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 Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. Vol. 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. ISBN 90 5199 413 3 (IOS Press) ISBN 4 274 90241 2 C3047 (Ohmsha) Third printing, 2002 Publisher IOS Press Nieuwe Hemweg 6B 1013 B G Amsterdam The Netherlands fax: +31 20 620 3419 e-mail: order@iospress.nl Distributor i n the USA and C a n a d a IOS Press, Inc. 5795-G Burke Centre Parkway Burke, V A 22015 USA fax: +1 703 323 3668 e-mail: iosbooks@iospress.com Distributor i n the UK and I r e l a n d IOS Press/Lavis Marketing 73 Lime Walk Headington Oxford OX3 7AD England fax:+44 1865 75 0079 Distributor in Germany, A u s t r i a and IOS Press/LSL.de Gerichtsweg 28 D-04103 Leipzig Germany fax:+49 341 995 4255 Switzerland Distributor i n Japan Ohmsha, Ltd. 3-1 Kanda Nishiki-cho Chiyoda-ku, Tokyo 101-8460 Japan fax:+81 3 3233 2426 L E G A L NOTICE The publisher is not responsible for the use which might be made of the following information. 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 This page left intentionally blank. xvii 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 v vii xi 1 2 2 2 2 3 3 3 3 4 4 5 6 6 7 7 8 8 8 10 11 12 13 13 13 13 14 14 14 14 15 15 15 15 19 20 xviii 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 20 20 20 22 23 23 24 24 24 26 29 30 33 33 36 38 39 40 40 41 41 42 45 46 48 49 52 52 52 52 53 54 54 57 58 58 58 58 58 59 59 60 60 60 61 61 61 61 xix 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 63 65 65 65 65 68 69 69 70 70 70 71 71 71 71 71 72 73 73 74 74 75 75 76 78 78 78 80 80 80 80 81 82 82 82 83 83 84 84 85 86 86 86 86 87 87 87 88 XX 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 89 90 90 91 91 91 91 93 93 93 93 94 95 95 96 96 97 97 97 97 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 99 100 100 100 101 102 103 103 105 107 107 108 108 109 110 111 113 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) 115 115 116 116 116 116 117 118 xxi 5.5.4. Cost-Efficacy 5.6 Indications and limitations References 119 120 120 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 123 124 125 126 126 126 126 126 128 130 135 135 136 136 136 13 6 137 137 137 138 138 138 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 139 139 140 143 143 145 145 145 146 146 147 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 149 150 151 151 152 xxii 8.3.3. Digital signature 8.4 Security on Internet 8.5 Security and legal issues associated with CPR References 154 156 159 160 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 161 161 161 162 163 163 165 165 165 166 166 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 169 170 170 171 172 172 173 175 176 177 178 179 180 180 180 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 181 181 182 184 185 186 187 187 xxiii 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 189 189 190 191 191 191 192 192 193 194 195 195 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 197 197 198 198 200 200 202 203 203 204 205 208 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 210 210 211 212 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 213 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 219 219 219 219 220 221 221 221 xxiv 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 223 223 224 226 227 228 229 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 231 231 232 233 234 234 235 235 237 237 237 238 239 239 239 239 240 240 240 240 240 Annex VII: Questionnaire on Telemedicine T. M a i r i n g e r VII. 1 Introduction VII. 2 Questionnaire model 242 242 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 246 246 246 249 249 XXV 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 250 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 252 253 254 254 255 256 258 259 259 261 262 262 262 263 264 264 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 266 266 267 267 Annex XIII: Letter of Consent 269 Subject Index Author Index 271 295