HANDBOOK OF TELEMEDICINE
Studies in Health Technology and Informatics
Editors
Jens Pihlkjaer Christensen, European Commission DG XIII/C-5, Brussels; Tim De Dombal *j% University of Leeds;
Ilias Iakovidis, EC DG XIII Health Telematics, Brussels; Zoi Kolitsi, University of Patras;
Jaap Noothoven van Goor f, ACOSTA, Brussels; Antonio Pedotti, Politecnico di Milan; Otto Rienhoff,
Georg-August-Universitat Gottingen; Francis H. Roger-France, Centre for Medical Informatics, UCL, Brussels;
Niels Rossing, Centre for Clinical Imaging and Engineering, National University Hospital, Copenhagen;
Faina Shtern, National Institutes of Health, Bethesda, MD; Viviane Thevenin, CEC DG XII/F BIOMED-I,
Brussels
Volume 54
E a r l i e r p u b l i s h e d in t h i s
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series
24. M.F. Laires, M J . Ladeira and J.P. Christensen (Eds.), Health in the New Communications Age
25. A . Hasman, A . Albert, P. Wainwright, R. Klar and M. Sosa (Eds.), Education and Training in Health
Informatics in Europe
26. C O . Kohler, O. Rienhoff and O.P. Schaefer (Eds.), Health Cards '95
27. B. Barber, A . Treacher and CP. Louwerse (Eds.), Towards Security in Medical Telematics
28. N . Pallikarakis, N . Anselmann and A. Pernice (Eds.), Information Exchange for Medical Devices
29. S.J. Weghorst, H.B. Sieburg and K.S. Morgan (Eds.), Medicine Meets Virtual Reality
30. C Roux and J.-L. Coatrieux (Eds.), Contemporary Perspectives in Three-Dimensional Biomedical
Imaging
31. The SEISMED Consortium, Data Security for Health Care I, Management Guidelines
32. The SEISMED Consortium, Data Security for Health Care II, Technical Guidelines
33. The SEISMED Consortium, Data Security for Health Care III, User Guidelines
34. J. Brender, J.P. Christensen, J.-R. Scherrer and P. McNair (Eds.), Medical Informatics Europe '96
35. M. Di Rienzo, G. Mancia, G. Parati, A. Pedotti and A. Zanchetti (Eds.), Frontiers of Blood Pressure and
Heart Rate Analysis
36. M . Sosa-ludicissa, N. Oliveri, C.A. Gamboa and J. Roberts (Eds.), Internet, Telematics and Health
37. J.A. Sevastik and K.M. Diab (Eds.), Research into Spinal Deformities 1
38. R.A. Mortensen (Ed.), ICNP in Europe: TELENURSE
39. K.S. Morgan, H.M. Hoffman, D. Stredney and S.J. Weghorst (Eds.), Medicine Meets Virtual Reality
40. G. Lowet, P. Ruegsegger, H. Weinans and A. Meunier (Eds.), Bone Research in Biomechanics
41. J. Mantas (Ed.), Health Telematics Education
42. J. Brender, Methodology for Assessment of Medical IT-Based Systems
43. C. Pappas, N . Maglaveras and J.-R. Scherrer (Eds.), Medical Informatics Europe '97
44. G. Riva (Ed.), Virtual Reality in Neuro-Psycho-Physiology
45. J. Dudeck, B. Blobel, W. Lordieck and T. Biirkle (Eds.), New Technologies in Hospital Information
Systems
46. U . Gerdin, M . Tallberg and P. Wainwright (Eds.), Nursing Informatics
47. W. Ceusters, P. Spyns, G. De Moor and W. Martin (Eds.), Syntactic-Semantic Tagging of Medical Texts:
The Multi-TALE Project
48. J. Graafmans, V . Taipale and N. Charness (Eds.), Gerontechnology
49. L. van den Broek and A.J. Sikkel (Eds.), Health Cards '97
50. J.D. Westwood, H.M. Hoffman, D. Stredney and S.J. Weghorst (Eds.), Medicine Meets Virtual Reality
51. J. Mantas (Ed.), Advances in Health Telematics Education
52. B. Cesnik, A . McCray and J.-R. Scherrer (Eds.), Medlnfo '98
53. M . C Sievert, D.E. Moxley, N.J. Ogg and T.B. Patrick, Thesaurus of Health Informatics
ISSN: 0926-9630
Handbook of Telemedicine
Edited by
Olga Ferrer-Roca
President
CATAI C o n s o r t i u m
Responsible
f o r the First UNESCO Chair of
Telemedicine
F u l l Professor
of P a t h o l o g y , Faculty of M e d i c i n e , University of L a L a g u n a ,
Tenerife, Canary Islands,
Spain
and
Marcelo Sosa-Iudicissa
S c i e n t i s t a n d Projects A d m i n i s t r a t o r , M a n a g e r STOA Office
E u r o p e a n P a r l i a m e n t , Scientific and Technological
Options
STOA, B r u s s e l s , B e l g i u m
in
Brussels
Assessment,
IOS
Press
Ohmsha
Amsterdam • Berlin • Oxford • Tokyo • Washington, D C
© 1998, The authors mentioned in the table of contents
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, without the prior written permission from the publisher.
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ISBN 4 274 90241 2 C3047 (Ohmsha)
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PRINTED IN THE NETHERLANDS
V
Foreword
It is an honour and a pleasure to respond to the kind invitation of the Catai-Telemedicine
consortium to present the " H a n d b o o k of T e l e m e d i c i n e " . As a physician, a scientist and an
educator, keen on the prospects of technological progress and their influence in the training
of the young professionals, I am extremely satisfied to see the birth of an informative and
comprehensive publication in the new discipline and practice of telemedicine. As a
politician and a Member of the European Parliament I am satisfied to see that this book is
the result of a broad collaboration bringing together experts and knowledge from all the
corners of Europe, from Norway to Spain, and from the United Kingdom to Austria,
attaining a quantum leap with the added value that makes the resulting whole bigger that
the simple sum of its parts.
On the verge of the 21st Century, and in view of the economic, social, technological
and cultural transformations contained in the term " i n f o r m a t i o n society'',
we shall all -as
citizens, professionals, administrators and policy makers- be called on to re-think our views
on health matters. The European s o c i a l p r o t e c t i o n m o d e l has made possible a high degree
of coverage of the health needs of the population. Scientific progress, better diagnostic and
therapeutic means, as well as healthier life-styles have contributed to "add years to life"
and "life to years". On the other hand, patients are changing from a passive role in respect
to their own health problems, and are now better informed and willing to assume more
responsibilities for their well being and that of their families. There is also a will to access
medical and other services that should be much more easily available, in terms of place and
time, bringing care closer to household and communities.
In this context, the advent of telemedicine and telecare could not be more
opportune. As we enter an era that has also been described as the society of k n o w l e d g e , it
becomes ever more imperative that medical practitioners and other health professionals
offer their clients the best existing information about a particular disease affecting them.
Time, distance or physical obstacles can no longer justify placing a barrier between a
patient's ailment and the best existing knowledge on how to manage it, wherever in the
world it is to be found. And here is where telemedicine can be of higher value, by making
it much easier to use expert advice from the hospital specialist to the primary care doctor,
or from a doctor to a nurse, or from a world-class specialist to another specialist confronted
with particularly complex cases. The ability of telemedicine to offer "just-in-time" help
where it is most needed is one of its main assets.
It goes without saying that telemedicine can and should also play an important role
there where emergencies, or geographic or other conditions (isolation, bad weather,
catastrophes), call for the use of this new model of medical delivery. Another case would
be that of underserved populations or regions with a critical shortage of health personnel, as
in the case of developing countries.
However, as telemedicine develops, the need for basic accepted principles for its
practice becomes evident. Medicine has always been strict in respect to "the practice of the
art", and the same should apply for the new and numerous telemedicine and telecare
applications. If we accept that telemedicine should be "medicine at a distance", it should
have the same requirements as plain medicine: use by qualified personnel, an un­
ambiguous legal framework defining the rights and obligations of clients and providers,
and well-defined quality standards.
vi
One of our main preoccupations in respect to health informatics and telematics is
that the proper protection of patients' health information should be guaranteed at all costs.
Confidentiality, integrity and security of medical data affecting the most intimate
conditions of a person have to be fully assured, both at the technical and at the legal levels.
When travelling through networks, patient information should be made anonymous, and
appropriate mechanisms including encryption should be used as required. Medical doctors
and other professionals should observe the highest ethical standards in this respect, and a
new deontology adapted to the information age might need to be sought.
A major challenge and opportunity opened up by telemedicine is the new vista for
training and education. Offering a means to acquire general medical knowledge in itself,
telemedicine will also dramatically change the way in which the new generations of
doctors, surgeons, and nurses will be trained in the future. The availability of teaching
materials, both in traditional support forms like this book, and others in multimedia
formats, will be in high demand for that purpose.
In summary, telemedicine and telecare make a reality out of the best promises of
information and communication technology for the benefit of patients and citizens. In the
era of the massive extension of the Internet they take full advantage of the existing and
future connections and tools. It is also the dawn of a golden age of shared knowledge that
will be put at the disposal of a much broader base of beneficiaries. If all this can be
accomplished with the necessary caution that the introduction of such fantastic changes
requires, and with an exacting respect for the person for whom it is intended, it will offer a
shining future for the ancient and noble health professions. Let us hope that this book
makes a significant contribution in that direction.
Pro/. Alain Pompidou
Member of the European Parliament
Chairman of STOA, Scientific and Technological Options Assessment
Strasbourg, June 1998
vii
Introduction
O. FERRER-ROCA
C d t e d r a de A n a t o m i a P a t o l d g i c a , F a c u l t a d M e d i c i n a ,
U n i v e r s i d a d d e L a L d g u n a 3 8 0 7 1 , Tenerife,
C a n a r y Islands, Spain, c a t a i @ r e d k b s . c o m
The present book has been written with the objective of tackling the social need to clarify
what telemedicine is; if it is just a way to provide medical services that do not require any
training or if training is just linked to the use of certain devices; or if, on the contrary, we
are facing the year 2,000 having, in teaching centres and universities, using scientific
concepts that are closer to the knowledge of the past century and far from the new social
demands and knowledge of the next century.
It is notable how some people in a position of social responsibility in the health
professions have not yet fully understood the importance of the new information society,
particularly in its links to telemedicine. The reasons is not only that the subject and basic
knowledge was not introduced in their careers, but also the unstructured inputs of
information on telemedicine in their continuous education. This has led to the fact that
although technology is at the present moment available, telemedicine cannot develop due to
numerous constraints associated with the absence of legislation, lack of quality of service
guarantee at all stages of the telematic provision chain, absence of computerised based
health care organisation.
This concatenated effect on telemedicine practice clearly shows that its knowledge
and practice is a complex one that requires something other than training to send the
information at a distance. According to one of the numerous definitions of telemedicine,
"providing medicine at a distance", any doctor being trained in the use of some telematic
devices could effort that practice. The reality is far from this because, to assure a safe
practice, people have to learn and bear a minimum understanding of a wide range of topics:
from economics to telecommunications and from medicine to legal aspects. Technology
learning is not limited to technology itself but linked to its social practical consequences in
all their aspects.
To guarantee that none of the aspects related with telemedicine are missed, this
minimum knowledge has to be fixed, organised and in some way standardised. This was
the aim of the CATAI/Telemed consortium when the partners applied for financial support
to the Leonardo da Vinci Programme to build up the Body of Knowledge (BoK). This BoK
should establish the minimum threshold to consider a student capable to face telemedicine
problems in all possible aspects: technical, managerial, development, practice, control, etc.
This would offer the complementary advantage of being able to use telemedicine across
borders with the security that E U people will have similar knowledge, if this B o K is
recognised for training purposes.
The work presented in this book is a collaborative European endeavour to establish
the minimum requirements for the safe practice of telemedicine. It is complemented in its
training purposes with a multimedia manual prepared by the Consortium that is available
directly from the authors. Also the Annexes and Chapter 12 - "Emerging Issues", provide
some of the scientific and practical knowledge that should be taken into account in a
comprehensive teaching initiative.
According to the opinions of the participating experts, there are 12 topics to take
into account in teaching telemedicine. These aspects are discussed along the respective
viii
chapters. Some of them, due to their extension or the variety of aspects, were covered by
different people, and were subdivided into sections.
The clearest example is Chapter 3, dealing with Telemedicine Applications; it is
obvious that each medical subspecialty can have peculiar indications or even limitations to
be practised at a distance. Since telemedicine is too young to have acquired sufficient
experience in each medical application the chapter included only those that at the present
moment provide more or less clear and differentiated guidelines for their use based on
scientific evidence. This is regardless the fact that different scenarios require organisational
and technical accommodation in a specific environment, such as in the case of telemedicine
in prisons, in the Army, in ships, in insular regions.
The demand for a book as the one proposed here can be clearly detected in the
Faculties of Medicine, Computer Science, Telecommunications, Biomedical engineering
and even in Nautical Studies that have the broader experience in radio medical support. It is
also in demand in Schools of Nurses, among technical people and even in vocational
training since none of the books found in the literature cover in a structured and systematic
way the basic knowledge linked to telemedicine.
The main purpose of this book is to structure the basic knowledge linked to teaching
to provide or practising telemedicine as well as an overview of the technology
developments linked to this new discipline.
As expressed in the title, the book is precisely structured as a "handbook" whose
main value is the joint opinion of all the participating authors of what are the minimum
teaching requirements for anyone that would like to learn telemedicine. It is not a full
treatise nor a complete recollection of all telemedicine applications or telemedicine basics.
It was built with the aim of creating awareness to the academic authorities and health care
community representatives on the fact that telemedicine practices in any of their aspects
(technology development, telecommunications approach, law and regulations, medical
practice), require a minimum knowledge that has to be respected in order to guarantee safe
and appropriate medical practice.
Table 1. Body of Knowledge (BoK) of Telemedicine.
CHAPTER
1
2
3
4
5
6
7
8
9
10
11
12
CONTENTS
History of Telemedicine
Minimal Technical Requirements
Main Telemedicine Applications
Basic Technical Knowledge
Quality Control and Assessment
Use and Indication of Telematic Tools in Telemedicine: Internet
Training, including Distance Training, Teleworking and Teleteaching
Data Security and Privacy
Liability and Legal Aspects
Health Economics in Telemedicine
Technology Transfer and Social Aspects
Emerging Issues
Nowadays this fact is enhanced by the evidence that welfare expenses cannot be
endlessly increased, whilst an efficient health provision system in the context of the
information society, will mark a new trend to configure health care practice in the next
century. If training and teaching schemes are to cope with the demands of society it seems
obvious that those careers and professions that are purveyors to the B o K of telemedicine
should consider structured and sufficient training in telemedicine. The main components of
the B o K are listed in Table 1.
ix
Each school and training institution according to their student's level and needs can
then amplify or adapt the content of the Handbook, assuring at least a uniform and basic
knowledge through the E U . All the authors and the editors hope that the consensus, effort,
work and time invested into this handbook can encourage the use of telemedicine by
increasing the technological level of users and providers. Delivered by the C A T A I consortium: http://www.redkbs.com/Catai; http://anpat.drmm.uniud.it/ctmed
Definitions
The world's most recent trends in the provision of health services and in the health sector
in general, defines telehealth as an integrated term including any telematic application. It
includes therefore any medical informatics and health informatics. More specifically the
international consultation carried out by the WHO during 11-16 December 1997, submits a
report which offers a working definition of "health telematics": composite term for health
related activities, services and systems carried out over a distance by means of information
and communications technologies, for the purpose of global health promotion, disease
control and health care, as well as education, management and research for health. This
also embraces the telematics in health research and health services management, as well as
specific applications for " telemedicine" and "tele-education in health".
Table 2. Telehealth Applications.
CATEGORY
| USERS
1 All forms of medicine at distance:
| Physicians
Teleconsultations, telepathology, teleradiology, telepsychiatry,
Health care professionals
Teledermatology, telecardiology etc.
Health care institutions
2 Inter-institutional, patient and clinical records and information systems
Health care institutions
Electronic health and clinical records and data bases accessible by
Health care professionals
network
Health care workers
Physician's office
Researchers
3 Public Health and Community Health Information networks (CHINS) and Government
multiple-use health information networks
Epidemiologists
Public health professionals
Physicians offices
Pharmacies
Clinics and CHINS
4 Tele-education and multimedia applications for health professionals
University and colleges
and patients and networked research databases. Internet services
Associations
Researchers
Physicians
Health Care professionals
Patients
5 Telemonitoring, telecare networks, telephone triages
Customers
remote home-care and emergency networks
Elderly
Chronically ill
Disaster victims
i Accident victims
Telenurses
1 Call centre users
i
| Call centre operators
-i
X
According to Canada's industry web site (http://strategics.ic.gc.ca/cinch) telehealth
can include the elements presented in Table 2.
Under the term of telehealth are included: provision or confirmation of diagnosis,
surveillance, epidemiology, management, clinical and research information, literature
search and retrieval, health and wellness, health and medical educational contents.
The potential scope of telemedicine is therefore enormous and can be summarised
in three main aspects as presented in Table 3.
Table 3. Scope of telemedicine.
MEDICAL INFORMATICS
i.e. Computer patients record systems / on-line information
R E M O T E DIAGNOSIS & CONSULTATIONS
i.e. Medicine provision to undeserved areas
CONTINUING MEDICAL EDUCATION
i.e. Special technique dissemination
Updating rural practitioners
To conclude with, telemedicine, telehealth and the proper harnessing of the
potential of Internet, will herald the 21st Century scenarios and opportunities as presented
by some of our colleagues in these fields: " U l t i m a t e l y , t h e g o a l i s t o p u t a l l these t e c h n o mechanisms
a t t h e s e r v i c e of m a n , a t t h e s e r v i c e of society, a t t h e s e r v i c e of a n i m p r o v e d
q u a l i t y of life t o w a r d s t h e p e r m a n e n t i m p r o v e m e n t of t h e q u a l i t y of c a r e offered t o p a t i e n t s ,
t h e m a i n t e n a n c e , c o n t i n u i n g e d u c a t i o n a n d up-date
of p r o f e s s i o n a l k n o w l e d g e a n d
p r a c t i c e , b e t t e r h e a l t h e d u c a t i o n , a n d f o r a m o r e effective
p r e v e n t i o n a n d a v o i d a n c e of
diseases a n d h a n d i c a p s . T h i s new e r a w i l l a l s o offer a n o p p o r t u n i t y t o p a t i e n t s a n d c i t i z e n s
t o have a much m o r e a c t i v e a n d r e s p o n s i b l e p a r t i c i p a t i o n i n t h e i r d e c i s i o n s o n h e a l t h
m a t t e r s , life styles a n d self-care.
D o c t o r s a n d p a t i e n t s , p r o v i d e r s a n d c i t i z e n s , we s h a l l a l l
be w i s e i n o u r m u t u a l i n t e r a c t i o n s , thanks t o a n adequate
supply of i n f o r m a t i o n , k n o w l e d g e
a n d e x p e r t a d v i c e , t h a t t h e "Information
Society" w i l l p u t a t o u r d i s p o s a l " [5].
In helping at the up-stream level where the future generations will learn and find
intellectual nourishment, the Handbook of Telemedicine, expects to be able to make its
modest but solid contribution in that direction.
References
[1]
[2]
[3]
[4]
[5]
World Health Organisation- Executive board 101 session, 21 January 1998.
WHO international consultation. 11-16 December 1997.
Telehealth in Canada. Agenda item 3.1 Plenary meeting. World Telecommunication development
conference (WDTC-98) Valleta, Malta 23 March-1 April 98. Document 62-E, 19 February 98.
http: //www.who.ch/inf/pr/1997/pr97-98.html.
M . Sosa-Iudicissa, N. Oliveri, C. Gamboa, J. Roberts: Internet, Telematics and Health. Under the
auspices of the Pan American Health Organisation - World Health Organisation PAHO/WHO and the
International Medical Informatics Association (IMIA). IOS Press, Amsterdam, Berlin, Oxford,
Tokyo, Washington; Series on Studies on Health Technology and Informatics, No 36; 1997. 530 p.
ISBN: 90-5199-289-0. p. X X V .
xi
Handbook of Telemedicine
Biographical Profiles of Contributors
Prof. Dr. Alain Pompidou
Born on 5 April 1942, Paris, France.
Member of the European Parliament since 1989. Chairman of S T O A Scientific and Technological Options Assessment. Member of the Committee on
Research, Technological Development and Energy of the European Parliament.
Chairman of the E P Delegation for relations with Japan.
Doctor in medicine and sciences, and professor of histology at Rene Descartes
University, Paris V ; specialised in cytogenetics and molecular cytology.
Former scientific advisor of the Atomic Energy Commission, of the scientific
committee of I N S E R M , and to the World Health Organization. Member of the
Human Genome organisation (HUGO) Ethics Committee. Member of the
Council for Applied Sciences (Academy of Sciences, France).
Scientific Advisor of the French Prime Minister (1993-1997).
Author of numerous scientific publications and studies. Author of the book
"Souviens toi de 1'Homme: L'ethique, la vie, la mort", Ed. Fayot, 1989
Address:
Faculte de Medecine Cochin
24, rue du Faubourg Saint Jacques, F-75014 Paris
Prof. Dr. Olga Ferrer-Roca MD, PhD
Born in Barcelona, Catalonia. Spain. Studied Medicine in the University of
Barcelona 1967-1972, with Summa Cum Lauda and First Award. She is
Specialised in Pathology in 1973. Trained in Orthopaedic pathology in the
Lariboisiere Hospital in Paris, in Endocrine Pathology in St. Thomas Hospital in
London, in General Pathology in St. Lukes Hospital in Milwaukee U S A , in
Lymph Node pathology in Univ. Kiel. Germany, in Lung Pathology in St.
Bartholomew Hospital London. PhD in Medicine, Summa Cum Lauda in 1975
with the Thesis: "Tumor-cariotype correlation", started in 1970 with massive
tumour tissue culture and cariotyping. Started computer science applied to
Pathology in 1976 developing the Texcan Software of image analysis including
densitometry, and highly specialised visual textural analysis. In the field of
Telemedicine since 1982, took the Chair of Pathology in the University of L a
Laguna in 1982. First to do distant telematic D N A quantitation in 1989.
Teaching Pathology and new technologies in the Faculty of Medicine; teaching
Telemedicine in the Faculties of Medicine and the Computer Science engineering
school since 1995. Leader of the C A T A I Commett/Leonardo projects in
Telemedicine; in 1992 founded the C A T A I non-profit association for the
promotion of the Information Society.
E-mail: catai@redkbs.com
xii
Dr. Marcelo Sosa-Iudicissa, MD
Medical Doctor, University of Zaragoza, Spain; Residency Training in General
and Family Medicine; postgraduate studies in Public Health; Preventive and
Social Medicine; Occupational Health; Pharmaceuticals;
Business
Administration; Information Technology Management. Responsible for the
Scientific and Technology Options Assessment (STOA) office in Brussels,
European Parliament. Previously, Director of the National Library of Health
Sciences (Spain); Scientific Officer, European Commission, Telematics
Applications programme; Principal Investigator, health information systems,
National School of Public Health (Madrid); Responsible, information systems
development, including data processing and library automation, Spanish National
Institute of Health; Civil Servant (with tenure), National Epidemiology Centre
(Spain); Lecturer, Health Information and Documentation, Complutense
University, Madrid; Public Health and Preventive Medicine, University of
Buenos Aires. Has collaborated with the World Health Organization and the
International Telecommunications Union. Has published several professional and
scientific papers and seven books, the most recent being "Internet, Telematics
and Health" (ISBN 90 5199 289 0).
E-mail: MSosa@EuroParl.EU.Int
Dr. Francois Allaert, MD, PhD
Medical Doctor, Lawyer specialised in computer and European Law, Ph D in
Bio informatics. Medical University of Dijon, France. Director of a Centre for
Drugs and Medical Devices Evaluation (CEN BIOTECH) and of the French
Agency for Healthcare Data Protection (APSIS). Lecturer at Medical University
of Dijon and Nancy (France) and senior lecturer at the Public Health School of
Liege (Belgium). Author of more than 200 hundred national and international
papers and two books dedicated to Computer Law in Medicine. Chairman of the
working group "Data Security" of the European Medical Informatics
Association. Convenor of the CEN TC 251/WGHI "Healthcare data Security
and Software quality" depending from the European Union. Associated member
of European Telematics projects: MEDSEC, TRUSTHEALTH, and ISHTAR.
Vicenzo Delia Mea, PhD
Born in Como, Italy. In 1992 graduated in Computer Science at the University
of Udine. Since then he has worked in the field of image analysis, telemedicine
and Internet in Medicine in the department of Pathology at the University of
Udine. In 1998 he obtained his PhD in Morphometry at the University of Sienna
with the thesis "Models and Methods for Telepathology". Main research
interests: biomedical image processing, hypermedia, and telemedicine, with
particular attention to applications of Internet protocols to telepathology.
xiii
Anastasia Kastania
Born in Athens, Greece. She is a Research Scientist in the Department of
Clinical Therapeutics, Medical School, National University of Athens & also in
the Department of Biomedical Engineering at the Athens Technical Institution
and works in the Department of Informatics of the Athens University of
Economics & Business. She received her B.Sc. in Mathematics in 1987 and
Ph.D. degree in Medical Informatics in 1993 from the National University of
Athens. Her chief research interests are multichannel biosignal modeling, pattern
recognition and biosignal classification and interpretation. Other interests are
Medical Education and research in the field of computer assisted methods for
teletraining and distance learning. As a member of the C A T A I Consortium she
studies and teaches the planning, design and delivery of telemedicine educational
services.
Sophia Markidou, MD
Born in Athens, Medical doctor (1971) and PhD (1975) by the University of
Athens. Specialised in Cytology, 1977; in Pathology 1983 with special training
in Image Analysis in the University of Chicago, 1984. Director of the
Diagnostic Cytology Lab. at the Anticancer Oncology Hospital of Athens "St.
Savas" since 1986, and Assistant Professor of Pathology at Athens University
since 1988. Working in the field of Telemedicine, image analysis and
Telecytology since 1992, have been actively participating in the European
projects related with Telemedicine of DGXIII (ATM, Telematics) and DGXXIII
(Leonardo).
Thomas Mairinger MD
*
Born in Braunau, Austria. Medical Doctor by the University of Innsbruck,
Austria, graduated with the thesis: "Epidatei - computerised management of an
adult seizure clinic" in 1989. Specialised at the Dpt. of Pathology of the
University of Innsbruck, completed his training in 1996. Since 1996, senior staff
pathologists at this department. Main scientific interests: Telepathology,
especially questions of acceptance and implementation; Image analysis ( D N A Cytometry, Morphometry, Texture) with special attention to DNA-Cytometry
on thin histology sections. Member of the Austrian Society of Pathology
(Treasurer), LAP - German Division.
Steinar Pedersen, MD
Born in Troms0, Norway. Medical doctor by the University of Oslo, specialised
in Otorhinolaryngology in 1986. Founded the Department of Telemedicine at the
University Hospital of Troms0, Norway in 1992. The department is involved in
several telemedicine projects and routine services within pathology,
dermatology, otorhinolaryngology, psychiatry, in the geriatric field, radiology,
distant teaching, cardiology and neurology. He founded the International
Conferences on Medical Aspects of Telemedicine (1993). He is member of the
Editorial Board of The Journal of Telemedicine and The Journal of
Telemedicine and Telecare. He is the President of The International Society for
Telemedicine.
xiv
Carmelina Ruggiero, Bio-Eng, PhD
Born in Italy. Received the Laurea from Genoa University, the Ph.D. degree
from London University (Imperial College) and the D.I.C. from Imperial
College. Since 1983 she had a chair as associate professor of bioengineering at
Genoa University. Her main research interests include the study of biological
systems by data signal and image analysis, by modelling, and experimental
techniques; medical informatics, with special reference to knowledge based
systems; and cellular and molecular engineering. Her work on biological
systems relates to the motor control of muscle, to respiration and to the
cardiovascular system, with special reference to biomedical signal and image
analysis and computer modelling. As refers to medical informatics she has been
working on medical knowledge based systems with special reference to
oncology, on telemedicine and on home care technology. As refers to cellular
and molecular engineering, her research activity mainly relates to
hemocompatibility of biosensors and prosthesis and protein structure
determination. She has also been working on bacteriology and virology, with
special reference to classification methods based on artificial neural networks.
Antonio Sousa Pereira Eng, PhD
Degree in Electrical Engineering (EE) at the Engineering School of the
University of Porto (1977) Ph.D.at the University of Aveiro (1987). With the
University of Aveiro, since 1978 as Associate Professor of Image Processing at
the Department of Electronics and Telecommunications where he is Scientific
co-ordinator. Researcher of INESC - Instituto de Engenharia de Sistemas e
Computadores. Responsible by the involvement of INESC in several R & D
national and European projects in the area of telematics applied to health care
such as: I T H A C A , EPIC, H O S P I T A L 2000, ISCAMI, M O M S ; Leader of the
group responsible for the product I N T E R A C T , a tool for teleradiology; more
than 10 publications in scientific journals; supervisor of several Ph.D. students
in the area of Medical Imaging. Member of the Working Party of the
Programme T E L E M A T I C S - Healthcare, of the C E C D G - XIII; Director of
INESC-Aveiro since November 1997; Director of the Electronics and
Telecommunications Research Centre from 1987 to 1992.
V. Strobl
Born in Innsbruck, Austria. Studied economics at the Leopold Franzens
University of Innsbruck. She received her B.SC. in social and economic sciences
in 1996. Her thesis was a "Strategic Analysis of the Implementation of a Burn
Centre at the Plastic Surgery Department of the University Clinic in Innsbruck".
Presently she is in the clinical period of Medical School in Innsbruck. She
specialises in economic research in health care with focus on telemedicine. She
is now working at the Institute of Biostatistics and Documentation in Innsbruck
working in a project managing a Health Information Network.
XV
Richard Wootton, MD
Born in London. Career scientist with the Medical Research Council at the
Clinical Research Centre in London for 15 years. Then professor of Medical
Physics at the Hammersmith Hospital and Royal Postgraduate Medical School
for 7 years. In 1995 established the Institute of Telemedicine and Telecare at
Queen's University in Belfast. The institute is the only academic organisation in
the U K dedicated to research and teaching in telemedicine. Currently it has a
number of research trials in progress including the international Multicentre
teledermatology trial. He is the founder editor of the Journal of Telemedicine
and Telecare, published by the Royal Society of Medicine.
Acknowledgements
The authors want to thank the numerous experts, colleagues, and friends that contributed
gathering and assembling the Body of Knowledge of Telemedicine, as presented in the
book. Some of them have granted us valuable input during the three-year duration of the
Leonardo project, even if for one reason or another they do not appear as authors in the
chapters.
In particular, we want to thank the supporting team of the Catai Consortium at the
co-ordination site integrated by: Esther Gomez Ruiz, Raides Rodriguez Dominguez,
Maritza Estevez Gonzalez, Isaac R. Hernandez Rodriguez, Francis Le Roy Lienard, Jose
Luis Fernandez, Seguismundo Cardenes, Guillermo Nunez Perez, Juan Antonio Perez
Gomez. We are also obliged to the contributors and participants to the regular Catai Winter
and Summer courses (http://www.redkbs.com/Catai).
Finally, we have to especially thank the many friends and colleagues that
encouraged us to undertake the challenge of introducing Telemedicine in spite of the
numerous difficulties encountered.
The authors, Tenerife, June 1998
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Table of Contents
Foreword, A . P o m p i d o u
Introduction, O. F e r r e r - R o c a
Handbook of Telemedicine, Biographical Profiles of Contributors
Chapter 1: History of Telemedicine
M S o s a - I u d i c i s s a , R. W o o t t o n a n d O. F e r r e r - R o c a
1.1 Introduction and perspective
1.2 An overview of early experiences
1.3 Main phases of telemedicine history in view of the prevailing technologies
1.3.1 Pre-electronic telemedicine
1.3.2 Electronic telemedicine
1.3.3 Telegraphy
1.3.4 Telephony
1.3.5 Radio
1.3.6 Television
1.3.7 Wireless communication
1.4 Relevant international and country developments
1.4.1 United States
1.4.2 United Kingdom
1.4.3 Germany
1.4.4 Japan
1.4.5 France, L . L a r e n g andM
Sosa-Iudicissa
1.4.6 Norway, S. Pedersen
1.4.7 Portugal
1.4.8 Italy, C. R u g g i e r o , R. S a c i l e a n d M . G i a c o m i n i
1.4.9 Spain
1.4.10 Greece, D . S o t i r i o u
1.4.11 Canada
1.4.12 The Netherlands
1.4.13 Finland
1.4.14 Belgium
1.4.15 Austria, T. M a i r i n g e r
1.4.16 China
1.4.17 Arab Countries
1.4.18 Russia
1.4.19 Australia
1.4.20 Iceland
1.4.21 Sweden
1.5 Conclusions
References
Chapter 2: Minimal Technical Requirements
O. F e r r e r - R o c a a n d A . S o u s a P e r e i r a
2.1 Introduction
2.2 Type of information and standards
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2.2.1 Audio
2.2.2 Data
Standards
Systems
EHCR
Electronic cards
Medical vocabulary
DSS
2.2.3 Fax
2.2.4 Still images
2.2.5 CSCW, Computer Supported Co-operative Work
2.2.6 Video
2.3 Types of communications and networking
2.3.1 Networking architecture
2.3.2 POTS
2.3.3 ISDN
2.3.4 A T M
2.3.4.1 Problems linked to A T M technology
2.3.4.2 Standards
2.3.5 Other Fixed Networks
2.3.6 Air/wireless communications
2.3.6.1 Radio frequency transmission, R. L u r a s c h i
2.3.6.2 Microwaves transmission
2.3.6.3 Satellite
2.3.6.4 G S M (Global System for Mobile Communications)
2.3.6.5 Cellular Digital Packet Data (CDPD)
2.4 Acquisition/displays
2.4.1 Acquisition systems
2.4.1.1 Cameras
2.4.1.2 Scanners
2.4.1.3 Other medical specialised acquisition systems
2.4.2 Display systems
2.4.2.1 Analogue devices
2.4.2.2 L C D
2.4.2.3 Laser displays
2.4.2.4 Holographic representations
2.4.2.5 Virtual screen devices
2.5 Computation/storage systems
2.5.1 Computer speed up systems
2.5.2 Storage systems
2.5.2.1 Magnetic systems
2.5.2.2 Mixed Systems
2.5.2.3 Optical systems (laser devices)
2.5.2.4 Solid State Disks (SSD)
2.5.2.5 Experimental storage systems
2.6 Human and organisational factors
2.7 Legal aspects
References
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Chapter 3: Main Telemedicine Applications
O. F e r r e r - R o c a
Introduction
Teleradiology, C. R u g g i e r o
Definition
Basic Parts of a Teleradiology system
1. Image Acquisition and management
2. Display systems
3. Communication Network
4. Interpretation section
Telepathology, O. F e r r e r - R o c a
Introduction
Applications
Requirements
1. Multimedia database
2. Colour images of sufficient resolution
2.1. Dynamic range
2.2. Spatial resolution
2.3. Compression methods
3. Interactive control of colour
4. Controlled sampling
5. Security and confidentiality tools
Telequantitation at distance
Telecytology, S. M a r k i d o u , P . K a r a k i t s o s a n d A . P o u l i a k i s
Definition
Applications
Telecardiology, D . S o t i r i o u
Introduction
Main requirements
Examples
Portable solutions
Telehome-Care, C. R u g g i e r o , R. S a c i l e a n d M . G i a c o m i n i
Introduction
Technical aspects
Home-based applications
I) Tele-alarm, for safety and security
II) Tele-homecare
Cost Savings
Case example
Teleoncology, C. R u g g i e r o , R S a c i l e a n d M . G i a c o m i n i
Introduction, F . P u g l i s i
Advantages
Applications of Teleoncology
Area of Domain
Diagnostic aspects
1. Teleradiology
2. Telepathology
Prognostic factors
Therapy aspects
Follow-up aspects
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Databases
Telesurgery, O. F e r r e r - R o c a
Introduction
Minimum requirements
Telepsychiatry, O. F e r r e r - R o c a
Introduction
Specific requirements
Teledermatology, R. W o o t t o n a n d M . L o a n e
Introduction
Techniques
1. Store-and-forward teledermatology
2. Real-time teledermatology
Conclusions
Primary Care, O. F e r r e r - R o c a
Computer-based health records
Minimal Injury Units (UMIs)
Telephonic medicine
Telephonic Medicine, O. F e r r e r - R o c a
Introduction
Applications
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Chapter 4: Basic Knowledge on Multimedia Data Exchange
4.1 Introduction
4.2 Some technical terms
4.3 Network classification
4.3.1 Networking architecture
4.3.2 Networks with significance in Telemedicine
4.4 Categories of multimedia communication
4.5 Protocol hierarchies for multimedia communication
4.6 The H.320 series (videophone based on ISDN)
4.7 The T. 120 series of recommendations
4.8 The H.324 series (videophone on PSTN)
4.9 The H.323 series (videophone over L A N s and the Internet)
4.10 Media coding
4.10.1 Media coding for still images
4.10.2 Media coding for audio
4.10.3 Media coding for motion video
4.10.4 How does still image coding work? Lossy JPEG sample
4.10.5 How does motion video coding work? H.261 coding
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Chapter 5: Telemedicine Quality Control and Assurance
O. F e r r e r - R o c a
5.1 Introduction
5.2 Controlled variables
5.3 Control case management
5.4 Sufficient data for analysis
5.5 Serious and appropriate statistical evaluation
5.5.1. Analysis of concordance-precision-reproducibility
5.5.2. Analysis of validity
5.5.3. Cost-Benefit Analysis (CBA)
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5.5.4. Cost-Efficacy
5.6 Indications and limitations
References
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Chapter 6: Internet in Telemedicine
V. d e l l a M e a
6.1 The Internet
6.2 Basic concepts
6.3 Security
6.3.1 Secure socket layer
6.3.2 Firewalls-proxies
6.4 Quality of service
6.5 Personal communications
6.5.1 Internet electronic mail
6.5.2 Group collaborations: newsgroups and mailing lists
6.6 Medical data sharing: the World Wide Web
6.7 Forthcoming developments
6.7.1 IPv6
6.7.2 Real time transport on the Internet
6.7.3 A T M
6.7.4 Agents
6.8 Internet and Telemedicine
6.8.1 Telemedicine needs
6.8.2 E-mail applications for Telemedicine
6.8.3 WWW applications in Telemedicine
6.9 Internet problems
6.10 Conclusion
References
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Chapter 7: Distant Training, Teleworking and Teleteaching
A.N. Kastania
7.1 Introduction
7.2 Organisational environment
7.2.1 Technology: equipment and standards used
7.2.2 Manager
7.2.3 Studio
7.2.4 Staff to assure functionality and maintenance
7.3 Teleworking design and development
7.3.1 Definition and importance
7.3.2 Usage guidelines and modalities
7.4 Conclusions
References
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Chapter 8: Data Security and Privacy
O. F e r r e r - R o c a a n d F . A l l a e r t
8.1 Introduction
8.2 Standards
8.3 Mechanism of security
8.3.1. Encryption
8.3.2. Phases of encryption
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8.3.3. Digital signature
8.4 Security on Internet
8.5 Security and legal issues associated with CPR
References
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Chapter 9: Liability and Legal Aspects
F . A l l a e r t a n d O. F e r r e r - R o c a
9.1 Introduction
9.2 Main deontological applications
9.2.1. Security and privacy of medical data
9.2.2. Protection against malpractice
9.3 Contract scenarios
9.3.1 Teleassistance
9.3.2 Teleconsultancy
9.3.3 Exceptions
9.4 Legal protection
9.5 Conclusion
References
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Chapter 10: Economics and Strategic Planning
V. S t r o b l a n d O. F e r r e r - R o c a
10.1 Introduction
10.2 Constraints for the widespread use of Telemedicine
10.2.1 Constraints linked to economy
10.2.2 Constraints linked to social acceptance
10.3 Cost/benefits
10.3.1 Source of data on cost/benefits
10.3.2 Difficulties of costTbenefit analysis in Telemedicine
10.4 Strategic Planning for Telemedicine implementation
10.4.1 Analysis of the present situation and the demand
10.4.2 Objectives and strategies
10.4.3 Decision Theory
10.4.4 Cost-benefit
10.4.5 Plan implementation
10.5 Conclusion
References
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Chapter 11: Social Aspects of Technology Transfer
T. M a i r i n g e r a n d O. F e r r e r - R o c a
11.1 Definitions
11.2 Introduction
11.3 Forces affecting technology transfer
11.4 Scenarios for Telemedicine technology transfer
11.5 Technology transfer requirements in telemedicine
11.6 Strategy of telemedicine technology transfer
11.7 Conclusion
References
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Chapter 12: Emerging Issues
O. F e r r e r - R o c a a n d V. d e l l a M e a
12.1 Multimedia packet oriented networks
12.2 IP switching
12.3 Virtual LANs
12.4 MOS (Media Operating Software)
12.5 Cellular Digital Packet Data (CDPD)
12.6 Open telecommunications based on agent technology, V. d e l l a M e a
12.6.1 Definitions
12.6.2 Functioning
12.6.3 Applications
12.6.4 Agent languages
12.6.5 Standards
References
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Annex I: Standardisation Bodies
M . S o s a - I u d i c i s s a , J . L . M o n t e a g u d o P e n a a n d O. F e r r e r - R o c a
1.1 Introduction
1.2 Types of standards
1.3 Standards and Telemedicine
1.4 A changing scenario
1.5 Main standardisation efforts with an impact on Telemedicine
1.6 Activities in Europe
1.7 Activities in the US
1.8 From research to market through standardisation
1.9 Importance of participating in standardisation work
1.10 Other regulatory bodies
1.11 Conclusions and further reading
References
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Annex II: Most Common Statistical Evaluations
O. F e r r e r - R o c a
II. 1 Two binormal ROC curve analysis
II. 1.1 Of independent data sets
II. 1.2 Of correlated data sets
References
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Annex HI: List of New Terms
O. F e r r e r - R o c a a n d M . S o s a - I u d i c i s s a
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Annex IV: Colour Theory
O. F e r r e r - R o c a
IV. 1 Introduction
IV.2 Lights colours and colours of objects
IV.2.1 Light colours
IV.2.2 Colours of objects
IV.3 Three-dimensional representation of colour
IV.4 Colour spaces
IV.5 Response of the detectors
IV.5.1 Variations in gamma correction
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IV. 5.2 Detector response
IV.5.2.1 Light spectrum sensitivity
IV.5.2.2 Densitometric aspects
References
Annex V: Networking Schemes
O. F e r r e r - R o c a
V. 1 IEEE model for LANs
V.2 Requirements and network segmentation
V. 3 Common Management Information Systems, P . B a q u e r o Perez
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Annex VI: TCP/IP Functioning
O. F e r r e r - R o c a a n d V. d e l l a M e a
VI. 1 Transmission control protocol and Internet protocol
VI. 1.1 Datagramme structure
VI.2 IP Addresses
VI.2.1 Subnetwork mask
VI.2.2 Network classes
VI.2.3 Special conventions
VI.2.4 Multiple IP addresses
VI.3 TCP protocol
VI.4 TCP commands
VI.4.1 File transfer commands
VI.4.1.1 FTP-Command
VI.4.1.2 TELNET-Command
VI.4.1.3 MAIL-Command
VI.4.1.4 Other Commands
VI.4.2 Backup commands
VI .4.2.1 TAR-command
VI.4.2.2 RMT-Command
VI.4.2.3 DDATES-Command
VI. 5. Other issues related with Internet
VI.5.1 Codification of e-mail
VI.5.2 Compression systems
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Annex VII: Questionnaire on Telemedicine
T. M a i r i n g e r
VII. 1 Introduction
VII. 2 Questionnaire model
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Annex VIII: Electronic Transactions. Levels of Protection
O. F e r r e r - R o c a
VIII. 1. Introduction
VIII.2. The standards
VIII.3. Transactional issues on Internet
VIII.4. Levels of protection
References
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Annex IX: Perception Diagram
0. F e r r e r - R o c a a n d P . P l a z a
IX. 1 Introduction
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Annex X: Image Formats
O. F e r r e r - R o c a , RJ. R o d r i g u e z a n d A . S o u s a P e r e i r a
X . l GIF format
X . 1.1 Minimum format implementation
X . 1.2 Image definition
X . 1.3 Extensions
X.2 TIFF format
X.3 M P E G 2 format
X.3.1 MPEG2 variants
X.3.2 Differences between MPEG1 and MPEG2
X . 4 PNG format
X.4.1 Chunks
Annex XI: A Bit of Maths and Computers
E. Ruiz Enriquez
XI. 1 Introduction
XI.2 ASCII
XL3 Binary notation
XI. 4 Integer mathematics
XL5 Prime numbers
XL6 Blocks, product cipher and cipher feed-back
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Annex XII: Broadcast Multimedia Communications
XII. 1 Introduction
XII.2 Broadcast multimedia communications: the H.331
XII.3 Future trends
XII.3.1 Switched versus packed networks
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Annex XIII: Letter of Consent
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Subject Index
Author Index
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