Telemedicine journal : the official journal of the American Telemedicine Association最新文献

Objective: The ISIS Center at Georgetown University received a grant from the U.S. Army to act as systems integrator for a project to design, develop, and implement a commercial off-the-shelf teleradiology system to support the U.S. troops in Bosnia-Herzegovina. The goal of the project was to minimize troop movement while providing primary diagnosis to military personnel. This paper focuses on Digital Imaging Communications in Medicine (DICOM) 3.0 related issues that arose from this type of teleradiology implementation. The objective is to show that using the DICOM standard provides a good starting point for systems integration but is not a plug-and-play operation.

Methods: Systems were purchased that were based on the DICOM 3.0 standard. The modalities implemented in this effort were computed radiography (CR), computed tomography (CT), film digitization (FD), and ultrasonography (US). Dry laser printing and multiple-display workstations were critical components of this network. The modalities and output devices were integrated using the DICOM 3.0 standard. All image acquisition from the modalities is directly to a workstation. The workstation distributes the images to other local and remote workstations, to the dry laser printer, and to other vendors' workstations using the DICOM 3.0 standard. All systems were integrated and tested prior to deployment or purchase. Local and wide area networking were also tested prior to implementation of the deployable radiology network.

Results: The results of the integration of the multivendor network were positive. Eventually, all vendors' systems did communicate. Software configuration and operational changes were made to many systems in order to facilitate this communication. Often, software fixes or patches were provided by a vendor to modify their DICOM 3.0 implementation to allow better communications with another vendor's system. All systems were commercially available, and any modifications or changes provided became part of the vendor's commercially available package.

Conclusion: Seven DICOM interfaces were implemented for this project, and none was achieved without modification of configuration files, changes or patches in vendor software, or operational changes. Some of the problems encountered included missing or ignored required data elements, padding of data values, unique study identifiers (UID), and the use of application entity titles. The difficulties with multivendor connectivity lie in the understanding and interpretation of standards such as DICOM 3.0. The success of this network proves that these problems can be overcome and a clinically successful network implemented utilizing multiple vendors' systems.

A fully automated, noninvasive data-acquisition system was developed to permit long-term measurement of physiological functions at home, without disturbing subjects' normal routines. The system consists of unconstrained monitors built into furnishings and structures in a home environment. An electrocardiographic (ECG) monitor in the bathtub measures heart function during bathing, a temperature monitor in the bed measures body temperature, and a weight monitor built into the toilet serves as a scale to record weight. All three monitors are connected to one computer and function with data-acquisition programs and a data format rule. The unconstrained physiological parameter monitors and fully automated measurement procedures collect data noninvasively without the subject's awareness. The system was tested for 1 week by a healthy male subject, aged 28, in laboratory-based facilities.

The Ohio Department of Rehabilitation and Corrections (ODRC) implemented a telemedicine pilot project in March of 1995. The project brought together the Southern Ohio Correctional facility in Lucasville, the Corrections Medical Center in Columbus, and The Ohio State University Medical Center, also located in Columbus. Its purpose was to evaluate the use of two-way interactive video for the delivery of health services. With two-way interactive video, physicians in one location established audio and video links with inmates hundreds of miles away. Data were collected on the potential savings as a result of telemedicine usage in the Ohio prison system. Costs associated with telemedicine and those incurred without telemedicine were determined on per-consult basis for comparison. The cost for a medical consult to be performed at the Corrections Medical Center averaged $263.51 per inmate. The cost for a medical consult via telemedicine varied from month to month, depending on the utilization volume. The ODRC experienced savings for telemedicine usage when 129 or more consults were performed each quarter. During the third quarter, 145 telemedicine consults were performed. The cost per consult for telemedicine usage during this quarter was $255.19. There was a savings of $8.48 per consult, resulting in a quarterly savings of $1206. As the utilization of telemedicine continued to increase in the fourth quarter, the amount of savings increased.

Background: Advances in newborn screening and pediatric management of sickle cell disease have resulted in patients living well into adulthood. For adults, preventive care and medication monitoring are crucial for optimal health maintenance. The Medical College of Georgia (MCG) in Augusta provides consultative services and comprehensive medical care to about 1200 sickle cell patients residing in middle and southern Georgia. An increase in the demand for clinical services in this patient population has resulted in expansion of sickle cell outreach efforts throughout the state.

Objective: A telemedicine clinic for adult sickle cell patients was established in order to meet the growing clinical demands.

Methods: An on-site outreach clinic was introduced in the target area. After 10 months of operation, a monthly telemedicine clinic was offered to patients as an option for routine medical follow-up. A clinic model was used, with scheduled appointments and a public health nurse assisting at the remote site. Phlebotomy and laboratory services enhanced the telemedicine encounter.

Results: Over a 12-month period, 52 encounters for 28 patients from 17 medically underserved counties were completed. All patients were African-American, and 89. 3% had Medicaid or Medicare insurance coverage or both. The clinic encounter time was 24 +/- 7.9 minutes (mean +/- SD), comparable to that for all telemedicine clinic encounters during the same period.

Conclusions: The adult sickle cell population in rural Georgia accepts innovative health care delivery using telemedicine. Thus, the telemedicine sickle cell clinic has increased access to care for rural patients in underserved areas. For providers, it has allowed greater clinical productivity and diminished travel time to outreach clinics.

Relatively little information exists concerning the delivery of ophthalmic services via telemedicine, yet ophthalmology is particularly amenable to the utilization of such applications. This paper discusses the technological issues pertinent to the research, development, and assessment of teleophthalmology delivery systems and begins to define the parameters that will determine the sustainability of teleophthalmology. A prototype urban teleophthalmology delivery system is presented in the context of improving access to eye care for an underserved inner-city population. Potential enhancements to the prototype telephthalmology system are discussed.

Like any clinical interaction, teledermatology requires accurate, timely, and relevant information. The need to provide reliable, representative, diagnostic-quality images to the consultant is obvious. Predetermined patient views for a given clinical presentation and optimal hands on techniques to acquire them are not standardized. As a result, the training provided to those who take the images is inconsistent. Anecdotal evidence from the author's telemedicine practice is employed to support this contention. A formal collaboration between the telemedicine and medical photography communities is proposed to generate such standards and a relevant curriculum.

Objective: To determine the feasibility of home monitoring of patients with cardiac disease or hypertension.

Methods: An improved home electrocardiographic and blood pressure telemonitoring system linked to a central workstation was tested in 10 patients in Macau for 3 months.

Results: The total number of connections was 1377. Of the automatic alarm connections, 32.5% were false positive, with the percentage of false positives ranging from 7.6 to 54.6 for different patients. Both patients and physicians found the system easy to use.

Conclusions: Further investigation is required to match the number of patients with the system capacity. A more robust dysrhythmia detection algorithm is needed to reduce the number of false alarms. Nevertheless, the results were sufficiently good that the trial is being expanded.

Objective: To determine if the Georgia Statewide Academic and Medical System Telemedicine Network can deliver subspecialty pediatric care to rural areas of Georgia.

Materials and methods: A retrospective review was conducted of a clinical experience, over a 30-month period from November 1993 through June 1996, involving 13 pediatric cardiology-related encounters in seven male and six female patients. Patients' ages ranged from 5 days to 16 years. Eleven encounters were initiated because of a suspicion of congenital heart disease (CHD); two encounters involved postoperative evaluations in patients who had recently undergone cardiac surgery at the Medical College of Georgia (MCG).

Results: Of the 11 patients suspected to have CHD, five had CHD documented during the telemedicine evaluation, of whom two were transferred to MCG for further invasive evaluation and surgical correction. Three others with CHD, and the remaining six patients who required no further subspecialty follow-up, were followed in their home communities by their primary care physicians.

Conclusions: Telemedicine is a useful tool for the evaluation of infants and children with suspected CHD.

Background: Rural patients who develop dermatologic disorders often do not seek specialty care because of multiple logistical and economic factors.

Objective: To assess the effect of teledermatology consultations on the cost of care for a given episode of illness.

Methods: Telemedicine records were reviewed for 119 visits by 87 patients referred for teledermatology consultation over a 17-month period.

Results: Seven patients (8%) required follow-up in the dermatologist office for extended care, while 20 patients (23%) (52 visits) underwent follow-up teledermatology evaluation. The average duration of the dermatologic condition for each patient prior to the telemedical consultation was 17 months. The average of care for the diagnosed dermatologic condition, for all patients during an average period of 8 months prior to teledermatology was $294, compared with $141 for the 6 months after diagnosis by teledermatology.

Conclusions: Telemedicine can be effective for dermatology consultation in new patients referred from rural communities. Our data indicate teledermatology can decrease the cost of care for the diagnosed condition.