The 21st century will be the most remarkable and dynamic age in human history. Change is the only permanent constant for the future. The speed of data exchange and analysis is vital in making adequate decisions. Broadband Internet is the foundation of 21st century civilization, virtual reality, biotechnology, nanotechnology, and artificial intelligence that transform into an unrecognizable economic, social and political life we know.

1. Telemedicine and Recreation
Eliya Kostova MD
VARNA STARTUP WEEK IN HEALTH TECH 2017

2. Introduction
THE 21ST CENTURY WILL BE THE MOST REMARKABLE AND DYNAMIC AGE IN HUMAN HISTORY.
CHANGE IS THE ONLY PERMANENT CONSTANT FOR THE FUTURE.
THE SPEED OF DATA EXCHANGE AND ANALYSIS IS VITAL IN MAKING ADEQUATE DECISIONS.
BROADBAND INTERNET IS THE FOUNDATION OF 21ST CENTURY CIVILIZATION, VIRTUAL REALITY,
BIOTECHNOLOGY, NANOTECHNOLOGY, AND ARTIFICIAL INTELLIGENCE THAT TRANSFORM INTO AN
UNRECOGNIZABLE ECONOMIC, SOCIAL AND POLITICAL LIFE WE KNOW.

3. Internet and High Technology in Medicine
The application of Internet communications and High technologies in medical practice is included
in the concepts:
Telemedicine - exchange of medical information through electronic communication to improve
patient's health status by telephone, satellite technology, real-time / asynchronous video
conferencing, robot remote control, wireless and wearable devices.
Telecare (Remote care for the patient) - health care for old and disadvantaged people. Sensors,
home surveillance cameras, robots, a set of devices, etc. are used to organize the risk and
support of people with dementia, with a high risk of falling and injuries, bums, invalids and timely
hospitalization.

4. Purpose
• Reducing the need to transport a patient in the absence of a specialist
• Mapping of medical specialists by regions for rapid contact with them
• Distance learning of medical personnel and patients
• Videoconferencing
• Technological progress in various branches of medicine

5. Purpose
• Improving the comfort and confidence of the patient
• Easy, comfortable, mobile communication between the doctor and the patient
• Bringing to the optimum minimum of time and cost factors
• Striving to reach the highest level of quality of medical service and quality of life of
the patient

6. Purpose
Telehealth -Telecommunication with Health-Care Services
Clinical Application:
• Transfer of photo material for diagnosis
• Group / individual exchange of health
services, video conferencing training
• Transfer of medical data for diagnosis /
consultation on therapy
• Patient Monitoring, Tracking
• Emergency health advice
Non-clinical use:
• Distance learning (medical staff, patient)
• Administrative meetings with specialists
in telehealth networks, supervision and
presentations
• Surveys
• On-line information and management
of medical data.

7. Evolution of Health Technology
• Application in ancient times
- Tribe - The primitive man during a mammoth hunt has fallen into a ditch and called for help, people from tribe advised him
from distance
- Ancient China - The pulse was recorded by the movement of a string tied to the wrist of the patient, and the latter was in
another room.
- Africa - African villagers have used smoke as a signal not to enter the village during an epidemic
- Galen (131-201), a supporter of disease symptomatology, sends the diagnosis and prescription for treatment by mail
• Application in the range 1600-1800
- Theophast Rhinodo ("The Presence of the Absent") (1584-1653)-offers free treatment to the poor. He publishes a brochure in
which he lists symptoms of various ailments, presenting body parts. The patient himself examines his symptoms, which parts of
the body are affected. By post, Rhinodo sends the diagnosis and prescription for treatment.
- In Europe and England between 1600-1800 years, the review was usually without direct contact with the patient. Then the
physical methods of study were still in the beginning state. Auscultation and ophthalmoscopy did not find their place until the
middle of 1800 years. The best way to diagnose was skin color, appearance and pulse. Other features were not necessary.

8. Evolution of Health Technology
- William Heberden (1710-1801) - diagnosis of angina pectoris with a "glancing look". The diagnosis depended entirely on the
patient's story, the experience of the listener, retransmission of the story. Physical contact with the patient was not needed.
- Herman Berhave (1668-1790) -gave advice to colleagues and pharmacists by mail.
- Erasmus Darwin (1731-1802) – Grandfather of Charles Darwin advised the patients with a dizzying headache to make cracks
on them backs.
- In 1900, people living in remote areas of Australia used a dual-channel radio powered by dynamo, spinning pedaling on a
wheel to communicate with Royal Flying Doctor Service Australia.
One of the most important reasons for the remote diagnosis and treatment for 1600-1800 years is the large distances to which
it was the widespread population and poverty.
Doctors from Galen to Kullen have used the technology of their time to help the needy.

9. Evolution of Health Technology
• Today
- The first international conference to discuss the medical aspects of telemedicine was held in 1993 in Tromso, Norway. A
group of experts are discussing the possibility to establish an international association. Escalate opposing views and the idea is
not implemented.
- The second conference was held at Mayo Clinic in 1995, along with the second Mayo Telemedicine Symposium. Again, there
is no consensus on the creation of a telemedicine association
- The Third International Conference, Kobe, Japan in 1997. An Organizing Committee was founded (Dr. De Beikky, Dr. Golberg,
Dr. Coop, Dr. Nichozian and Dr. Satta (USA), Dr. Kastelano (Mexico), Dr. Medvedev (Russia), and etc.). The International Society
for Telemedicine and eHealth ( ISfTeH) was established.
- The first conference of the International Society for Telemedicine and eHealth ( ISfTeH) is held in Jerusalem, Israel, as the
fourth International Conference on Medical Aspects of Telemedicine.
- 15.-17.3.2018 The 23rd International National Conference on Telemedicine and eHealth “Health communities facing cyber
transformation”. Cruise on the Baltic Sea between the capital cities Helsinki, Finland and Stockholm, Sweden
- 29.4-1.5.2018 USA Chicago Annual Conference of American Telemedicine Association
-24-25.9.2018 Hong Kong World Congress Telemedicine and Medical Informatics

10. Evolution of Health Technology
• Bulgaria
- Project 2003 -ТК - 01, "Development of a system for remote transmission of information on the status of living biological
sites", Research Area at Angel Kanchev University of Rousse, Bulgaria. The project aims to develop a node to control the
essential vital parameters of the organism and to design a system for their remote transmission.
- Institute of Psychology, Department of Psychophysiology and Neurophysiology, Bulgaria. The section focuses on the following
main areas: examining the components of attention and executive ability in childhood in the norm and in children with learning
disabilities; cognitive deficits in excessive daytime sleepiness syndrome and overcoming it in people with sleep disturbances
during sleep; discrimination and nomination of Braille characters and Cyrillic alphabets for blind and partially-sighted persons
when comparing the individual modality of the stimulus; practical application of the telemedicine model in Bulgaria -
multinational long-term project of the International Association.
- Project "Septemvri", BAS, BulgariaThe project provides an internet connection between 10 health centers and telecenters on
the territory of Septemvri Municipality. Each station also has blood pressure measuring and ECG devices. Patients will be able to
provide services to measure their health parameters in their daily activities - at home, at work, or during rest. Upon completion
of the study, the resulting information is processed by a computer and made available online to the treating physician or
specialist cardiologist for analysis and follow-up. The pilot project was implemented jointly with the Bulgarian Academy of
Sciences and the Bulgarian Association of Telecentres with the assistance of the Municipality of Septemvri.
- Project "Using the Mobile Service eHealth / Telemedicine for Slightly Settlements" is presented by the Ministry of Transport and
Communications, Bulgaria. The initiative is in co-operation with the International Telecommunication Union and is a follow-up to
the project to deploy electronic health services in sparsely populated regions in Bulgaria, Romania and Turkey "September
Telecentre

11. Evolution of Health Technology
• Bulgaria
- 2004 established E-health Foundation Bulgaria, a non-governmental non-profit organization to support the development of
e-health at national level as part of the e-government of the Republic of Bulgaria.
- New Bulgarian University - eHealth Department
- 18.5.2017 Sofia, Bulgaria 12th Conference on E-health “ICT – the Transforming Power in E-Health”
Organizers: ICT Media and E-health Bulgaria Foundation

12. Technical Support
For each telemedicine procedure:
• Creating an effective telemedicine workstation with adequate licensed or non-software
• Connecting a telemedicine workstation with a telecommunication line
The basic conditions for telemedicine equipment are as follows:
• A favorable environment for the transfer of medical information
• Low price
• Standardization
• Availability, simplicity and reliability of the information process
• Technical and information security

13. Technical Support
Classic Package:
• Desktop PC, SVGA monitor,
Multimedia, CDROM / CDRW /
DVD, Internet connection
adapter
• High-end scanner
• Digital camera
• Digital video camera
• Web camera
• High-end printer
• Removable microphone
• Modem for connection to the
hospital information system
• A package of specialized
digital devices for diagnosis
and treatment
• Assistive equipment
Clinical package:
• Desktop computer, SVGA monitor,
multimedia, CDROM, internet
connection adapter
• Digital camera
• Printer
• Modem
• Assistive equipment
Optimal Clinical Package:
• Desktop computer, SVGA
monitor, Multimedia, CDROM /
CDRW
• High-end scanner
• Digital camera
• Web camera
• Printer
• Modem
• Additional equipment
Minimum package:
• Desktop computer, SVGA
monitor
• High-end scanner or digital
camera
• Modem

14. Technical Support

15. Technical Support
Teleconsultation is a discussion of a clinical case, conducted from a distance, accurately responding to precisely
formulated questions to make it easier to make the right decision. They can be run on-line and off-line.
Static Medical Information Dynamic Medical Information
XR Digital Imaging, MRI, Scan ,Micro Imaging Patient voice, Auscultation, Psychiatry, Cardiology,
Surgery, Endoscopic Surgery
A synchronic Technics Synchronic Technics
Email, web, applications Email & Messengers, Video conferencing connection,
SMS/MMS

16. Technical Support

17. Indications for Teleconsultation
• Establish a diagnosis
• Establishment of treatment
• Diagnosis and treatment in rare, severe and atypical cases
• Establishing Complicated Preventive Procedures
• Need for a new or rare operation (procedure)
• Lack of specialist or little experience in diagnosing and treating a disease
• The patient has doubts about the diagnosis, treatment and outcome
• Reduce the cost of diagnosis and treatment, but not at the expense of quality and effectiveness
• Searching for and selecting a medical establishment more appropriate for urgently planned
patient treatment, timing coordination, and conditions for hospitalization
• Medical care for patients far removed from a medical center when the geographical distance is
insurmountable
• Search for alternatives to clinical work
• Obtain additional knowledge and experience on solving medical problems

18. Applications
Telemedicine has widened in the various branches
of medical science.
Research on Internet communications applications
in medical practice has found that they are most
commonly used as follows:
Medical Department %
Radiology 25
Cardiology 15
Pathology / Cytology 15
Surgery/ Orthopedic 15
Emergency, disasters
and accidents
10
General Practitioner 10
Monitoring of
chronic and
disadvantaged
people
5
Other applications 5

19. Applications
TeleRadiology provides the ability to transfer radiographic images
(Rhythm, Scanner, MRI, etc.). The presence of the components is
required :
• Digital and digital data (most often photos)
• Sending station
• Transfer link
• Receiving station
• The process starts from the sending station. Image data is
scanned and forwarded to a modem.
• The transfer link may be cable, optical fibers, microwaves, clouds
TeleRadiological process can be performed in three ways:
• Point-to-Point Data Transfer - includes the sending station, the
receiving station, and the transfer line. Allows viewing of data from
one location to another in a building.
• LAN (Local Area Network) connection - when many sending
stations are available and the receiving station is connected via a
transfer line. Allows data visualization of several different locations
in a building.
• WAN (Wide Area Network) connection - when many LAN
connections are linked to one another and form a transfer path
for data to reach different geographic points.
• Clouds Base Platforms - the ‘cloud’ is the ability to host a software
platform or service from a remote location that can be freely
accessed and used anywhere via Internet access.

20. Applications
Hipax software enables easy realization of different types of
projects. From elementary visualization to request diagnostic
station. From a single user to a large information network and
PACS protocols.
The Hipax system enables you to acquire photo data,
process, archive, transfer, record patient information,
automatically or on CD, SCAN and MRI imaging, single-user
data transfer to the global network.
In teleradiology, Hipax offers two workstations:
• Diagnostic workstation for extreme, fast transfer, MPR;
• Modular station offering various additional features.

21. Applications
Hipax Features
• Extremely fast display of large series of
photos
• Optimized process
• Parallel actions - downloading and
processing of image data
• SQL based database
• Step-by-step workstation of one user to
PACS
• Available in different languages
• Importing photo data from DICOMDIR CD, local hard
drive or network. Single image or entire directory with
all subdirectories
• Optimize image data (levels, zoom, filtering, etc.);
• Measurement (distance, angle, field, density);
• DICOM data accumulation, verification, error correction
• DICOM email
• DICOM printing (film)
• Export Image Data-IPEG, PNG, AVI formats
• Export sound files, movie, documents and files
• Printing data from a window (paper)
• Patient / photo administration
• Automatically delete old photos and patient
data depending on the location of these local
hard drive recordings
• Reference tables
• Accumulating feature for serial processing
• 16-bit filter
• Multi-plan reconstruction
• Creating a patient CD - manually or with a
Primera CD robot
• Change picture using DICOM protocol (eg 2D
3D switching)
• Different compression rates (from 2 to 20);
• Using different communication techniques
(internet, radio, satellite)
• Encryption of data
• Teleconferencing with 16 participants

22. Applications

23. Applications

24. Applications
CarDiCon is a program for the operation and transfer
of DICOM protocols used in invasive Telecardiology. It
features high performance, visual sequential selection,
intuitive editing, stand-alone frame mode, zoom,
window selection (partial image), serial editing, variable
frame rate, DICOM convoy in AVI format.

25. Applications
Technologically and clinically proven trans-phone
electrocardiographic monitoring is an example of the
application of telemedicine technology in cardiology.
The HeartView mobile device (Aerotel) is
equipped with:
• 10 cables
• Fast, simultaneous recording of 12 ECG
• Registration of changes in the ST segment
• Record speed - 2.5 seconds for each
output, 10 seconds for long recording
• Separate signal transfer from each lead with
1mv calibration
• ECG data can be downloaded from any
computer using the serial interface
• Power supply - batteries

26. Applications
Aerotel is provided with:
• 2 electrode-thumb, chest
• 2 active buttons
• Record and archive 30-second heart rate recording
Its convenient design allows:
• 24-hour monitoring of chronic cardiac patients
• follow-up patients
• patients with rhythm disorders
• pediatrics

27. Applications
Cardio on-line monitoring center has the following characteristics:
• Windows based software
• Sound card for receiving ECG signal via telephone line and forwarding to
HRS Center
• ECG Patient Records Database
• Demographic database
• Stand - alone and network operating options
• Automatic identification of the patient's identification code through the HBS
system
• ECG comparing an option to detect changes in the current record
• Archiving of unedited and unannounced ECG records for post processing;
• Automatic heart rate measurement, RR and QT interval, QT zoom interval,
ECG recording
• Administration of monitor images
• Security system for authorized access
• Direct sending of an ECG record to a predefined e-mail
• Automatically grant password-only access to patients who want to have
their ECG records in WEB
• email support
• Internet access via COM interface and Remote Manager
• COM based Web connection interface
• Automatic editing and more
In patients living in remote, isolated areas, the use of multifunctional
systems is appropriate. They enable the measurement of blood
pressure, weight, blood sugar, saturation, respiration, ECG and others.

28. Applications
DermExpert incorporates Apple’s renowned ease-
of-use technology with VisualDx’s unparalleled
differential diagnosis aid. After a clinician takes a
picture of the patient’s skin, DermExpert
immediately identifies the skin lesion morphology,
which is critical to making a more accurate
diagnosis at the point of care.

29. Applications
Telemedicine finds application in Rehabilitation
by using intelligent exoskeleton robots with web
based control. They hold the patient's limbs and
facilitate rehabilitation. They are mostly used in
rehabilitation of patients after spinal cord injury,
orthopedic surgery, disturbed muscle control,
etc.
Initially, a rehabilitator performs the necessary
movements with the limb. They are being
photographed. Photos are analyzed by
specialized software. The information is
processed and the required mechanical model is
created.

30. Applications

31. Applications
The components of the basic telemedicine
workstation are as follows:
• Computer, SVGA monitor, multimedia, CDROM
• High-end scanner;
• Digital camera with the ability to capture a short
film
• Printer
• Modem
• Packet of diagnostic apparatus
• Additional equipment
• GSM camera phone, MMS
The components of the additional station are:
• mobile operator 1-GSM with camera, MMS
• mobile operator 2-PDA, digital camera for PDA, wi-fi card
or GSM with GPRS
The information is transmitted by:
• Direct internet connection;
• Dial-up;
• GPRS or Wi-Fi internet line;
• GSM, SMS, MMS.
Telemedicine finds its place in the treatment of Traumatism and Polytraumatism, expressing itself in
a common, collective intellect by medical professionals who solve the problem of the patient.

32. Applications
Telemedicine is used in patients with neurological diseases with
telerehabilitation.
RESPECT is a speech rehabilitation system for the National
Rehabilitation Hospital, USA. Helps easy, accessible, timely,
confidential communication. A system of the National Institute of
Biomedical Imaging and Bioengineering, USA, was developed for the
telerehabilitation of congenital and communicative disorders.

33. Applications
One of the applications of telepatology is the
transfer of microscopic images through
transfer-visualization systems.
The imaging system captures a picture from
the microscope, compresses, and through the
DICOM protocol is forwarded to another user
or workstation.

34. Applications
In the peacekeeping missions of UN, telemedicine has a
major role in providing medical care. The telemedicine
service includes: teleconsultation, medical and dental
diagnostics, ECG, EEG, laboratory research, ultrasound,
Ro graphy and more
Telemedicine methods at UN missions are divided into several levels as follows:
1. Base level:
• Electronic medical record
• Medical evacuation permit
• Teleconsultation
2. Intermediate level:
• Telemonitoring
• Telelab
• Teleradiology
3. Specialized level:
• Little Surgery
• Operations

35. Applications
Stages of action:
• Real-time audio-visual contact with a hospital specialist engaged
in UN mission (level 2 or 3) and a hospital specialist not engaged
in the mission;
• Real-time audio-visual contact with emergency service specialists
(Level 1) and other hospital specialists engaged in a UN mission
and not engaged in the mission;
• Real-time audio-visual contact with isolation soldiers and hospital
specialists engaged in UN mission as well as levels 1,2,3.

36. Applications
In Bulgaria DEMONIX offers telemedicine software - MIS 2000.
Includes patient database, ECG record, blood pressure dial, digital
filters, monitoring, spectral analysis of heart rate, baroreflex sensitivity,
stress test, etc.
The minimum requirements for the Personal Computer are:
• Pentium 100 MHz
• 32 MB RAM
• 500 MB hard drive
• Windows 95, 98, or Windows NT
• Printer
MIS 2000 supports digital recordings of holter arterial blood pressure. Offers
standard and additional diagnostic assessment methods such as:
• Evaluation of 24-hour rhythm - through Cosinor analysis. Combined with
the telemedicine capabilities of MES 2000, remote consultations with
specialists (cardiologists) are possible
• 24-hour variability in blood pressure and heart rate
• Histograms
• Reports with all metrics

37. Applications
EUTIST-M is a project of the Polytechnic University of Valencia, Spain.
The project is part of a group of 11 projects aimed at informing different sectors of
medicine about new technologies. Funded by the European Commission. Dermatology
(ADAM, DERMA), Radiology (CREAM, DISMEDI), Surgery (FRAFEM, ISAC), Cancer
Screening (AUTOSCREEN), Intensive Care (IONIC), Hearing Aid (DEAF).
eVITAL project of the Department of Information and Computing, Brunel University, UK.
Using telemonitors in patient homes. The vital signs are monitored, the data are
transferred to a monitoring center, and at any moment the medical staff is clear with the
condition of the patient
INTREPID project of Elyros, Belgium - a multi-sensory virtual intellect for the treatment of
phobias.
MEDASHIP project of University Medicine Berlin, Germany-telemedicine consultancy for
seafaring.
DELTASS (Disaster Emergency Logistic Telemedicine Advanced Satellite System) project of
University Medicine Berlin, Germany. A satellite system designed to improve the efficiency
of disaster relief.

38. Applications

39. Applications

40. Applications
Mobile technologies in healthcare can be divided into 2 categories.
The first group is mHealth applications that doctors and other health
workers use in their daily activities.
The second group is applications that work directly with the patients
themselves - precisely this trend demonstrates particularly rapid
growth rates.

41. Applications

42. Applications

43. Applications

44. Conclusion
• The application of High Technology and Internet Communications in
Medical Practice ensures that time and cost of medical care are reduced to
optimal limits. On the other hand, the increase in quality and efficiency is
significantly increasing. Promote rapid data transfer and telecommunication
between patient and general practitioner; general practitioner - emergency
aid; hospitals; hospitals and medical professionals; advancing technical
progress in various medical directions.
• Telemedicine contributes significantly to improving the prevention of the
population through training; access to specialized medical assistance and
populations in the outermost regions of the planet
• The patient's easy and convenient access to the doctor, the rapid transfer of
information, teleconsultation play an important role in the efficiency of
hospital care, which on the other hand decreases and the need for frequent
hospitalization
• Multifunctional systems for measuring vital signs, monitoring, placing
cameras in the home, intelligent robots increase the quality of life and the
timeliness of medical care for the elderly, the chronically ill and the
disadvantaged.
• Teleconsultations and videoconference links make it easier to solve health-
related cases involving specialists from different parts of the world, reducing
the need for patient transportation.
• Telemedicine provides comfort and confidence to the patient that at any
time, wherever he is, he can receive qualified medical assistance.
All this makes Telemedicine a desirable and prospective method of the new millennium.

45. “Telemedicine is moving like lightning. We're able to do so
much more than before.”
Andrew Watson, Chief Medical Director of Telemedicine at
University of Pittsburgh Medical Center

46. Thank you!
VARNA STARTUP WEEK IN HEALTH TECH 2017