Abstracts from theFirst Nordic Congress

of TelemedicineThe First Nordic Congress of Telemedicine took place on June 17-19,1996, in Kuopio, Finland.This international gathering had 150 attendees and featured commercial exhibits, eight keynotespeakers, workshops, panel discussions, and invited papers. The Congress was chaired by Dr.Marten Quist, Chairman of the Finnish Society of Telemedicine. Dr. Matti A.K. Mattila servedas the local organizer. The Congress was organized by the Finnish Society of Telemedicine inclose cooperation with Kuopio University, Kuopio University Hospital, the University of Oulu,the University of Turku, and the City of Kuopio. Funding was also provided by the FinnishAcademy of Sciences.

Selected abstracts from the meeting have been included for publication. These abstracts havebeen edited by the Journal for consistency of style and to meet space limitations. Any questionsconcerning the meeting should be addressed or faxed to Dr. Matti A.K. Mattila at KuopioUniversity (Fax 358-17-364-5388). The Second Nordic Congress of Telemedicine will be held in1998 in Iceland.

TELERADIOLOGY VERSUS TRAVELING RADIOLOGYSERVICE: AN ECONOMIC APPRAISALBergmo, T.Department of Telemedicine, University Hospital of Troms0,9038Troms0, Norway. Tel +47-776-27476, Fax +47-776-28157, E-mail tmatsb@rito.noTeleradiology between Tromse Military Hospital (TMH) andUniversity Hospital of Tromse (UHT) was permanently estab¬lished in 1992 after a test period of two years. The former is alocal hospital situated 160 km or 2.5 hours car travel from UHT.The average load is 25 patients a day and 6000 patients (8000examinations) per year. The current teleradiology serviceinvolves daily transmission of digitized radiographs to theradiology department at UHT. Conventional radiographs andhandwritten requisition forms are scanned, images are reviewedon a multi-screen workstation, and reports are transmitted backto the local hospital.

The aim of this economic appraisal is to establish whetherteleradiology between two locations is more or less expensivefor the public sector than a traveling radiology service, withsimilar outcomes. Teleradiology and traveling radiology servicecost annually NOK 646,900 and NOK 1,069,000, respectively.Total cost per patient for teleradiology is NOK 108 and fortraveling radiology service NOK 178. To obtain a positiveconclusion in favor of teleradiology, the number of patientsinvolved has to be above 1576 per year. The actual alternativefor radiology service, the costs and depreciation of the technicalequipment contain elements of uncertainty. Different circum¬stances and figures will impact this conclusion.

TELEPATHOLOGY—A CHALLENGE FOR NETWORKINGBusch, P.C.Department of Pathology, University Hospital, Uppsala S-75185, SwedenPathology is undergoing growth, increased subspecialization,and increasing complexity with rapidly developing insights inthe molecular events governing cell life in health and disease.Thus, the demands on diagnostic skills increase and at the same

time the economic pressure minimizes the possibility forexpansion. Therefore, modern communication technology offersa way to control and enhance the quality of diagnostic workandbroaden the knowledge base. Byincreasing communicationbetween pathologists, both "horizontal" (second opinionconsultation) and "vertical" (expert consultation), the frames ofreference for diagnostic criteria can be consolidated.

Quality control can be rapidly assessed with many participat¬ing pathologists in a short time. Enhanced quality of diagnosticwork can be achieved in telepathology by building referenceimage databases which can be updated regularly, and to whichindividual pathologists can contribute. Expert panels can beformed for each subspecialty and multimedia databasesorganized, also enclosing immunohistochemical, genetic, andclinical data. Using telepathology, multicenter clinical studiescan be facilitated.

The Swedish experience from a National Test of Telepathol¬ogy is described as well as the EUROPATH project. The latteris funded by the European Commission and involves a majorityofEuropean countries. Representatives for Pathology, Cytology,EORTC (European Organization for Research and Treatment ofCancer), and European industries take part in an effort topromote telepathology.

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TELEMEDICINE IN CARDIOLOGICAL EMERGENCIES:PREHOSPITAL THROMBOLYSISCamerucci, S., Arrabito, B., Biagjni, M., Rizzo, N., Dauri, A.International Radio Medical Centre (C.I.R.M.), Via dell'Architet¬tura 41,1-00144 Rome, Italy. Tel +39-6-592 3331-2, Fax +39-6-592333, E-mail cirm@agora.stm.it; I.P.A.M. II Regione Aerea, ViaGobetti 6/a, 1-00185 Rome, ItalyPrehospital thrombolysis in acute myocardial infarction (AMI)is one of key factors in reducing mortality and improving leftventricular function. Medical air transport can bring aid in shorttime in remote areas. The Italian Air Force is equipped withhelicopters (Sikorsky HH3F), furnished with cardiac monitoringand cardiopulmonary resuscitation (CPR) units. InternationalRadio Medical Centre (CIRM) cooperates with Italian Air Forcein selecting cases of medical emergencies where a benefit isexpected from aero-medical evacuation.

In the last 4 years, the 15th Wing stationed in Ciampinoairport was involved in many cardiologjcal emergencies and 15selected patients with AMI received prehospital thrombolysiswith Urokinase, within a median time of 90±15 min from thealert of the aid chain. The 15 patients (12 men and 3 women,mean age ±58 years) received 2 million unit U.K. i.v. in 15 min,plus heparin 12,500 U s.c. The ECG showed 10 anterior AMI (7M, 3 W) and five inferior AMI (5 M); during the transportationwe noticed the normalizing of the ECG in 7 patients (5 M, 2 W),in five cases of anterior and two cases of inferior AMI. Allpatients were safely transported within 60 min to the nearestcoronary case unit; no deaths and bleeding occurred during theprehospital phase as well as no dangerous arrhythmia. In a one-week follow-up after the admission in a coronary care unit, one

patient (M, 54 yrs, with anterior AMI) died on 2nd day ofventricular fibrillation.

Our experience suggests that under conditions of difficultaccess, an early decision-making process through telemedicinecombined with medical air transport could assure an early andeffective treatment of patients with AMI.

TELEMEDICINE SERVICES FOR SEAFARERS: A NEWAPPROACHCamerucci, S., Fulvio, S., Rizzo, N., Dauri, .International Radio Medical Centre (C.I.R.M.), Via dell'Architet¬tura 41,00144 Rome, Italy. Tel +39-6-5923 331-2, Fax +39-6-5923333, E-mail cirm@agora.stm.itSeafarers work and live on board ships sailing all over theworld, often in isolated conditions. Crews of merchant ships or

fishing vessels are small, average 15-20 persons. They need tobe self-sufficient for several days when they are far from port.When a seaman suffers from an illness or has an accidentonboard, the Captain can request radio medical advice from a

radio medical centre about the treatment of the patient untilport arrival.

Since 1935, the International Radio Medical Centre of Romeoffers free radio medical assistance to 700 patients a year andreceives more than 10,000 medical calls. To improve its services,C.I.R.M. is developing new methods and technologies. Untilnow, medical assistance for seafarers is performed by radio orsatellite messages. Recently, new communication systems havebeen developed to transmit medical data (video images,electrocardiograms, laboratory test results, etc.), to medicalfacilities located far from the patient. Now C.I.R.M. is engagedto develop a new telemedicine multimedia system, whichallows providers to manage voice, video, and data transmissionsbetween ship and shore by satellite.

The system is based on a modular portable device with avideo image transceiver and heads up display. This systemincludes a PC with software to guide the Captain in examiningthe patient and also in suggesting first aid procedures. Throughthis portable system, the Captain is able to take care of thepatient under the guidance of a physician from a remotetelemedicine centre.

TELERADIOLOGY—IMMEDIATE EXPERT KNOWLEDGEGitlin, I.N.DPH, Dept. of Radiology and Radiological Sciences, The JohnsHopkins Medical Institutions, Baltimore, Maryland 21287, USAThe deployment of new technologies in health care is partlydependent on the success of health care reform. "Many of thepolitical imperatives driving telemedicine derive from theanticipated use ofmanaged care incentives to provide accessiblelow-cost health care to all Americans."

Telemedicine is being advocated as a process of deliveringhealth care with the potential of reducing cost while maintain¬ing quality. However, little is known about the efficacy andcost-effectiveness of the technology in routine diagnostic andtherapeutic practice.

Recent improvements in electronic displays and relatedsoftware should promote acceptance of telemedicine, teleradiol¬ogy, and image management systems by health care providers.Comparative studies of film versus screen interpretationsindicate gradual improvement in the relative accuracy ofreadings on electronic displays. Using Receiver OperatingCharacteristic (ROC) analysis based on carefully designedstudies, it appears that systems with adequate resolution,luminance, size, and image manipulation algorithms areavailable that can provide diagnostic accuracy equal to that offilm interpretation. Widespread use of this technology willdepend on demonstrating cost/benefits, especially with regardto communication with requesting physician.

POSSIBILITIES AND LIMITATIONS OF TELEPATHOLOGYHelle, M„ Helin, H.Department of Pathology, Mikkeli Central Hospital, Porrassal-menkatu 35, 50100 Mikkeli, Finland. Tel +358-55-351 2450, Fax+358-55-351 2479Telepa thology has been in daily use between Tampere Universi¬ty Hospital and Mikkeli Central Hospital since 1993. Still videoimages of paraffin sections have been transmitted via the two-way digitized telephone network (ISDN). The system is easy touse, costs are low, and the image quality is good.

Consultations between pathology specialists are common indaily practice, particularly for difficult cases. The usual proce¬dure is to submit glass slides to another pathologist. Review ofa slide under a microscope enables more adequate morphologicevaluation than a tele-image. Sending slides per mail is cheaperthan using telepathology connection and the time delay isusually tolerable.

Telepathology offers, however, many possibilities to improvecommunication between pathology laboratories. Progress inhardware, software, and high capacity telecommunicationshould improve the quality and increase the utility of tele¬pathology services. A multi-pathologist vidéoconférence can

hardly be replaced by mail services. Such conferences can bealso utilized in medical training and quality assessment.Histopathologic and cytologie databases can be created andregularly updated using images transmitted by telepathologyconnections.

It is important to standardize systems in telepathology toenable communication of individual workstations for nationaland international networks.

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TELEMEDICINE: CURRENT STATUS AND A VIEW OF THEFUTUREHouse, A.M.Faculty of Medicine, Memorial University ofNewfoundland, St.John's, Newfoundland, Canada A1B3V6. Tel (709) 737-6645, Fax(709) 737-6118, E-mail maxhouse@kean.ucs.mun.caIf the use of telephone in health care is excluded, the develop¬ment of telemedicine over the past three decades has beenrather erratic. Expensive broadband projects in the late 1970swere not sustained.

During the '80s there were a few successful projects usinginexpensive telephony-based systemsformedical data transmis¬sion and limited consultation. The telemedicine programme atMemorial University of Newfoundland, the world's longestoperating system, was one of these.

During the late '80s and early '90s telemedicine projectsemphasized the use of interactive video conferencing. The latestphase of telemedicine in the past three years has turned to theuse of the least expensive systems that meet needs. "Multi¬media" and "store and forward" technologies seem to be in theascendancy. The worldwide expansion of the Internet, withincreasing scalability and capacity, appears to have the potentialfor meeting many health and educational needs.

There has been limited reporting in the literature ofadequateevaluation of systems and programmes, and very little soliddata are available on the economics of telemedicine. Further¬more, health professionals have not fully recognized thebenefits of information technologies in health and health care.

The future will see a blurring of the lines between healthinformation systems and télemedicine/telehealth systems.Computer voice recognition, when perfected, will be a majoradvance. The increasing digitization of delivery networks,increasing affordable bandwidth (e.g., ATM in urban areas), andthe increasing capacity of the desktop computer are leading toa significant degree of convergence.

The challenge of the future will not be technical, but willrelate to human factors, coordination, remuneration, regulatoryissues, confidentiality, and privacy.

DIGITAL IMAGING NETWORK FOR OPHTHALMICPHOTOGRAPHYHvytinen, P., Alanko, H., Nieminen, H., Tuulonen, ., Airak-sinen, P.J.Department of Ophthalmology, University of Oulu Hospital,P.O. Box 22, 90221 Oulu, Finland. Tel +358-81-315 3547, Fax+358-81-315 4499, E-mail pauli.hyytinen@oulu.fiWe have developed a digital imaging network using Unixworkstation computers, 10Base-T Ethernet network, imagearchiving software, and Kodak DCS™ digital camera bodyconnected to fundus cameras with an optical reducer. The 24-bitcolor images (1280x1024 pixels) are loaded to Silicon GraphicsIndigo™ server computer, archived to patient "folders" (GBA'sImage Archive™ software), and stored on hard disks in com¬

pressed format (1.3 GB magneto-optical discs). The images are

displayed through the network on Silicon Graphics Indy™workstations located in the clinic. Hard copies are printed withKodak™ XLT 7720 printer.

EXPERIENCES OF TELECARE IN AMBULANCE SERVICESImmonen, ., Mattila, M.A.K.Emervest Ltd., 70211 Kuopio, Finland. Tel +358-71-240 610, Fax+358-71-240 211. Department of Information Services andResearch, Kuopio University Hospital, 70211 Kuopio, Finland.Tel +358-71-173 380, Fax +358-71-172 035During primary transportation, patient monitoring and report¬ing to the hospital are very limited. There are nowadaystransportable monitors which collect data in their memory. Datacan also be transmitted and used in order to get expert advicefor the ambulance crew.

A portable data collecting and wireless transmitting unit isdesigned for normal daily work in ambulance car service. Inuncomplicated cases the data are used in the form of a com¬

plete patient report upon arrival to the hospital and forbookkeeping and billing. In critical cases, there is a chance toestablish a real time connection to a hospital or expert center.Monitored parameters and alphanumeric information providea more accurate and informative basis for evaluation of patientstatus than a verbal conversation using cellular phone.

Pulse oximeter or other monitoring devices are connected toa portable computer at the scene and until arrival at thehospital. The whole transportation phase of the patient can berecorded and if necessary transmitted for supervision of an

experienced doctor.

CLEVER MEDICAL REFERRAL—A NETWORK PROJECT INTHE NORTH KARELIA HOSPITAL DISTRICTItkonen, P.North Karelia Hospital District, Tikkamäentie 16, 80120 Joensuu,Finland. E-mail pentti.itkonen@pkshp.fiThe North Karelia Hospital District has launched a project with theobjective to develop a partnership between the different care

institutions in the region. The prestudy phase has been completedand the first phase at the national level started in 1994. Thenational project is called the TERVE-project. The background ofthe TERVE-project is as follows:

From the patient's perspective the project should:• Provide health care services more efficiently• Provide appropriate care at the right moment and place• Provide high standards in health care throughout a region• Provide specialised care in rural areas to reduce the necessity for

patients to travelFrom the medical practitioner's perspective the project should:

• Support the follow-up of patients in a more efficient way• Coordinate activities between different health care institutions

and levels• Provide for rapid reporting of results of investigations and

procedures back to the primary health care provider• Support a patient management system by using a clever referral

(core process redesign and re-engineering)One of the main goals in the TERVE-project is to develop a

clever medical referral between the hospital and health centers andwithin the hospital. The main idea is that the clever referral can makecertain booking functions automatically and streamline health care

processes in the whole region.

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INTERNET AS A TOOL FOR CLINICAL LABORATORYMEDICINEJulkunen, ., Penttilä, I.M.Department of Clinical Chemistry, University of Kuopio, FIN-70210 Kuopio, Finland. E-mail Antero.Julkunen@uku.fiElectronic networks have an important role in transferringinformation inside the scientific community. In Finland manyhospitals, health centres, and private companies are installingcommunication links to electronic networks. This has providedlaboratory scientists an opportunity to utilize these services.

The most traditional usage of networks is the electronic mail.Besides mail, Usenet newsgroups provide an opportunity tospread information to millions of people around the world.Currently, there are few international newsgroups concernedwith clinical laboratory medicine (e.g., sci.med.laboratory,bionet.diagnostics). There are at least two international listsdealing with medical laboratory science (ACB-list, in UK, andMEDLAB-L, in Canada).

In Finland there is an experimental database system forclinical chemistry (ftp.funet.fi) in Helsinki. Ourown departmenthas its own WWW home page (http://www.uku.fi/~julkunen/klkemeng.html).

Services for clinical laboratory scientists in the internationalnetworks are now in development. Laboratory scientists haveto learn how to benefit from these new methods of informationexchange.

COMMUNICATIONS IN CLINICAL CHEMISTRY: SUC¬CESSES AND FAILURES IN OXFORDKay, I.D.S., McVittie, J., Nurse, D.Oxford Medical Informatics Unit, Department of ClinicalBiochemistry, Oxford Radcliffe Hospital, Oxford England. E-mail kay@vax.ox.ac.uk and http://oxmedinfo.jr2.ox.ac.ukSince 1979 we have developed a single Laboratory InformationManagement System (LIMS) for the biochemistry, haematology,and immunology laboratories at six sites in three hospitals. Thiscovers all of the Oxford hospitals and surrounding generalpractitioners.

We have encouraged the move from look-up on LIMS to thetransfer of structured reports without human intervention intoclinical management systems. This has been achieved to theRenal Unit, Intensive Therapy Unit, Diabetes Centre, ClinicalHaematology System, and Oxford Clinical Work Station inCardiology in the hospitals, and to about 47 general practices.Since 1990 the American Society for Testing and Materials(ASTM) 1238 standard has been used for all implementations.

Current projects include communication of structuredrequests and reports with reference laboratories, transmissionofmicrobiology andràdiology reports and discharge letters, andpublication of hypertext systems for laboratory handbooks andinformation on metabolic diseases using Intranet technology.

Projects which have not yet achieved routine use includeremote requesting.

Factors leading to successful projects include conservative,modular technology, use of existing standards, local control,and incremental development. Factors limiting success includeunique identification ofpatients and analyses, and the function¬ality of the clinical end systems.

HUMAN PERFORMANCE STUDIES IN TELEMEDICINEKrupinski, E.A.Department of Radiology, University of Arizona, Tucson,Arizona, USA. Tel (520) 626-4498, Fax (520) 6264376, E-mailkrupinski@radiology.arizona.eduIn any telemedicine system, the final measure of its acceptanceis whether clinicians using it can reach diagnostic decisions withthe same level of confidence as with traditional systems. Thus,it is necessary to evaluate rigorously telemedicine systems thatare to be implemented clinically. One performance evaluationmethod uses Receiver Operating Characteristic (ROC) analysis.This talk will review ROC basics and present the results ofstudies which used this method to evaluate performance usingtraditional viewing modalities in pathology and radiology withthose that are telemedicine based. Significant differences indiagnostic performance have generally not been found betweenthe two modalities, but differences in perceived quality (e.g.,sharpness, structure visibility, contrast) and ease of use often dodiffer. The implications of these differences from the diagnosticand ergonomie points of view will be discussed. Emphasis willalso be placed on assessing the human-computer interface as itrelates to diagnostic performance. Results from a recent studyrecording eye-position of radiologists as they scanned imageson film versus a CRT monitor will be presented. Differences inscanning patterns may not only influence detection anddecision processes, but may also influence the time it takes toreach a diagnostic decision.

QUALITY ASSURANCE IN TELEMEDICINEKrupinski, E.A.Department of Radiology, University of Arizona, Tucson,Arizona, USA. Tel (520) 626-4498, Fax (520) 626-4376, E-mailkrupinski@radiology.arizona.eduAs computing speeds increase and computer costs decrease,more and more hospitals are implementing telemedicinesystems. Aside from various network protocols and standards(e.g., ACR/NEMA), there are very few established and acceptedmethods for quality assurance. This issue is crucial, however, ifpatient care is to maintain its high standard. Various aspects ofquality assurance and control that can be used easily andefficiently in the clinical routine are described. Primary empha¬sis is placed on assessing the human-computer interface as itrelates to quality assurance of diagnostic performance. Inparticular, aspects of workstation design are discussed usingresults from a variety of studies which have used eye-positionrecording techniques to study how clinicians scan imagesduring the diagnostic decision process. The concept of perceptu¬al linearization of CRT monitors for use in telemedicine settingsis also explained and its implications discussed.

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TELEMEDICINE APPLICATIONS IN FINLANDKvist, M.Department of General Practice, University of Turku, P.O. Box23,20521 Turku, Finland. Tel + 358-21-333 8423, Fax + 358-21-3338439, E-mail marten.kvist@utu.fiThe rapid development of the telecommunications technologywith digitized networks has enabled telemedicine applicationsin health care using ISDN-lines or rapid data networks (ATM)between health institutions. Among the Scandinavian countries,Finland was the first to start with transfer of X-ray images bymeans of television in 1969.

Based on a survey made in January 1996, there are 40 sitesusing telemedicine applications. Additionally, 11 nursing schoolsand 3 technology research units have equipment which can beused in telemedicine. Most of the applications are in radiology,but some are in pathology, dermatology, psychiatry, clinicalneurophysiology, clinical chemistry, and general practice. Thepotential for distance learning is substantial. More than 30 siteshave introduced telemedicine either in 1995 or in 1996. Teach¬ing of telemedicine to medical students started in 1995 at theUniversity of Turku.

Telemedicine may improve the quality of care when an

expert opinion can be obtained without delay. The costs forinvestments in telemedicine technology are still rather high, butwhen efficiently used, the cost per unit of service will diminish.The main savings are for the patients, in reduced travel andtime loss from work

SAKU: A MEDICAL INFORMATION SYSTEM TO IM¬PROVE THE EMERGENCY MEDICAL SERVICESLaurikkala, J.,1 Klemola, I.,1 Juhola, M.,1 Immonen, A.,2 Rantan-en, H.,3 Hirvonen, A.4department of Computer Science and Applied Mathematics,University of Kuopio, P.O. Box 1627, 70211 Kuopio, Finland;2Emervest Ltd., Savilahdentie 6, 70210 Kuopio, Finland;3Emergency Services College, Hulkontie 83, 70820 Kuopio,Finland; 4TT-Government Service Ltd., Tieto Group, P.O. Box203, 40101 Jyväskylä, FinlandIn recent years, there has been a growing interest in improvingthe quality of emergency medical services. The SAKU-projectwas started in 1994 in order to respond to this demand byusing Computer Science. SAKU (SAKU=the name of an

emergency system, derived from the Finnish word sairaankulje-tus, "emergency services") is an information system whichconsists of two subsystems called Datamedic and Doctor whichinteract with each other via data communications.

Paramedics use Datamedic at the scene or during thetransportation to record sensory perceptions, actions, andmedications. Datamedic records data automatically from a

patient monitor. Registered information is sent by a computeror fax to the receiving hospital.

The Doctor-system is operated by an expert physician, whoevaluates the transmitted data and then consults the paramed¬ics. Consultation is transmitted to the Datamedic as text, or

voice if the physician prefers to talk with the paramedics.Various reports and statistical data can be generated from

the collected information. These are useful for training, account¬ing, and billing.

The SAKU-system was designed and implemented withobject-oriented software methodology and tools in the Depart¬ment of Computer Science and Applied Mathematics at theUniversity of Kuopio, together with Emervest Ltd. and TT-Government Service Ltd. Datamedic has reached the level ofcommercial application and it is currently being tested. TheDoctor-system is still under development.

DIRECT INTERACTIVE USE OF SURGICAL ROBOTLouhisalmi, Y.Laboratory of Machine Design, University of Oulu, P.O. Box444, 90570 Oulu, Finland. Tel +358-81-5531011, Fax +358-81-5532026, E-mail yrjo@me.oulu.fiA surgical robot is under development. Its main feature is theinteractive human-hand and robotic use, which is acquired bydevelopment ofnew mechanical clutch-drive trainconstruction.The size and weight of the robot are suitable for surgical use.

The construction conforms with requirements for safety,precision, and user friendliness. Experience from developmentof the neuronavigator system has been encouraging.

Theoretical studies of workspace and ergonomics forprecision surgery have guided the design of this robot. Tasksfor the robot have been identified in terms of surgical need,navigation, precision, programmability, and remote control.Non-contact surgical treatment methods are recommendednow. Contact methods may also be included by addition of thetactile sense, in future. A prototype is under development inour laboratory. Initial application will be oral and maxillofacialsurgery, eye surgery, and neurosurgery.

TELEMEDICINE DEVELOPMENT PROGRAM IN SATA¬KUNTA REGION: C-MEDILoula, P., Lummevaara, T., Rantanen, P.Tampere University of Technology, Pori Unit, P.O. Box 30, 28601Pori, Finland. Tel +358-39-627 2740, Fax +358-39-627 2727, E-mailloula@pori.tut.fiTampere University of Technology, Pori Unit, is coordinating thedevelopment of a program to improve the network infrastructure inSatakunta. The Satakunta region on the west coast of Finlandconsists of 27 local communities, with a population of about 240,000inhabitants.

The health care component of this program, called C-Medi, willfocus on developing telemedicine services including centralisedarchiving, databa se capabilities, on-call arrangements, education, andconsultation services. Satakunta central hospital will providetelemedicine services for the Noormarkku, Harjavalta, and Kankaan-pää health care centres, and the Rauma area hospital. The providedservices will cover at least radiological, pathological, and ultrasoundconsultations. A cost/benefit analysis will be performed during thefirst phase.

The objectives of this program are to develop networked servicesthat improve quality of care including equality, availability ofmedical competence, independent living, and prevention of illnessaspects. The program will be arranged with various local develop¬ment and pilotingprojeds that also include cost/benefit analyses andfeasibility studies. These pilots will produce demonstrations on howto use resources efficiently and how to change organisations andprocesses connected to the health care delivery system.

The development program is funded by the Regional Council ofSatakunta and EU. It is organised in close cooperation with theMed ¡Net-development program of the Finnet-group.

REMOTE CONSULT FOR CLINICAL NEUROPHYSI¬OLOGYLoula, P., Räty, E., Rauhala, E., Erkinjuntti, M.Tampere University of Technology, Pori Unit, P.O. Box 30,28601 Pori, Finland. Tel +358-39-627 2740, Fax +358-39-627 2727,E-mail loula@pori.tut.fiThe departments of clinical neurophysiology in SatakuntaCentral Hospital and Tampere University Hospital have used indaily routine ATM (Asynchronous Transfer Mode) connectionsince January 1995. ATM technology can ensure adequate datatransfer capabilities, very short delay, and low variation indelay. Video conferencing software with a capacity for sharedapplications has been used.

For home-based interaction, ISDN has proven to be a mostpractical and economical solution. ISBN can be used for voiceand data transfers with a bandwidth of 128 kbps.

Reference1. Räty, E., Loula, P., Koivisto, J., Rauhala, E., Erkinjuntti, M.,

Häkkinen, V. Distributed clinical neurophysiology—MediNeuro:an advanced telemedicine application. The proceedings of theNordic Telemedicine Conference January 30-31,1996, Stockholm,Sweden, p. 83.

TELEMATICS IN HEALTH—AN INTERNATIONAL PER¬SPECTIVE WITH EMPHASIS ON TELEMEDICINEMandil, S.H.W.H.O., Geneva, SwitzerlandOne of the reasons for the resurgence of telemedicine today isthe recent emergence of practical examples that demonstrate itspotential influence on the accessibility, quality, management,and economy of health care services. Described here are

examples of national and international projects that rely on

computing, networking, and telecommunications inhealthcare.This is followed by an evaluative overview of these applica¬tions. More than thirty examples are cited from both developedand developing countries, and between them. The potential roleof telemedicine in the equitable provision of quality health care

services is stressed, current key issues are discussed, and usesof telemedicine within a nation and between nations are

described.

TELECONSULTATIONS IN PREHOSPITAL CAREMattila, M.A.K.Department of Information Services and Research, KuopioUniversity Hospital, 70211 Kuopio, Finland. Tel +358-71-173380,Fax +358-71-172035The need for immediate expert advice may be acute in an

emergency outside of the hospital. The patient can present withlife-threatening symptoms which require emergency care. Theattendant may not be well trained or experienced in diagnosisand selection of an appropriate therapy. In some cases there isnot enough time to reach a hospital by transportation beforethis results in a fatal outcome or inappropriate treatment,leading to deterioration in the patient's condition. Thus, underthese conditions the need to get immediate expert help iscritical.

In order to be able to give practical advice, the expert needsto have a complete and dynamic picture of patients' vital signsand a short informative clinical summary. The teletransmittedinformation may be obtained by analogous instruments andmonitors which the expert would use. This type of prehospitalteleconsultation requires user-friendly practical and instantsystems, preferably in wireless form.

THE POSSIBILITIES OF VIDEOCONFERENCING INTELEPSYCHIATRYMielonen, M.-L., Isohanni, M., Moring, J.Department of Psychiatry, Oulu University Hospital, Kajaanin-tie 43,90220 Oulu, Finland. Tel +358-81-315 7011, Fax +358-81-333 167Telepsychiatry means interactive psychiatric communicationover distance, which enables simultaneous sound and videoconnections between two or more consultative parties. Theprincipal telepsychiatric communication methodisvideoconfer-encing, which can replace the customary face-to-face encoun¬

ters, when patients and their families live a long distance awayfrom the mental health professional. Consultation between twohealth care providers located some distance apart is alsopossible. The method saves traveling, time, trouble, andexpense.

Videoconferencing is rapidly increasing as a means of dailypatient care and consultation. To our knowledge, the firstexperiences in Finland were carried out at the Department ofPsychiatry, University of Oulu, where it has been used forfamily therapy, occupational counseling, consultation, andteaching. The preliminary results have been promising. Interac¬tive videoconferencing removes the distances and provides an

easy, fast, and moderate-priced method to offer psychiatricservices despite the geographical distances.

Videoconferencing at the Department of Psychiatry, OuluUniversity Hospital, has been used for the following:• Planning of patient care• Family therapy• Consultation• Occupational counseling• Education ·

Based on our experience, technical and equipment require¬ments for videoconferencing in telepsychiatry include thefollowing:• User-friendly• Good audio quality• Good video quality—bandwidth equivalent of 3 ISDN-lines

needed (i.e., 384 kbps)• Good audio and video synchronization• Camera zoom capability and far end camera control• Document camera or PC to transmit still images or other

educational materials

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INTEGRATED SOLUTION IN A NATIONAL TELERADIOLOGYSYSTEMPalsson, T., Eiriksson, ., Jonsson, S., Björngvinsson, J.B., Brekkan, A.'University Hospital of Iceland, v/Eiriksgata, IS-121 Reykjavik, Iceland;University of Iceland, v/Hjardarhaga, IS-107 Reykjavik Iceland; Prim,

Skulgata 63, IS-105 Reykjavik, Iceland; ^5kyn Electronics, Grandagardi 5,P.O. Box 7185, IS-127 Reykjavik, IcelandThe Icelandic health care system is based upon primary health carecenters and general family practitioners. These institutions are linked to

hospitals at various levels but now three hospitals and one privateinstitution provide specialised radiology service. Teleradiology service hasbeen in operation since 1992 between the University Hospital of Icelandand the provincial hospital in the of Vestmann Islands. Annual numberof radiological examinations there is roughly 2200. Between 1992 and 1995around 400 images were sent [1]. The main results of this projectdemonstrated the usefulness of teleradiology, and interest from otherhealth care institutions and authorities has followed.

As a result of experience from teleradiology in Iceland, a nationalteleradiology service is being established; 4 institutions are now connectedand another 12 will be connected this year and in 1997 according to needand feasibility. The purpose is to provide specialist service to clinicians inremote health care institutions using one country-wide network. Receiversare institutions with specialist radiological service. The teleradiologyservice is a self-supporting service and taken as an ordinary radiologicalservice by the speciality hospitals who allocate manpower and equipmentto provide it.

Economics and quality are key issues. All software and hardwaresolutions are made locally. Solutions are based on open systems (DOS,Windows 3.X/95/NT and SCSI interface) and each hospital has integratedsoftware (manufactured by Prim and University of Iceland) for filmscanning, image, viewing, and transfer. A high quality film scanner ismanufactured by Skyn Electronics (73 urn pixel size, 8 or 12 bits). Transfersare based on open standards (e.g., PPP, CAPI 2.0, EFT) and are enabledwith Remote Access Service and uses physical media such as analogmodems and ISDN (BRI). Image format can be raw binary or DICOM.

Software will be transferred to Windows NT (version 4) to providebetter security to the hospitals and the data and more capability ingraphical viewing. Interactive communications willbe implemented, usingsimilar transfer methods as described.

Reference1. Palsson, T., Brekkan, ., Eiriksson, A. Establishing a National Teleradiology

and International Consultation system. CAR '95. Proceedings. Berlin, Germany:Springer Verlag, 1995, pp. 717-722.

WIRELESS RADIOLOGICAL CONSULTATION WITH GSM DATATRANSFER AND PORTABLE COMPUTERSReponen, I-, Ilkko, E., Jyrkinen, L., Karhula, V., Tervonen, O., Koivula, A.Department of Diagnostic Radiology, University Hospital of Oulu,Kajaanintie 50, 90220 Oulu, Finland. Fax +358-81-3155420, E-mailjarmo.reponen@oulu.fiDigital global cellular networks like GSM make it possible to transmit datato portable computers. The purpose of this study was to examine ifpresent mobile technology can transmit high quality images outside thehospital network.

CT scans of 44 consecutive patients were transmitted to a portablecomputer and interpreted by an experienced neuroradiologist. Transmis¬sion times and results were recorded. Two weeks later the same cases

were interpreted on films.Images were captured from a GE workstation with a screen image

capture program. Eight-bit, full resolution images were compressed usingJPEG with a quality factor 75 and transferred to a server. The radiologistused a Compaq 420 CX computer with an active matrix screen. Thetelecommunication protocol was the TCP/IP running on the top of a dial-up PPP connection. The physical connection was established by using a

Nokia 2110 GSM phone and a Nokia cellular data card (nominal speed of9600 bit/s). Images were interpreted with a Polyview program.

The average transfer time for a single image was 55 seconds (includingonly FTP connection time). The averaged total connection time per imagewas one minute. Thus, sending an 18 image standard head CT scan

required 18 min.Transmitted images were considered acceptable for final diagnosis in

80% (35/44) of the cases and acceptable for preliminary diagnosis(comparison to older images needed) in 20% (9/44) of the cases. Thediagnosis from the transmitted images was the same as from the originalsin 95% (42/44) and slightly different (no effect to the patient care) in 5%(2/44) of the cases.

According to the neuroradiologist's opinion, in 8 cases the imageconsultation was critical and saved a hospital admission.

A useful remote consultation link can be built with available technolo¬gy. However, faster wireless networks are needed.

TURKU UNIVERSITY HOSPITAL RADIOLOGY DEPARTMENT DICOMNETWORKSaarela, R., Ristimäki, J., Karhapää, T., Mässeli, E., Laiho, ., Sauna-Ano, M.,Kormano, M.,Telecom Finland Ltd., Berner Ltd., Helsinki, Finland; nTamro Ltd., Helsinki,

Finland; Department of Diagnostic Radiology, Turku University Hospital, Turku,FinlandDICOM should increase the speed and quality of patient care and the cost-effectiveness of image transfer, handling and storage. All DICOM compatibleimaging devices, workstations, archives, and hard copy devices can be connecteddirectly to the DICOM network of the Radiology Department. Unfortunately, a

large installed base of imaging devices, hard copy devices, and workstations existwhich are not DICOM compliant.

One of the goals of the current installation in the Department of Radiology ofTurku University Hospital (TUH) was to demonstrate how a network of DICOMcompatible and incompatible imaging equipment can be assembled to work in a

large scale university hospital environment.TUH Radiology Department DICOM network uses ATM technology to achieve

a flexible, high-speed, wide-area network infrastructure. This type of solutiongives the advantages of PACS without geographical limitations.

Another goal of this installation is to demonstrate how a 10 Mbit/s ATMconnection will serve the needs of interpretation and archiving of digital imagesat the distance of 30 km with annual flow of 13,000 new patient examinations,corresponding to more than 30,000 X-ray images. The third goal is to evaluate thefunctional capacity of a 155 Mbit/s intra-hospital ATM connection and a digitaltape archive and RAID (Redundant Array of Inexpensive Data) configuration tohandle the demands of nearly 100,000 imaging studies annually. The work loadcaused by digitizing old films into the digital tape archive in concert with newexaminations is also being evaluated.

Until April 1996 the following equipment is connected to network:• DICOM-workstations (Cemax) for image handling• DICOM-archive (Cemax) for image storage and retrieval• Three CR modalities (Fuji) using custom interfaces• A film scanner (Pinja) using DICOM SEND feature• A digital chest unit ( ) also using DICOM SEND feature• A workstation (Cemax) at Turku University Dentistry Department

Connecting Ethernet LAN's and non-DICOM compatible hard copy devicesinto the ATM network is in progress. Two other hospitals are connected to thenetwork using ISDN. The latter are used for less regular telemedicine interactions.

REAL TIME INTERACTIVE VIDEO TELEDERMATOLOGY TRIALIN FINLANDSuhonen, R., Hollmén, A.Mikkeli Central Hospital, Department of Dermatology, 50100 Mikkeli,

Finland. E-mail raimo.suhonen@sIl.fimnet.fi; Kuopio UniversityHospital, Department of Dermatology, 70210 Kuopio, FinlandThe first Finnish teledermatology trial was started late 1994 betweenMäntyharju Municipal Health Center and Mikkeli Central Hospital,dermatologie clinic. Later also a dermatologist-dermatologist link hasbeen included in the project (Mikkeli Central Hospital and KuopioUniversity Hospital). The trial is based on ISDN connections andPictureTel equipment from the Finnet Group of Finnish telephonecomplaints.

Several modifications of video cameras and main units have beenin use during the trial. The simplest versions of vidéoconférence equip¬ment have not proven to be suitable for this purpose, mainly becauseof low quality of the picture. The present technique uses 3 pairs ofISDN lines = 384 kBit/s, an automatic pan-tilt-zoom camera withautofocus, and cordless near and far end control. The placement of thevideo camera was modified to be more suitable for teledermatology. Acombination of real time and a high quality still picture was used.

The trial has been focused on the use of the on-demand interactivevideo consultation. The general practitioner in Mäntyharju may call thedermatologist during regular clinic working hours. This saved GPandpatient time, but did not permit long discussion.

Teleconsultations seemed to be suitable for various problems indermatology. In some eczemas, nodular or bullous diseases, it providedthe diagnosis and treatment. In skin tumours it provided usefulinformation for the GP—to perform a biopsy or to send the patientwithout delay to the most suitable specialist.

So far there has not been any billing or reimbursement in the trial.The line- and equipment costs were initially covered by the Etelä-SavoHospital District and later by the Finnet Group.

Ithasnotbeendetermined whetherteledermatology is cost-effectiveunder real time video consultation or store-and-forward consultation.

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THE CURRENT SITUATION AND STATUS OF TELE¬MEDICINE IN FRANCEThierry, I.-P.,1 Dubois, O.,1 Duvaux, C.,1 Fay, J.-M.,2 Faure, H.21Conseil National de l'Ordre des Médecins (National MedicalBoard); Ministère du Travail et des Affaires Sociales, Sousdirection des systèmes d'information et des investissementsimmobiliers (Ministry of Labor and Health, Department ofInformation Systems and Equipment)Telemedicine is a new and dynamic domain of interest inFrance. Early "pioneers" started experiments in 1970. Theprimary use of the technology is for grand round and medicalstaff meetings, and several international demonstrations havebeen organized during the last three years. The projects are

usually established within "regions," and public hospitals are

prominent promoters. Several medical specialties are buildingnational telemedicine networks (i.e., Pathology, Radiology,Epidemiology, ENT). Regulation, legal and ethical aspects, andthe impact of telemedicine on the French health care system are

three subjects of major importance for the public bodies as wellas for the professionals and the public. The French Ministry ofLabor and Health, the "Conseil National de l'Ordre desMédecins" (CNOM, the French National Medical Board), andthe CNIL (Commission Nationale Informatique et Liberté) are

addressing major topics and problems in the development oftelemedicine in France.

NETWORKED EDUCATION AND TELEMEDICINEWootton, R.Institute ofTelemedicine and Telecare, Queen's University, Belfast BT97BL, UK

Continuing developments in computing and telecommunications openup exciting new possibilities for distance education. Much of the tele-education in medicine to date has consisted of a one-way informationflow, either by a conventional broadcast technique, or by use of pre¬recorded video cassettes. Interactive teaching, which is generallyagreed to be superior, requires more advanced technology, and istherefore more expensive. Examples of interactive education include:• the INSURRECT project for teaching surgery to UK medical under¬

graduates using the SuperJANET national ATM video network• the EuroTransMed satellite broadcasting operation for CPD in

Europe• the well-established programmes of the Mayo Clinic, broadcast by

satellite in the USAWhat are the characteristics of the ideal distance education system?Besides being affordable (obviously), it should be:

• universally available• multilingual• interactive• auditable• teaching from recognised centres of excellence

In principle, the power of the network could be used to create a

virtual centre of excellence, by linking together experts from all over

the world. The network could in turn provide interactive linksbetween the virtual centre and the students. A variety of communi¬cations media could be used for this purpose, though none are ideal.They include:• the Internet (problems of bandwidth and control)• satellite systems (problems of cost and the reverse channel)• terrestrial networks, such as the ISDN (problems of cost and

availability)However, the main barrier to the creation of a virtual centre of

medical teaching excellence is probably not the technology, but theorganisational problems. In this tele-education mirrors the problemsfacing telemedicine generally.

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