infections and cancers can lead to significant morbidity and costly hospitalizations. USA Teledermatology. Curr Probl Dermatol. which are now no longer in service. In some cases a dermatologist may be able to make a nursing home visit while in others the resident has to be transferred to . 2003. The goal of this technology is to allow for the remote transfer of data to improve the efficiency of healthcare.Burg G (ed): Telemedicine and Teledermatology. Zelickson Department of Dermatology. look at simple technical solutions and finally explore our experience. 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. Minneapolis. prisons and in the military settings [1–3].1. There have been many telemedicine programs initiated with great enthusiasm. As with adding any new technology. Due to inherent structural changes in aging skin the elderly are more likely that the general population to have significant cutaneous disorders [4–7]. In the following this chapter will explore the potential need for teledermatology services in the nursing home setting. These cutaneous disorders such as pressure ulcers. Karger. Due to the resident population the nursing home is another potential setting where teledermatology can solve several practical problems. Teledermatology has been helpful in several clinical settings where dermatology care is scarce and difficult to employ such as in rural or undeserved populations. Minn. 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. (c) easy. (b) convenient. It is beyond the scope of this chapter to evaluate all the potential devices and systems that can be used for teledermatology. or store-and-forward system has also been evaluated for teledermatology. However. 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. however they are time consuming and often difficult to arrange for all parties to be available at the same time [3]. (b) accurate. With this system the medical data is recorded and Zelickson 168 . resolution). (d) image acquisition (color. specialists are as busy as ever with less time to be able to make nursing home calls. (2) Transmitting data (real-time or store-and-forward): (a) fast. (b) consistent. There are several ways to address the problems associated with access of dermatologic care at nursing homes. This would be up to the individual dermatologist and to date is too inefficient for many to adopt. the cost of healthcare is growing significantly in the USA with no signs of slowing down [11]. The main components are the following: (1) Data acquisition: (a) easy to use. This can lead to significant morbidity and unnecessary expenditures. The second would be to employ technology to solve the problem. (4) Consult reply: (a) timely. resolution). and (6) Medical/legal issues: (a) malpractice. 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. (c) confidentiality. While in many cases this is an effective way of practice. topography.the specialist’s office. Thus. Furthermore. Since it is difficult for many residents to travel out of the nursing home. they do not always have good access to dermatologic care [12]. the devices used for telemedicine have gone through great advances in the past several years. (3) Reviewing data: (a) fast. 10]. All the while. The former requires real-time videoconferencing linking the patient and care give on one end and the consultant on the other end. The second type of system. (b) informed consent. 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. it is important to address several main components that are needed in order to give the patient the best medical care possible using teledermatology. topography. (b) image viewing (color. one way to improve care would be to increase the number of dermatologists that make nursing home visits. As with all technologies. The two basic types of telemedicine systems are live teleconferencing systems and store-and-forward systems. (5) Billing. the growing nursing home population is at risk for cutaneous disease and due to the poor mobility and potential costly transportation. (c) pertinent associated findings. images with accurate lighting for color and topography as well as images of associated areas. if liquid nitrogen is needed to treat a lesion. For the sake of this article the following discussion will be focused on a store-and-forward system. Teledermatology in the Nursing Home 169 . In light of this. there are no such standards in teledermatology. As with any type of system. In addition. however this is often time consuming and the specialist may not have the needed supplies to completely take care of the situation i. As noted above. the data for teledermatology is a bit more complex. 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.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. however. but aspects such as associated findings and the color. Noting these issues a study was performed using a simple store-and-forward system in the nursing home setting [12]. 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 [13–16]. Furthermore.e. The image resolution should be at least 1. for many residents it is difficult if not dangerous to travel. Care must be taken to insure patient confidentiality when setting this up. Not only are dermatologists interested in the pertinent patient history. Although one comparative study showed store-and-forward systems may be less clinically efficient than realtime videoconferencing. dermatologic consultations for nursing home residents are currently obtained by either having the resident transferred to a dermatologist’s office or have the dermatologist come to the resident. topography and ‘feel’ of the skin are very important in determining a correct diagnosis.forwarded to the consultant and the consultant can review the data at any time and return an opinion. This includes pertinent associated history. For the dermatologist it is most efficient to have the nursing home resident transferred to the specialty clinic. Unlike teleradiology where there are strict standards of image resolution. the system must include an informed person for acquiring the dermatologic data. A nursing home visit by the dermatologist would be the best scenario from the residents’ perspective. however with improvements in technology there are now many ways to do this. All of this data must be accurately transmitted to the consultant. either by printing and keeping a hard copy or backing up the data on another hard drive or disk. This can be a formidable task given the size of some of the images being sent. the better the data put in the better it is coming out. it is very inefficient for a dermatologist to spend the time traveling to see only a few patients. Telemed J 1997.144:696–707. 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). Sauvage T: Skin problems: Epidemiology of pressure ulcers in a skilled care facility. Berk SL: Infections in the nursing home. Watson HW. Olive KE.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. 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. Haynes BK. Wootton R: Teledermatology: A review. Burdick AE. A more detailed cost analysis will be needed before permanent funding is in place to sustain this type of teledermatology system. Smith GT: Telemedicine for dermatology care in rural patients. Olson B. the program was discontinued for lack of funding for store-and-forward teledermatology. Despite the cost savings. The correct treatment plan was given 70. however the results showed very good concordance compared to face-to-face consultations.3:227–233. Langemo DK. Arch Dermatol 1997. Zelickson 170 . No incorrect treatment plan would have led to substantial morbidity. pp 1–12. A diagnosis and treatment plan was determined by examining a still image and patient history alone and in combination. The cost analysis of the study included a store-and-forward telemedicine system for USD 9. J Gerontol Nurs 1992. Marks R: Structure and function of aged skin. 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. Norton SA. In this study the correct diagnosis was made for 67. image alone and both respectively.18:29–39. Buonocore E. Hanson D. Berman B: Teledermatology and underserved populations. Phillips CM. These were compared to an on-site dermatologic consultation.8:821–834. Julius CE. Lippincott. the teledermatology nurse. References 1 2 3 4 5 6 Burgiss SG. Eedy DJ. Clin Geriatr Med 1992. Br J Dermatol 2001. image alone and both respectively. Philadelphia. The resolution was poor compared to today’s standard.This study enrolled 29 patients in which a dermatology consult was requested by the primary care giver. who was an infection control nurse working at the nursing home. 85 and 88% of the time given the history alone. 1987. Hunter S.133:197–200. 87 and 90% of the time given the history alone. the patients and the dermatologist. The system used in this study was easy to use and well adopted by the primary care team. Burd C. A nurse. in Skin Diseases in Old Age. The residents are at risk for cutaneous disease and there are real barriers to specialty care. Brandeis GH. Bloomer SE. et al: Pressure ulcers: The Minimum Data Set and the Resident Assessment Protocol. Grichnik JM. Dwyer JT. US Bureau of the Census. Arch Dermatol 1997. Fax 1 952 4737281. Department of Dermatology.41:749–756. Perednia DA: Store-and-forward teledermatology. et al: Consensus of the nutritional screening initiative: Risk .45:627–632. Hicks N.91: 783–787. Wootton R: A comparison of real-time and store-and-forward teledermatology: A cost-benefit study. Loane MA. Hall RP. J Am Acad Dermatol 1999. 1 612 3380711.edu Teledermatology in the Nursing Home 171 .41:693–702. Houston MS. Myers SA. Calobrisi SD. High WA. 42:776–783. Simor AE: Two years of infection surveillance in a geriatric long-term care facility. Fox PD: Efforts to improve primary care delivery to nursing home residents.113: 171–174. Ratner D. Telemed Today 1996. McEvoy MT: Related articles assessment of the accuracy of low-cost store-and-forward teledermatology consultation. Am J Infect Control 1991. Thomas CO. Gordon M. Corbett R. White JV Lipschitz DA. Stechuchak KM. Drugge RJ. Brain Zelickson. Simel DL. Office of the Actuary. 1002 Medical Acts Bldg. Eedy DJ. Berlowitz DR. Bickers D: The uses of digital photography in dermatology. Lotery HE. Horner RD: Reliability and accuracy of dermatologists’ clinic-based and digital image consultations. J Am Acad Dermatol 1999.19:185–190. Steele K. Homan L: Teledermatology in the nursing home. Healthcare Financing Administration. National Health Statistics Group. J Am Diet Assoc 1991.4:18–21. Paisley J. Mathews C. Minneapolis. J Am Geriatr Soc 1997. E-Mail zelic002@umn. Foy ME. factors and indicators of poor nutritional status in older Americans.143:1241–1247. Zelickson BD. Whited JD. Adv Wound Care 1995.8:18–25. MD. Drage LA. J Am Acad Dermatol 2000. MN 55422 (USA) Tel.7 8 9 10 11 12 13 14 15 16 17 Darnowski SB. University of Minnesota. Br J Dermatol 2000. Hossain M. Fama T. vol 32. H. difficult diagnostic and therapeutic problems cannot be discussed with colleagues – a considerable disadvantage in comparison to working in a large department of dermatology. Popal a. other technical equipment available in private practice. fast and secure transfer of medical data including high-resolution image data in sufficient quality should be obtained for medical information.1. the consultation of experts in dermatologic healthcare centers via teledermatology would present a desirable tool for dermatologists working on their own. 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. Glaessl a. M. This investigation shows the standard of the technical equipment available in private dermatologic practices prior to the launching of a teledermatologic project. located both in cities and rural areas. Germany and bClinic of Dermatology and Allergology. and the use of image documentation systems. Stolz b a Department of Dermatology. Modern telecommunication technologies such as ISDN and Internet are very helpful for data transfer. 2003. Communication software allowing live videoconferencing or the sending of image data as attached files via e-mail have become routine proceedings. operating system software. Monitoring this study. a teledermatology questionnaire was added to the regular information letters. . Hospital Munich-Schwabing. For these consultations. Curr Probl Dermatol. Coras a. Basel. Materials and Methods Eighty-four dermatologists in private practice in Bavaria. Germany Most private dermatologic practices in Germany are run by only one dermatologist. Karger. B. Landthaler a. W. For this reason.4 A Survey among Dermatologists in Practice about Teledermatology A. Therefore. which included the following topics: computer equipment.Burg G (ed): Telemedicine and Teledermatology. University of Regensburg. were contacted by questionnaire. pp 172–175 5. 54% of questionnaires were returned. Further medical education and positive marketing effects regarding their own private practice could demonstrate other applications of teledermatology for practicing dermatologists. but the percentage of office use and private matters is not known. regarding different medical software distributors used in private practice in Germany. 33% were younger than 40 years and 23% were older than 50 years. modems).e. 74% use the modern ISDN technique and 56% use e-mail regularly.Results In all. most dermatologists in private practice use computer systems favoring Windows 95 operating software. Moreover. UNIX. 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 Survey among Dermatologists 173 . 55% are interested in patient-related teleconsultations with dermatologic clinics. Only 15% use their own digital image documentation system but 46% would be interested in buying such a system within the next year. Telemedicine is no suitable tool for daily diagnostic problems of physicians in remote areas. 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%). Discussion These data show that dermatologists in private practice are interested in telemedical applications in medical services. or Apple. 55% of the dermatologists in private practice would communicate with dermatologic clinics by teleconsultations. 41% are in touch with sending attached files via e-mail (store-and-forward technique). 40% prefer a more common teleconsultation via phone and computer. In addition. most common is the software of Medistar and Compumed. Of the dermatologists answering the questionnaire. Of the dermatologists in private practice with telecommunication equipment (i. Aspects of teledermatologic applications included in the questionnaire showed the following results: proposing several aspects of possible teledermatologic applications. The dermatologists’ main fields of interests for teleconsultations are common therapeutic problems and the differential diagnosis of pigmented skin lesions. only 35% with other practicing dermatologists. Nowadays. Only some of the dermatologists surveyed provide their own website on the Internet. however. In dermatology. but only 26% would be interested in the automatic diagnosis of pigmented skin lesions. Results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. Lyon CC. hard. Provost N. Bloomer SE. Br J Dermatol 1998. Landthaler M. Mathews C. DeDavid M.139:81–87. Kopf AW.22:163–165. Wootton R: Diagnostic accuracy and clinical management by real-time teledermatology. Dermatology 1998. Loane MA. Harrison PV Kirby B.4(suppl):31–32. A recent study indicating that teledermatology is achievable using a low-technology. Furthermore. Schofield R: Teledermatology – High technology or not? . Rabinovitz HS. Gore HE. Griffiths CE. especially for people from rural areas. Parry EJ.and software equipment have already been published [5]. Harrison PV: Digital imaging and teledermatology: Educational and diagnostic applications of a portable digital imaging system for the trainee dermatologist. 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]. Arch Dermatol 1997. Esmail A. Bergman B: Teledermatology and underserved populations. Eedy D. Phillips CM. Burdick AE. a telemedical service for dermatologists in private practice by specialized dermatologic centers can improve the quality of medical care. In conclusion. Steele C. Telemedicine is acceptable for the patients to referring and consulting physicians [9]. Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Also. In our survey. 3 4 5 6 7 Glaessl/Coras/Popal/Landthaler/Stolz 174 .6:138–141. Roland MO. The quality of digital images used in dermatologic healthcare centers for concordant diagnosis is very important [6]. low-cost approach confirms that [3]. Walther T. Clin Exp Dermatol 1997. Wootton R: Comparison of teleconsultations and faceto-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. J Telemed Telecare 1998. Corbett RO. J Telemed Telecare 1998.196:299–304. Schiffner R. Recently. Steel K. Eedy DJ. Dickinson Y. Corbett R. Gilmour E. Stolz W. Mathews C. References 1 2 Norton SA. Other results indicate that most dermatologic cases can be successfully managed by real-time telemedicine only [4]. J Telemed Telecare 2000. travel to dermatologic centers is no longer necessary. Stolz W: Teledermatology – The requirements of dermatologists in private practice.performed by physicians in remote areas [1].and software requirements. Campbell SM. Loane MA.133:197–200. digital imaging of suspected skin cancers can reach almost complete agreement both among clinical and digital examination [8]. Detailed data of our survey concerning most favorable applications. Glaessl A. Wasti Q. Gore HE. other authors have illustrated that teledermatology has the potential for diagnosing and managing cases referred from primary care [7].4: 95–100. According to this questionnaire. Consequently. teleconsultation of experts in dermatologic centers is the most favorable application. dermatologists currently seem to prefer low-tech applications concerning communication hard. Kölner Platz 1. MD. Hall RP. Klotz PJ. Langille DB: Telemedicine in Nova Scotia: Report of a pilot study. E-Mail wilhelm. Clinic for Dermatology and Allergy. Simel DL: A pilot trial of digital imaging in skin cancer.8 9 Whited JD. Drugge RJ. Reid DS. Grichnik JM. Fax 49 89 3068 3918.4:249–258.stolz@kms. Wilhelm Stolz. Hospital Munich-Schwabing.4:108–112. Mills BJ. 49 89 3068 2294. J Telemed Telecare 1998. D–80804 Munich (Germany) Tel. J Telemed Telecare 1998.de Survey among Dermatologists 175 .mhn. Allen MJM. Sargeant JM. Weaver LE. Mason WF. Burg. Therefore. Curr Probl Dermatol. Additionally. in teaching is still very low in Switzerland. . because it can reduce the costly personal presence of teachers in schools and universities. and Dermatologische Klinik. even at university level. it is a well-suited tool for teaching and learning purposes. Project Coordinator: Dr. as well as the Internet. the Internet is a fast. Karger. Zumikon. pp 176–181 5. Basel. the use of computers and modern communication technologies. many university students own a computer or have easy access to computers. In international science. accessible and very important tool for exchanging information and access to databases. Günter Burg b a b Praxis für Dermatologie und Venerologie. and another CHF 30 million in a second step in 2000. 2003. because the skin as an organ is readily accessible and visual aspects are very important. Universitätsspital Zürich. Also. dermatology is an ideal speciality to develop multimedial teaching concepts.2 Teledermatology-Teaching Burg G (ed): Telemedicine and Teledermatology. vol 32. the DOIT project was accepted by the VCS in the first group and a grant was given to develop the DOIT program. 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. which was named DOIT (dermatology online with interactive technology). the Department of Dermatology of the University Hospital of Zürich (Director: Prof. including the Internet. In the field of medicine.1 Dermatology Online with Interactive Technology (DOIT) Urs Bader a. Bader) decided to enter the VCS with a proposal for a computerbased dermatology teaching project.2. Among over 100 proposals. Claudio Cipolat b. Switzerland History The computer as an instrument in everyday work is becoming increasingly important.5. Therefore. Despite all these facts. (2) CyberTrainer – an interactive training unit (virtual dermatology clinic). Panizzon) and Zürich (Prof. This is a computer program with exercises on diagnoses. Rufli). but without the need for the patient to be present. G. Burg). both to be used offline and online via the Internet. as well as of postgraduates in a further step. The pedagogical and didactical objectives of the project are: (1) the student attends a virtual clinical course in dermatology. (5) the presence of students. potential participants in the program are the students of the Medical Faculty of Geneva and of other German. and no need for the physical attendance of students and teachers. Th. (6) partial replacement of frontal lecture. The cases presented will be updated regularly.or French-speaking countries. (2) the student learns to solve dermatological problems on his own. The Dermatologic Clinic of Geneva will not be participating. and consists of three parts: (1) CyberLecture – a virtual lecture text and atlas. (3) CyberNet – a discussion forum which will be used for discussion of case presentations (in CyberTrainer) in analogy to bedside teaching. L. An already existing virtual student textbook of the lecture is accessible via the Internet (http://www-usz.unizh. for the benefit of dermatological patients. R. Lausanne (Prof. Dermatology Online with Interactive Technology 177 . In the four participating medical schools. accessible via the Internet.ch/vorlesung/. 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. Additionally. The combined use of the three modules will provide the stage for problemoriented learning for students and improve their skills in dermatology. The program is planned to be ready for use for the students in July 2003.The DOIT Project The CyberDerm DOIT project is primarily a program for dermatological training of medical students. The content of the course is adapted to the ‘Lernzielkatalog’ of the Swiss Medical Faculty and has been approved by the participating medical schools. Braathen). patients and tutors in the classroom and clinic is reduced. The target group are the students in the 4th and 6th years of their studies. The DOIT project will replace a major part of the lecture as well as bedside teaching and clinical courses. Bern (Prof. using different databases as well as the Internet for gathering of information. diagnostic procedures and therapy. diagnosing and treating dermatological patients in clinical practice. (4) the student can discuss questions and answers in tutorials. (3) the student has more ease in examining. and (7) the examination results are better. 555 students enter the clinical part of the medical studies each year. Login: Student. It was adapted to the ‘Lernzielkatalog’ and approved by the heads of the participating dermatology units to form part 1 of the project (CyberLecture). password: Sommer). G. diagnostic procedures. she/he sends the answers to the project coordinator. clinical picture and therapy of the disease. Burg (http://www-usz. metabolic disorders with skin manifestation. and Diagnostic value 3: the student must have heard of the disease. urticaria and drug reactions. and the course will focus on diagnosing and treating such common diseases. and therapy. and the content adapted to the weighing of the three groups of diagnoses presented above. autoimmune disorders of the skin. fungus. a text part and four to five questions with five possible answers (multiple-choice). Diagnostic value 2: the student must have some knowledge of pathogenesis. sexually transmitted diseases. Updates can be downloaded by the Internet. eczema. bacterial). acne and rosacea.unizh. After answering the questions. and tumors of the skin. chronic wounds. 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. psoriasis/lichen. Rare diseases will not be presented in the course.Content The patients/cases represent the most common dermatologic diseases in everyday general practice.ch/vorlesung/). The cases will be presented in a structured scheme: one case consists of three to five clinical or histological pictures. The content is adapted to the ‘Lernzielkatalog’ of the Swiss Academy of Medical Sciences. The latter was adapted to the ‘Lernzielkatalog’ and profoundly specified. the major fields are: infectious diseases of the skin (viral. The ‘Lernzielkatalog’ discerns three groups of diagnoses: Diagnostic value 1: the student must have in-deep knowledge of pathogenesis. The CyberTrainer program provides the background grid for the cases. In dermatology and therefore the DOIT program. Bader/Cipolat/Burg 178 . genodermatoses. the so-called collagenoses. where a program will check the answers and send an immediate feedback with comments to the student. these will be added and updated regularly by the project leader and partners. The main part (CyberTrainer) consists of patient-based exercises on diagnosis. The student will be given multiplechoice questions on clinical examples (virtual patients) given in the program. Pictures were added. therefore more and more detailed questions on each patient are possible. One patient can be presented as several ‘cases’. clinical picture and therapy of the disease. (2) WebCT: contains a lot of tools. (3) OLAT: platform of the Institute of Informatics of the University of Zürich. A link to the Dermatology Clinic of the University Hospital where the participant is studying is established via the Internet and CyberNet. an adapted version of the HTML lecture of Prof. In the end. internal networks of the university hospitals can be used by students participating physically within the hospitals. The media approach is based on still images (JPEG format) and text. CyberNet. The student will receive a confirmation of attendance (credit points) for answering the questions and taking part in the tutorial. but will not be realized in the first phase. The most extensively studied platforms were: (1) Top Class: contains a lot of tools. Other links exist to Medline databases. The DermaTrainer part as the main part of the project was newly developed from the start. students using the program at home can access by the Internet. respectively. The tutorials are done by using part 3 of the project. such as internal medicine) is possible. diagrams and sound data (for other specialities. Technical Aspects The project is principally based on commercially available hardware: PC system with Microsoft WindowsTM operating system. Links will be available within the program. and which automatically give the appropriate credits. principally a good platform. the student is encouraged to access databases such as Medline and specific to dermatological databases. easy to handle.To better answer the questions. but no Dermatology Online with Interactive Technology 179 . CyberLecture is a HTML database. which is also accessible by the Internet. and finally replace them. expensive. no image database. and a discussion of the questions and answers can take place. The software had partially existed already. textbooks and dermatological atlases. the most important being CyberLecture. This confirmation will be adequate to the confirmation of attendance of lectures and courses in the beginning. which made them unsuitable for the project. difficult handling. diagnostic procedures and dermatologic therapy with emphasis on aspects unique to the speciality. For online access to the program. very complex. Inclusion of video strips. Discussion forums supervised by a specialist in dermatology will take place on a regular basis about the patients presented in the program. by which the participation and the correctness of the answers can be checked. the medical student will have an overview on the most important dermatological diseases in everyday general practice. Burg for the students of the University of Zürich. Evaluation of commercially available platforms for CyberTrainer showed specific disadvantages. The effect of the program for the student will be a better performance in examinations. 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. and extension to more difficult cases for the formation of residents in speciality training and for continuous medical education of dermatologists in practice. unclear questions of standards and copyrights. and Brian D. it was decided to program a stand-alone project. http://apps. An identical evaluation was started by the medical faculty of the University of Zürich.ucla. The inclusion of cases will be continuously ongoing. 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. and (4) Viviance: expensive. This evaluation is ongoing. Good program.uni-regensburg. USA.personnel available. after some months of evaluation. the most important of them are reviewed and compared to the DOIT project. Other Training Programs in the Internet Similar projects with different features and focus already exist in the Internet. with adequate distribution of workload and contributions.g. On the other hand. University of Illinois. Below. Because the time schedule of those evaluations did not meet the demands of the DOIT project. to ensure future compatibility of computer-based medical teaching projects.edu/medyear3/derm/ Interactive dermatology cases. especially the cases and texts.or English-speaking versions of some parts of the program. MD. the VCS actually favors no specific software for its projects. Los Angeles. similar to the DOIT project. which has the advantage of independence from limitations of the used platform. Good interactive features. University of California (UCLA).de Bader/Cipolat/Burg 180 . internal medicine). Madden. are possible.medsch. Usatine. the use of the program for other specialities will be possible (e. Outlook/Future A French version of the cases will be prepared by the project partner in Lausanne. Programming started in October 2001 and will be completed by December 2002. MD. Elaboration of Italian. http://www-derma2000. If appropriate. but not identical.. Calif. Interestingly. but not planned in the first phase. Only in English language. By Richard B. The cases are prepared and photographed by the participating dermatology clinics. Only 24 cases included. By Prof. A database. step-by-step-approach to the patient.htm DOIA and PeDOIA: Dermatology Online Internet Atlas and Pediatric DOIA: Dermatology atlases.ch Dermatology Online with Interactive Technology 181 . Praxis für Dermatologie und Venerologie.Virtual dermatologic clinic. MD. Fax 41 43 288 0203. Germany.net/bilddb/index_d. Questions are multiple-choice. Landthaler. Urs Bader. directly accessible via the Internet with exceptional pictures and good links. some free text answers possible.bader@hin. Geissacher 6. Not interactive. Language: German. not a teaching program. University of Erlangen. CH–8126 Zumikon (Switzerland) Tel. E-Mail urs. http://www. Germany.dermis. Diepgen. the student has a good overview of the speciality of dermatology. 41 43 288 0202. University of Regensburg. By Prof. When the program is completed. no other interaction enabled. 2 Telematics-Based Teaching in Dermatology Klaus Böhma. The advantages of computer-based learning lie in particular in the integration of local as well as distant students and teachers. multimedial learning. CBT. vol 32. The user can choose his times. with individual emphasis. better qualifications on the part of the general population are increasingly required. Because of this high degree of penetration on the part of information technology. pp 182–190 5. whereby modern technology comprises the following concepts: e-learning. and Web-based training (WBT). Germany Motivation With the change from a production-oriented to a service-oriented society. bHealth & Media GmbH. the number of Internet users was over 500 million in August 2001. the establishing of computer-based training (CBT) and further education courses would seem to be a logical consequence. . the phases of training and application.2.Burg G (ed): Telemedicine and Teledermatology. According to recent investigations (NUA Internet Surveys: www. life-long learning and qualification process. Thus there exist training courses on CD-ROM (CBT) or some on the Internet. Mainz. 2003.com). are becoming more and more a continuous. 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.nua. Teachers are enabled to impart basic knowledge and thus to ensure an equal stage of knowledge for all students. Karger. and he can repeat the material being learnt at will. Basel. Wolfram Wiegersb a Fachhochschule Mainz. As a consequence of this trend. Curr Probl Dermatol. often these are differentiated on the basis of the medium carrying the content. Fachbereich I. Darmstadt. once separate. online learning. which are accessible via the Internet/Intranet with a Web browser (WBT). in the interpretation of rare indications for a diagnosis [1]. The application of such systems permits the more flexible and more individual arrangement of 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. With the application of ICT-based teaching and study systems there is a real possibility of clear improvement in the costbenefit relation. 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.The e-Learning Market Although traditional teaching and learning methods frequently display insufficient flexibility and availability. must often visit expensive. From a technical point of view. Here. increasing performance capabilities in telecommunications and information technology (telematics) already allow not only the imparting of factual knowledge. the constant introduction of new technical aids represents a particular challenge for the qualification of physicians and medical personnel. But just in the context of continuous training or further education. This is exactly the area for the application of multimedia technology. Experts estimate that cost savings in the region of 20–25% can be achieved through the application of ICT in training and further education. some 90% of all US colleges and universities will be offering their students courses in the form of e-learning by 2005. but also the illustration of complex matters. Along with the consideration of new research results. 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. According to the most recent prognoses of IDC Research. time-consuming special courses or congresses. the commercial market volume for e-learning in Europe by the year 2005 will be around USD 6 billion. as well as people in medical professions otherwise. the time spent and the financial investment often no longer reflect the actual usefulness in a balanced way. Medical courses are of interest especially because physicians and clinic personnel.g. the dynamics of the development in the areas of application and research create a special problem. and limitations of time and geography can be overcome to some extent. Furthermore. According to prognoses in the IDC report. This is of importance e. they still dominate modern training and further education. The pioneer in the area of e-learning is the USA. While a Telematics-Based Teaching in Dermatology 183 . rather than fulfilling the criteria of a true online course. (3) Flexibility of the instruction material. updating. In order to attain the greatest possible acceptance of an ICT-based teaching and study system. that pertaining to instruction material. and on a user-oriented level [5]. This must be guaranteed both on a content level. 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.number of courses already exist for the area of medicine both on CD-ROM and in the Internet. as well as a tutor support. and re-use or multiple use of teaching and learning material and thus offer enough potential for cost limitation. Demands on the Telematics-Based Learning Environment For Internet-based learning platforms the following important requirements can be formulated [3. (2) Applications must be user-friendly in their conception and attractive in price. teachers and students. 4]: (1) Use of a standard communications infrastructure such as the Internet or the WWW. as. Adaptation by the user plays an important role here. Bidirectional communication possibilities and discussion forums. for example.e. adaptation to the individual approaches in knowledge dissemination and acquirement is needed. many of these remind one rather of an electronic book with pages that must be turned. i. Both given forms of teaching and self-determined learning must be equally possible. (5) At the same time. the social components of knowledge dissemination may not be ignored. which would allow a simple modification. (4) Basically. which offers some medical courses on CD-ROM in study centers as well as some which can be downloaded from the Internet [2]. a teaching and study system must permit individually adapted and demand-oriented learning. Böhm/Wiegers 184 . In this regard the two most important user groups. must be taken into consideration. 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. In this context the support of active dealing with study content as a goal should be mentioned. (6) Sufficient support in creating teaching and learning materials should also be achieved. the VIROR project (Virtual University Upper Rhine). or if the contents of the offers are at least generated or certified by such sources. This results in the demand for no limitation to teaching and learning strategies. German universities have dedicated themselves recently to various projects concerning the theme of ‘Studying via the Internet’. Numerous facets must be considered in realizing an ideal learning platform. gain access to the courses via the Internet. and the possibility of contacting other students or the tutor. support and course standardization [9]. which contains the courses and user information. The administrator has the task of handling the system with regard to technology. in particular. the current state of learning in the courses. comprising in particular the registered courses. The course server is connected to the data bank. The student receives his individual environment through the course server. authors. the optimal design of courses [7]. In addition. Of especial significance – with regard also to future systems – are the construction of such systems regarding information technology [6]. Figure 1 shows a model of the architecture for an Internetbased learning environment [3. 6]. dealing with the need for extensive simulation calculations (see below). which cannot be dealt with more closely here. considerations of security [8].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. but also to content and user accounts. students and tutors. ensuring Telematics-Based Teaching in Dermatology 185 . Standard Architecture of a Telematics-Based Learning Environment The demands described above are fulfilled to a certain degree by available learning platforms. a computing server is also connected to the course server. The users of the system. A model of the architecture for an Internet-based learning environment. 1. 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. Through the use of all media (text. For application in the dermatological area the following scenarios in particular can be identified: (1) The conveyance of expert knowledge. which is currently used for the most part as the basis Böhm/Wiegers 186 .and expanding the state of knowledge of all participants (students. most importantly. 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. A successfully completed course should visibly increase the qualification of the physician participating. modem) have already been fulfilled or are being set up on the part of the end users to a great extent. Here. For future course construction the mark-up language XML would be most suitable. (4) Investigation of conference recordings and the presentation of the corresponding sequences with audio and video support. for trying this knowledge out in the form of explorative units. as these permit an efficient search in image and video material. practicing physicians. sound. Accompanying measures such as tutoring will not be gone into more deeply here. especially of transfer benefits. too. for example special training in the area of diagnostics. Here the support by up-to-date knowledge management mechanisms is essential. and finally those which test the knowledge acquired. this is superior to HTML. Operation Phase In the operational phase the aspects of course construction and provision are the main ones to be taken into consideration. (2) Simulation training for dealing with the newest medical apparatus can be carried out. and assistant personnel) according to need. video and animation) the matter in question can be imparted in a vivid and. The arrangement is of simple simulation programs combined with courses. and should enable him to make economic use of this qualification. interactive way. (5) Rapid. such as a separation of content and layout with XML. (3) Access to image and video archives containing case studies. (6) A significant role will be played by the certifiability of the courses offered. The technical prerequisites and the demands on infrastructure (PC. Course Construction For the standardized conveyance of knowledge. which contain components for imparting expert knowledge. image. courses from a didactic point of view consist of small instruction units. the application of knowledge management is of great importance. but by means of ‘hands-on’ exploration as well. In this way the build-up of know-how is not accomplished in a purely theoretical manner. delivers the course-relevant content. Currently. This will further improve the quality. The simplest tool for constructing a WBT course could in principle be a simple HTML editor. which contain ready-made drafts. and he is available for the evaluation of questionnaire tests. as it were. If. complex multimedia WBT courses are to be developed. One chooses from among various options and can attain quite good results without any HTML programming knowledge whatsoever. During the operation. which is. such as the relatively great degree of visualizing in dermatology. but also to implement multimedial content. however. the development of a complete WBT course is a task for a whole team of editors. and of the development of questionnaire tests. such as audio and video sequences or animated graphics. (2) The online editor takes care of the didactic and content-relevant layout. the following also fulfils a task: The tutor is the person to turn to for answers to concrete questions. and for this reason the construction of a WBT course can be divided into several single jobs: (1) The author. (3) The Web designer drafts a graphically sophisticated user surface and the navigation. only usable in a limited way for the realization of credible multimedia presentations with interactivity. 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. with which forms can be created and which have JavaScript commands at their disposal. or if knowledge is to be tested in multiple-choice questions.language. Professional tools enable the user to not only comfortably develop the pages of the course and the navigation. (4) The programmer finally combines graphics. Macromedia Authorware Attain or Macromedia Dreamweaver Coursebuilder (see example in figure 2). He is responsible for ensuring that specific characteristics of a particular area of expertise. the HTML code is created retroactively. in this case the dermatologist. such as Asymetrix Toolbook II Instructor. in the Internet so-called ‘what you see is what you get’ (WYSIWYG) programs are preferred. as this will allow the exchange of courses among different domains [9–11]. Should a simple text representation be sufficient. as the intention is not to simulate a book with all this technical effort. correspond to the instruction content. however. as XML has greater suitability for data storage regardless of medium. By choosing ready-made elements. Basically. then one should use the corresponding professional tools. In each course the greatest possible degree of interactivity should be aimed at. then often relatively simple HTML editors will suffice. Of great importance is the current ongoing development of courseware standardization. design and functionality to realize a course. Telematics-Based Teaching in Dermatology 187 . ASP means that software is no longer bought as a product licensed by a firm. a data bank management system. an applications server. Learning Service Providing The model described above represents a complex client server architecture. 2. there is a permanent need for updating the applied components. In the e-learning segment this is also known as Learning Service Providing (LSP). and a communications infrastructure. which requires components such as a WWW server. the use of Application Service Providing (ASP) makes sense here. For this reason. Böhm/Wiegers 188 . The LSP offer can be regarded as a serious alternative to the existing client-server networks in companies.Fig. administration and updating. Along with the demanding technical requirements of these systems. but is rented from a so-called Application Service Provider. one pays only for the actual use (see table 1). The economic advantages: instead of investing in software packages and keeping resources available within one’s own company for their care. An example of an dermatological training course for patients and medical staff created with Macromedia Dreamweaver. Englert G: Die Virtuelle Universität. but especially for the practicing dermatologist. in Computers and Graphics. No 2–3. Mengel M. Oulu University Press. Darmstadt. in Herbst M (ed): Informationsmanagement in der Medizin. who can thus participate in the newest developments in his area of speciality without time-consuming and expensive travel. The advantages of LSP Supplier: Medical societies and associations Users: Students. on the other a completely technological approach to education appears neither logical nor desirable. Mengel M. Hessen Media. 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. Schnaider M: Internet-basierte Aus.und Weiterbildung – Das System IDEALS MTS. Passo J: Computer-Based Teaching Technology for Software Engineering Education. 1999. References 1 Böhm K. This is true for the clinician. Amsterdam. But it is clear even now that telematics-based training represents a necessary supplement for the development of quality lifelong further training. Mengel M.Table 1. On the one hand. 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. Kassel. Oulu. 2000. 1998. Steinkopff. 1998. Zentraldruckerei der Universität Gesamthochschule. vol 22. the advantages as compared to conventional methods must be confirmed. 2 3 4 Telematics-Based Teaching in Dermatology 189 . physicians. Elsevier Science. et al: A concept and system architecture for IT-based lifelong learning. ISO/IEC JTC1 SC36 Information Technology for Learning.und Weiterbildung basierend auf einem modularen Kurskonzept.org/doc/36N0077.de/~lindner/PROMETEUS/SIG-DESIGN/Discussion/Spec-FD2001–07–01. IFIP TC6/TC11.igd. Dordrecht.doc Prof. Lindner R: The IDEALS Modular Training System.de Böhm/Wiegers 190 . Geoinformatik und Vermessung. in Steinmetz et al (eds): Communications and Multimedia Security Issues of the New Century.org/doc/36N0075.pdf. Hornung C. in Thema Forschung 2/97 – Computer Graphics. Educ Technol Soc 2001. Darmstadt 2001.4(1). http://jtc1sc36. Technische Universität Darmstadt. Education.-Ing. Holzstrasse 36. D–55116 Mainz (Germany) Tel.ni. Worms. Fachbereich I. Böhm K.fhg. Mengel M: Konzepte einer benutzerangepassten graphischen Autorenunterstützung für Aus.din. Fax 49 6131 2859699. and Training http://jtc1sc36. Dr. 1997. Proc of CMS. Herdecke.php3?id 482 Prometeus: http://www. 2000. 49 6131 2859672. GCA. 2001.5 6 7 8 9 10 11 Martinez M: Key Design considerations for personalized learning on the Web. Graf F: Secure e-learning. Fachhochschule Mainz.pdf DIN NI: http://www.de/sixcms/detail. Marketing und Kommunikation. Klaus Böhm. E-Mail [email protected]. Kluwer Academic. Basel. and the possibility of borrowing and loss. W. Hamm. pp 191–194 5.2. 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. Digital Archives When analyzing the life cycle of digitized dermatological images. …) of the raw material to produce a digital ‘master’ form. (5) navigation in the database and selection of images or other teaching material for lectures.Burg G (ed): Telemedicine and Teledermatology. Esser. Due to the large volume of those archives. 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. and (6) digital recording of presentations that may themselves be categorized and may become an integrated part of the database. (4) categorization and storage of the master files together with ‘thumbnails’ for referential purposes in relational databases.and Video-Sequences for Teleteaching Holger Höhn. Curr Probl Dermatol. clipping. Albert Lehrstuhl für Informatik II. (3) review and processing (cleaning. Karger. J. These large collections are considered as ‘treasures’ of a clinic and are usually organized according to individual diagnoses or groups of related diagnoses.3 Image Archives. conference contributions or online-/offline courses. Universität Würzburg. 2003. Audio. . access to specific images may be a severe bottleneck both for lecturers and especially for students. (2) generation of the ‘raw’ digital form. storage and organizational problems. H. 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. vol 32. Germany Traditional lectures and conference contributions in dermatology are based to a large extent on the presentation of slides. Categorization of data is supported by a Java application with extensible hierarchical and alphabetical pick lists of diagnoses. Learning objects available for students on top of this database include extensive supply of clinical. 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. For detailed inspection a higher resolution of about 1. 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’. By this. presenting and recording lectures and quizzes. etc.and video-sequences. As results of database queries the integrated pictures of the SENTIMED archives are first shown as thumbnails. Along these principles the Department of Dermatology and the Chair for Computer Science II in Würzburg jointly developed digitized image archives and a software package for generating. histological. simulated exams or quizzes. localization. The slides were scanned with best available resolution and stored on a database server providing information about diagnosis.As images are only one type of learning objects in dermatological teleteaching. The applet allows two kinds of zooming of regions of the entire image: locally a Höhn/Esser/Hamm/Albert 192 .g. The tools employed can be easily adapted for other visually oriented medical disciplines like radiology and pathology. Clinical Modification) and MeSH (Medical Subject Headings) [3] to build up a XML database. In uncompressed format the images were also archived on more than 130 CDs. ICD-9-CM (International Classification of Diseases. The lists strictly follow international standards like ICD-10 (International Classification of Diseases) for diagnoses or ICD-0 for localizations. the phases listed above have to be generalized and adapted e. respectively. Database Components The first building block of the package are the digital image archives in SENTIMED which consist of over 4. for each image. data input can be accelerated and typos are excluded.024 768 pixels together with the related information given in the archives is displayed by a Java applet. for ordinary texts. audio. It exploits UMLS (Unified Medical Language System) [2]. type and color of lesion etc. localizations. immunofluorescence and other images on special diagnoses. and training aids for the ‘diagnostic eye’. lectures in simple playback mode. The second database component is the navigation layer which documents the mutual relations of the categorization data in a semantic network.000 high-resolution slides covering more than 600 dermatological diagnoses. texts. divX gave the best impression of observed quality/compression ratio.and Video-Sequences for Teleteaching 193 . Each of these sources offers links to nodes which are parents. Furthermore. The third block consists of authoring tools (mainly Java applications and applets) for generating and presenting lectures or conference contributions. Image retrieval is supported by a fast and comfortable search on the SENTIMED image archives. clinical categories. time stamps. audio. Here also. While the images and the semantic network are installed on a clinic intranet server. Audio. the applications reside on local PCs inside the intranet. which extracts and transfers the specified region from the highest resolution image back to the applet. diagnoses or skin regions. a Java applet proposes a query which can be modified by editing or browsing in MeSH terms. Nodes in the semantic network combine information from the SENTIMED image archives. …). Thus. children or siblings of the current node. For PubMed access.4-fold magnification is calculated from image data without loading data from the server.1 [7]) defines a framework for hierarchically composing lectures and quizzes from images. Learning Objects Care was taken to build an open and extensible system of cooperating modules based on (de facto) standards.e. semantic net information can be extracted to each image shown in the Java applications. mp3 for sound material from lectures and for other reading voices is preferred. The parts. MeSH and ICD9-CM. Entry points to the network are several alphabetical and hierarchical lists of e. a high-quality magnification up to factor 8 is reached. The interface to the Internet is given by context-sensitive links to external sources like Medline-PubMed [4]. For video-clips. semantic net and Java tools cooperate in such a way that images found in the semantic net can easily be imported into the application. a CGI script on the clinic intranet server can be called. Access rights are then controlled by the different roles of users or by special data exports. Appropriate data formats and players for videos and sound have also been tested and ranked. UMLS. This allows to work on a common platform for all kinds of media data. wherever these were available. The current ‘Learning Object Modelling’ Standard (Draft 6. The semantic network can be presented to any user and explored by a standard Web browser inside the clinic intranet.and video-sequences together with their administrative data (author’s name. Currently. It is important that this one platform is supporting lecturers as well as students. interfaces to other common presentation tools like MS Powerpoint are provided. RxList [5] or ‘CD Klinische Dermatologie – Online’ [6]. for storage on a CD. Alternatively. i. Image Archives.g. URL: http://www2.gov/PubMed/ RxList – The Internet Drug Index. URL: http://www.pdf Jürgen Albert. USA. 49 931 888 6600. CD Klinische Dermatologie – Online.nlm. Am Hubland.uni-wuerzburg.org/doc/ wg12/LOM_WD6–1_1.dimdi. Informatik II.uni-wuerzburg. URL: http://ltsc.ncbi.ieee. Universität Würzburg. students as well as lecturers showed high acceptance of multimedial presentations. USA. At the same time.informatik.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. modified or brought up to date. Fax 49 931 888 6603. URL: http://www. References 1 2 3 4 5 6 7 SENTIMED. URL: http:// www.6. USA. The integration of further multimedial components like video-clips of diagnostic or therapeutic procedures or graphical animations is easy to accomplish. an existing presentation can easily be repeated.nlm. On next occasion. Universität Würzburg.de/sentimed/ National Library of Medicine: Unified Medical Language System (UMLS). URL: http://www.de/ Draft Standard for Learning Object Metadata.com/ Schmoeckel C. the technological shift to digital archives can enhance the accessibility of teaching material in dermatology drastically. IEEE P1484. In a kind of back-loop. It seems crucial to us that. image archives will provide the unique opportunity for students to revise passed or missed lectures and to train their visual knowledge. Germany. complete lectures become themselves part of the archives.de Höhn/Esser/Hamm/Albert 194 .rxlist. except for the technical level (replacing a slide projector by a multimedia projector).nih. In recent surveys. The semantic network layer guides the fast retrieval of images and related information in the context of an intranet/Internet.nih. D–97074 Würzburg (Germany) Tel. URL: http:// www.gov/research/umls/ Deutsches Institut für Medizinische Dokumentation und Information.multimedica.de/ National Library of Medicine: PubMed. As a next step.1. Lehrstuhl für Informatik II. no principal reorganization of lecturing is required. E-Mail albert@informatik. Ludwig Maximilian University. Consequently. 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. 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. W. vol 32. Munich. therefore. Gruber b. 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. N. Arnold & Schleich GbR College24. One important benefit to both students and teachers is the temporal and local independence and. Arnold c.Burg G (ed): Telemedicine and Teledermatology.4 Dermatology Course 2000: An Interactive Multimedia Dermatology Course for Students Programme Description and First Results W. M. 2003. teach me and I remember. Popala. and dDepartment of Dermatology. Germany ‘Tell me and I forget. Stolz a. The fast-moving advances in information technology allow a large and ever increasing variety of computer applications. Curr Probl Dermatol. 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. Roescha. Hamburg. Landthaler a c Departments of aDermatology and bPaedagogy III. University of Regensburg. also in medicine. For example. A. Burgdorf d. H. 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. pp 195–200 5. the willingness to make decisions is growing.2. This famous sentence by the philosopher and statesman Benjamin Franklin fits multimedia teaching programmes perfectly. H. the possibility of individually . Karger. Dr. Basel. involve me and I learn’. JavaScript. (3) Sexually transmitted diseases. (11) Acne and acne-like skin diseases.g. 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. 3. Microsoft Internet Explorer 4 and Netscape Navigator 3 upward compatible to Netscape Communicator 4 are defined as Internet browser for Windows 3. the following 16 training units are planned for the Dermatology course 2000 with units 1. (12) Hair diseases and epizoonoses. At present. no special computer knowledge is required for the use of this Web site. 4 and 6 already being available: (1) Anatomy of skin and dermatological examination of skin lesions. If a short dermatological repetition is required during a lesson. (13) Mycoses. Especially the interactive structure of the course supports the development of key competences which are essential in daily medical practise. Windows 95. Dermatology 2000 is acknowledged in four out of five Bavarian medical schools. are present. 2. for example if suggestions for improvement should be required. (10) Chronic venous insufficiency (CVI). Course Description and Latest Results The start page of Dermatology 2000 shows the course lessons available. (14) Blood vessel malformations. Successful participation is honoured by the issuance of certificates and credit points are awarded for the examinations at the respective home university. The feedback symbol allows the student to correspond with the lecturer. (8) Bullous dermatoses. the participant may use a well-illustrated index of all types of skin lesions. and Java. (7) Erythematous and papulous dermatoses. (9) Collagenoses. and (16) Pigmented skin lesions. (5) Allergology. (2) Viral infections of the skin. however. (4) Bacterial infections of the skin. e. Dermatology 2000 included five training units. (6) Atopic diathesis and atopic dermatitis. Stolz/Roesch/Popal/Arnold/Gruber/Burgdorf/Landthaler 196 . Technical Aspects At the end of the year 2001. The main purpose of Dermatology 2000. Windows NT and UNIX. Various function keys. is the transformation of theoretical background knowledge into applied knowledge. (15) Benign and malignant tumours. 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.planning their study time. Overall.x. The establishment of a chat room that allows participants to exchange their experiences and impressions is planned in the near future. Since the different modules are programmed in HTML. an info button or a bookmark button. At the end of each chapter the essential contents Dermatology Course 2000 197 . images. Case example for a typical sexual infection (see text for details). The image of the patient’s skin lesion can be enlarged by clicking on it (Screenshot of Dermatology Course 2000. The first lesson covers basic dermatological knowledge (e. typical dermatological cases representing the selected group of diseases are demonstrated in a playful but always realistic manner (fig 1). Additionally. As just a few of the listed questions are useful for the process of correct diagnosing. The use of video sequences. graphs and animations lends variety to teaching and represents the multimedia aspect of Dermatology 2000. 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. 1. primary and secondary skin lesions). a short overview about the course’s content is given. The student has to decide upon the correct questions. On the following page. the participant should only select the appropriate questions. The student has to construct the medical history of the virtual patient by choosing some of the anamnestic questions given. After clicking on each necessary question the detailed image of the respective skin lesion appears and the student has to assess the correct diagnosis. 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. chapter 3). 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.Fig.g. In this programme. already in 1989. medical education is thought to profit from this kind of method. the student has pass a final chapter test. Furthermore. 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. a programme called ‘PlanAlyzer’ was introduced [3]. 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.8% were pleased to be able to work with a programme without any record of wrong answers. the examination results achieved must be able to compete with those of conventional teaching. at the end of the summer term 2000. Discussion In recent years the importance of a new teaching method based on the use of case examples. second. To examine the participants’ learning process. Another early programme for the diagnosis of radius fractures was developed by the Department of Surgery of the University of Heidelberg [4]. 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. Dermatology 2000 participants had a lower rate of mistakes compared with students passing conventional apprenticeship (17 vs.8% of the students felt motivated to learn more about dermatology and 86. the so-called ‘cognitive apprenticeship’ [1]. 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.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. the idea of creating a computer programme arose in order to reduce that outlay. In order to obtain a certificate for the successful participation. as cognitive apprenticeship requires a large number of patients and lecturers. For this reason. 89. Two factors are crucial for the successful establishment of a new teaching method: first students have to accept the new method and. In this context. figures showed that our on-line course was immensely accepted: 84.are summarized shortly. especially if diagnostic or therapeutic procedures will be studied [2]. The evaluation of Stolz/Roesch/Popal/Arnold/Gruber/Burgdorf/Landthaler 198 . However. Above all. students had to find out the correct diagnosis for virtual anaemia patients. 27% mistake rate). has been frequently discussed for several study courses. Thus. [20] could show a significant improvement in the participants’ knowledge of diagnosing pigmented skin lesions after completion of their on-line programme.g. Learning and Instruction. pp 437–467. pp 453–494. 16] and surgery [17]. 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. we take part in this development. 9]. Essays in the Honour of Robert Glaser. References 1 Collins A. 7]. Hillsdale.com). dietetics [14]. A good example for an already established on-line case-based learning module for continuing medical education is the melanoma lecture hall (melanoma. During recent years. Mandl H (eds): Psychologie der Erwachsenenbildung. Hogrefe. especially with regard to the question if the transformation of theoretical knowledge into applied knowledge of the students has been accomplished. in Resnick LB (ed): Knowing. in particular. dentistry [11–13]. anatomy [8. The long-term results of the on-line programme will be revised after 12 and 24 months. in Weinert FE. cardiology [15. Gruber H. many programmes have been established in different medical sectors. e.this computer-based training method showed 15–20% better scores than the lecture. Mandl H. 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].lecturehall. radiology [10]. multimedia programmes do not always represent the most successful teaching method. Newman SE: Cognitive apprenticeship: Teaching the crafts of reading. in pathophysiology [6. Harris et al. Erlbaum. D/I/4. Experts estimate that although computer-based teaching methods only represent 2% of today’s teaching methods in Germany but already 20% in the USA [19]. although 87% of the students stated that their experience with computers was limited or insufficient. 2 Dermatology Course 2000 199 . writing and mathematics. With the planned establishment of additional modules for our courses for the medical education of both residents and dermatologists. Enzyklopädie der Psychologie. 1989. they will climb to 20% in Germany and 40% in the USA until 2005. Renkl A: Lernen und Lehren mit dem Computer. 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. Brown JS. A further point underlining the importance of multimedia programmes is their growing role in professional education in future. Modern textbooks. Naturally. Göttingen. MD. J Digit Imag 2001. p V1/1. Zentralbl Gynäkol 1998. Miller JA: Enhancement of achievement and attitudes through individualized learning-style presentations of two allied health courses. Gross M: Interactive computer-assisted learning program for diagnosis and therapy of recurrent laryngeal nerve paralysis (in German). Jerosch J. Kolasa KM.31:200–204. Schuhbeck M. 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Chirurg 2001. et al: Computer-based exercises in anemia diagnosis (PlanAlyzer). Comput Methods Programs Biomed 2000.68:433–438.120:471–473. Stehle A.27:150–156.14(suppl 1):113–116. Web-based learning environment for pathophysiology.77:695–699. Acad Med 1999. Fam Med 1999. Markus PM. Filler TJ. Wilhelm Stolz. J Allied Health 1998. Becker H: Teaching and learning in surgery – The Göttingen curriculum (in German). Konig S. Frank MS. Thomas GA.10: 1042–1046. Hospital Munich-Schwabing. Fax 49 89 3068 3918.3:35–43. et al: Possibilities of multimedia online teaching in medical education (in German).74:123–129. Kofranek J. et al: Computer-based training – A new method in surgical education and continuing education (in German).stolz@kms. Harris RB: The Internet and the globalisation of medical education. Acad Med 2001. et al: A virtual classroom for undergraduate periodontology: A pilot study.323:1106. Feb 1999. Salasche SJ. 13/14.mhn.72:613–620. Ziegler C: Auf der Suche nach dem neuen Lernen.61:157–162.5:139–147.de Stolz/Roesch/Popal/Arnold/Gruber/Burgdorf/Landthaler 200 . Julen N. D–80804 Munich (Germany) Tel. Kallinowski F. Clinic for Dermatology and Allergy. Lechner SK. Bradshaw M: An interactive multimedia solution to learning removable partial denture design.7:177–182. 49 89 3068 2294. Petrusa ER. Eur J Dent Educ 2001. et al: Teaching medical students cancer risk reduction nutrition counseling using a multimedia program. Dermoscopy and especially digital dermoscopy is based on twodimensional pictures and though ideal for telemedicine purposes.3 Teledermatopathology Burg G (ed): Telemedicine and Teledermatology. so-called ELM criterias. Auflichtmikroskopie. The simplest way to acquire digital dermoscopy images is to use a digital consumer camera (such as the Nikon Coolpix). Therefore. Geneva. the best treatment currently is still early diagnosis and surgical excision. Curr Probl Dermatol. amplified surface microscopy. Karger. especially for malignant melanoma [12. Switzerland In the last two decades a rising incidence of malignant melanoma has been observed [1–8]. depending on the type of skin lesions and experience of the physician [9–30]. Department of Dermatology. It uses an immersion technique to render the skin surface translucent and has been shown to increase diagnostic accuracy for pigmented skin lesions.1 Teledermoscopy Ralph P Braun. we will try to provide a neutral overview of such devices which are currently commercially available. This technique allows to visualize structures. vol 32. one can use special dermoscopy attachment with a built-in lens and light source (http://www. Since devices for digital dermoscopy become more affordable.5.com/. Its use increases diagnostic accuracy between 5 and 30% over clinical visual inspection. Basel. Due to a lack of adequate therapies for advanced metastatic melanoma. and which facilitate the diagnosis of pigmented skin lesions [35. University Hospital. 36]. easy-to-use in vivo method that has been described to be useful for the early recognition of malignant melanoma. Jean-Hilaire Saurat . http://www.teachscreen. dermatoscopy. The performance of dermoscopy has been investigated by many authors. 27. Dermatoskopie) is a simple. These attachments are available for . Basically everyone who owns a computer with Internet access and an e-mail account is potentially able to practice telemedicine and teledermoscopy. which are not visible by clinical examination alone. pp 201–206 5.opticalneuhaus. 2003.3.de). Dermoscopy (also known as epiluminescence microscopy. 31–34]. CCD or 3CD) and a camera body (fig. Almost all systems nowadays use LED light sources because of colour reproducibility and standardization purposes. Its quality is one of the most important factors for the price of such a system. Transmittance of an image using digital dermoscopy. an optical system (lens or optic with zoom).Light source Optical signal Electrical (video) signal Skin Camera chip Optical system Frame grabber Digital image Camera Computer Fig. Inside the camera there is a light source (LED or halogen). 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. The light source illuminates the pigmented skin lesion. and is the visible element for the patient. Some systems use a polarization technique instead of immersion liquid. 1). 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. 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.skinscan. We have the impression that this is true in some cases but that some structures are much Braun/Saurat 202 . The advantage is that the use of immersion liquid is not necessary any more and that the examination is faster. 1. This might be confusing for the dermatologist.de)). For this reason. various consumer cameras. a camera chip (CD. A multitude of systems are commercially available which all look similar even though there are big differences between them. The camera is one of the most important components of the system because it determines the image quality. All systems for digital dermoscopy offer the possibility of telemedicine and some of them even offer additional features such as computer-assisted diagnosis. a zoom function increases the size and the weight as well as the price of the camera. The light is reflected from the skin and passes the optical system of the camera. small lesions or precise evaluation of a part of a lesion). The absence of calibration and standardization renders the interpretation more difficult but not impossible. The camera chip is the heart of every camera. In the majority of the cases a simple lens system is sufficient even though a zoom function is helpful in some cases (i. The best camera cannot provide digital images of good quality when a bad frame grabber is used and vice versa.harder to evaluate with polarization than with immersion liquid. a specific software has to be used to store and retrieve the images. 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). 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. Arpage AG. Therefore. This system is independent from any time schedules and can easily be done between different countries or continents. Some of the systems have built-in conferencing modules with a text or voice chat function which enables both partners to directly interact (Dermanet. On the other hand. Colours are important in dermoscopy and the colour reproducibility is important for the diagnosis at distance based on dermoscopy images. The frame grabber is the component which is very important for the quality of the final digital image. Reinach Switzerland). 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. Once the digital image is stored on the hard disk of the computer. standardization and colour calibration of the digital images is suitable to assure the quality of the remote diagnosis. In some settings this might be a useful feature. 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 is an electronic element which transforms an optical signal (the light reflected by the skin lesions) into an electrical signal (video signal). The disadvantage is that these systems do not allow direct interaction or discussion between consulting physician and consultant at distance. 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. Teledermoscopy 203 .e. The last issue is the reimbursement situation for teleconsultations. The system is designed for computer-assisted diagnosis and digital follow-up of pigmented skin lesions.co.dermogenius. a 3CD camera which is very well designed and very lightweight. 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. Germany. http:// teachscreen. Since patient data and images are transmitted during a teledermoscopy consultation. and that its diagnostic performance depends on the ‘level of diagnostic difficulty’ and on the experience of the consultant at distance [38.com) is a standardized fully calibrated system which uses LED illumination. International standards such as encryption protocols remain to be defined. legal and financial aspects.derma. The Microderm system (Visiomed AG. The system uses a CCD video camera and is designed for computer-assisted diagnosis.ch) use a rather heavy camera with a built-in zoom optic allowing up to 70 magnification which also allows excellent macroscopical images. Arpage AG. Bochum. 39]. there are still some important items which have not been addressed: This mainly concerns data safety. dermatologist in private practice) who is in charge of the patient (treatments and consequences).de) and its Swiss versions (Dermanet. Even though most of the technical issues such as standardization and calibration have already been solved or are currently being solved. The FotoFinder Medic (Teachscreen.at) has two different video cameras for dermoscopy and macro images. http:// www. Germany. Bad Birnbach. Germany.In alphabetical order we will give a brief overview over the characteristics of the different systems: The DermoGenius ultra (Rodenstock Präzisionsoptik. http://www. The MoleMaxII (Derma Instruments.dermanet.e. http:// www. Until now. teledermoscopy has been performed as a study or between friends or local Braun/Saurat 204 . 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. Austria. It uses an e-mail-based store-and-forward system as well as a teleconsulting feature which is integrated in the software. Reinach.visiomed. Vienna. It has an e-mail-based store-and-forward system as well and a conference module for teledermoscopy. Teledermoscopy can be performed via a store-and-forward system (images attached to an e-mail). Another important issue is the legal aspect.de) uses a well-designed calibrated camera with a sophisticated optical system with a zoom function. Switzerland. Munich. http://www. It has been shown that teledermoscopy consultation is technically feasible [37]. there is a need to protect these sensitive data. 6:179–187. Marghoob AA. Ferrario M. Welkovich BA. Sagebiel R. Barnhill RL. Wolf IH. Berlin. Hartge P. Sober AJ: Melanoma risk in individuals with clinically atypical nevi. Delfino M: Epiluminescence . Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Grin CM. Blackwell Wissenschaft. Br J Dermatol 1998. Arch Dermatol Res 1994. Elder D: Human melanocytic neoplasms and their etiologic relationship with sunlight.287:13–15. Dermatology 1998. Regalia C. Sagebiel RW: Risk factors for melanoma incidence in prospective follow-up. MacKie RM: Clinical accuracy of the diagnosis of cutaneous malignant melanoma.138:283–287.4:37–40. Bart RS: Techniques of cutaneous examination for the detection of skin cancer. Crutcher WA. Bucchi L: Epiluminescence microscopy versus clinical evaluation of pigmented skin lesions: Effects of operator’s training on reproducibility and accuracy. J Invest Dermatol 1989. Rassner G: Auflichtmikroskopie pigmentierter Hauttumoren. Arch Dermatol 1994.130:999–1001. Slade J.130:1002–1007. A new method for the clinical diagnosis of malignant melanoma (in German). Braun-Falco O. Stanganelli I. Schneider JS. Lorentzen H. Smolle J. Leo E: A possible new tool for clinical diagnosis of melanoma: The computer. Harrison C.14:1044–1052. Holly EA. Clark W. Fenske NA. ed 1.75(suppl):684–690. Carli P.3:149–156. Erez IR: Epidemiology of malignant melanoma. Thieme.196:199–203. Tarone R: Recognition and classification of clinically dysplastic nevi from photographs: A study of interobserver variation. Arch Dermatol 1990. Melanoma Res 1998. References 1 2 3 4 5 6 7 8 9 10 11 MacKie RM: Strategies to reduce mortality from cutaneous malignant melanoma. Sagebiel RW: Clinical diagnosis of dysplastic melanocytic nevi. 1993. Tonelli T. microscopy for the diagnosis of doubtful melanocytic skin lesions.120:801–805. Kerl H: Sensitivity in the clinical diagnosis of malignant melanoma. Kopf AW. Kelly JW. Soyer HP. Morton CA. Since it has been clearly shown that the highest diagnostic accuracy can be obtained while consulting an expert. Arch Dermatol 1994. Soyer HP: Dermatoscopy.126:763–766. Secher L.92:297S–303S. Bilek P. Kreusch J. Guerry D. Elder D. Acta Derm Venereol 1999. Dtsch Med Wochenschr 1995. Mason G. Kang S. Mihm MC.networks of dermatologists who discussed cases without reimbursement. Larsen FG: The dermatoscopic ABCD rule does not improve diagnostic accuracy of malignant melanoma. Cancer Epidemiol Biomarkers Prev 1995. Stuttgart. epidemiology. Halpern A. Argenziano G. Bronzera SJ. Fitzpatrick TB. Koh HK: Etiology. Arch Dermatol 1998. Wolf IH. Stolz W. Hanson L. worldwide incidence and etiologic factors. Salopek TG. 12 13 14 15 16 17 18 19 20 21 Teledermoscopy 205 .79:469–472. Petersen CS. Med J Aust 1997. Sterry W. Landthaler M: Farbatlas der Dermatoskopie.16:361–367. Bart R.134: 1563–1570. De Giorgi V Sammarco E.167:191–194. risk factors and public health issues of melanoma. Semin Surg Oncol 1993. Kopf AW. Dermatology and Venereology Society of the Canton of Ticino. 1991. Cascinelli N. Elwood JM. Henham AP: A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. Weismann K. Elwood JM: Recent developments in melanoma epidemiology.8:425–429. Fabbrocini G. J Am Acad Dermatol 1986. Yeatman JM. Cancer 1995.9:165–167. Moore DH. Levenstein MJ: Accuracy in the clinical diagnosis of malignant melanoma. Kerl H. J Am Acad Dermatol 1987. the reimbursement question for these expert consultations should be addressed. Curr Opin Oncol 1994. Kelly JW. Melanoma Res 1993. 135:1467–1471. Hautarzt 1990.9:470–476. Wolff K: In vivo epiluminescence microscopy: Improvement of early diagnosis of melanoma. 1989. Menzies SW.8:529–537. Criteria of cutaneous melanoma progression.113:237–242. University Hospital. Puppin D. Kerl H. Cerroni L. telediagnosis of pigmented skin tumors: A teledermoscopic study.45:15–19. Smolle J. Fritsch P. Chimenti S. Konsensus-Treffen der Arbeitsgruppe analytische Morphologie der Arbeitsgemeinschaft dermatologische Forschung. in Ackerman AB (ed): Masson’s Monograph in Dermatopathology. Pehamberger H. Soyer HP: Face-to-face diagnosis vs. Argenziano G. Peris K. Castello G: Epiluminescence microscopy as a useful approach in the early diagnosis of cutaneous malignant melanoma. Secher L. Steiner A. Tanaka M. A useful tool for the diagnosis of pigmented skin lesions for formally trained dermatologists. Petersen CS. Dermatology 1998.41:513–514. Pechlaner R: Differentiation of benign from malignant melanocytic lesions using incident light microscopy. Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. E-Mail braun@cmu. Pellacani G. Pehamberger H. Wolf IH. Dell’Eva G. De Giorgi V Delfino M: Epiluminescence microscopy: . Hofmann-Wellenhof R. Kenet RO. Steiner A. Kopf AW.100:356S–362S.7:433–434. Binder M. Pehamberger H. Bosco L. Schulz H: Maligne Melanome in der Auflichtmikroskopie. Arch Dermatol 1999. Crotty KA. Kerl H. 1998. Wolf IH. Schwarz M. Weismann K. DeDavid M. Pizzichetta MA. Smolle J. Piccolo D. pp 301–311. Kreusch J. Saurat JH: Amplified surface microscopy. CH–1211 14 Geneva (Switzerland) Fax 41 22 372 9470. McGraw-Hill. Smolle J.79:301–304. Wasti Q. Cavicchini S: The dermoscopic versus the clinical diagnosis of melanoma. Public Health 1999. Serafini M. Acta Derm Venereol 1999. Winkler A. Hofmann-Wellenhof R. Argenziano G. Seidenari S. Schindera I. Fritsch P.ch Braun/Saurat 206 . J Telemed Telecare 2000. Stolz W. Palmieri G.196:299–304. Binder M. J Invest Dermatol 1993. Burroni M. Stanganelli I. Ferrari A. Fabbrocini G. Melanoma Res 1998. Benelli C. Chimenti S. New York. Pozzo VD. Rabinovitz HS. Soyer HP. J Am Acad Dermatol 1997. Masson. J Am Acad Dermatol 1998. Salomon D. Steiner A. Soyer HP: Teledermoscopy – Results of a multicentre study on 43 pigmented skin lesions. Ascierto PA. Akt Dermatol 1991. Hamburg. Kaider A.48:904–909. Roscetti E. rue Michelis-du-Crest.28: 923–927. Braun R. Schulz H: Auflichtmikroskopische Differenzierung maligner Melanome. Wolff K: Improvement of the diagnostic accuracy in pigmented skin lesions by epiluminescent light microscopy. Schulz H: Epiluminescence microscopic characteristics of small malignant melanoma. Bahmer FA. Nov 17. MD. Schaeppi H. Stolz W. 24.unige. Provost N. Larsen FG. Sydney. 1996. Pehamberger H: Epiluminescence microscopy. Assessed by expert and non-expert groups.17: 134–136.6:132–137. Carli P. Braun. Arch Dermatol 1995. Eur J Dermatol 1999.131:286–291. Department of Dermatology. Stolz W: Diagnostische Kriterien in der Auflichtsmikroskopie.22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Lorentzen H. McCarthy WH: An Atlas of Surface Microscopy of Pigmented Skin Lesions. Mazzocchetti G. Hautarzt 1997. Piccolo D. Magrini F.37:68–74. Parasole R. Satriano RA. Hautarzt 1994. Ralph P. Ingvar C. Anticancer Res 1987. Wolff K. Skodt V: Clinical and dermatoscopic diagnosis of malignant melanoma. Rohrer C. Bucchi L: Diagnosis of pigmented skin lesions by epiluminescence microscopy: Determinants of accuracy improvement in a nationwide training programme for practical dermatologists. Gasparini G. Burg G (ed): Telemedicine and Teledermatology. U. Two recent meta-analyses have shown that the employment of dermatoscopy results in improved diagnostic accuracy in melanocytic lesions. 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. this technique has represented an improved approach for examination of pigmented skin lesions in daily routine practice besides conventional microscopy and macroscopic investigation. Coras a. questions regarding the diagnosis of pigmented skin lesions could be clarified by consulting an expert. 3]. Glaessl a. Landthalera. Gilching. especially for physicians experienced in this field [2. d Department of Dermatology. R. J. Hospital Munich-Schwabing. [5] evaluated the analogy between the direct clinical diagnosis and the telediagnosis of 43 cutaneous pigmented lesions using a digital photo camera. pp 207–212 5. Stolze Department of Dermatology. 2003. Karger. A multicentre study by Piccolo et al. W. by transferral of the patient to a clinic specialized in pigmented lesion. Curr Probl Dermatol. W. who are interested in telemedicine. University of Geneva. b Private Practice. Kinatederb. Germany. University of Regensburg. A. or by teledermatology. Bayreuth. vol 32. Since quality and . dermoscopy. Klövekornc.3. epiluminescence microscopy. Switzerland.e. 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. Lepskia. Braund. c Private Practice. Germany. Teledermatoscopy might present a solution for the problem of lower levels of sensitivity and specificity for inexperienced users [4]. For dermatologists in private practice. i. Germany.2 Teledermatoscopy in Daily Routine – Results of the First 100 Cases B. Basel. Germany a Often. e Clinic of Dermatology and Allergology. M. Dermatoscopy. This consultation could be personal. we analysed the outcome of the first 100 cases in our teledermatoscopy approach. To elucidate the possibilities of teledermatoscopy using a computerized dermatoscopy system with a video camera. Since the development of a hand-held device [1]. this type of expert consultation may present a favourable alternative. correct classification rate was 88.reproducibility of digital images are very important. Using teledermatoscopy. Matrox Meteor II frame grabber and Matrox G 400. The recording field is 11 11 mm. Corresponding patient data and medical history as well as informed consent were received via fax to assure high data security. suspicious atypical melanocytic nevi (n 5).S. Rodenstock Präzisionsoptik LINOS Co. Results In 16 months. Germany. The resolution of the camera is more than 700 TV lines with an actual pixel size of 512 512. In 45 lesions.1% for face-to-face diagnosis (table 1). excision was performed because (a) of the diagnosis of a malignant melanoma/ atypical nevus. Germany).2 on a IBM-compatible computer (750 MHz Pentium 3 computer with 128 MB RAM.L. and malignant melanocytic skin lesions (n 16). and shading correction). a total of 100 pigmented skin lesions were collected. graphic card. According to our algorithm of dermatoscopy [7]. 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. used the same technical equipment for the acquisition of digital images (Dermogenius® ultra). 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. Switzerland.. The quality of digital images was sufficient in 90% of the cases. After a total duration of 16 months.dermogenius. or (c) of the patient’s request. The camera is calibrated on a daily basis prior to use for shading and colour corrections. The histopathologic diagnosis of the majority of cases occurred at the Department of Dermatology Regensburg by one of the co-authors (M.8% compared to 91. Coras/Glaessl/Kinateder/Klövekorn/Braun/Lepski/Landthaler/Stolz 208 . Atypical melanocytic nevus was only diagnosed if one or two but not every feature of malignant melanomas were present [6]. The images were stored and processed using the Dermogenius Software Version 1. which corresponds to a magnification of 20 . The system consists of an ergonomic and easy-to-use hand-held 3-CCD camera (Dermogenius® ultra. gain control of camera. (b) a benign lesion was diagnosed but a malignant melanoma could not be entirely ruled out. Materials and Methods Each of the three participating dermatologists in Bayreuth and Gilching. University of Regensburg. as well as Geneva. melanocytic lesions were divided into benign (n 24). 56 K modem. Munich. www. The images were then evaluated by a physician experienced in dermatoscopy. 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). or W. the two different approaches were compared with the histopathologic diagnosis as golden standard.com. The lesions were diagnosed (diagnosis 2) both based upon the digital images and the history of the patient (table 1). Table 2. and papillary nevus). 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. congenital nevus.Table 1. The comparison of face-to-face diagnosis with teledermatoscopy for diagnosis of malignant melanoma/atypical nevi revealed a sensitivity 85. 91. Melanocytic nevus (also including dermal nevus. Other diagnosis (collision tumours either seborrhoeic keratosis and melanocytic nevus or melanocytic nevus and blue nevus). 85.7 vs. In 5 cases our diagnosis could not be confirmed histologically (table 2).6%. LMM lentigo malignant melanoma.8 vs. In 3 cases our diagnosis corresponded with the diagnosis of the dermatologists Teledermatoscopy in Daily Routine 209 . ALM acral lentiginous melanoma.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. SSM superficial spreading melanoma.6%.8% Histologic diagnosis 24 15 7 2 5 16 14 2 45 F Incorrect diagnosis.7% and specificity of 91. melanocytic nevi revealed a sensitivity of 85. recurring nevus.7% and specificity of 95. teledermatoscopic diagnoses for malignant melanoma/atypical melanocytic nevus vs. 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. our clinical diagnosis was malignant melanoma but histology showed a congenital nevus. [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.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. The evaluation of pigmented skin lesions by dermatoscopy mainly depends on the experience of the physician. Piccolo et al. The method itself is based on a two-dimensional picture and thought ideal for telemedicine purposes. They were able to identify each of the 9 melanomas in the study by teledermatoscopy. Since dermatoscopy is a relatively new method. The main purpose of a study by Provost et al. 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. which can be increased with a formal training for just 2 half days [4]. the dermatologist identified an irritated seborrhoeic keratosis. In both cases without confirmed histology the diagnosis of the dermatologists in private practice did not correspond with ours: in 1 case. [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. 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]. in 1 case the clinical diagnosis was malignant melanoma but histology revealed an irritated spindle cell nevus. while we diagnosed a multiform reaction and histology revealed an amelanotic malignant melanoma. Braun et al. the dermatologist diagnosed an irritated active melanocytic nevus. Discussion Dermatoscopy is a noninvasive method for both the differential diagnosis of pigmented skin lesions and the early diagnosis of malignant melanoma. Recently. whereas in the second case. [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 Coras/Glaessl/Kinateder/Klövekorn/Braun/Lepski/Landthaler/Stolz 210 . not every dermatologist has acquired that experience so that a consultation by teledermatoscopy might be beneficial [8]. Berlin. Pehamberger H. Braun-Falco O. A recent survey by Glaessl et al. could spare unnecessary distress for the patient and. Piccolo D. Lancet 1989. Kittler H. Such positive results became possible because the reproducible colour-adjusted image acquisition was identical in all participating centres. van Horn M: The precursor lesions of superficial spreading and nodular melanoma. Kenet OR. Braun-Falco O: Skin surface microscopy. Ferrari A. Wolf HI. could save public money. Hofmann-Wellenhof R. J Am Acad Dermatol 1997. Aegerter P. Bilek P. Magrini F.15:1147–1165. This is further underlined by the absolute concordance in the two collision tumours. the teledermatoscopic diagnosis of our study demonstrated a sensitivity of 85. Epstein MN. Steiner A. Soyer PH: Teledermoscopy results of a multicentre study on 43 pigmented skin lesions. Clark W. Cerroni L. Tanaka M.3:159–165.8%.transmission of their digitized images. Burgdorf WHC.6%. Landthaler M.137:1343–1350. Chimenti S. Pehamberger H: Epiluminescence microscopy of small pigmented skin lesions: Short-term formal training improves the diagnostic performance of dermatologists. The use of teledermatoscopy for the diagnosis of pigmented skin lesions could contribute to a reduction in travel time and workload in dermatology clinics. Mazzocchetti G. Schaeppi H. The procedure of teledermatoscopy is simple with the images sent by e-mail. Müllner M. Wolff K. Merkle T. Beauchet A. Bafounta ML. where both the dermatologists outside and inside diagnosed collision tumours between seborrhoeic keratosis respectively blue nevus with melanocytic nevi. While face-to-face diagnosis showed a sensitivity of 85.7% and a specificity of 91. Kittler H. this service may be in high demand. Pizzichetta AM. J Telemed Telecare 2000. while providing a faster and more efficient service [5]. These figures point to the fact that the examined lesions sent by dermatologists with great experience in the field of dermatoscopy were difficult cases. Elder DE. Wolff K. Smolle J. ultimately.6:132–137. Hum Pathol 1984. Our results demonstrated similar sensitivity and specificity for teledermatoscopy and face-to-face diagnosis. 2002. Also there was high agreement in the diagnosis of the atypical melanocytic nevi and Spitz nevi. Binder M: Accuracy of the clinical diagnosis for melanoma with and without dermoscopy: A meta-analysis of diagnostic test performance. Braun R. Their data indicated that the images retain sufficient information for diagnostic purposes. References 1 2 Stolz W. Argenziano G. Stolz W. In the future. 3 4 5 6 7 Teledermatoscopy in Daily Routine 211 . Lancet Oncol 2002. ed 2 rev. Greene MH.7% and a specificity of 95. Cognetta A: Color Atlas of Dermatoscopy.2:864–865. Landthaler M. Stolz W. if such high concordance between face-to-face diagnosis and teledermatoscopy can be demonstrated. Guerry D. Kerl H. Binder M. Puespoeck-Schwarz M. Bilek P.36:197–202. Saiag P: Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Arch Dermatol 2001. Blackwell Science. [11] showed that a high proportion of dermatologists in private practice would be willing to use a teledermatoscopic service. Walther T. J Telemed Telecare 2000. Clinic for Dermatology and Allergy.mhn. Landthaler M. Fax 49 89 3068 3918. Arch Dermatol 1999.42:770–775. Kerl H. Piccolo D. Stolz W: Teledermatology – The requirements of dermatologists in private practice. Hofmann-Wellenhof R. Dermatology 1998. MD. DeDavid M. Kölner Platz 1. Ramelet AA. Burroni M. Tapernoux B. Meier ML. telediagnosis of pigmented skin tumors: A teledermoscopic study. Soyer HP: Face-to-face diagnosis vs. Kopf AW. Thürlimann W. Wolf IH. D–80804 Munich (Germany) Tel. Chimenti S. Dell’Eva G. Pelloni F.de Coras/Glaessl/Kinateder/Klövekorn/Braun/Lepski/Landthaler/Stolz 212 . Wilhelm Stolz. Rabinovitz HS. E-Mail wilhelm. J Am Acad Dermatol 2000. Smolle J. Saurat JH.135:1467–1471. Stolz W. Provost N. 49 89 3068 2294. Schilling M. Peris K.196:299–304.6:138–141.8 9 10 11 Braun RP. Schiffner R. Krischer J: Teledermatoscopy in Switzerland: A preliminary evaluation. Bart RS: Comparison of conventional photographs and telephonically transmitted compressed digitized images of melanomas and dysplastic nevi. Glaessl A.stolz@kms. Hospital Munich-Schwabing. Wasti Q. and (4) clinicopathologic correlations. No single morphologic and immunophenotypic feature or molecular biologic findings allow to differentiate these two lymphoproliferative disorders with sufficient diagnostic . [1] and Rashbass [2]). University Hospital. telepathology means to transfer digital images of biopsy specimens from one pathology center to another remote center. Serge Reichlin. Four major applications of telepathology can be distinguished. namely: (1) telemicroscopy. The term ‘look-alikes’ has been introduced for those pathologic conditions. In most circumstances. Clinical data on patient’s history and laboratory investigations are helpful adjunctive information for diagnosis of most biopsies in surgical pathology. diagnosis in dermatopathology essentially depends on information of clinical manifestation of the skin lesion which has been excised. ‘Look-alikes’ are a common and characteristic feature of dermatopathology and can be observed in inflammatory as well as in neoplastic skin disorders. Günter Burg Department of Dermatology. (2) online image atlases. (3) second-opinion/decision expert systems. but clinical presentation is usually of minor diagnostic impact. For example. In sharp contrast. Karger. see Kayser et al. Curr Probl Dermatol.3 HistoClinC: A Web-Based Telemedicine Application for Clinicopathologic Correlations in Dermatopathology Werner Kempf. where different disorders share the same pathologic features [3].Burg G (ed): Telemedicine and Teledermatology. Zürich. 2003.3. vol 32. Basel. 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. This is mainly due to a considerable overlap of pathologic features in different skin disorders. 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. pp 213–220 5. chronic inflammatory skin disorders like chronic eczema and malignant cutaneous lymphoma like early stages of mycosis fungoides (fig. Similar problems are encountered in the differential diagnosis of benign. pityriasis rosea and eczema share most histologic features and can only be distinguished by combined evaluation of clinical manifestation and histologic findings (fig.Parapsoriasis benign Eczema ? Parapsoriasis ? T-cell lymphoma ? T-cell lymphoma malignant Fig. On the other hand. The clinical manifestation and the course of the disease are crucial informations to establish final diagnosis. 1. digital images of the skin Kempf/Reichlin/Burg 214 . 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]. ‘Look-alike’ in neoplastic skin disorders: Identical histologic features with infiltrates of lymphoid cells in the upper dermis. 2). early diagnosis of malignant processes such as cutaneous T-cell lymphomas may allow early therapeutic intervention to potentially prevent disease progression and fatal outcome. Alternatively. 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. 1). 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. For example. The majority of ‘look-alikes’ concerns the large group of inflammatory skin diseases. photographs of the clinical features are occasionally submitted as hardcopies together with the biopsy specimens. To overcome those limitations of histologic evaluation. 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. the dermatologist/clinician and the dermatopathologist. In particular. 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. 2. All these approaches are time-consuming for the involved parties. etc. In this way. In cases. i. adjustment of colors. ‘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. HistoClinC 215 .e. the patient.) to be adequate for analysis.Pityriasis rosea Self limiting Eczema/atopic dermatitis ? Pityriasis rosea ? PLEVA? Atopic dermatitis Chronic recurrent Fig. digital images of various size sent by e-mail via the Internet need first to be downloaded by the pathologist. usually as images attached to e-mail messages. 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. are usually printed out to be available beside the microscope and often require additional modification (image size reduction. lesions are submitted in various forms. where skin lesions are disseminated or difficult to recognize on photographs or digital images. the system should enable the dermatopathologist to increase diagnostic accuracy of dermatopathologic evaluation. 3. respectively. i. Thus. One major technical issue was secure identification of the biopsy specimen and the protection of data. The concept is schematically depicted in figure 3. since no personal data like the patient’s name are necessary for case identification. Those numbers are generated by the dermatopathology center and printed on self-adhesive labels. the clinician/dermatologist and the dermatopathologist.e. University Hospital. A Web-based application accessible by Internet was chosen as a platform to enable easy and widely available access to the application. After having shot digital images of the skin lesions.Upload of Dermatologist clinical images Dermatologist Archive Dermatopathologist Clinicopathologic correlation Second opinion via Internet Experts Fig. they can be uploaded into HistoClinC as jpg files by the dermatologist from his or her personal Kempf/Reichlin/Burg 216 . which are sent out to the dermatologists in private practice. to avoid transfer of name the patients are identified by a number. Access to the application is regulated by password and login. Each number is used only once in the system. submission and retrieval of clinical images. HistoClinC was programmed using ‘cold fusion’ technology and is run physically on a Web server located at the Department of Dermatology. since the application can be accessed via the Internet. but no other security portals are required. 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. and to have insight into the clinicopathologic correlation for both parties. HistoClinC The technical goals of the system were to facilitate the handling. Switzerland. Schematic concept of a system for clinicopathologic correlations in dermatopathology. Zürich. a short description of histologic features and the final diagnosis HistoClinC 217 . 5 computer (PC). 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. 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. 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. but not by name. 4. After the histologic images have been uploaded. During the signingout process.4 Fig. on which the HistoClinC application runs. 5. Note: Identification of the patient is achieved by a number and the date of birth. After the correlation of clinical and histologic findings. The application allows the upload of four clinical images at maximum and to add clinical description to the images. 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). digital images are created using a digital camera mounted on the microscope and connected to the PC. a final written report containing patient’s name and date of birth and a detailed description of the biopsy specimen is sent by mail to the dermatologist. 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. which represents a much faster procedure compared to the conventional way. 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.. 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. In addition. the case submitters as well as the dermatopathology center.e.are added. are minimal and the costs are low compared to similar systems. 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. Discussion HistoClinC is a Web-based application of telepathology which allows correlation of clinical and histologic findings in skin disorders. i. The HistoClinC project was started in December 2000. 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. In addition to the above-described function. respectively. Adobe Photoshop program) can be circumvented. 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 Zürich. sending of histologic slides to experts by regular mail. After only 10 months.g. Furthermore. HistoClinC allows to inform expert pathologists by e-mail asking them for evaluation of a case. In addition. HistoClinC images can be evaluated by other experts in the context of ‘second opinions’ via direct Internet-based access to the cases. one further advantage of this application refers to the use of numbers for the identification of patients and biopsy specimens. Switzerland. instead of patient’s name which would require more sophisticated data protection systems. For the dermatopathology center. The technical requirements for both parties. 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 Kempf/Reichlin/Burg 218 . 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. Both approaches result in practical problems such as transfer time and critical quality of the images. size. we assume that HistoClinC and other similar system will replace ‘classic’ clinicopathologic correlation. In our experience. The scientific evaluation of applications like HistoClinC includes various aspects. 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. 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 [5–7]. the dermatologist who submitted the clinical images as well as the biopsy specimen. 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. Second. So far. despite these limitations. Ideally. such systems can be used for open and distance education [9]. First. correlation between the diagnoses based on the clinical images and the histomorphologic diagnoses seems to be good.another consultant expert. HistoClinC 219 . In the future. So far. reimbursement for the performance of clinicopathologic correlations has to be defined since the correlations require manpower and technical maintenance. Most colleagues in private practice provide one or two clinical digital images. 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. 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. rarely three images per patient were uploaded. 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]. surface structure and coloration. but needs to evaluated in appropriate prospective studies which are currently ongoing. In this case. However. In addition. In addition. In summary. establishes and is responsible for the final diagnosis taking into account all available data. 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. 36: 1–7. Marchevsky AM: ‘Virtual microscopy’ and the Internet as telepathology consultation tools: Diagnostic accuracy in evaluating melanocytic skin lesions.200 cases. Williams & Wilkins. CH–8091 Zürich (Switzerland) Tel.21:525–531. Baltimore. Binder SW. Ackerman AB. René Rüdlinger for their timeless and kind collaboration during the installation and the tests of the HistoClinC system.21:183–191. 4 5 6 7 8 9 Werner Kempf. E-Mail kempf@derm. Felten CL. and PD Dr. Burg G: Approach to lymphoproliferative infiltrates of the skin. Dummer R. Elgart GW. The difficult lesions. Histopathology 2000. MD. Petra Ellgehausen.21:101–106. Okada DH. Telemed J 1999. Chongchitnant N.21:97–99. Blum S. Krupinski EA.111(suppl 1):S84–S93.unizh. References 1 2 3 Kayser K. Rolf Sidler and Oliver Jäschke for programming HistoClinC and to the dermatologists Dr. Rashbass J: The impact of information technology on histopathology. ed 2. Berman B. Kempf W.Acknowledgements We are very grateful to Nicolas Miescher.5:323–337. 1997. Sanchez J.ch Kempf/Reichlin/Burg 220 . Burdick AE: Dermatopathology via a still-image telemedicine system: Diagnostic concordance with direct microscopy. Anal Cell Pathol 2000. Beyer M. Am J Clin Pathol 1999. Dunn BE. Guo Y: Histologic Diagnosis of Inflammatory Skin Diseases. Weinstein RS: Routine surgical telepathology in the Department of Veterans Affairs: Experience-related improvements in pathologist performance in 2. Szymas J: Teleeducation and telepathology for open and distance education. Almagro UA. Recla DL. Dr. 41 1 255 4403. Dierks C: Legal aspects of telepathology. Department of Dermatology. Norbert Hilty. Telemed J 1997. Kayser G: Recent developments and present status of telepathology. 41 1 255 8733. University Hospital. Am J Dermatopathol 1999. Choi H.3:27–32. Anal Cell Pathol 2000. Dr. Strauss JS. An Algorithmic Method Based on Pattern Analysis. Urs Hess. Anal Cell Pathol 2000. Gloriastrasse 31. Martin Grob. pp 171–172. 6 Global Telemedicine . 2]. only 40% of skin conditions are being diagnosed and managed by dermatologists. the number of published articles on teledermatology has increased substantially. Given the current reimbursement by Medicare and managed care organizations. there has been a significant reduction of medical dermatologists in the USA.1 Teledermatology in North America Hon Pak San Antonio. vol 32. Tex. Given the reimbursement limitations. 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. Interestingly. Based on the available data from these studies and . Karger. 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]. It is expected that the demand for dermatologists will only increase with our aging population. USA Background The USA spent USD 36. Curr Probl Dermatol.Burg G (ed): Telemedicine and Teledermatology. This shortage of medical dermatologist in the USA is projected to worsen in the next several years. even though there is evidence that dermatologists are more cost-efficient and better equipped to manage all skin diseases directly. Unfortunately. 2003.7 billion in 1997 on dermatologic care which included approximately 33 million outpatient visits to the dermatologists [1. making direct access for all patients untenable. a significant number of dermatologists are performing more cosmetic and laser procedures leaving fewer dermatologists to manage patients with routine skin problems.. In the last few years. Recently. Basel. interest in teledermatology has increased due to the ongoing shortage of dermatologists in the USA with few viable alternative options. pp 222–225 6. Jim Grigsby and Anne Burdick. there is sufficient evidence supporting the diagnostic equivalency (correlation) of teledermatology to a face-to-face evaluation with a dermatologist [4–15]. Although most dermatologists who have used S&F teleconsultations would agree that teledermatology is a clinically effective method to deliver specialty consultation. Of note. 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. credentialing and malpractice insurance. although more ideal for education. Led by Drs. is that it is not optimal to handle a large volume of consults as seen in a normal outpatient dermatology setting. the outcome of this effort is not clear. However. The current state regulations do not permit physicians to provide services across state lines unless they have the appropriate state licenses. there is debate on a national medical license to practice telemedicine. however. Unfortunately there are many barriers which are inhibiting teledermatology from growing to its full potential: reimbursement.our experience in the US military. Although interactive telemedicine consultations are being reimbursed in the USA. In addition. Barriers Given the current shortage of dermatologists in the USA. Although there are many studies (mostly from outside North America) alluding to the cost-effectiveness of teledermatology. interstate licensing. only Hawaii and Alaska currently have pilot studies in which SAF teledermatology consultations are being reimbursed. the author has received funding to perform a comprehensive outcomes study for SAF teledermatology in the military setting. formerly HCFA) evaluating SAF teledermatology is currently underway. by utilizing those dermatologists with the appropriate state licenses (whether they reside in that state or not). On the issue of credentialing. The issue with interactive teledermatology. there is debate on the final outcome (which includes clinical and cost outcome in addition to patients’ quality of life). Interstate licensing is an issue fairly unique to countries with similar healthcare systems as the USA. the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently revised their Medical Staff Standards for its Comprehensive Accreditation Manual for Hospitals [16]. outcomes studies are very few and those available are focused on IAV teledermatology and limited in scope. we can circumvent this issue. and thus only those healthcare organizations which serve populations across state lines are affected. Teledermatology in North America 223 . an outcomes study sponsored by the Center for Medicare and Medicaid Services (CMS. Most studies evaluating teledermatology show that patients benefit the most via an improved access to dermatology consultations. In the author’s opinion. In fact. 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. 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. there are very few carriers who will provide malpractice insurance just for telemedicine. Most importantly. Given the maldistribution of dermatologists in the USA. the most significant hurdle is in the area of malpractice insurance coverage. Given the current Pak 224 . Most experts feel that teledermatology will not replace dermatologists. is no longer a barrier. this decision to delineate privileges must be made at the receiving facility. malpractice insurance reform to broaden coverage for teledermatologists would significantly enhance the growth of SAF teledermatology. there must be significant reform. there are many technology solutions for teledermatology. Contrary to popular belief. Before teledermatology can be utilized to its full potential. the use of teledermatology is increasing given its proven clinical efficacy. Those that provide coverage will likely charge an annual premium with a minimal discount for part-time practitioners. However. Teledermatology is no longer a futuristic concept. What is more important is our understanding the business process and training requirements for teledermatology and how teledermatology should be implemented. In fact. many carriers do not specifically cover telemedicine.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. reimbursement or interstate licensing restriction. the most difficult barrier is not credentialing. instead of charging a fee based on the volume of consults. 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. although important. As evidenced by the increasing number of published studies. Furthermore. Technology for SAF teledermatology. but rather enhance our delivery of general dermatologic care to our patients. the new standard does allow the ‘receiving’ facility to use credentialing information from another JCAHO-accredited facility. Conclusions The author strongly believes that teledermatology will become a part of our daily practice of medicine. Royal Society of Medicine Press Ltd.state of dermatology today. Ellsworth L. DA: National Ambulatory Medical Care Survey.com Teledermatology in North America 225 . Gourdin FW. Brown NA: Survey of Teledermatology in the USA. in Wooton R. Russell HP. J Am Acad Dermatol 1998. Astwood D. Br J Dermatol 1998. Edwards RA. NZ Med J 1997. DA: National Ambulatory Medical Care Survey. Comprehensive Accreditation Manual for Hospitals. Goldyne ME: Evaluation of an asynchronous teleconsultation system for diagnosis of skin cancer and other skin diseases. Medical Staff Standards. Burt C. Barnard CM. Hyattsville/Md. Fax 1 210 916 3103. et al: Comparison of teleconsultations and face-to-face consultations: Preliminary results of a United Kingdom multicentre teledermatology study. Loane MA.jcaho. Simel DL. Phillips CM. Available at http://www. Lyon CC. et al: Reliability and accuracy of dermatologists’ clinic-based and digital image consultations. Loane M. Advance Data from Vital and Health Statistics: No 315.41:693–702. Schechter A. et al: Telemedicine evaluation of cutaneous diseases: A blinded comparative study. Homan L: Teledermatology in the nursing home.3(suppl):81–83. Woodwell. Telemed J 1999. Campbell SM. Arch Dermatol 1998. Hyattsville/Md. 2002. E-Mail hpak@teledermsolutions. Burt C. Lowitt MH. Cherry D. References 1 Cherry D. Advance Data from Vital and Health Statistics: No 322. Houston MS. Krupinski EA. 1999. Accessed March 17. Gilmour E. LeSeur B. 1998 Summary. Kauffman CL.5:257–263.133:161–167. et al: Diagnostic accuracy and image quality using a digital camera for teledermatology.37:398–402. Kessler II. London.139:81–87.html.org/standard/ stds2001_mpfrm. Calobrisi SD.42:776–783. J Am Acad Dermatol 1997. Telemed J E Health 2000. Grigsby B. teledermatology will empower us to provide consistent. 2002. Oakley A (eds): Teledermatology. Oakley AMM. Joint Commission on the Accreditation of Healthcare Organizations. Woodwell. J Am Acad Dermatol 1999. Arch Dermatol 1997. Kvedar JC.133:171–174. Arch Dermatol 1997.6:379–384. 1 210 916 0632. National Center for Health Statistics. cost-effective dermatologic care to our patients regardless of where they live. Lesher JL. Zelickson BD. J Telemed Telecare 1997. J Am Acad Dermatol 2000. San Antonio. 1999 Summary. et al: Assessment of the accuracy of low-cost store-andforward teledermatology consultation. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Hon Pak. Harrison PV: A portable digital imaging system in dermatology: Diagnostic and educational applications.38:27–31. 134:471–476. High WA. et al: Diagnostic accuracy of teledermatology: Results of a preliminary study in New Zealand. high-quality. et al: Teledermatology and in-person examinations: A comparison of patient and physician perceptions and diagnostic agreement. 2001. Burke WA. MD 1126 Beclaire. Davis LS. Menn ER. National Center for Health Statistics.37:398–402. TX 78258 (USA) Tel. et al: The substitution of digital images for dermatologic physical examination. et al: Reliability of dermatology teleconsultations with the use of teleconferencing technology. Whited JD. Since the initial phases of NASA’s space program. Basel. Joseph C. pp 226–232 6.000 miles of fiber-optic cables. In West Virginia. In separate endeavors in the 1970–80s. The Center of Excellence for Medical Information Management was established in 1993 as the first step in creation of telemedicine services.Burg G (ed): Telemedicine and Teledermatology. connecting over 600 facilities. by the US Department of Defense [5]. Harvard Medical School. the National Aeronautics and Space Administration (NASA) and Massachusetts General Hospital provided telemedicine services via telephone lines and a microwave link respectively [2]. [1] provided the first telepsychiatry service in Omaha. the first project began in 1985. aBrigham and Women’s Hospital and bMassachusetts General Hospital.2 Telemedicine Experience in North America Abrar A. 2003. Curr Probl Dermatol. In 1979. Nebraska. Mass. launched to document the efficacy of telemedicine services. followed by a separate group that organized the first teleradiology service in Montreal. continuous monitoring of environmental parameters has been a part of every space mission. USA History The beginning of telemedicine in the USA dates back to the 1950–60s when Wittson et al. telemedicine . At present. Karger. Prior to that. vol 32. Quebec. 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]. Qureshi a. Kvedar b Partners Telemedicine. Boston. allowing rapid communication via live video-conferencing or storeand-forward technologies. A collaborative effort by NASA and the Indian Health Services (IHS) was one of the first federally funded studies (STARPAHC). The Department of Veteran Affairs has a communications network that is composed of 23. 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].. Rural telemedicine has been a practical way to deliver services to remote areas where there is physician shortage [7]. with a central system based at a tertiary care hospital. These are just a few examples of telemedicine programs in North America. Distance learning is fast becoming an integral part of many telemedicine programs in North America. 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. The themes prevalent in the discussion include limited patient awareness. Early initiatives were supported by grant funding from government institutions or investments from hospitals looking to expand their referral base. North American telemedicine programs have been developed to meet the changing demand for remote healthcare services. most programs are managed and run by academic institutions and hospitals.g. using civilian communication satellites. Thus telemedicine programs in the USA have been niche-market oriented until recently. 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. increasing physician comfort and need for better revenue models for telemedicine sustenance.g. Current Status The demand for medical services to geographically remote areas and to unique markets such as prisons. reaching out to a surrounding population. mainly due to lack of financial support. This network was created to reach remote offshore sites such as oil rigs. Many programs need Global Telemedicine 227 . as early as 1983. 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]. why is telemedicine not playing a larger role in day-to-day healthcare delivery? More importantly. warships or space shuttles. has resulted in targeted telemedicine programs that fulfill a specific need. however many of the programs that were started more than 20 years back have ended. progress we are making in telemedicine research and trends that are emerging in North America. e. There has been tremendous progress since the first notion of delivering services over phone lines. Both videoconferencing and store-and-forward consultations are commonly used modalities. prison telemedicine. Hence. infrequently funded by industry. The prevalent question being asked today is. teleradiology or teledermatology [8] has helped reduce the distance between patients and specialty care.systems were used in Operation Desert Storm. Specialty telemedicine is also called ‘commercial telemedicine’ e. The initial strategy relied on creation of a hub-and-spoke infrastructure. Partners Health Care System. the number of telemedicine encounters has increased steadily and evidence for diagnostic effectiveness is highest for the field of dermatology.org. as long as they have access to a computer with a Web browser. Massachusetts. accessible at http://www. 111 are at academic centers. 68 in hospital-based networks and 80 are federal (federal. Programs funded and supported by governmental organizations have been successful in staying afloat. Inc. The service is available to anyone. as the prime purpose of these programs is to provide service. 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. POSC allows both patients and the patient’s primary care physician to request a consultation from a Partners Health Care System specialist. with movement towards Webbased services. user-friendly service by Partners Telemedicine. There is need for high-quality clinical trials that can impact policy and practice of telemedicine. Boston. anywhere. anytime. Another system developed by Healinx Corp. as a browser-based. allows patients and providers to interact via e-mail that is encrypted..partners. few studies address cost-benefit issues effectively.eclevelandclinic. military or Department of Veterans Affairs) representing 30 specialties in medicine. irrespective of the revenue generated [9]. Progress We believe that forward motion in telemedicine will spring from outcomes research and technology development. At least one time-and-place-independent system has been developed. The manner in which telemedicine services are offered to the population at large has taken a leap forward in the last year or so..com.org. Based on an Agency for Healthcare Research and Quality report published in July 2001. A more recent website launched by the Cleveland Clinic Foundation. Thus far. In large part. dubbed ‘e-Cleveland Clinic’ can be accessed at http://www. This Web-based tool is dubbed Partners Online Specialty Consultation (POSC) accessible at http://econsults. Emeryville. California.continued financial support to sustain themselves as the volume of remote consultations and distance learning is small. fulfilling a variety of service needs [10]. Of a total of 362 telemedicine programs that have been identified in the USA.healinx. the services are ‘free’ to individuals involved in governmental agency work. Qureshi/Kvedar 228 . Patients pay a nominal co-payment and physicians are reimbursed via this system. The same study quotes consultations or second opinions as the most common telemedicine activity. there is a tradeoff: added cost and reduced access. A study shows up to 26% of physicians are communicating with their patients over the Internet [12]. and to prevent fraud. 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. The trends are related to the economics of healthcare. The tools can be tested in outcomes studies and data shown to future users as proof of efficacy. skeptics will continue to doubt even the more robust security systems. economic analyses (cost-effectiveness) and satisfaction studies (patient and provider) [11]. faster and more accurate information to be transmitted cheaply across major distances. With new tools emerging every day.gov/hipaa/hipaahm. Better outcomes studies are needed to convince patients and physicians that telemedicine is effective.mediators and outcomes). Bringing the physician and patient to adopt telemedicine requires both awareness of and comfort with the technology. Studies comparing diagnosis between telemedicine encounters and real-time patient-provider encounters have conclusively shown comparable results in teledermatology and teleradiology. The Internet has played an important role in creating the infrastructure. financial and administrative information in an electronic format [see http://www. Despite customized security systems. For example. Emerging Trends A number of trends have emerged that will shape the adoption of telemedicine in North America. tools that allow automated tagging of data with unique patient identifiers ensure that no patient data gets recorded in the wrong medical record. The hope Global Telemedicine 229 . Although privacy and security of information transmitted is an absolute must. Technology Development Advances in IT have facilitated better. These security standards apply to any physician or allied healthcare professional transmitting healthcarerelated. The use of online tools for patient care is gaining popularity among physicians. HIPAA provisions include security standards to protect data confidentiality and integrity.hcfa.htm]. 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. telemedicine can become even more efficient and accurate. In the USA.000 used telemedicine services. Technology Adoption As a conservative estimate. Initially. formerly HCFA). both patients and clinicians must accept the processes involved and embrace technology. In 1997. A high level of patient satisfaction with the services will enhance volume of telemedicine activity and allow long-term implementation. A recent survey has revealed that 47% of patients reported access to the Internet compared to 72% of nurses and 100% of physicians [13]. The quest for corroborating answers between more than two or more resources seems to allay apprehensions about a disease. Increased patient awareness of telemedicine services will require improved user interfaces and marketing efforts. Healthcare Policy Impact Adequate reimbursement mechanisms have not been in place since telemedicine efficacy and safety had not been established until more recently. The most common specialty consultations were performed in psychiatry. about 2. For telemedicine to succeed. familiar sites. In 1998. a more recent trend is evaluation of wireless technology for telemedicine purposes. it is imperative that those in the telemedicine arena develop an understanding of the value proposition. For example. its diagnosis or treatment. Most patients searching for answers to their questions have chronic disease or cancer. improved work flow and design.000 video and store-and-forward encounters were documented [14]. and about 45.is that newer security measures will always be one step ahead of anyone attempting to compromise them. has been limited [see http://www. Provider Comfort. The average Internet user seems to fit a very different profile than that of an Internet user with a medical problem. With such high degree of technology adoption. telemedicine coverage by the Center for Medicare and Medicaid Services (CMMS. Consumer Awareness. It seems clear that technology advancement will move faster than its appropriate adoption. physicians can be convinced to come on board with telemedicine endeavors with solid outcomes research published in peer-reviewed journals. of the 750. The most common application in the USA is teleradiology.000 teleradiology studies were performed.gov]. more than half of the US population has access to and use the Internet.000 physicians in the USA.hcfa. about 250. Strategies need to be in place to evaluate emerging technologies so that they may be utilized efficiently. Before patients are approached with the notion of fee-for-service. Economic Model. 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. coverage was provided for situations where patient-physician Qureshi/Kvedar 230 . American Hospital Association. After the Balanced Budget Act (BBA) of 1997. CMAJ 2000. Ment Hosp 1961.273: 483–488. Allen A: Telemedicine technology and clinical applications. Canna M: Telemedicine on the move: Healthcare heads down the information superhighway. and for an interactive audio-video (videoconference) interaction between patient and physician. Med Prog Technol 1992. Telemed J 1996. and allied health professionals such as nurses. one can foresee a future where telemedicine is part and parcel of any brick-and-mortar healthcare delivery system.2:241–246. accurate care via secure networks will become the driving force behind telemedicine and telehealth services. Ricketts TC: The changing nature of rural health care. hence free-market adoption. 1994. The eventual goal would be to eliminate the notion that technology drives telemedicine. in Hospital Technology Feature Report. Brick J. Telemed J 1995. Berek B. Harnett JDM. Brick JE: MDTV Telemedicine Project: Technical considerations in videoconferencing for medical applications.18: 151–163. Reddy ER. provisions were made for coverage of rural areas with shortage of health professionals. JAMA 1995. with payment expected at the time of service rendered. pharmacotherapy.21:639–657. The Future If telemedicine is both a method of healthcare delivery and a means of sharing medical knowledge. occupational and speech therapy services are being targeted as the next in-line modalities to be reimbursed through third parties. References 1 2 3 Wittson CL. Annu Rev Public Health 2000. telemedicine adoption would be more palatable and less threatening. Instead.face-to-face contact was not necessary such as in radiology. To get third-party payers involved with reimbursement of telemedicine services.12:22–23. The role of telemedicine would be to support routine healthcare rather than replace it. Brauer GW: Telehealth: The delayed revolution in health care. and physical. vol 13. Perednia DA. Store-and-forward technologies. McManamon PJ. Turner J. quality clinical research is needed to evaluate the economic impact of telemedicine. There was no provision for line charges or facility fees.162:206. rapid.1:67–71. In a supportive role. No 6. Snelgrove C: Telemedicine and fetal ultrasonography in a remote Newfoundland community. Zimnik PR: A brief survey of Department of Defense Telemedicine. psychotherapy. 4 5 6 7 8 Global Telemedicine 231 . Affleck DC. Johnson: Two-way television group therapy. social workers and psychologists could not get reimbursed for telemedicine services. the demand (from patient and provider) to deliver remote. Bartlett PJ. there is a move towards cash-based services. pp 1–65. sleep studies. Albeit slowly. org Qureshi/Kvedar 232 . Booker L. Lovich D. Hailey D: Assessing telemedicine: A systematic review of the literature. Whelan T. Gustke S.129:495–500. Kohane IS. Technology Assessment (24 suppl):1–32. Boston. 1 617 724 5517.9 10 11 12 13 14 Mandl KD.165:765–771.281:1066–1068. Sigouin C. JAMA 2001. Strode SW. BCG Focus. Brandt AM: Electronic patient-physician communication: Problems and promise. Browman G: Internet use among physicians. Roine R. MA 02114 (USA) Tel. obstetric and clinician-indirect home interventions: Evidence report.286:1451–1452. Silverstein M: Vital signs update: Doctors say e-health delivers. Sept 2001. Suite 216. MD Massachusetts General Hospital Associate Physician. Qureshi. Brigham & Women’s Hospital. Von Knoop C. Cocking L. Fax 1 617 726 7530. nurses and their patients. Two Longfellow Place. Ohinmaa A. Abrar A. Allen A: Technical and clinical progress in telemedicine. E-Mail aqureshi@partners. CMAJ 2001. Ann Intern Med 1998. Telemedicine for the Medicare population: Pediatric. JAMA 1999. Jadad AR. many clinics and hospitals in many areas do not have regular access to modern ways of communication. 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. Basel. Curr Probl Dermatol. Dermatologische Klinik. Neil Pakenham-Walsh Universitätsspital Zürich. Karger. Zürich. particularly specialists.Burg G (ed): Telemedicine and Teledermatology. Does telemedicine make sense for these countries under such conditions. Several countries do not have a single radiologist. pathologist or dermatologist [1]. where skin diseases are abundant but almost neglected by many public health services? Under such circumstances. It is these and other questions regarding teledermatology in African countries that we want to discuss briefly.000 inhabitants. telemedicine is very different in the developing countries compared to that in the developed world. fewer than 10 doctors per 100. . 2003. Workers in rural healthcare. on average. and if so. Very basic needs such as power supply or telephone access cannot be taken for granted. how should it be delivered? And what about teledermatology in these areas. Therefore. Our contribution is based on our personal experience with a teledermatological link between Tanzania and Switzerland. vol 32. who serve most of the population. Prosper Doe. pp 233–246 6. Switzerland The probability of a child dying before age 5 is 10 times more likely in developing countries than in developed countries. Sub-Saharan Africa has.3 Teledermatology in Sub-Saharan Africa Peter Schmid-Grendelmeier. Many countries of subSaharan Africa have less than USD 40 to spend on healthcare per person per year. Telemedicine in General in African Countries Many developing countries have an acute shortage of doctors. The specialists and services that are available are concentrated in cities. In Africa. half of which are from the so-called third world. the digital transmission of x-ray images needs such an ‘unorthodox’ approach. thus enabling anyone with e-mail to consult a radiologist for an opinion.are isolated from specialist support and up-to-date information by poor roads. Inmarsat Inmarsat is a coordinating production of the ITU Report and is a participant in the European Telemedicine Corporation Group (ETCG). there are already quite numerous reports about other telemedical activities in this and other areas with limited resources [2–7]. These reports contain a survey of telemedicine in 60 countries. 9]. and a lack of libraries. 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 a suitable approach may be to photograph an x-ray image on a light box with a digital camera. Two of them are Inmarsat and the Health Information Forum (HIF) International Network for the Availability of Scientific Publications (INASP). 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. Consumer image scanners are cheaper and can provide reasonable quality but are not suitable for full-size radiographs. Such expertise is more needed than just the knowhow about what is technically possible in industrialized nations.048 2. On the other hand. Digital radiology offers a potential solution but is expensive. scarce and expensive telephones. Sub-Saharan Africa represents possibly the continent with the least developed network of transport. As an example.048 pixels [8. Inmarsat provides a satellite phone system capable of reaching virtually even the most Schmid-Grendelmeier/Doe/Pakenham-Walsh 234 . 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. Both organizations are presented below in more detail. 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. There are projects that focus on aspects of promoting telemedicine and the use of the electronic media in countries with limited resources. Laser film scanners are very costly. While there are still very few reports about teledermatology in Africa. Cheap and appropriate technologies and good ideas are mandatory to overcome these obstacles. Access to radiological expertise remains a challenge in developing countries. connections and also paths of digital communication – and has to face the above-mentioned difficult conditions. Health Information Forum: INASP-Health runs regular thematic workshops.html). INASP-Health. North and South. 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 Directory: INASP-Health publishes the directory of organizations working to improve access to reliable information for health professionals in developing countries. Teledermatology in Sub-Saharan Africa 235 . INASP is a cooperative network of partners working to improve access to information worldwide. Reports from various African countries were involved in these meetings. Partners are kept up to date with current events in the field through the INASP Newsletter.000 a unit. Available on the INASP website. with rates for some voice and data services of under USD 3 per minute. the ITU and the Midjan group are involved in these meetings. Its health program. (The cost of usage has also dropped. and as a reference for those in resource-poor settings who are seeking support.org/index3. or partial aspects such as teleradiology. INASP-Health activities include: Advisory and Referral Network: INASP-Health promotes collaboration and sharing of expertise and experience through its advisory and referral network.remotest place on earth (http://www. North and South. the Directory serves as a networking tool for building professional relationships and sharing information. Kenya/Mali/Senegal (teleobstetrics.) Conferences for telemedicine in developing countries are organized regularly. The emphasis is to support and help those involved in health information work. in countries with limited resources. Representatives of the WHO. International Network for the Availability of Scientific Publications (INASP) INASP is a very useful organization for promoting access to information. 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. distance learning) and Tanzania.inmarsat. Inmarsat’s latest generation of satellite phones is the size of a laptop computer and can be purchased for less than USD 3. The nations involved so far include the Congo (telemedicine in emergencies and disasters). publishers. librarians and information workers worldwide. such as reports about telemedicine in general. which involves more than 750 organizations and individuals. with guest speakers from developing countries and e-mail contributions from health professionals. both printed and electronic. Overwhelming health problems due to major killing diseases such as malaria. the Azores [12] or Taiwan [13]. 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. The contact address is Neil Pakenham-Walsh at INASP_Health@compuserve. the ILDS developed the project UNIDERM to focus on providing healthcare to developing nations (www. Therefore. there is also not much emphasis given to teledermatology in these areas. librarians. e-mail your name.org) it currently operates two Regional Dermatology Training Centres (RDTC). 10]. To join HIF-net at WHO. including health professionals. it offers also a great potential in an area like subSaharan Africa. affiliation and professional interests to INASP_Health@compuserve. publishers.ifd. tuberculosis and in the recent years the dramatic HIV/AIDS epidemic leave little space and money for the mostly non-lethal skin affections. Launched in July 2000 in collaboration with WHO. which suffers a shortage of dermatologists as well as limited communications and transportation. reports about established teledermatological connections in this area are still rare. A third RDTC is under development in francophone Africa.com. Although the potential use and projects are discussed [2–7]. one in Tanzania and the other in Guatemala serving rural community nurses.inasp.int/ina-ngo/ngo/ngo090. and international agencies worldwide. Through the IFD (www. As dermatology is not a primary focus of healthcare in the developing countries.‘HIF-net at WHO’ is ‘the’ e-mail discussion list dedicated to issues of health information access in resource-poor settings.org.com. More information is available under http://www.htm) [9. Therefore.uk. Among others. It currently has over 500 participants. 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 International League of Dermatological Societies (ILDS) of Dermatology has recognized this lack of skin care.who. We describe here our experience with teledermatology Schmid-Grendelmeier/Doe/Pakenham-Walsh 236 . the list promotes cross-sectorial communication among providers and users of health information. very little importance is given to dermatological problems in these regions. Except leprosy and some infectious diseases affecting also the skin such as onchocerciasis. NGOs. 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]. 25 1997 Since Dec. 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. 2.and software package was transferred to the RDTC (fig. Northern Tanzania (table 1. In a first step a telephone line had to be requested and established. The RDTC located at the slopes of Mount Kilimanjaro. fig. 1997 Oct. Using the experience won in the Swiss Dermatologists’ Telenetwork (Dermanet®/www. 1997 Sept. still digital camera.ch).Fig. There was no possibility to use Teledermatology in Sub-Saharan Africa 237 . a complete hard. Table 1.dermanet. 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. leprosy and STD [14]. 13. 1.000 inhabitants only in 1997. 1997 May 1997 June 1997 Aug. 1997 Jan. 4 1997 Sept. 1). Steps towards the teledermatological link between Moshi and Zürich Jan. 28. 1997 Mid Dec. the density of telephone lines in Tanzania was still about 3 per 1.8-kBaud modem) [15]. 12 1997 From Sept. desktop PC Pentium 133 Hz. which aims to promote knowledge for allied health professionals in dermatology. Taking video pictures of patients required a relatively extensive counseling. Here a mobile computing system based on a laptop would have been very beneficial compared to the desktop version. Using only dustcovers for protection. Repeated attacks from termites feeding on telephone and power wires were an unexpected challenge to be faced. the system proved to be astonishingly resistant against heat and humidity. as most patients were not all used to being photographed or even realizing the images of themselves on a computer screen. By means of a provider just starting up in the local town. clinical pictures and later also digitized histopathological slides of either unclear or very interesting skin findings could be discussed through videoconferencing. Also theft proved to be a major risk which had to be prevented by multilockable doors and iron-protected windows. The equipment used at the RDTC. 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.Fig. Due to voltage instability and repeated power cuts. cellular and satellite phones at that time in Tanzania – what has changed significantly in the meantime. Finally. This proved to be very cost-saving and advantageous for the otherwise quite vulnerable telephone connections. which allowed interactive discussion with colleagues from Switzerland and in a later Schmid-Grendelmeier/Doe/Pakenham-Walsh 238 . a unit for uninterrupted power supply had to be interconnected to avoid severe damage of the system. we could finally establish the necessary access to the Internet. Still the camera used at that moment made the space and versatility of a desktop necessary. 2. The contact was and is of course also very dependent on the initiative and knowledge of some single individual participants of the RDTC. The software normally needs to be updated once a year. Therefore. 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 Zürich (Switzerland) and Moshi (Tanzania). Image transfer was done after consultation time due to time restriction. This time allowed also a rather fast exchange via the Internet. The technical equipment is still working after 3 years.m. password-protected way of exchange. Expertise was also received by sending digitized pictures as e-mail attachments to colleagues for consultation. a common hour for a videoconference could easily be found at around 1 p. although it suffered hard due to several severe crashes during massive power fluctuations and also a quite impressive termite invasion. Using a camera linked with a cable to the PC. partly on an external ZIP drive. all the patients first had to be sent to the room with the PC/video equipment (which had to be safe-locked). 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. 19 kBaud). although to a very limited extent. The exchange of images had always to be agreed first. but sufficient to exchange the transmission of a JPEG-compressed picture within 1–2 min. The speed of transmission was limited due to the locally available telephone connections (max. Several cases were discussed during a total of four live videoconferences. Thus. partly on the PC hard disk.m. This exchange is still ongoing – 3 years after. Also colleagues from Europe started to ask for expert opinions at the RDTC about their patients with dark skin or potentially tropical skin diseases. images of about 30 patients (clinical or histopathological slides) were taken and saved. 100–150 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. Within the first year of the system being installed. This was due to the fact that all the patients had to register before 9 a. 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. 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. So a mutual exchange of knowledge could be started.stage also from other countries. So there was little time left to take digital pictures of interesting cases. Also pictures initially could not be taken in the examination room. Teledermatology in Sub-Saharan Africa 239 . to be seen the same day (rule given by the hospital authorities). Documenting the patients with digital images was therefore rather time-consuming – in periods of sudden power cuts sometimes even a matter of a luck. 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. Mozambique. To develop reliable teledermatological communication possibilities. e. having expanded to dermatologists working in other African countries such as Uganda. 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. 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. A ‘horizontal’ exchange might therefore be more beneficial than a ‘vertical’ exchange in this aspect. Schmid-Grendelmeier/Doe/Pakenham-Walsh 240 . various centers in developing countries. But. Speed of the CPU is less important than enough hard disk space to store the saved images. real online videoconferencing does not seem to be a crucial prerequisite. 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. Lessons We Learned: Technical Needs As stated above.g. Ghana and Senegal that have all access to the Internet. would possibly bring a higher impact of teledermatology. these are: Computer Including Necessary Software Ideally a mobile computer (notebook).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. Here an exchange between various areas with similar conditions. due to fact that skin findings can be discussed in most cases with still images. some basic requirements are nevertheless also mandatory in developing countries [16]. allowing temporary independence from locations and electric power supply or desktop system protected by UPS (unbreakable power supply). The exchange of digital images via e-mail offers a very useful and appropriate possibility of exchange. Briefly. A close-up function should be available. easy to use and cheap (USD 300–800). New technologies such as GPRS may additionally facilitate rapid digital exchange for text and images. These benefits have been shown by SatelLife [26]. The patient’s findings are described in an e-mail. enlarging the potential of digital image transfer significantly [19–21]. hard. Still images. 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]. are much more adapted than very data consuming live images. it is now available. Software to compress the size of the images additionally is crucial. These allow sending e-mail attachments such as image files. where we installed our teledermatologic link in 1997/98. in 53 out of 54 African countries [22]. and digital photographs of the patient and their investigations. Devices for image storing should be replaceable. With modification. Using a low earth orbit satellite and phone lines.400 pixels or better) that are adequate for dermatologic needs [17. but permits specialist support in the management of difficult cases and is economical. this technique can be effective for telepathology and teleultrasound.000 healthcare workers. robust. Teledermatology in Sub-Saharan Africa 241 .and software requirements are simple. serving over 10. E-mail has many advantages in poor countries: it is cheap. This store-and-forward telemedicine does not allow real-time interaction. permitting a form of low-cost telemedicine. Software update should be possible via Internet or CD-ROM and not needing computer professionals – possibly many hundreds or even thousands of kilometers away. Whenever possible it should be usable in the mother tongue of the applicants. several research databases and training courses are available [24. there was no Internet provider in Tanzania in 1996. 18]. 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. especially for teledermatology but also teleradiology or pathology. 25] (table 2). Additionally. and the information does not have to be transmitted in real time. it provides e-mail access in 140 countries. fast learnable and stable. Mobile and cableless cameras are of much better use than desktop systems.Digital Image Source Modern digital cameras are small. at least in the capital cities. For example. are attached. but there are several now including even Internet coffee shops located in the KCMC in Moshi.900 1. They can create high-resolution images (1. such as electrocardiograms and x-ray films. Software The software should be easy to use. electricity can by far not be taken for granted in developing countries. Electric Power Supply Taken as very ‘natural’ in our setting. An alternative is offered by the free access to the Internet during a limited time during each day.org/index3. 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. 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. Therefore. Some useful websites for telemedicine/teledermatology in sub-Saharan Africa (partly mentioned in the article) www3.org.inmarsat.freemedicaljournals. such as the UN or WHO.ch Despite these fascinating new possibilities with their tremendous potential. international organizations.uk/ www.edu/~super1 www.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’.who.org/africa www.htm www. 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. Especially in rural and remote areas of developing countries there is sometimes no power supply at all.int www. it also has to be considered that a very limited part of the population in developing countries has access to these facilities.inasp. a monthly rate of around USD 20–30 – the average for an Internet access in East Africa – is just unaffordable.htm www. governmental authorities and military groups mostly use these systems.who. If a person earns around USD 50–100 a month.medicusmundi.org www.Table 2.pitt.sn.apc. which is offered free by various organizations.ch www.ifd.dermanet. Schmid-Grendelmeier/Doe/Pakenham-Walsh 242 .int/ina-ngo/ngo/ngo090. Power cuts due to natural. facilities for digital image transfer should be accessible for all disciplines. technical assistance and teaching of users on a long-term basis. but also a continuous support for hard. which does not only include a generous donation from the equipment in the beginning. Such studies are even more needed in sub-Saharan Africa – as in this region the limited resources have to be spent even more cautiously [28–31]. In addition. but such projects should also be sustainable. Some financial participation from the recipients should also be included from the beginning. 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. Also the sponsor has to care about sustainability. cardiology or dermatology. such as radiology. screens and digital cameras. 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. as otherwise such a project risks becoming just a nice toy.and software. the power current often fluctuates enormously. pathology. 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. but of a rather limited stability. In such areas. according to their possibilities.In semi-rural or urban areas. pathologists or dermatologists Teledermatology in Sub-Saharan Africa 243 . Sustainability Sustainability is one of the principal demands of all assistance directed to developing nations. which no one feels responsible to maintain. units warranting uninterrupted power supply are absolutely crucial. 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]. There are various investigations that can prove the cost-benefit and accuracy of teledermatology in industrialized nations. technical and man-made problems can be frequent. In areas with such limited resources as encountered in the health systems of many parts of sub-Saharan Africa. Therefore the existing power peaks and drops can be harmful to technical equipment such as computers. Pilot projects like our Tanzania-Switzerland connection may be a first step in demonstrating the benefits and also cost-effectiveness of telemedicine. power is generally available. In most countries healthcare is considered a public service. a digital image is sometimes just beyond the patient’s understanding. this is probably one of the regions that might benefit most from this technology. 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 patient’s lifetime. Videoconferencing is feasible as shown by our experience. 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. 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. especially for people working in Schmid-Grendelmeier/Doe/Pakenham-Walsh 244 . easy-to-use and not too expensive technologies. Combined for example with histopathological images. teledermatology even offers a service just unavailable in many regions or even nations of developing countries. however. 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. sustainability and basic requirements should be checked very carefully before investing in such facilities in a setting mentioned above. 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. The emphasis should rather be given to simple. Also there is a tremendous lack of care and knowledge for patients with skin diseases in these areas. Teledermatological exchange does implicate fun and professional enrichment – but mostly it is also a simple necessity. Still. computers and mobile phones more so are also spreading rapidly in Africa. In our experience. Therefore. A possible widespread use will by far outweigh the few advantages won by a videoconferencing system limited to a few centers linked together.or any easy accessible library. Religious customs also have to be considered among those who sometimes do not permit to be photographed. Not the most ambitious project regarding technical aspects is needed. Acknowledgments We are indebted to Günter Burg. for continuously promoting and supporting a teledermatological link between Tanzania and Switzerland. Telemedicine in South Africa: Bridging the gap (www.4(suppl 1):75–79.htm). Arch Dermatol 1997. Geneva. Burdick AE. Switzerland and Dermanet®.4(suppl 2):1–85. Ruebeck D.92:178–182. So our emphasis should go to find means and ways to spread the tools for a reasonable and appropriate teledermatology in these areas. S Afr Med J 1998. To improve the still very restricted care for patients suffering from skin diseases in these areas is the final aim. References 1 2 3 4 5 6 7 8 9 WHO advisory meeting on radiology education. A report of study group 2 of the ITU Development Sector. J R Soc Med 1999. for providing the facilities (such as a safe room and separate telephone line) to use the system. Chairman of the Department of Dermatology of the University of Zürich. WHO. The computer equipment used in Tanzania was provided by Roche® Pharma Switzerland and free software support given by Arpage Systems® AG. Buncke GM. Arch Anat Cytol Pathol 1995. 43:285–287. Wright D: Telemedicine and developing countries. 1999.133:197–200. Hsieh YJ: Survey of infectious skin diseases and skin infestations among primary school students of Taitung County. Berman B: Teledermatology and underserved populations. Corr P: Teleradiology in KwaZulu-Natal. Wu YH. 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. Principal of the RDTC in Moshi.321:465–466. BMJ 2000. Kind G.99:128–134. J Trauma 1997. Buncke HJ: Using the Internet for rapid exchange of photographs and x-ray images to evaluate potential extremity replantation candidates. Teledermatology might contribute its small. Wright D: Telemedicine delivery to developing countries. but useful part to this aim. Wright D: The International Telecommunication Union’s report on telemedicine and developing countries. Norton SA.3(suppl 1): 76–78. eastern Taiwan. McGrath JD: Information technology and telemedicine in sub-Saharan Africa. Fraser HSF. The exchange between the few colleagues caring for patients with skin diseases can doubtlessly be promoted by teledermatology. A pilot project. J Telemed Telecare 1998.remote or rural areas. Goncalves L. medicusmundi. 10 11 12 Teledermatology in Sub-Saharan Africa 245 . J Formos Med Assoc 2000. Siko PP. We also thank Henning Grossmann. Whitehouse RW: Use of digital cameras for radiographs: How to get the best pictures.43:342–344. Su HY. Buntic RF. Phillips CM.88:48–49. Strachan K: Health system trust. J Telemed Telecare 1998. J Telemed Telecare 1997. Cunha C: Telemedicine project in the Azores Islands.ch/bulletin8207. J Telemed Telecare 1997. Royal Society of Medicine press. E-Mail peter. BMJ 2000. Berlin.5(suppl 1): S107–S111. the Internet. Burg G: Teledermatology as a new tool in subSaharan Africa: An experience from Tanzania. Donofrio LM. Calobrisi SD. Gargum A. et al: Diagnostic accuracy and image quality using a digital camera for teledermatology.12: 621–628.4(suppl 1):56–57. in Wooton R. Dermatol Clin 1994. 41 1 255 3083. Millikan LE: Dermatologic diseases of eastern Africa. Doe P. et al: Multicentre randomised control trial comparing realtime teledermatology with conventional outpatient dermatological care: Societal cost-benefit analysis.edu/~super1 Groves T: SatelLife: Getting relevant information to the developing world. et al: Patient cost-benefits of real-time teledermatology – A comparison of data from Northern Ireland and New Zealand.pitt. J Am Acad Dermatol 2000. J Telemed Telecare 1999.13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Kopf AW: International Foundation for Dermatology.6(suppl 1):S74–S76. Gloriastrasse 31. London 2002. Warshawski R. Vidmar DA. Ellsworth L. Wootton R. Cruess D. et al: The effect of decreasing digital image resolution on teledermatology diagnosis. McEwan AJ. Bloomer SE. Telemed J 1998. Burg G: Where the basics lack: Teledermatology in sub-Saharan Africa. Duffill M. et al: Preliminary findings from a teleultrasound study in Alberta.com. www. Corbett R. A challenge to meet the dermatologic needs of developing countries. Yellowlees P: Successful development of telemedicine systems – Seven core principles.42:833–835. MD Universitätsspital Zürich.com The Global Health Network supercourse: Epidemiology. Dermatol Clin 1993.apc. www.3:215–222. Telemed J 1999. Springer. Kerr P. Szymas J. Silvis N. Yellowlees P: Practical evaluation of telemedicine systems in the real world. Hansen R.org/africa/ FreeMedicalJournals. Hsieh P. Fax 41 1 255 4403.313: 1606–1609. Milesi L.sn.4:267–276. pp 231–244. electronic education and publication in pathology. Davis P. Haeffner A. Drage LA.5:375–383.freemedicaljournals. McEvoy MT: Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. High WA. Telemed J 1999. Oakley AM.11:311–314. Oakley JM (eds): Teledermatology. J Am Acad Dermatol 2000. BMJ [email protected] Schmid-Grendelmeier/Doe/Pakenham-Walsh 246 . 1998. Masenga EJ. Kuehnis L. Johnson MA. LeSueur B. J Telemed Telecare 2000. CH–8091 Zürich (Switzerland) Tel. Kayser K. Houston MS. Accessible under www3. African internet connectivity.42: 776–783. Schmid-Grendelmeier P. Weinstein R: Telepathology: Telecommunication.6:97–101. J Telemed Telecare 1998.320:1252–1256. Wright D: The sustainability of telemedicine projects. Schmid-Grendelmeier P.5:257–263. Krupinski EA. Levine N. J Telemed Telecare 2000. and global health. Dermatologische Klinik. Jhangri GS. Peter Schmid-Grendelmeier. Taylor P: An assessment of the potential effect of a teledermatology system. Claudio Cipolat. January 2000–February 2002. The most common diagnoses made on the basis of the patient’s history and electrocardiogram were: acute myocardial infarction. It was stated that with its use. angina pectoris. Günter Burg Dermatologische Klinik. but due to the limited amount of space and time for collection. Basel. 463 calls were received. During the first year of service. Telecardiology Slovenia At the University Medical Centre of Ljubljana.Burg G (ed): Telemedicine and Teledermatology. They represent a selection made by the author. paroxysmal tachycardias and atypical chest pain. this was not possible. . time from onset of symptoms to initiation of treatment was shortened. pp 247–251 6. Universitätsspital Zürich. The source from which the articles were obtained was the Journal of Telemedicine and Telecare. The overview is divided into the various medical fields where telemedicine is already of increasing importance. vol 32. Telemedical work in these two countries is presented in the next two chapters. Many more articles would also have been suitable for presentation. a telemedical project involving the transtelephonic transmission of electrocardiograms was established and has been used on a regular basis since 1997. Curr Probl Dermatol. 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. which in turn reduced disability and mortality due to cardiovascular diseases and also improved cost-benefit [1]. Karger. 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. 2003.4 Telemedicine in Europe Roger Kropf. Furthermore. dermatologists and patients) were satisfied with the teleconsultations. 1 specialist in internal medicine and 1 GP. 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. as described by the authors. It was found that this form of telecardiology was clinically viable and more efficient than the traditional method of delivering this data to specialists. Japan. Generally all persons involved (GPs. Teledermatology The Netherlands A feasibility study in teledermatology was undertaken in the town of Groningen. An average of 85% of the telediagnoses were correct when histopathology was used as golden standard. Kropf/Cipolat/Burg 248 . 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’.Italy At six Italian hospitals. UK. The main drawback was the sometimes extremely long time for transfer especially when only one instead of three ISDN lines was used [2]. 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. consisted mainly of getting advice on patient medication and diagnosis. These results confirmed that teledermoscopy could be reliably used for the diagnosis of pigmented skin lesions. 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. Italy. USA. However. The benefits. whereas faceto-face diagnosis by an expert dermatologist was correct in 91% of the cases. the degree of accuracy will depend on the expertise of the observer [4]. Austria. 1 oncologist. the GPs reported that the teleconsultations were also of educational value [3]. The dermatologists returned their responses by e-mail. the medical officers at the South African hospital valued the educational benefits gained during this project [7]. United Kingdom In Northern Ireland a pilot study was conducted by means of supporting breast-feeding mothers with videophones at home. United Kingdom–South 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. It could possibly be a valuable alternative.Additional benefits were the prevention of unnecessary laboratory and specialist examinations [5]. Moreover. where it was analysed and a report faxed back to the peripheral unit [8]. The data was then transmitted via modem to an operations centre. The outcome stated by the two authors was that this form of teleophthalmology is reliable. As outcome.and hardware over a 2-year period. Case discussions were conducted with the use of videoconferences using ISDN lines. Teleophthalmology Sweden A trial of teleophthalmology was conducted between a GP and an experienced ophthalmologist using desktop videoconferencing soft. especially in rural areas where physical distance between patient and specialist can represent a significant obstacle [6]. as well as sometimes a considerable delay of the streamed acoustic data. the potential to save on hospital visits and home calls was recognized [9]. Potential problems were the poor quality of transmitted pictures. No significant problems were experienced during the 12-month study period. 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. Telemedicine in Europe 249 . The patients were assessed using televideoconferences as well as traditional face-to-face consultations. but also abroad. cognitive assessment of 27 patients with a history of alcohol abuse was performed. After both trials the patients were handed a satisfaction questionnaire. The aim was to create a network of histopathologists not only throughout the UK. especially in rural areas of Croatia [11].pathology. The teleconsultations were significantly longer (mean 40.4) than the face-to-face consultations (mean 33. SD 6.uk Telepsychiatry United Kingdom At the Clinical Psychology Department of Dunain Hospital in Inverness. but which could be circumvented using a software system called webcam32.3). 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].ac. General Telemedicine Croatia In Croatia a feasibility study was conducted by means of using real-time Internet conferencing between a GP’s clinic in Selca on the island of Brac.7 min. Kropf/Cipolat/Burg 250 .0 min. 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. a telepathology network using standard videoconferencing technologies was established. and a team of specialists in ‘Sveti Duh’ General Hospital. It was suggested that the formation of a permanent on-line specialist service would improve the access to healthcare.le. Further information can be accessed at http://tele. SD 5. The main problems encountered were network restrictions due to firewalls. Most patients expressed high overall satisfaction with the teleconsultation as well as with video and audio quality in particular.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. located in Zagreb on the mainland. Piccolo D. Matek P. Coelho H. J Telemed Telecare 2001. Gersak B: Transtelephonic transmission of electrocardiograms in Slovenia. Gloriastrasse 31.7:193–198. Lusic M. Vinas MA. J Telemed Telecare 2001.6:147–151.6:205–208. Ferrari A. Argenziano G.usz. Cerroni L.6:132–137. Cook C. Pollio F. Grgic M. Paiva T. Kenet RO. J Telemed Telecare 2001.6:S162–S164. Sinclair M. Smolle J. . Cruz M. Bennie L: The consistency of neuropsychological assessments performed via telecommunication and face to face. Navarro T. Schaeppi H. Chimenti S. Fregonara M: Telecardiology: Results and perspectives of an operative experience. Ostojic V Stipic-Markovic A. Van Heerden A. Peck DF. Stolz W. Di Lieto A. 41 1 255 3340. an online antibiotic information database was developed to help non-specialist doctors in treating patients with infectious diseases. References 1 2 3 Gorjup V Jazbec A. J Telemed Telecare 2000.6:172–176.7:54–57. Rincon D. Saroglou G. Braun R. Fax 41 1 255 4403. 1. Reker CH. Soyer HP: Teledermoscopy – Results of a multicentre study on 43 pigmented skin lesions. Kennedy C. CH–8091 Zürich (Switzerland) Tel. Araujo MT. J Telemed Telecare 2000. Vatopoulos A. J Telemed Telecare 2000.7:119–120. Iannotti F. Calvert J: Telemedicine as a support system to encourage breast-feeding in Northern Ireland. van der Veen JP: Teledermatology as a tool for communication between general practitioners and dermatologists. Hofmann-Wellenhof R. . MD Dermatologische Klinik. Tanaka M. J Telemed Telecare 2000. Maren N.053 queries were received. Lazenbatt A. Mazzocchetti G. Salaminios F: Remote access to an expert system for infectious diseases. Belo C: Neurological teleconsultation for general practitioners. Zivkovic N. 4 5 6 7 8 9 10 11 12 Roger Kropf. Wilbrink J. J Telemed Telecare 2001. Murdoch I: Utilization and practical aspects of teleophthalmology between South Africa and the UK. Fogliardi R. The participants stated that the database served them for treatment of patients as well as for education about antibiotics.7:25–26. Kerl H. Donnelly CL. Kirkwood KT. Rodrigues R. Salmon S. Van den Akker TW. Knol A.7:149–154. Carneiro G. During the first 8 months of online service. J Telemed Telecare 2000. E-Mail Roger. Magrini F. The continuation of the database was encouraged [12]. Blomdahl S. Wolf IH. Frissiras S. Universitätsspital Zürich. Catalano D. De Falco M. Post J. Iskra M: A feasibility study of real-time telemedicine in Croatia using Internet videoconferencing. J Telemed Telecare 2001.7:20–22. Tountas Y. Tudman Z. Pizzichetta MA. J Telemed Telecare 2001. Pontillo M. J Telemed Telecare 2000.6:339–342. Lof R: Tele-ophthalmology for the treatment in primary care of disorders in the anterior part of the [email protected] At the centre for Health Services Research at the University of Athens. Trajbar T. Frumento E.ch Telemedicine in Europe 251 . Schiraldi P: Telecardiotocography in prenatal telemedicine. Cvoriscec B. Almeida A. verifiability and confidentiality of transmitted information must be clarified.Burg G (ed): Telemedicine and Teledermatology. vol 32. To overcome these obstacles. a further application is the use of the ‘new technologies’ in fields like teledermatology. issues of secure e-mail transmission. the creation of structures defining a legal.5 Telemedicine in Germany Jörg Tittelbach. the German Ministry of Education and Research has established an initiative called ‘Telematikplattform’ (telematics platform) as an exchange platform for . the availability. security. validity. organizational and technological framework is necessary for a successful implementation and use of communication and exchange technologies. Therefore. 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. teleradiology. This will be the subject of the following paragraph. 2003. Besides the consideration in the public. the lack of an organizational structure leading the single players of the healthcare system has proved to inhibit necessary developments. Basel. Peter Elsner Department of Dermatology. pp 252–256 6. Therefore. 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. Karger. telepathology. Besides the technical requirements. Friedrich Schiller University Jena. Different political conditions have proved to be an obstacle in the optimal application of a modern information infrastructure in the field of medicine. Curr Probl Dermatol. In this context. an interoperability of many players and providers cannot be guaranteed resulting in a diversity of solutions and approaches. telesurgery and others. the different players in the field of transmission and exchange of medical data and information. the use of all available empirical data in medical care and the creation of an infrastructure for planning. Those who will benefit from this introduction are not the same who have to take care of financing the new equipment needed [1]. The aim of this initiative is the improvement of medical care. leading physician. avoiding disadvantages due to uncoordinated treatment and quality management. the initiative ‘Aktionsforum Telematik im Gesundheitswesen’ (ATG) has been established. an increased effectiveness of financial resources. ATG – Forum for Telematics in Healthcare The major aims of this forum are to intensify the interaction and interoperability of in. the Ministry of Economy and Technology. supporting the thesis that this initiative can cause a sustained change in the healthcare sector. That is possibly why investment in such technologies is currently still limited to the institutions of each player. 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]. and will be discussed next. ‘security infrastructure’ and ‘European dimension’ [2]. ‘electronic medical letter’. In Germany no defined reimbursement is given for the implementation of information technologies for medical purposes. the Ministry of Health. The participants of this project are the German Ministry of Education and Research. Technical Preconditions At present the various German healthcare providers are technically well equipped. non-medical organizations and pension-insurance organizations. Telemedicine in Germany 253 . One of the most important and promising facts. private and public health insurance providers. No common financial pool has been established. The main topics are managed in different work groups like ‘electronic prescription’. is the broad basis of this initiative among all players in Germany’s healthcare system. controlling and supply of research. 96% of dermatologists in private practice used a computer and 56% used e-mail on a regular basis [3]. hospital and pharmacy organizations as well as parts of the pharmaceutical industries. As an initiative to overcome these shortcomings. A further hindrance for the introduction of modern data-exchange technologies is the allocation of financial resources.and outpatient care with the intention of cost-saving. In a recently published study it was shown that in Bavaria. Another very interesting dermatological resource is the teleteaching webpage www. an atlas of paediatric dermatoses. further developments focus on the introduction of the XML schema. The aim of this project is the virtual reproduction of the situation of a patient’s consultation. an information portal of atopic dermatitis and skin cancer as well as case reports and dermatological lectures. One of the best known teledermatological resources in the German Internet is the website www. The student is guided from the patient’s history. This standard is implemented in large medical devices like radiology systems as well as in end-user devices. data acquired by technical devices (GDT) and others. DICOM (Digital Imaging and Communications in Medicine) as a third important standard and is used for the exchange of medical images. Outside the clinics.net.de. that is maintained by the University of Regensburg (Prof. which is maintained by the Universities of Erlangen and Heidelberg under the leadership of Prof. BDT). This site offers the visitor access to an online dermatology atlas of about 4. These standards focus on the transmission of administrative data (KVDT. Tittelbach/Elsner 254 . This standard is mainly used for the data exchange between bigger institutions and clinics. clinical examination and description of the clinical finding through the diagnostic process to the correct diagnosis. A standard for the exchange of medical information between physicians has not been established. Application and Examples The previous paragraphs have described the general situation and use of modern telecommunication systems in the medical field. Stolz). During the whole lecture the student has the option to ask for (computerized) advice and explanations.500 images. A German user forum is adopting these specifications for the particular needs throughout Germany. Therefore. it is used in teledermatology. Diepgen and Prof. Schuler.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.dermis. telepathology and other systems. Currently. a set of standards (called xDT) is defined. The results gained in the tests within this system are applicable for getting credit points. This paragraph will show certain projects as an example for the ‘state-of-the-art’ use of telemedicine and teledermatology in Germany. laboratory data (LDT).derma2000. a very interesting initiative showing the wide application of telecommunication in dermatology is the project ‘www.de (28-11-2001). universities. http://www. 2 Telemedicine in Germany 255 . different initiatives and projects show promising results but need further development and integration.de’. In addition to organizational and legal information and recommendations for quality management. http://atg. 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. 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. References 1 Debold P. Debold und Lux Beratungsgesellschaft für Informationssysteme und Organisation im Gesundheitswesen mbH. Today. Normally. Aktionsforum Telematik im Gesundheitswesen. The intention is to guarantee a more cost-effective and quality-managed care of patients. Gesellschaft für Versicherungswissenschaft. The presentation of all these initiatives would exceed the possibilities in this book. This. Lux A: Kommunikationsplattform im Gesundheitswesen: Kosten-Nutzen-Analyse Neue Versichertenkarte und elektronisches Rezept. the intermittent treatment of severe dermatoses in young patients can cause severe study disadvantages. A large number of health Internet portals.und Gestaltung eV .de/kpf/kna_bericht_v10a. ethical and legal framework for the application of these new media for the exchange of personal medical data. Furthermore. will provide a better interaction between the different healthcare providers.net) as a collective forum of different medical sections has a broad impact on daily clinical practice. The common initiatives of the different players in the healthcare sector have a key importance for establishing standardized interchange interfaces. Hamburg.gvg-koeln. the Internet is frequently used by both doctors and patients as a valuable resource of medical information.kids-inzell. ultimately leading to a retardation in comparison to classmates.pdf (28-11-2001). companies and private persons.vdak. in combination with building the political.The webpage of the AWMF (workgroup of scientific medical societies) (http://awmf. 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. medical databases and programs for CME (continuing medical education) is maintained by different interest groups like self-help associations. Dudek J: Einführung in die Chancen und Voraussetzungen von Telematikanwendungen im Gesundheitswesen. Deutsches Medizin Forum. Schollmayer A. Jäckel A. MD Department of Dermatology.de Tittelbach/Elsner 256 . Stolz W: Teledermatology – The requirements of dermatologists in private practice.uni-jena. Bad Nauheim. Landthaler M. J Telemed Telecare 2000. D–07740 Jena (Germany) Tel. Friedrich Schiller University.3 4 Glaessl A. 49 3641 937370. in Jäckel A (ed): Telemedizinführer Deutschland 2000. Jörg Tittelbach.6:138–141. E-Mail tittelbach@derma. Erfurter Strasse 35. Fax 49 3641 937343. Walther T. Schiffner R. 1999. in which optical information is important. Also. especially the Internet. internal medicine. . pp 257–260 6. the most important task is the transport of virtual images between practices and/or hospitals. is actually more a political problem than a technical one. but the expense – not only on the cost side – far outweighs the benefit. with the limitation that technical development also increases size of image data. mostly containing text and sometimes images. bPraxis für Dermatologie und Venerologie. making the use of telemedicine even more useful. Curr Probl Dermatol. so that these projects run on a low level. Therefore. This. Karger. 2003. In radiology. Zumikon. Video teleconferences have also taken part between gastroenterologists and psychiatrist groups. is used for ‘usual’ information exchange. is well suited for the development and the use of telemedicine. firewall technology often limits size of passing data. vol 32. modern information technology. Theo Rufli c. Universitätsspital Zürich. demanding faster equipment. these problems will be solved.Burg G (ed): Telemedicine and Teledermatology. e. Switzerland Switzerland. Günter Burg a a Dermatologische Klinik. which makes transmission slow or dependent on special equipment such as glass fibers. Another limitation is data security for those large images. therefore. its situation in the alpine mountains causes long travelling times for many patients. In the other specialties. The problem is in image size. Basel. Although Switzerland is a small country in geographical size. Universitätsspital Basel. Urs Bader b. With future technical development. on the other side. therefore radiology and dermatology have the most advanced telemedical systems. as a highly developed country with an up-to-date healthcare system. especially those not living in city centers.6 Teledermatology in Switzerland Claudio Cipolat a.g. cDermatologische Klinik. the Internet is not optimal for use which makes transmission again dependent on secured equipment. distribution of access to healthcare is uneven. Telemedicine in Switzerland is mostly used by specialties. Therefore. 2 GB hard disk. The completed structured referral form includes a short history. Data is archived in an electronic chart. It can be retrieved.000 bps. 32 MB RAM. Tapernoux. and communication is possible by chat room or telephone audio conference on-line. (5) modem analog or integrated services digital network (ISDN). organized by Dr. and differential diagnoses. Digital pictures must be of excellent quality and should show or describe the localization of the lesion. The communication platform used by Dermanet is based on the Internet Protocol (TCP/IP). speed at least 28. color depth true color (24. representing about 25% of all dermatologists in Switzerland. especially the Internet. The experience of the Basel-Zürich group is presented below.Teledermatology in Switzerland Because of the importance of optical information in the speciality. and even with distant locations such as Tanzania [1] or a congress in the United States [2]. and (6) digital camera (video or still). where the pictures can be looked at real-time in a virtual conference room. Now. (2) operating system Windows 95 or above/Windows NT. an Internet-based teleconferencing system (Dermanet) was developed by a network of Swiss dermatologists. The system was also used for a study to demonstrate accuracy of teledermatologic diagnosis of nevi. with communication by e-mail. which now consists of 75 physicians. the monthly ‘coin du practicien’. description of the localization and type of the lesions.or 32-bit). (4) screen resolution 800 600 pixels. Each Dermanet participant has the following hardware (minimum requirements): (1) PC system. and used again for another teleconference. At first. at which any member of the Dermanet group can participate: monthly teleconferences of the Dermatologic Clinics of the University Hospitals of Basel and Zürich. Cipolat/Bader/Rufli/Burg 258 . teleconferences were organized on a one-by-one approach between participants. edited. The images can be looked at off-line. image files are JPEG (joint photographic evaluation group) format and do not exceed 300 kB. The Dermatologic Clinic of Geneva has organized some teleconferences as well. where the mouse pointers of all participants logged in are shown. To ensure reasonable transmission time. or the system has the possibility of a teleconference. Pentium 133 MHz or faster. dermatology is ideally suited for the use of modern communication technology. The image transmission time is 30–50 s using ISDN. B. Participants forward their still images along with relevant data about the patient with interesting or difficult cases through Dermanet. even histologic pictures can be looked at real-time in a teleconference. With the correct equipment (microscope with digital camera needed). relevant laboratory data. teleconferences take place regularly. (3) graphic card 4 MB. Patient details are anonymous. monthly teleconferences in German language have taken place since November 1998.048-bit (password or ‘passphrase’ consisting of up to 256 characters). The goals of these teleconferences are: (1) discussion of unclear cases. Experience showed that the maximum group size that is feasible for a single teleconference consists of 12 members. Among the 75 members of the Dermanet working group. medical information may easily fall into the wrong hands. The data also is sent through a tunnel further preventing unauthorized access and misuse of the information. proprietary systems such as Dermanet provide better security for patient data than the open. The development of the Dermanet system was supported by Roche Pharma (Switzerland) AG. and. firewall. Without adequate security. because access to unsecured data via the Internet is easy. The further goals were to simplify communication among dermatologists. and (7) closed user groups. (4) support of all common transfer protocols. organized by the Dermatology University Clinics of Basel and Zürich.024. at which members of the Dermanet network can participate. because no additional encoding of data is necessary. Encryption of data is based on DES3 with a 168-bit key. about 8–12 dermatologists participate in each conference. and presentation of interesting cases for teaching purposes. e-mail-based systems. In Internet-based telemedicine. (2) confrontation of clinical pictures with histology (3). data security is of uppermost importance. The conference is alternately chaired by the Dermatologic Clinic of the University Hospitals of Basel (Prof. and the patient may not consent to telemedical activities. otherwise too many persons interfere with each other in the virtual telephone conference room. Experience with Monthly Teleconferences In the pioneer group.and software-protected by Arpage’s Security and Access System (ASAS) security software. (5) end-to-end encryption. Authentication is achieved by keys of 1. medical education. T. to improve the intellectual exchange among specialist physicians. (6) access control on any user level and on any hardware resource.024-bit and more). 1. (3) data integrity (MD5 hash/checksum). (2) data privacy (168-bit 3DES). Rufli) and Teledermatology in Switzerland 259 . All services and transfers are password-. They belong to an active group of about 20 members which participate regularly. very important. Security measures built into the system also ease handling.Data Security In general. service for patients and referring physicians is to be improved.to 2. Also. which provides the following: (1) tunneling (through firewalls if needed) authentication (RSA. Claudio Cipolat. Haeffner A. 37 conferences were organized until November 2001. during which 2–4 cases can be discussed. Tapernoux. MD Dermatologische Klinik. G. Burg G: Teledermatology as a new tool in subSaharan Africa: An experience from Tanzania. C. Most practitioners do not have the equipment for photographing histologic pictures. a questionnaire was sent to the members. histologic pictures can be discussed as well. 42:770–775. either prerecorded off-line or real-time on-line. The equipment necessary is available in Basel for images off-line. Meier M. B. As a consequence. for both possibilities in Zürich. Masenga EJ. In 22 cases.ch Cipolat/Bader/Rufli/Burg 260 . Therefore.Zürich (Prof. Dr. Ramelet AA. In total. Krischer J: Teledermatoscopy in Switzerland: A preliminary evaluation. since 2000. Problems also could be identified: technical limitations. Geneva. with updates of the program and the telephone system. In 23 cases. CH–8091 Zürich (Switzerland) Tel. Universitätsspital Zürich.42:833–835. In addition.usz. a diagnosis could be made. References 1 2 Schmid-Grendelmeier P. long transmission times due to inadequate compression of pictures. Second follows benefit in assistance for diagnosis and therapy for a given patient. Bader. 48 patients were presented as teaching cases. Pelloni F. monthly teleconferences in French language under the name of ‘le coin du practicien’ are organized by Dr. Thürlimann W. such as sound and stability of the phone teleconference. the ease of use and stability of the program. Saurat JH. Braun RP. Cipolat). during which 122 cases were discussed. The duration of each conference is 30–45 min. If appropriate. the monthly teleconferences with the University Dermatologic Clinics of Basel and Zürich are a well-accepted tool for the Swiss dermatologists. Dr. The time point of the conferences could be optimized as well. Gloriastrasse 31. diagnosis was uncertain even after the teleconference. Tapernoux B. E-Mail cipolat@der. Fax 41 1 255 4403. J Am Acad Dermatol 2000. The results of the questionnaire with identification of problems led to optimizing the technical aspects of the conferences. J Am Acad Dermatol 2000. directions for therapy could be given. in 21 cases. During the sending time of the pictures. Schilling M. U. Burg. The main benefit is seen in teaching and communication with the university center. the patient is presented and then discussed in the group. To evaluate the benefits of the conferences. 41 1 255 2550. participation in teleconferences is rewarded with CME (continuous medical education) credits. In 9 cases. diagnostic steps were advised. 195 Häffner. 2 Doe. 191 Fischer. R. 195 Bader. 154 Moring. 247. 233 Popal. M. P. B. N. H. H. W. A. 148 Haroske. 233 Dyson. M. 191 Arnold. B. 158 Gruber. 154 Kurzynski. 207 Granlund. S. G. 58 Höhn. M. I. 102 Hicks. W. 172. L. 195 Christen.A. 191 Isohanni. G. 62 Kropf. 207 Demartines. 102 Ohinmaa. 43 Gabathuler. J. L. 132 Olver. 176. H. A. 39 Hamm. 102 Braun. 195. 257 Burgdorf. N. A. 207 Lichtsteiner. G.R. 207 Klövekorn. U. D. 195 Poulsen. 6. H. 2. H. 76 Boesch. R. 71 Albert. M. 257 Beglinger. 33. 6 Glaessl. G. 132 Müller. P. 213 Kinateder. 172.S. 87 Mielonen. P. 226 Landthaler.B. M. 222 Pakenham-Walsh. H. 252 Ernst. A. C. K. 207 Kristiansen. S. A. 132 Jundt. 127. 76 Fischer. 247. 102 Helfrich. 207 Lepski. B. 172. 43 Esser. 33. I. 76. U. 102 Kempf. M. L. 213. 62 Qureshi. 94 Denz. 102 Milesi. R. J.Author Index Airaghi. 76 Folkers. A. G. H. 176. 33.-L. 247 Kühnis. 83 Kvedar. 201 Burg. 172. 71 Böhm.G. 182 Brauchli. J. H. 102 Oberli. 17 Burg. 43 Marincek. 213 261 . N. M. H. W. 76 Elsner. H. 39 Geiges. J.C. 12 Haller. M. 132 Mihatsch. K. 121 Otto. M. 207 Braun. A. U. 226 Reichlin.P.L. C. 102 Cipolat. 43 Pak.W. M. G. 176. 257 Coras. 191 Hammack. 76 Oberholzer. W. H. 207 Tachakra. 62 Zeevi. 43 .D.U. 24 Wiegers. B. 87 Whitten.-H.R.V Väisänen. W. D. 102 Stolz. 233 Stauch. L. 12 Author Index 262 . 195 Rufli. 201 Schmid-Grendelmeier. R. H. P. B. J. 132 Voellmy. 53 Tittelbach. T. S. 172. K. 257 Satava. 252 Tran. 115 Zelickson. 195. 141 Saurat. K. V . W. G.Roesch. 167 Zepter. A.S. 182 Wittrup Jensen. P.M. 145 Global Positioning System 144. see Security. 118 twelve-lead electrocardiograms 116. 244 technical needs cameras 241 computers 240 electrical power 242. 234 economic resources 233 ethics and patient education 244 Immarsat 234. security profile 74. telemedicine use 10 Application Service Providing. see Image and video compression Correctional telemedicine benefits 149 characteristics of prisons and healthcare provider risks 148. 117 historical perspective 116. 151 development 149 standards for healthcare in prisons 148 263 . 236 radiology 234 sustainability 243 synergy with industrialized world 243 teledermatology prospects 244 Tanzania-Switzerland connection 236–240. telemedicine doctor shortages 233. 243 Internet access 241. 242 software 241 Airlines. 75 Authentication.Subject Index Africa. transtelephonic clinical research 118 event recorders 117. 117 Italy experience 248 pacemaker monitoring 116 prospects 119 Slovenia experience 247 Case presentations. advantages 188 Arpage Security and Access Services. telemedicine cardiovascular disease epidemiology 115 congestive heart failure patient monitoring 118 electrocardiogram. medical data Cardiology. 145 heart rate 144. Internet access 36. 142 costs 146 establishment 141 graphical interface 142–144 performance of hardware 144. vital signs monitoring core temperature 145 Everest Extreme Expedition clinic components 141. 235 International Network for the Availability of Scientific Publications 235. 145 rationale 141 skin temperature 145 Compression. 37 Climbers. 149 cost-effectiveness 150. 65 meta-analysis 65. 66. 67 cost-utility analysis 64 financing 68 marginal cost 54. 64. Dermatology Course 2000. 160. 163 real-time videoconferencing 158. 69 net additional costs 68 prospects for study 69 teleoncology 124. 164 Germany experience 254. see Nursing home teledermatology prospects 29. telemedicine. 64. 160. 158. 259. 155 digital image transfer 155. 158. 255 North America experience 222–225 nursing homes. Teledermatoscopy advantages and limitations 29 Africa experience 236–240 applications. see Security. medical data Data compression. 260 Dermatology. 162 patient outcomes 163. see Security. 192. Dermatology online with interactive technology. 159. 37 course construction and tools 186. Internet access 8. see also Dermanet. 164 patient satisfaction 163 physician confidence 162. 164 store-and-forward teledermatology 158. 63 commercial influences on research 67.Correctional telemedicine (continued) technology 150 Cost analysis. 9 Dermanet adaptation to other disciplines 157 database access 156 development 154. see HistoClinC European experience 248 evaluation studies of consultations diagnostic accuracy 161 management plan accuracy 161. 125 telepsychiatry via videoconference 136 willingness to pay 68 Cryptography. HistoClinC. 66 cost-effectiveness analysis 63. 258 hardware requirements 258 Moshi station 156 prospects 156. 156. 159. 193 digital archives 191. 185. 64. 182 resource lists 37 textbooks 36 Subject Index 264 . overview 24. 36. 25 store-and-forward teledermatology 27–29. 213 clinicopathologic correlations. 164 research history 24. telemedicine classification of health consequences 62. 30 real-time teledermatology 25–27. 151 cost-benefit analysis 63. 68 correctional telemedicine 150. 38 learning objects 193 Learning Service Providing 188. 164 survey of Bavarian dermatologist’s attitudes 172–174 teaching tools. 157 security 259 teleconferencing 156. 192 interactive training programs 37. 186 architecture of telematics-based learning environment 185 case presentations 36. see also Dermatology Course 2000. Dermatology online with interactive technology application scenarios 34. 189 lectures 35 link collections 37 market for e-learning 183 rationale for use 33–35. 66 cost-of-illness analysis 65 cost-minimization analysis 63. 66. see Image and video compression Data protection. 189 databases 35. medical data Databases. see Germany. telemedicine ATG forum 253 communication standards 254 political framework 252. 248 dermatology 248 general telemedicine 250. 180 training applications 177 DermoGenius ultra. 140 requirements 137 responsibility area 134 Germany. see Switzerland. telemedicine consulting 84–86 general telemedicine experience Croatia 250 Greece 251 patient monitoring 84. 196 prospects 198. telemedicine Electrocardiogram. 181 content 178 modules CyberLecture 177–179 CyberNet 177. 197 Dermatology online with interactive technology comparison with other training programs 180. 249 obstetrics 249 ophthalmology 249 pathology 250 psychiatry 250 survey of Bavarian dermatologist’s attitudes 172–174 Switzerland. 208 DICOM. telemedicine Family practice. image standard 88 Economics. 145 Gynecology. 199 technical aspects 196 training units 196. 85 skills required of doctors 83 TelFam system 84–86 FotoFinder Medic. 255 Global Positioning System. teledermatoscopy 204. telemedicine cardiology 247. 198 overview 195. 118 twelve-lead electrocardiograms 116. teledermatoscopy 204 General Packet Radio Service.Dermatology Course 2000 cognitive apprenticeship 198 outcomes 197. 253 technical preconditions 253 teledermatology 254. 42 prospects 40–42 rationale 39 teleconferencing from 1997 to 2001 39. 138 project origins 133 prospects 139. 40 United Kingdom experience 249 Subject Index 265 . 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137. patient monitoring in primary care 80 Germany. image and video compression 19 Europe. 117 Entropy coding. Oulu experience advantages and limitations 138. 178 objectives 177 origins 176 participating institutions 177 prospects 180 technical aspects 179. telemedicine Italy experience 249 training at University Hospital of Zürich advantages and disadvantages of videoconferencing 41. telemedicine neurology 248. see Cost analysis. transtelephonic clinical research 118 congestive heart failure patient monitoring 118 event recorders 117. image and video compression 21–23 Error frame. 179 CyberTrainer 177. 251 Finland telepsychiatry. climber monitoring 144. 263.H. 168 specialist visits to nursing homes 167. 104. 123 definition of teleoncology 121 economic evaluation 124. 219 functions 216–218 implementation 218 legal aspects 219 look-alikes in dermatopathology 213. 169 rationale 167. telemedicine clinical applications 128. 218 I-frame. 111 Joint Pictures Experts Group. Web browser origins 8 MPEG. image and video compression 17. 214 overview of system 216 rationale for development 214. 21 Information Society evolution 12. 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 77. 21 National Aeronautics and Space Administration. 249 Nurse. 215 reimbursement 219 scientific evaluation 219 technical issues 216. 130 Sweden experience 249 technology 128 United Kingdom-South Africa connection 249 Subject Index 266 . 18 goals 17 lossy vs lossless algorithms 17 prediction 18–20 preprocessing 18 quantization 21 transformation 20. advantages 188. Internet access 35 Microderm. image standard 89 Learning Service Providing. telepathology 103. 122 assessment clinician satisfaction 123. 129 effectiveness 129 pilot projects 127 prospects 129. teledermatoscopy 204 Mosaic. 19. teledermatoscopy 204 Mobile extranet infrastructures. telemedicine applications 121. 189 Lectures. image and video compression 17. development 13–15 HistoClinC advantages and limitations 218. history of telemedicine 9. Portugal experience with telemedicine 248. telemedicine satisfaction survey 58–61 Nursing home teledermatology components and system requirements 168. 19 High-speed networks. 80 MOEBIUS. 125 equipment 122 medicolegal issues 125 prospects 125 Ophthalmology. development 15. 170 Oncology. image and video compression 20 Image and video compression entropy coding 21–23 formats 17. 13 high-speed networks 13–15 internet-based computerized patient records 15. 16 iPath. 124 patient satisfaction 122. patient monitoring in primary care 80 MoleMaxII. 168 study of store-and-forward system 169. 10 Neurology. 103 modular design 111. 193 Space medicine. 91 regulatory requirements for Internet data 71 rules for data transfer 72 Security Onion and layers of security 72–74 United States law 229. 111 iPath software 103. telemedicine training by Swiss Center of Pharmaceutical Sciences contact with students 48 design 44. 96 consultation 95 interactivity 96. 75 confidentiality 71 cryptography 73 Dermanet 259 identification and authentication 71 integrity 72 intranets 77 radiology data 90. 88 implementation economic challenges 90 legal issues 90 security 90. medical data Arpage Security and Access Services security profile 74. 92 technical requirements hardware 89 image size 88 image standards 88. 105 hardware modules 104. 112 United Kingdom experience 250 Pharmacology. archives 192. 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137. telemedicine conferences 95. 89 Resource lists. 44 pnn development of online courses 45. 97 mentoring 97 prospects 100 requirements 94 robotics and telesurgery 97. 47 Vireal Lab 48 Virtual Laboratory 47 Web-Based Training 45. telemedicine satisfaction survey 58–61 Pathology. telemedicine Africa 234 applications 87. 104. 105. 46 teamwork 48 TELEPOLY videoconferencing system 45–47 Top Class 46. 90 prospects 91. telemedicine use 10 Security. Internet access 37 Seafarers. 140 Quantization. telemedicine aims 102 architecture of system 103. history of telemedicine 9. 47 Psychiatry. 138 project origins 133 requirements 137 responsibility area 134 prospects 139. 230 SENTIMED. telemedicine definition of telepsychiatry 132 United Kingdom experience 250 videoconferencing with patients advantages 132 historical perspective 133 Oulu experience advantages and limitations 138. 91 system integration 90 interaction types 89. image and video compression 21 Radiology. 45 integration into curriculum 48–50 origins 43. 98 Subject Index 267 . 111 model 102.Paramedic. 110 consultation active consultation 107 passive consultation 107–110 steps 105 database 105 expert module 104. 10 Surgery. Surgery. 47 Vireal Lab 48 Virtual Laboratory 47 Web-Based Training 45. telemedicine paramedical personnel satisfaction survey 58–61 pathology. 209. 176. 43. see Nursing home teledermatology obstacles ethical and legal considerations 4 funding 4 organizational resistance 3. telemedicine ophthalmology. 244. see Dermanet gynecology training at University Hospital of Zürich advantages and disadvantages of videoconferencing 41. 257 Dermanet. 55 focus group 53 Subject Index 268 . see Cardiology. telemedicine applications. 205 systems DermoGenius ultra 204. 245 Tagged image file format. see Pathology. 233. 208 FotoFinder Medic 204 Microderm 204 MoleMaxII 204 overview of features 203 Telemedicine. 42 prospects 40–42 rationale 39 teleconferencing from 1997 to 2001 39. telemedicine patient expectations attitude to change 55 cost control 54. see Family practice. medical data definition 2. 56. 6. overview 39. 56 psychological barriers 3. Tanzania-Switzerland connection 236–240. 44 pnn development of online courses 45. 95 virtual reality 98. 210 ELM criteria 201 image acquisition 201–203 outcomes study 207–211 performance analysis face-to-face diagnosis comparison 11 histological analysis comparison 207. 3. see Security. 154. 102. 210 visual inspection comparison 201 reimbursement for consultations 204. 45 integration into curriculum 48–50 origins 43. see also specific countries cardiology. see Dermanet. telemedicine data protection. telemedicine cost analysis. 94. telemedicine satisfaction survey 58–61 Teledermatoscopy color reproducibility 203 consultations 203. Dermatology. 204. see Oncology. 46 teamwork 48 TELEPOLY videoconferencing system 45–47 Top Class 46. Teledermatoscopy disciplines for applications 2. 57 technical and logistic restraints 3 oncology. see Cost analysis. see Ophthalmology. telemedicine (continued) telepresence 97 transmission rates 94. 78 family doctors. 47 teledermatology. 115. 201. telemedicine growth of field 95 historical perspective 6–10 impact on future healthcare 4. see Training Technician. 5 nursing homes. telemedicine. Dermatology Course 2000. 76 dermatology. 40 pharmacology training by Swiss Center of Pharmaceutical Sciences contact with students 48 design 44. 213. image standard 89 Teaching. 99 Switzerland. Dermatology online with interactive technology. 224 military experience 222. Web-Based Training Application Service Providing 188 demands on telematics-based learning environment 184 Learning Service Providing 188. see Radiology. 139 cost savings 136 practical experiences 135 preparation and planning of videoconference 137. 225 Universal Mobile Telecommunications System. see Correctional telemedicine psychiatry. pharmacy student training 46. see Surgery. Pharmacology. pharmacy student training 47 Virtual reality. 42 prospects 40–42 rationale 39 teleconferencing from 1997 to 2001 39. 227 outcomes research 228. videoconferencing system 45–47 TelFam. telemedicine. patient monitoring in primary care 80 Video compression.quality control 55 rationalization of care 53. 184 rationale for telematics-based teaching 182 Transformation. telemedicine. 5 Textbooks. telemedicine origins 2. 140 requirements 137 responsibility area 134 TELEPOLY 45–47 Virtual Laboratory. 138 project origins 133 prospects 139. Dermatology online with interactive technology. Dermatology Course 2000. Training. 228 technology adoption 230 technology development 229 teledermatology barriers 223. telemedicine consumer awareness 230 economic model 230. see Climbers. see Image and video compression Videoconferencing gynecology training at University Hospital of Zürich advantages and disadvantages 41. 47 Training. features 84–86 Telstar. Gynecology. Web-Based Training TELEPOLY. 224 credentialing 223. telemedicine radiology. 189 market for e-learning 183 medical applications of telematics-based teaching 183. see Psychiatry. Dermatology online with interactive technology. telemedicine surgery. surgery applications 98. Dermatology Course 2000. 229 privacy and security 229. vital signs monitoring Subject Index 269 . image and video compression 20. 54 patient monitoring in primary care 78–80 prisons. 230 prospects 231 provider comfort 230 services and applications 227. telemedicine satisfaction survey 58–61 Top Class. 223 prospects 224. see Dermatology. telemedicine. Oulu experience advantages and limitations 138. 224 economics 222. 40 historical perspective 133 psychiatry. Internet access 36 Therapist. 99 Vital functions climber monitoring. telemedicine. telemedicine. Gynecology. 21 United States. see also Dermatology. Pharmacology. telemedicine. 231 historical perspective 226. telemedicine training. 186. 13 data protection. see Security. 187 pharmacy student training 45. 9 medical resource limitations 8 origins 7–9 Subject Index 270 .Vital functions (continued) monitoring over networks 78. 187 dermatology training 182. 47 World Wide Web access evolution 12. medical data database access 8. 79 Web-Based Training course construction and tools 186.