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Telemedicine & Teleradiology- Bridging Barriers to Revolutionalise Diagnosis & Care- Dr. Kishan S. Rawat, SGRH, New Delhi


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  • The radiologists inevitably performed better with images subjected to the controlled lossy compression than they did with the original uncompressed images. Figure 3.3 shows a graph generated from the results of that study, where it is apparent that the accuracy of correct diagnosis was better at higher compression performance, as compared with the less compressed images
  • There are two processingsteps that help to secure the content of delivered images. First, to ensure theintegrity and authenticity of the transmitted data, the digest (or hash computingon data) and digital signature, as well as decoding signature and comparingdigest, on the images before and after transferring are performed at both thetransmitting and the receiving sites [30]. Second, to protect privacy, images aretransmitted through secure communication channels.
  • The robotic design of such a compact system is, however, delicate, since itmust be able to track the expert’s moves. The proposed robot kinematic(Fig. 13.6) offers an RCM. The ultrasound probe is rotated around the RCM bythree actuated pivot joints: R1, R2, and R3. A force of up to 20 N on the patientcan be exerted by a prismatic stepper motor P3. Two other actuated prismaticjoints, P1 and P2, give the x–y degrees of freedom to the probe.
  • Transcript

    • 1.
    • 2. Ameans of electronicallytransmitting patient‟sradiographic images andconsultative text from onelocation to another
    • 3. A. An image-sending stationB. A transmission networkC. A receiving/image review station
    • 4.  Image (film) digitizer ◦ Direct digitization:best ◦ TV camera digitizers („low-end‟) ◦ CCD scanner digitizers („mid-level‟) ◦ Laser scanner digitizers („high-end‟) Network interface device  Modem converts digital data into electrical impulses that are sent along transmission network.  The ideal sending station should have • very high resolution, • little or no compression, • very high transmission speeds
    • 5. A. Sending Station Specifications Image resolution : Pixel 512 x 512 (w x h) Image compression : ◦ Aim of compression  storage and transmission of the large number of radiologic images.  Maintain sharp edges and general textures for higher image quality ◦ Types of compression  Lossless (or reversible) compression  ABSOLUTELY NO LOSS of information.  < 3:1 is lossless  Lossy (or irreversible) compression  Less significant information discarded during compression  > 3:1 is lossy ◦ Benefits of compression  Helps to reduce  Storage requirements  Transmission cost  Time of transmission
    • 6. little observable differencebetween the various ORIGINALcompressed images and the uncompressed imageoriginal image ; CR=1:1; 8bpp
    • 7. The accuracy ofdiagnosis on medicalimages at differentlevels of lossycompression  Good lossy compression has no observable difference from lossless compression
    • 8.  Wire Fiberoptics Microwave Transmission speed (and cost) closely related to transmission mode. Two methods provide secure communication channels with TCP/IP-based DICOM image communication protocols: ◦ IPSec ◦ SSL/TLS IPv6 is a new version of IP : platform for higher-speed Internet functionality overcoming IPv4 shortcomings ◦ Larger address space ◦ Aggregation- based address hierarchy and efficient backbone routing ◦ Efficient and extensible IP ◦ Autoconfiguration ◦ Increased Security
    • 9.  Three critical issues for the development of teleradiology systems involved in the exchange of medical imaging data ◦ Data privacy ◦ Authenticity ◦ Integrity
    • 10.  Privacy refers to denying access to information by unauthorized individuals. Authenticity refers to validating the source of a message and ensuring that it was transmitted by a properly identified sender. Integrity refers to the assurance that the data were not modified accidentally or deliberately in transit and by replacement, insertion, or deletion.
    • 11. 1. Network interface (modem)2. PC with storage medium (e.g. disc drive)3. One or two TV monitors4. Optional hard copy device printer
    • 12. B. Receiving/Image Review Station specifications ◦ Modem: receiving unit modem must be > maximum speed of sending station ◦ Computer hardware ◦ Image enhancement software ◦ TV monitor: Resolution, size, split-screen, brightness
    • 13. Data flow of medical image securecommunication from one site toanother through the public Internet
    • 14. Tele-radiology Workflow Central PACS Hospital Hospital LAN Remote Center Internet Remote Center Remote Access Remote Center
    • 15.  It is important to make patient-specific data quickly available and usable to many specialists at different geographical sites. Integration of audio and videoconferencing with collaborative virtual reality images. A tele-immersive radiological system has been developed for ◦ remote consultation ◦ surgical preplanning ◦ postoperative evaluation ◦ education.
    • 16. Tele-immersive devices◦ Personal augmented reality immersive system (PARIS)◦ Configurable wall (C- Wall)◦ Physician‟s personal virtual reality display◦ ImmersaDesk
    • 17.  Provides augmented reality Avoids an important stereo vision depth perception conflict. A tracking system with two sensors has been installed on the PARIS. The system can generate stereo images from the viewer‟s perspective and let the user interact with the data directly in three dimensions
    • 18.  Tele-immersive display optimized for a conference room or small auditorium. Superior interactive visual display of medical data and the ability to interact over networks with collaborators in remote locations.
    • 19.  Because of the need for parallel processing of VR applications, a dual processor hyperthreading Intel Xeon PC was used in the VR system. Stereo glasses, an emitter, and high- quality CRT monitors used to generate stereo vision for the desktop configuration
    • 20.  Transportable furniture statement of the cave automatic virtual environment (CAVE) This drafting table format of the CAVE provides a large angle of view, stereo vision, and viewer-centered perspective. These are the basic ingredients of any VR display.
    • 21.  A PACS typically consists of an ◦ archive device ◦ diagnostic viewing stations for radiologists ◦ clinical review by physicians ◦ Servers to distribute the images throughout the hospital network. PACS extended to manage ALL medical images acquired within the hospital Use beyond radiology ◦ Secondary document acquisition, such as scanned documents ◦ Prescriptions and patient questionnaires.
    • 22. Demonstrates aphotographic imageon PACS of a 33-year-old womanwith lower-extremity venousinsufficiencyvaricose veins.Includes the1. photographic images2. demographic information and date
    • 23. Registration/ Review & Report Scheduling Examination Post-processing Reporting Consultation Collection Schedule Acquire Analyze Report Present Register and Capture and Examine Dictate Present schedule store and reports results to patient patient’s compare and ref. Physician-Triggered exam physiological patients share physician or Workflow information phys. diagnosis patient information PACS (email report HIS/ RIS Modality/ PACS/ PACS distribution) PACS Workstation/ (template Clinical Apps based reporting)
    • 24.  In Neurosurgical Services In Managing and processing obstrectical and gynecological data In Army & Disaster Situations In Dental Implantology Robotic Teleechography In Interventional Radiology Procedures
    • 25.  Multimedia messaging service (MMS) technology ◦ readily available, simple, and cost-effective method for the transmission of scan images. ◦ Clinical decision-making reducing the need for hospital call-back ◦ improving patient care. extradural hematoma from head injury. vertebral tumor causing significant spinal cord compression
    • 26. Useful in scenarios like remote locations, disaster scenes, battlefields, cruise ships, ground and air ambulances, and expeditions Requirement : Access to a network on which the camera phone can transmit data.A tactical emergency medicinephysician who is part of a policeSWAT team carries a compactultrasound unit attached to hisbackpack.
    • 27.  The main goal : ◦ Evaluate hundreds of blunt trauma victims to look for bleeding in the abdomen or perhaps signs of lung collapse in the thorax Transmits images of the scans using a camera phone Nearest trauma hospital identify victims who need urgent treatment
    • 28.  Greatest medical contributions to the recovery of a wounded soldier. Advantage : ◦ Know immediately which patient to attend first and transfer first The teleradiology system developed for combat support use is also suitable in humanitarian and disaster-relief operations performed by armed forces. Limitations : network functionality and bandwidth availability
    • 29.  Web-based collaborative clinical teleradiology ◦ set of services for quality assurance that enables expertise sharing and furthers health education opportunities. ◦ eliminating the radiation dose by the continuous physical presence in the catheter lab ◦ Minimizing travel costs Clinical teleradiology ◦ use of telecommunications to deliver real-time radiology services from one location to another for interpretation, consultation, and collaboration purposes
    • 30. E-learning in Synchronous Mode: Real timelearningE-learning in Asynchronous Mode: Storage ofdata and retrieving them at a later date for study
    • 31.  Telemedicine +image-guided surgery ◦ Digital images from imaging modalities can be transferred without any loss of information. ◦ Remote experts involved in surgical interventions or preoperative planning sessions. ◦ Continuous medical training and education.
    • 32.
    • 33.  Why needed ?? ◦ Providing skilled medical care to patients who are isolated from the specialized care ◦ True for patients living in isolated areas with reduced or substandard medical facilities. A tele-echography plant is a teleoperation scheme ◦ Made up of three main parts  Master station or expert station  Slave station or patient station  Communication link
    • 34. Mobile tele-echography using an ultralight robot(OTELO) tele-echography system
    • 35. OTELO robot kinematicsPHANToM desktophaptic device
    • 36.  A Web-based teleradiology system, called MITIS Records all the necessary medical information ◦ patient data, examinations, and operations ◦ Advanced image-processing tools for the manipulation, processing, and storage of ultrasonic and mammographic images.
    • 37.  Installed in a hospital‟s LAN ◦ access PACS servers or any other server within the radiology department, for image archiving and retrieval accessible to external physicians via the hospital‟s Internet connection Includes Mammographic image processing and evaluation
    • 38. WHY? More women in remote areas so waiting time is long. Mammograms require special expertise which are available only in cities. Mammogram films are 35-55 MB/film High resolution is must for minute lesions So cannot compress images and therefore high-speed transmission lines are needed. Satellite and T1 is the answer NASA is the satellite and telemedicine expert
    • 39.  Factors that contribute to dissatisfaction of the radiologists ◦ poor image quality ◦ Not having a clinical history ◦ not having enough images (especially priors) Spending long hours viewing very large data sets on computer screens may result in  visual fatigue or computer vision syndrome among radiologists, leading to dissatisfaction Factors that contribute to improved image quality ◦ Increased display luminance, ◦ use of a P45 (rather than a P104) phosphor in the CRT (cathode ray Tube)monitor faceplate ◦ perceptually linearized display
    • 40.  Nighthawk Model  Indian Model Relocates fully licensed domestic  Indian providers hire unlicensed radiologists to a country eight to indigenous radiologists - willing to 12 time zones ahead of the home work for one tenth the wages of country. radiologists in developed countries  This means that developing Advantages country teleradiologists can ◦ (1) compliance with existing undercut the prices of their first- licensure systems world competition. ◦ (2) hospitals doing business with Nighthawks do not need to fear  Indeed, India‟s market for being sued for negligent hiring or exporting diagnostic testing, supervising of their radiology staff. which is growing at the rate of 20% Disadvantages : per year, earned US $864 million ◦ (1) relocating domestic radiologists in 2005. overseas only perpetuates labor  Fear of the “India price” for shortages in the home market teleradiology services has the ◦ (2) the model is not a price- American College of Radiology competitive alternative to traditional (ACR) already lobbying for market radiology protection
    • 41. Teleradiology Workflow REFERRING PHYSICIAN RADIOLOGIST Referring physician orders Radiologist electronically submits radiology image procedure report and phones in any critical findings. Referring physician accesses online report through a secure channel 1 5 MODALITY Technologist performs scan 2 4WORKFLOW COORDINATORWorkflow coordinators ensure CENTRAL DATA CENTER (PACS) DICOM images and patientthat studies are complete and 3 clinical history is sent to centralroute to appropriateradiologists data center through a secure channel
    • 42. Key Drivers of Teleradiology Scarcity of qualityradiologists in tier 2 & tier 3cities Remote diagnostic centerswant quality reporting toincrease revenues Reduced time and cost oftravellingTo increase healthcarepenetration in remote area 4
    • 43.