CLINICAL PRACTICE

However no progress has been observed in bringing telemedicine into clinical practice. There are several reasons for that.

First, the medical staff is not prepared to implement modern telecommunication and computer technology. The complexity of the technology, its only partial adaptation for the direct implementation in medicine, and the lack of time leading medical experts have to master it are posing quite explainable problems for using telemedicine in practice.

Second, there is no system (or it is in the very initial stage) of teaching and training personnel in telemedicine.

Third, for the lack of special-purpose hardware and software for telemedicine sessions in real time many experts use standard business video conferencing many parameters of which do not meet the requirements set forth for telemedicine consultations.

And fourth, the financing of telemedicine implementation has not been sufficiently developed yet that gives a misleading impression of the necessity immediate investing of rather large funds that the majority of hospitals cannot afford.

In the authors' opinion, the best plan to be followed is to create inhospital medical video networks that do not require large financing in the initial stage and open fresh opportunities for clinical practice.

Potentialities of medical video networks.

The design and realization of medical video networks in any hospital should take into account its management and personnel organization systems. It is known that medicine, especially the Russian medicine, accepts innovations with great difficulty. Because of this each operator's station should be adopted for a concrete leading medical expert in one or other field of diagnosis or treatment.

A properly created medical video network will provide the following opportunities for a hospital:

• For the professional development of the hospital medical staff. A video network within a hospital provides an opportunity to follow the course of diagnosis and treatment and to be trained in the same in interactive mode without getting in the way of the process. Being a viewer of the work of hospital leading experts in the interactive mode with an opportunity of voice communication gives much more for any doctor than any multi-hour lectures. In the course of observation any medical student may take a note of the most interesting points and create his own video, audio, graphic and text data base. Merely theoretical workshops and lots of time and funds are no longer required This makes education much more efficient financially. In a similar way high-skilled doctors may follow the course of diagnosis and treatment of their young colleagues and intervene if required. Apart from training, they have a chance to prevent the young experts getting into an undesirable situation that may arise.
• Video consultations become possible during which different experts may investigate scheduled or urgent cases directly including diagnosis and treatment. For instance, the Moscow Oncologic Research Institute named after P.A.Herzen in the first stage of the creation of their video network organized an interaction between the endoscopic department (headed by Professor V.V.Sokolov) and pathomorphologic department (headed by Professor G.A.Frank). As a result a pathomorphologist may observe biopsy in the course of bronchoscopic or gasteroscopic diagnosis, record the picture of the tumor and the point where the biopsy was made that contributes greatly to further hystologic diagnosis.
• Leading experts of the hospital have an opportunity of more frequent consulting in the course of diagnosis and surgery. For instance, the head of the endoscopic department has an opportunity of remote consulting and participation in diagnosis that is being made by his employees. In this case he saves both time and efforts and at the same time his direct participation makes the medical procedure more efficient. In a similar way leading surgeons of the hospital have an opportunity of remote control over their subordinates and correction of their actions. Insurance medicine and patients may take this process as diagnosis or treatment with personal participation of leading experts.
• A new type of the interaction among medical staff is created. In the framework of the current system when an attending doctor is responsible for making a decision he may have additional opportunities of taking advice that makes his work more open for his colleagues. In the course of such consulting all hospital experts have practice in remote working together and become experts trained for commercial telemedical consultations in which other hospitals may take part as well.
• Possibilities of inter-operation consulting become wider. This is especially urgent for the hospitals that have several operating rooms located apart from each other. In this case no urgent search, call and waiting for a medical consultant are required to take advice on one or other complicated matter that may arise in the course of the operation. For instance, currently the Central Hospital at the Ministry of Realway Communications is realizing a project of creation of a video network to connect several operating rooms and the cytologic department (headed by Professor N.A.Shapiro). As a result the participation of leading cytologists in urgent diagnosis will reduce the time required to make diagnosis and improve chances to make a correct decision.
• Workable possibilities of telemedical consulting with participation of experts of different hospitals are created. With the availability of medical video networks in several hospitals it is really possible to conduct telemedical consulting among hospitals. This process becomes natural because experts of different hospitals who have gained experience in remote consulting in the framework of their local video networks may easily begin remote interaction.
• A base is created for rendering radically new medical services - a remote observation and consulting of home patients.Software and hardware of medical video networks will allow hospital experts to offer their patients a new type of medical services - an observation and consulting at home by means of telephone and other communication channels (depending on the financial situation of a patient). This is especially pressing for patients after operations or hospital treatment.

The realization of a pathomorphologic fragment of the medical video network.

A realization of pathomorphologic fragments of medical video networks is one of the initial steps in creating of a video network in a hospital in general. Within the framework of this fragment training sessions of both pathomorphologic research and scheduled or inter-operation consulting may be conducted.

There are several problems on the way they may be solved the efficiency of telemedical consulting in the course of pathomorphologic research depends mainly.

The first problem is how pathomorphologic preparations are made. This is a very important process, which is responsible for the quality of initial information and thus the efficiency of all further processes of pathomorphologic diagnosis. Let us use hystologic test to consider this aspect. For this process the quality of a glass plate (how thick it is, how uniform the both glass surfaces are, how transparent they are, etc.) the quality of methods used to prepare the tissue to be investigated, and the quality of its applying to the surface of glass are extremely important. Once the above processes have been done properly, one can be assured that all further stages of the hystologic test will have the greatest possible efficiency. Similar methods are available for cytologic tests.

The second problem is the problem of developing of a uniform procedure of telemedical pathomorphologic consulting for all parties involved. Thus it is extremely important to arrange for advance training of doctors, the subscribers of the fragment of the video network, in the diagnosis methods used by their high-skilled director in his every day practice.

Operational methods of a pathomorphologic fragment of the video network.

The most complete description of the operation methods of a pathomorphologic fragment of the medical video network may be obtained in the course of training usage of this fragment.

Several methods of traditional training of pathomorphologists exist:
Face-to-face training. A teacher studies a preparation under the microscope and a student or students in turn view those fragments of the preparation which the teacher offers them to view. Each fragment of the preparation is commented and discussed. The chief disadvantage of this method is that it does not make available to follow all actions of the teacher in the course of the review of the preparation and at the moments of changing from one fragment to another. In addition it is not possible to keep records of the preparation pictures with the required comments for their repeated reviewing.
Training with the usage of catalogues and other special literature. This method offers no interactive process and gives no opportunity to learn how to study a concrete preparation. A low quality of the illustrations is rather common for catalogues.
Computer training. This is the most progressive method that allows not only to follow diagnosis in real time but to discuss all actions of the teacher in the interactive mode as well.

None of the existing methods teaches telemedical, or remote consulting. While developing the DiViSy PM2000 software and hardware complex for pathomorphologic fragments of the video network all advantages of the existing methods of training were taken into account and added by some fresh possibilities offered by new digital and telecommunication techniques.

The greatest possible efficiency of teaching methods of pathomorphologic diagnosis may be gained providing the following:

• an uninterrupted visual control of teachers over all the diagnoses being made in real time,
• a duplex sound exchange among all parties of the training process,
• an availability for students to do immediate records of the most significant points of the diagnosis,
• an availability for students to do further individual digital editing of the records done (video, audio, text) for keeping records and refreshing previous materials,
• an availability for a teacher and students to communicate only in a remote audio/visual mode (an unavailability of direct contacts teaches remote contacts),
• an availability of the remote control over a microscope.

All the above availabilities are provided by the DiViSy PM2000 software and hardware complex.

The composition of the DiViSy PM2000 software & hardware complex for a pathomorphologic fragment of the medical video network.

The DiViSy PM2000 software and hardware complex is comprised of two types of telemedical units: DiViSy PM1 for a teacher (or a high-skilled doctor) and DiViSy PM2 for doctors involved in training (or doctors who would like to take part in telemedical consulting). An information exchange within the framework of this software and hardware complex is carried out through a local network which combines all telemedical units. If it is required to connect remote users, practically any communication channels may be used. In this case it should be taken into account that the speed of frame exchange of the pictures of the preparations to be studied depends on the speed of the communication channel.

The DiViSy PM1 telemedical unit for a teacher consists of a motor-powered Leica DMRXA microscope, an analogue 3CCD video camera, a BOVA-DiViSyPM1 unit for processing of video and audio information based on the Pentium III processor, a 17'' monitor, and required peripheral equipment (a video camera for video conferencing, a microphone, amplified speaker systems (a headset), a scanner, a printer, etc.).

The DiViSy PM2 telemedical unit for students consists of a Leica DMLB (DMLS) microscope, an analogue 3CCD video camera, a BOVA-DiViSyPM2 unit for processing of video and audio information based on the Pentium III processor, a 17'' monitor, and required peripheral equipment (a video camera for video conferencing, a microphone, amplified speaker systems (a headset), a printer, etc.).

The telemedical units include DiViSy PM2000 software, which allows:

• to provide in real time an entry and a conversion into the digital form of the video pictures received from both the microscope video camera and the video cameras for video conferencing,
• to provide in real time an entry and a conversion into the digital form of the sound signals from the users' microphones and to mix the sound,
• to transmit audio and video information among the parties involved in training. The DiViSy PM1 telemedical unit allows to manage the procedure of giving the floor to the parties involved in training,
• to record the training process either on the hard disk or on any other data carrier,
• to provide availability of simultaneous working with pictures of a pathomorphologic preparation for all the parties involved in training,
• to provide an output of the video information in the analogue form for viewing it on a TV monitor or recording it on a video recorder,
• to carry out a local and a remote control over the motor-powered microscope,
• to carry out other required functions in the course of training.

In addition, the telemedical units include standard peripheral equipment for a digital nonlinear montage that allows to edit educational films on the subjects of the workshops and lectures.

It is extremely important for the training process to place the telemedical units for experts to be trained in separate rooms isolated from each other. This allows to create an environment of the remote telemedical consulting and teaches the users to act at request of the teacher or their colleagues and to listen attentively to a user who has been given the floor without interrupting him, to wait for one's turn to be given the floor, and to manage the remote microscope independently. All this teaches the students to act together, that is required for telemedical pathomorphologic consulting in real time, and to participate in a more complicated process, in a video consultation. Developing rules of behavior during remote consulting is especially important for inter-operation telemedical pathomorphologic consultations when in the course of an operation the consulting doctor who may be far from the operating room makes an urgent diagnosis of the preparations with the doctor who is near the operating room and the diagnosis may be made within several minutes after the preparation has been made.

>The major results which may be achieved in the course of working in the framework of pathomorphologic fragments of medical video networks.

• Doctors are taught methods of pathomorphologic diagnosis through a detailed study of the methods of testing of various preparations perfectly known by a expert who teaches these methods.
• Doctors are taught methods of individual work on the telemedical units and methods of remote interaction with their colleagues and consulting doctors.
• Doctors keep personal records of the main and the most informative fragments of the lectures. The records contain video pictures of the preparations with the required sound and text comments.
• Doctors are taught methods of urgent inter-operation telemedical consulting for a further creation of such systems in their hospitals.

A regular work within the framework of pathomorphologic fragments of the medical video network will result in skilled experts who will be able not only to make top-quality pathomorphologic diagnosis but to take active part in bringing the new principles of working in remote telemedical consulting into every day practice.

Other fragments of the medical video network, endoscopic, ultrasound, X-ray, surgical, etc. will be operating in a similar way.

A distinctive characteristic of such fragments is their complete interfacing irrespective of the type of diagnosis or treatment. It is essential that all doctors, whose working in a definite fragment of the network is characterized by individual peculiarities, should have an opportunity of cooperating with doctors from other fragments. Such unification of the software and hardware potentialities of the operator's stations of doctors, the users of the video network, results in realization of video consultations. Different medical experts may be parties of a video consultation on the problems of concrete patients. For instance, when considering the diagnosis of an oncologic patient, who has undergone through several diagnostic processes, the attending doctor at the same time may discuss the problem of making diagnosis with a pathomorphologist, who explains his view and demonstrates a picture of the hystologic preparation, with a roentgenologist who may show an x-ray picture, with an expert in ultra sound diagnosis who demonstrates ultra sound pictures. Such discussion increases the likelihood of making correct diagnosis in complicated cases.

From December 14 through 17, 1999 in the conference hall of the Presidium of the Russian Academy of Science a subregional telemedicine workshop of the CIS and Baltic countries which was organized by International Electric Communication Union (ITU), Geneva, Switzerland, and Telemedicine Foundation, Moscow, Russia, was held. It was also attended by representatives of Belgium, Bulgaria, Malaysia, Norway, USA, Sweden, Japan and other countries.

At the same time with the workshop an exhibition of scientific and engineering achievements in telemedicine was organized. The DiViSy Research Center demonstrated on its exposition stand DiViSy telemedical units for pathomorphology, endoscopy, ultra sound, etc. Together with "Comcor" Company, the owner of the Moscow fibre-optical network for data transmission, a communication channel was organized with the Moscow Oncologic Research Institute named after P.A.Herzen and City Hospital no.33.

On December 15, 1999 a telemedical session on histology was conducted between the exhibition stand and the pathomorphologic department of the Moscow Oncologic Research Institute named after P.A.Herzen. Professor G.A.Frank conducted a training session on histology which was translated in real time to the exhibition through the fibre-optical communication channel and was on view simultaneously at three DiViSy telemedical units. The participants of the workshop attentively followed all stages of the diagnosis, viewed Professor G.A.Frank, heard his comments and asked questions. In this case within the framework of one channel two video flows of high quality and one sound flow were translated.

In a similar way other fragments of medical video networks will operate for endoscopy, ultra sound, x-ray diagnosis, control over laparoscopic and cavitary operations, etc. In this case all these fragments will be compatible with each other and make possible creating fully functional medical video network both for inhospital communication and communication among several hospital.

Summary.

At present all required software and hardware means for creating medical video networks are available.

The most efficient way to bring video networks into hospital practice is to do it by stages because it does not require large investments.

Bringing medical video networks into hospital practice is a real way of increasing the quality of the medical aid to be rendered and enhancing its efficiency.

A practice in medical video networks allows to develop methods of telemedical consulting, which will be used in working with remote hospitals.