INTERNATIONAL TELECOMMUNICATION UNION TELECOMMUNICATION DEVELOPMENT BUREAU
SECOND WORLD TELEMEDICINE SYMPOSIUM
FOR DEVELOPING COUNTRIES Buenos Aires (Argentina) , 7 - 11 June 1999
SOURCE:
REP. OF MAURITIUS - R. SEENUNDUN, BUSINESS SERVICES DIVISION, MAURITIUS TELECOM IMPLEMENTATION OF TELEMEDICINE IN DEVELOPING COUNTRIES: THE CASE OF THE REP. OF MAURITIUS
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SUMMARY OF CONTRIBUTION: During the past few years, due to an extraordinary pace of technological innovation and deployment, telecommunications services have become more and more widely available, and provided some answers to the rising problems of our information age society: • • • • telecommuting remote resources sharing on line access to knowledge experts for real time decision access to reference data, even for isolated remote site
Those technologies have evolved to reach a sufficient level of performance, reliability and affordability where high-quality medical image transmission can be easily achieved. Telemedicine is not a new concept. Healthcare professionals have been using the telephone to carry out their services for years. In addition, research efforts have begun utilising more of the telecommunication repertoire, including speech, text, data, picture, and video communication. Countries with rural areas (example, Australia, Canada and Norway) have been especially active in this field. Therefore, it is of utmost importance to plan for an adequate telecommunication infrastructure to be able to set up applications like telemedicine. This is a very important factor that should be taken into consideration before starting a telemedicine project. Telemedicine may be defined in several ways. The use of telecommunications and information technology is central in providing health services, regardless of locations. Thus a goal for telemedicine has been to eliminate travelling for patients and specialists. The following definition of telemedicine has been found useful. “The investigation, monitoring, and management of patients and the education of patients and staff using systems which allow ready access to expert advice and patient information, no matter where the patient or relevant information is located.” In this paper, the implementation of a telemedicine project will be looked into based on the Mauritian experience. Some problems which might be encountered with such a project are analysed and some recommendations are made.
CONTRIBUTION: 1 INTRODUCTION
Mauritius is a small island in the Indian Ocean situated at about 900 kms to the East of the Malagasy Republic with a population of about 1.1 million and covers a surface area of 2000 square kilometers. Mauritius Telecom Ltd is the only Public Network Operator in Mauritius and is mainly concerned with the expansion of the telephone network and the installation of digital switching and transmission equipment. Public network operators in developing countries have to listen and understand the customers' requirements and more importantly fulfill those requirements. Furthermore, as we are all becoming a more information dependent society, telecommunications is being used to realize a globally competitive economy. As the customer needs become more demanding public network operators have to fully exploit the various technologies available to them to match the requirements. In this context, a market survey was carried out by Mauritius Telecom in 1992 and a few projects were identified. One of these was the implementation of the Integrated Services Digital Network (ISDN). In 1994 Mauritius Telecom officially launched the ISDN whose aims are to provide end-to-end digital connectivity to support a wide variety of services, including voice and non-voice services. Total ISDN coverage was achieved in 1996. ISDN has been perceived for some time as a major potential communications breakthrough in medicine particularly where image transmission is required. The high-speed transmission by ISDN of radiological images for example is being used in several institutions internationally. One of the applications that were earmarked by Mauritius Telecom to run on ISDN was telemedicine. In 1997, a telemedicine project was presented to the Ministry of Health and was consequently implemented on a pilot basis. 2 PROJECT IMPLEMENTATION
The objective of the telemedicine project was to set up a system which will enable the transmission of very high-quality medical images (X-rays, scans) to a distant site using an ordinary telephone line connected to the ISDN network. This will enable remote diagnosis of medical images by experts. Mauritius being an island far away from the most developed countries in Europe and the United States need the expertise (in difficult cases) of highly-qualified personnel in the health sector of these countries. This can only be achieved using telemedicine. On the other hand, due to the projected decentralisation of the health services in Mauritius, telemedicine will be useful in linking small health centres to the main hospitals for consultation of medical information databases (example, X-rays, scans etc.) and remote diagnosis by a doctor. The Product used for the Project: Nowadays, it has become somewhat easy to transmit images between two remote sites. However, there are many more requirements which have to be considered in the design of an appropriate tool for medical communication. Actually, these requirements encompass the quality of image, the integrity of data, the confidentiality of information and the performance in terms of transmission speed. In addition, interactive communication has also to be offered to allow optimal communication between the sites. For the introduction of the telemedicine project, the Sigmacom product [1] has been found to include all the above functionalities and, therefore, provides a comprehensive tool for medical communication. This
product aims to respond to the ever increasing demand in medical multimedia communication (picture, data, voice). It offers modular products that include the state of art technologies in the following areas: 1) teletransmission 2) digital imaging 3) archiving and storage. The Sigmacom product offering targets all communication needs in every medical speciality: radiology, cardiology, ophtalmology, gastro-enterology, nuclear medicine and anatomo-pathology, etc. One of the applications of the Sigmacom products is Teleradiology-telediagnosis. It is this last application which was implemented in Mauritius for the Ministry of Health. For every transmission session, statistical information is generated and saved locally on the Sigmacom station. This will help to evaluate the usage of the image transmission network in terms of efficiency, profitability, and enhancement of quality of care. Project Description: The telemedicine project consisted in exchanging high-quality images of X-ray films or CT scans with specialists abroad for tele-diagnosis purposes especially in difficult and complex cases. This would allow medical personnel in Mauritius to establish an interactive communication with the experts to discuss about the diagnosis of the medical images being shared between them and, that, in real time. The equipment used for the project consist of the following: 1) A Personal Computer with the following specifications: • A Pentium Processor (166 MHz) • A 2.5-Gbyte Hard Disk • 32 Mbytes of RAM • A Super VGA Monitor of at least 17 inches with a Display resolution of at least 1032*1032 2) A negatoscope (as shown in Figure 1) fitted with a Black and White CCD camera plus zoom at the top and a glass pane with a bulb underneath at the bottom where the film is to be placed. The CCD camera is supported on a stand, which allows it to be adjusted sideways, forward and backward, and up and down. 3) connected on an ISDN line. The ISDN card is interfaced to the ISDN BRA line to transmit medical images to the distant end at the transmission speed of 64-kbps (using one of the two B-channels). The second B-channel will be available for simultaneously establishing a telephone call between the 2 sites to eventually discuss about the medical images using the “telecursor” function. 4) A Digitalisation card which is interfaced to the CCD camera. 5) The complete Sigmacom software (for the CCD camera and digitalisation card) which includes a compression and decompression software module. The Sigmacom software can be installed on Windows 95 or Windows.NT platforms.
Negatoscope
Adjustable CCD camera Passive Bus Digital card 17 inches SVGA monitor Video
ISDN BRA line NT1
ISDN phone
X-ray film
ISDN card Lit Glass pane
Keyboard CPU
FIGURE 1: The Telemedicine Station
The X-ray film is placed just below the CCD camera on the glass pane which is lit in the background to provide a clear image. The latter is displayed on the SVGA monitor simultaneously through the connection of the CCD camera to the digital video card installed on the Personal Computer. The CCD camera’ position, zoom and brightness is then adjusted accordingly to get the required image quality. s Then the medical image is compressed and stored as a file that can be transmitted to a distant station for remote diagnosis as and when required. The above telemedicine station offers a perfect integration of the following functionalities: a) Image compression (JPEG) It is now well established that the JPEG image compression does not cause any noticeable degradation, when performed with a quality factor of less than 20 (compression ratio of 10).The advantages which are obtained with image compression are an increase of capacity of storage and a reduction of transmission time (about 10 times faster). As an example, the transmission of a patient file of 15 CT slices of a resolution of 512*512 over the ISDN network will normally take 9 minutes. Using image compression with a quality factor of 20, it will take less than one minute. b) Interactive communication - Telecursor
Besides the possibility of transferring the patient’ files to a remote destination, the station also offers the s following features for real time interaction: 1) the “telecursor” function 2) remote control possibility for some commands The telecursor function provides the possibility for remote pointing with a cursor. Each party can watch in real time the movement of the cursor by the other side. Hence, both parties can comment about any particular area on the medical image being shared by them by making use of the telecursor function. It is also possible to control remotely the display of the next or previous image in the patient’ file and perform s an image reversal Right/Left or Top/Bottom. The telemedicine system described above has been tested successfully with France and Reunion island and radiologists on Mauritius side were very impressed with the quality of the medical images which were exchanged and also with the interactive communication that was possible using the telecursor function. The telemedicine project was started in the teleradiology field and will eventually be extended in other medical areas. At the same time, it has been proposed that the telemedicine application be used as tool to provide training facilities to the medical personnel. 3 PROBLEMS ENCOUNTERED
In the first phase, the telemedicine station was meant to be used on the international side as there was only one system installed locally. The problems were identified after the telemedicine station was installed and commissioned at a major hospital in the north of Mauritius. There has been practically no usage of the telemedicine equipment by the medical staff up to now. Investigations have been carried out to find out what are the possible reasons that have led to such a situation. Initially, it has to be highlighted that the equipment was not actually placed in a real working environment and, consequently, radiologists ignore the fact that the telemedicine station was forming part of their medical instruments. It could also be that medical officers do not feel the necessity of using this system in their day to day duties. They might think that they have all the expertise required and it was not necessary to get a second opinion or advice from their colleagues abroad. Some officers seem to be overloaded with work and they don’ have spare time for using the equipment. t It was also deduced that the system appeared to be too complex to some of its users especially as some of these were not computer literate. In fact, in the health sector there is a limited number of computers and competence for telemedicine. The medical officers did not know to whom to communicate to exchange medical images. Here, it should be pointed out that the majority of Sigmacom stations are actually installed in France and the users of the system had no other option than to communicate with these stations. In this respect, a list of hospitals in France equipped with the Sigmacom station together with a list of contact persons at these hospitals were handed over to the Ministry of Health. Here, there was the problem of language. Most medical officers have followed their medical courses in English at the university and they said that it would be difficult for them to work with their colleagues in France as they will have problems understanding the technical terms used in medicine. There is also the hesitation to make the
first move in a case where no bilateral agreement has been undertaken between the hospitals concerned. On the budgetary side, the high cost associated with international calls is a constraint in promoting telemedicine projects. 4 CONCLUSION AND RECOMMENDATIONS
The requirements for telemedicine in developing countries are not the same for different countries and the telecommunications infrastructure also varies a lot. The greatest need for telemedicine is actually in countries where there are hundreds of villages which are deprived of efficient health services due to their remoteness. The implementation of telemedicine projects is not easy and need to carefully planned among developing countries. The technology is not sufficient to get the telemedicine concept working as the participation of every individual is of prime importance. It is also important to educate people on the advantages that telemedicine offers. The following recommendations have been made below based on problems which have been identified earlier: 1) A telemedicine project has to be well planned and organised. The key players have to be identified right at the beginning of the project. The aims and objectives of the project have to be well defined. A project leader needs to be identified for telemedicine in the health sector. 2) More computer equipment has to be deployed in hospitals to drastically increase computer literacy. In this aspect, a simple project might be initiated by building up a database of medical information or creation of a web site which can be accessed remotely by medical officers through their personal computers over an intranet. 3) Adequate training concerning all aspects of telemedicine has to be provided to some key personnel in every hospital. These officers will afterwards be required to train the other medical staff who will directly be involved in telemedicine. 4) It is very important to identify correspondants with whom the medical officers want to communicate using the telemedicine system and from there exchange groups may be created. 5) An evaluation of the telemedicine project need to be carried out by monitoring the following parameters: number and type of exchanges that have taken place over the telemedicine application number of persons using the telemedicine application improvement in diagnostic quality whether cost savings through telemedicine is being achieved.
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