Using HSPA to improve the telemedical links on a moving ambulance

As the demand for faster and more effective health care increases, there is a growing need to establish mobile, high-speed communications between a moving ambulance and a consultation point (usually a hospital). The recent addition of HSPA (HSDPA and HSUPA) into the UMTS suite provides higher bandwidth and reduced delays, making this choice ideal for real-time telemedical applications. In this paper, we will describe a set of scenarios that took place in a typical large city area, along with their equivalent results: a moving ambulance was linked with a consultation station using HSPA and several videoconferencing sessions were initiated. Best-case, worst-case and average scenarios were recorded. Furthermore, in areas where the UMTS reception was marginal, a repeater was placed on top of the vehicle to boost up the signal power and thus maintain the higher bandwidth. Finally, treating doctors were asked to evaluate the effectiveness of this system's outputs, based on a variety of objective and subjective criteria.

Mobile consultant: evaluation of additional services

As the need for mobility in the medical world increases, newer systems and applications came to light; many of them based on wireless and mobile networks. PDA based systems were presented in the past, capable of videoconferencing and transmitting high quality images between a roaming consultant and a fixed point in the hospital. These systems not only had desirable characteristics but also incorporated additional services that were found of value: paging, Voice over IP calling, Internet, email, intranet, patient record update, etc This paper presents an engineering and clinical evaluation of those additional services based on both objective and subjective criteria. It concludes that such complementary services can be desirable as they increase personnel mobility, utilize the hospital resources more efficiently while at the same time increase productivity and decrease the cost of hardware and communications.

Mobile consultant: combining total mobility with constant access

Minimizing the time required for a medical consultant to offer his/her expert opinion, can be viewed as a life-saving procedure. We have designed and tested an integrated system that will allow a medical consultant to freely move either within, or outside the hospital, while still maintaining constant contact with the patients via videoconferencing and high-resolution imaging. The above system is explained in this paper, along with its advantages and its potential limitations. Conclusively, we demonstrate that such a system further increases the mobility of the medical consultant, while improving the healthcare service.

Using handheld devices for real-time wireless teleconsultation

Recent advances in the hardware of handheld devices, opened up the way for newer applications in the healthcare sector, and more specifically, in the teleconsultation field. Out of these devices, this paper focuses on the services that personal digital assistants and smartphones can provide to improve the speed, quality and ease of delivering a medical opinion from a distance and laying the ground for an all-wireless hospital. In that manner, PDAs were used to wirelessly support the viewing of digital imaging and communication in medicine (DICOM) images and to allow for mobile videoconferencing while within the hospital. Smartphones were also used to carry still images, multiframes and live video outside the hospital. Both of these applications aimed at increasing the mobility of the consultant while improving the healthcare service.

Performance of a wireless telemedicine system in a hospital accident and emergency department

We developed a mobile, wireless videoconferencing system suitable for use in a hospital accident and emergency (A&E) department. Four consultants, eight junior doctors and 11 nurses working in the A&E department tested the system. Transmission of three types of data (audio, still images and video) was tested. The audio for the breath and heart sounds was judged to have some disturbance. One consultant rated the diagnostic quality as good and one rated it as fair. The quality of the still images was judged to be from fair to excellent. The quality of the video was rated as good. Possible interference between the wireless local-area network and various medical devices in the A&E department were examined, but none was detected. The four consultants who tested the system were very positive in their initial comments. Eight of the 11 nurses remained sceptical about its use. Of a total of 20 patients who answered a survey, 13 were slightly anxious about the use of the system to transmit their data to a distant point. Overall, the performance of the system was satisfactory for use in the A&E role.

Ambulance 3G

Minimising the time required for a patient to receive primary care has always been the concern of the Accidents and Emergency units. Ambulances are usually the first to arrive on the scene and to administer first aid. However, as the time that it takes to transfer the patient to the hospital increases, so does the fatality rate. In this paper, a mobile teleconsultation system is presented, based primarily on third generation mobile links and on Wi-Fi hotspots around a city. This system can be installed inside an ambulance and will permit high-resolution videoconferencing between the moving vehicle and a doctor or a consultant within a base station (usually a hospital). In addition to video and voice, high quality still images and screenshots from medical equipment can also be sent. The test was carried out in Athens, Greece where a 3G system was recently deployed by Vodafone. The results show that the system can perform satisfactory in most conditions and can effectively increase the patient's quality of service, while having a modest cost.

Use of 3G mobile phone links for teleconsultation between a moving ambulance and a hospital base station

We developed a mobile teleconsultation system based on third-generation mobile phone links. The system comprised a laptop computer and a digital camcorder. It was installed inside an ambulance to allow video-conferencing between the moving vehicle and a doctor at a base station. In addition to video and voice, high-quality still images could also be transmitted. A series of 17 trial runs with real ambulance patients was conducted in the city of Athens. In general, the videoconferencing sessions produced relatively clear video. The bandwidth was high enough for a satisfactory video of 10-15 frames/s. During a total testing period of 23 h and in an area of about 180 km2, there were nine instances of signal loss, amounting to a total of 17 min. The general opinion formed by the doctors was that the system produced good results. All initial diagnoses made using the system agreed with the final diagnoses of the patients. The study showed that the mobile system could reduce the time before an ambulance patient is seen by a doctor.

Mobile e-Health: The Unwired Evolution of Telemedicine

The movement of telemedicine from desktop platforms to wireless and mobile configurations may have a significant impact on future health care. This paper reviews some of the latest technologies in wireless communication and their application in health care. The new technologies can make the remote medical monitoring, consulting, and health care more flexible and convenient. But, there are challenges for successful wireless telemedicine, which are addressed in this paper.

The accuracy of length and angle measurement in videoconferencing teleradiology

Telemedicine was used to make measurements on a series of radiographs. The first group consisted of 25 radiographs of the cervical spine; four lengths were measured on each. The second group consisted of 100 wrist radiographs showing Colles fractures; the degree of backward angulation of the distal fragment was measured on each. Measurements were made via a videoconferencing link. The consultant used the shared white boarding facility to indicate where on the film the measurements were to be made. The videoconferencing link was used to check that the measurements were being made correctly and a nurse measured lengths and angles. In addition, the consultant used the link to read the scales on the measuring instruments for himself. Four different methods of measuring length were tested and three methods of measuring angle. A transparent plastic ruler was best for measuring length-the emergency nurse practitioner and the consultant made almost all measurements to an accuracy of 1 mm. A protractor with pen marker was best for measuring angles; all were made to within 2 degrees. Simple methods can be used to measure lengths and angles in videoconferencing teleradiology.

Four years' experience of telemedicine support of a minor accident and treatment service

In 1996 we studied patients attending a minor accident and treatment service in London, some of whom were the subjects of teleconsultations with a main hospital emergency department. In the subsequent four years, 56,139 patients were seen at the minor accident and treatment service unit. Teleconsultations were performed in 2032 cases (3.6%). Most of the teleconsultations (58%) concerned patients with fractures. The main reason for teleconsultation was to review and discuss radiographs (46%). In comparison with the 1996 study, both the emergency nurse practitioners and the consultant had improved the accuracy of their teleradiology diagnosis, although the difference was not significant. Most of the telemedicine patients (90%) did not need a transfer to the main department. Thus telemedicine allowed local decision making in the majority of cases. In the 1996 survey, 75% of patients were sent to their general practitioner or to the main hospital department; in the present survey, this proportion had halved, to 38%. The present study showed that teleconsultations are an effective way of preventing patients being transferred unnecessarily from a minor accident and treatment service to the main hospital accident and emergency department.

Social presence in telemedicine

We studied consultations between a doctor, emergency nurse practitioners (ENPs) and their patients in a minor accident and treatment service (MATS). In the conventional consultations, all three people were located at the main hospital. In the teleconsultations, the doctor was located in a hospital 6 km away from the MATS and used a videoconferencing link connected at 384 kbit/s. There were 30 patients in the conventional group and 30 in the telemedical group. The presenting problems were similar in the two groups. The mean duration of teleconsultations was 951 s and the mean duration of face-to-face consultations was 247 s. In doctor-nurse communication there was a higher rate of turn taking in teleconsultations than in face-to-face consultations; there were also more interruptions, more words and more 'backchannels' (e.g. 'mhm', 'uh-huh') per teleconsultation. In doctor-patient communication there was a higher rate of turn taking, more words, more interruptions and more backchannels per teleconsultation. In patient-nurse communication there was relatively little difference between the two modes of consulting the doctor. Telemedicine appeared to empower the patient to ask more questions of the doctor. It also seemed that the doctor took greater care in a teleconsultation to achieve coordination of beliefs with the patient than in a face-to-face consultation.

Level of diagnostic confidence, accuracy, and reasons for mistakes in teleradiology for minor injuries

The objective of this study is to determine whether eliminating uncertainty in diagnosis improves accuracy in teleradiology for remote trauma management and to assess the correlation between the probable reason for the mistake and the level of confidence. An emergency physician interpreted 2133 radiological series transmitted from a community hospital to an emergency department using videoconferencing equipment. He marked his level of confidence as 1 = sure positive; 2 = fairly sure positive; 3 = unsure; 4 = fairly sure negative; 5 = sure negative. The emergency physician also entered free-text comments, e.g., feeling tired, to enable a better understanding of what was happening. The accuracy, sensitivity, and specificity were 97.3% (98.6%), 94.48% (96.72%), and 98.63% (99.42%), respectively. Figures in brackets represent the 93.5% of cases in which the level of confidence was graded as sure. Boredom and hurry were the main reasons identified for mistakes. Reducing uncertainty in diagnosis may improve the accuracy of screen interpretation. This first series must be reproducible by others before any general use of such systems can be made for primary diagnosis. American College of Radiology standards must be met.

Are accident and emergency consultants as accurate as consultant radiologists in interpreting plain skeletal radiographs taken at a minor injury unit?

The objective of this study was to compare the accuracy of an accident and emergency (A&E) consultant in interpreting plain skeletal radiographs with that of a consultant radiologist (CR). It took the form of a retrospective study of 2133 radiographs taken in a Minor Injury Unit (MIU). A&E consultant reports on these films were compared with those of a CR and also with a gold standard. The A&E consultant diagnoses achieved an accuracy of 98.5% (CR 97.8%), sensitivity of 97.8% (CR 98.1%), specificity of 98.8% (CR 97.7%), positive predictive value of 97.3% (CR 95.1%) and negative predictive value of 98.97% (CR 99.07%) (gold standard of 100%). In conclusion, the A&E consultant reports of plain skeletal radiographs generated from an MIU were as accurate as those of a consultant radiologist. This could have significant implications for the wet reporting of A&E departmental radiographs.

Using telemedicine for distance education

We assessed the use of videoconferencing as an educational tool for students and emergency nurse practitioners based at a minor injuries unit. Nineteen teaching sessions were conducted by videoconferencing, followed by a debriefing session in which the participants made observations about their educational experience. The participants observed that the experience was rewarding. The success of the teaching session depended on group size: an upper limit of six is recommended. The teaching sessions encouraged debate, independent thinking and peer communication.

Avoiding artificiality in teleconsultations

The ideal videoconferencing environment would produce the minimum feeling of artificiality for its users. We assessed nurse and patient perceptions of artificiality by varying the technical and operational procedures for telemedicine in a minor injuries unit. Twenty-five patients and eight emergency nurse practitioners (ENPs) participated in simulated teleconsultations under a variety of different conditions and completed a Likert-scale survey. There was a close correlation between the ENPs' ratings and the patients' ratings for the various factors (r > 0.99). In relation to technical factors, a flicker-free television screen and the user being seated close to the screen were preferred. Similarly, in relation to operational procedures, an initial explanation of telemedicine, introductions and adequate preparation were also preferred. The study suggests that careful attention to technical specifications and operational procedures can reduce the perceived artificiality of teleconsultations.

Changes in the workplace with telemedicine

The opinions of 110 emergency nurse practitioners (ENPs) practising telemedicine in 11 British minor injury units were sought using a questionnaire. There were 90 respondents (82%). The respondents thought that, since telemedicine had been introduced, they had become more open to change (96%) and more ready to grasp opportunities (93%). They considered that they were more keen to learn new things (99%) and were better disposed to teaching others (90%). They adopted a more advisory and supportive role (80%), found the work environment more varied (83%) and were well disposed to teamwork (64%). The power balance with doctors had changed (86%) and doctors indulged in dialogue rather than direction (69%). The results suggest that although changes have started in the workplace, they have not been as dramatic as a previous study of patients had predicted.

Long-distance education in radiology via a clinical telemedicine system

The objectives of the present study are to examine quality of learning, improved comprehension, and the preferred method of learning with teleradiology. Thirteen pairs of medical students transmitted 2,133 radiological series of skeletal injuries telemedically from a community hospital to the main emergency department. Students marked their diagnosis, quality of learning, improvement in comprehension, and preferred method of learning, each marked on a Likert scale. The quality of learning of the 13 sessions marked by the pairs of the students was ranked as excellent = 6, good = 16, fair = 4, unsatisfactory = 0, poor = 0. This was in contrast with the radiological series, which was marked as excellent = 55% or poor or unsatisfactory = 27.5%, most of the poor marks, as explained by the students, being awarded to transmissions in the second half of what had been very long sessions. The pre-tuition comprehension improved from 73 series marked as poor, and 1,037 series marked as unsure. The preferred method of tuition was teleradiology only in 21.8%, teleradiology teaching enhanced by clinical features, lectures and personal study in 62%. Teleradiological sessions needed to be reduced to an hour. Teleradiological teaching is a good method as long as the session lasts no more than 60 minutes, is interrupted by a 10-minute coffee break, and is supplemented by clinical features, lectures, and personal study.

Depth perception in telemedical consultations

This study aimed at quantifying diminished depth perception in telemedicine due to the two-dimensional image and to devise coping strategies for the problem. Two hundred and thirty-five patients in the telemedicine room of a Minor Accident and Treatment Service were studied. The magnitude of impaired depth perception was noted. Seven coping strategies were used and the resolution of the problem was measured. Depth perception was judged to be less than 90% of binocular vision in 235 cases. This improved to more than 90% of binocular vision in 99 of the 234 cases (42.13%) when using of all strategies. Improvement by rotation of the camera 30 degrees at a time in the axial plane was the most useful strategy and it occurred in all 235 (100%) cases. Light adjustment and angulation occurred in 206 of 235 cases (87.66%). Comparison with the opposite side helped in 179 of 235 cases (76.17%), skin color and texture in 139 of 235 cases (59.15%), shutting one eye in 103 of 235 cases (43.83%), enlarging the image in 85 of 235 cases (36.17%), and diminishing depth of field of lens in 77 of 235 cases (32.77%). Other visual cues occurred in 63 of 235 cases (26.81%). Impaired depth perception is a significant problem in telemedicine. It can be improved to make a confident diagnosis in most cases by adopting a variety of strategies that are described in this paper.

ENP review clinics

As public expectations of the health service progressively increase, there will be greater pressure to increase the staffing of A&E. departments. An additional expectation is that the public wants the provision of local services. An option is to ask ENPs to do review clinics. This paper looks at the feasibility of this innovation.

Evaluation of telemedical orthopaedic specialty support to a minor accident and treatment service

Over three and a half years there were 200 teleconsultations between emergency nurse practitioners at a minor accident and treatment service and the orthopaedic service of a main hospital. The main problems were fractures (93% of cases). The reasons for consultation fell almost equally into four groups: request for direct ward admission; discussion and decision about treatment; decision about the disposition of a case; and diagnosis. The technical quality of the majority of teleconsultations was considered satisfactory. Following the teleconsultation, 39% of patients were admitted to hospital, 6% were transferred to the accident and emergency department for a face-to-face consultation, and 56% were discharged and referred to a review clinic. Of the 200 cases, 193 needed teleradiology and the nurse practitioners and the orthopaedic registrars diagnosed all these cases correctly, as judged by the subsequent radiologist's report. Teleconsultations save time and prevent the unnecessary transfer of patients to main hospitals.

A follow-up study of remote trauma teleconsultations

We conducted a follow-up study of patients who had attended a nurse-led minor accident and treatment service (MATS) and who had participated in a teleconsultation. Over three and a half years, 31,510 patients had attended the MATS unit and 1854 patients (5.9%) of these had participated in a teleconsultation. Of the 1854 telemedicine patients, 1199 had been referred to hospital or clinic and 1153 had actually attended. Retrospective examination of the relevant hospital records showed that in 25 cases (2%) the original telediagnosis was considered incorrect at face-to-face review and that treatment was either begun or changed in 264 cases (23%). All patients, including those discharged home after the teleconsultation, were sent a questionnaire about any changes to their injury. Of the 655 patients discharged home, a questionnaire response was obtained from 598 (91%). Following discharge, 43 of these patients had sought help from another health-care provider (the majority from their general practitioner). Of the 46 patients referred to hospital who did not keep their follow-up appointments, questionnaire results were obtained from 35 (76%). Nine of these patients had sought help from another health-care provider (the majority from their general practitioner) but there had been no change in diagnosis or treatment. Our findings suggest that teleconsultations are an effective means of delivering minor injuries care.

A pilot study of the technical quality of telemedical consultations for remote trauma management

The technical performance of a telemedical system when used for remote trauma management was compared with face-to-face consultation. Two rooms, 20 yards apart, were linked telemedically in the same Accident & Emergency Department. Two hundred patients, with 'minor' and 'moderate' injuries, underwent the two types of consultation. The Accident & Emergency consultant marked physical parameters using a five-point pre-determined Likert scale. The following parameters were thought to be of excellent quality when compared to face-to-face consultation: overhead fluorescent lighting for the background illumination, video lighting for a close-up view, sound quality after volume adjustment, echo-cancellation after adjustment and lip synchronization. However, the following parameters scored poorly: sound before volume adjustment, echo-cancellation before adjustment, fine and coarse movements. It can be concluded that the quality of lighting and image quality are good in telemedicine. Sound and movement still present some problems. This technology is likely to be used more frequently for remote trauma management.

The changes patients expect to result from telemedicine

A focus group of 12 persons who had been the subject of telemedical consultations met four times to discuss what changes to the health service they expected to result from the widespread introduction of telemedicine. There was general agreement about four main themes. First, rationalization of care would occur. For example, health-care spending would have to take into account the need for local care and there would be more primary care, with telemedicine providing easy access to specialists. The implementation of home care would be facilitated. Second, there was an expectation that costs would be controlled, for example by the use of multi-skilled personnel and by having fewer, smaller, newer and different hospitals. Third, quality control would be introduced (e.g. the widespread use of evidence-based medicine). Fourth, it was agreed that a change of professional attitudes would be needed, particularly among doctors (e.g. more openness, less bluster and less hierarchy). Telemedicine is likely to be a great driver of change in the health service. The changes relating to the location and type of work are fairly predictable, but the changes in relationships are likely to be profound.

Colour perception in telemedicine

A doctor's experience of examining patients is for the most part in artificial light, which is known to affect colour perception. However, the phenomenon of colour constancy (the perceived stability of the colour of objects, despite changes in the illuminating light) allows the eye and brain to compensate, to some extent. Colours like red, yellow, green and blue, which are processed by basic colour-opponent mechanisms, show better colour constancy than intermediate colours. These are the very colours that are involved in skin tones. A skin rash can therefore be viewed sometimes acceptably with lower-quality telemedical systems. Colour is undoubtedly important in telemedicine, but while a great deal is known about the fundamentals of colour perception from laboratory experiments, little is known about the effects of colour on the outcome of the telemedical process. The field of colour perception therefore represents a fertile area for telemedical research.

Supervising trauma life support by telemedicine

The resuscitation room in a community hospital was linked with a main hospital accident and emergency department using telemedicine equipment working at 384 kbit/s. Fifteen simulated casualties replicated the 'moulage' scenarios in the Advanced Trauma Life Support Course Manual of the American College of Surgeons. Each of the 15 scenarios was broken down into three main parts: the primary survey, resuscitation and the secondary survey. While a physician in the community hospital undertook each task, a senior doctor in the accident and emergency department recorded his degree of confidence in the supervision of the task on a five-point scale. There were features of the management which the supervisor found difficult, mainly related to the camera view and the use of a proxy examiner. However, supervising major trauma management by telemedicine was feasible. The average scores were mostly above 3 and often above 4 in the assessment of the primary survey and the resuscitation. The average scores were mostly above 3 for the secondary survey but were less often above 4 than for the primary survey and the resuscitation. Trials of remote trauma management with real patients appear to be justified.

A comparison of telemedicine with face-to-face consultations for trauma management

We compared the accuracy of teleconsultations for minor injuries with face-to-face consultations. Two hundred patients were studied. Colour change, swelling, decreased movement, tenderness, instability, radiological examination, severity of illness, treatment and diagnosis were recorded for both telemedicine and face-to-face consultations. Colour change showed an accuracy of 97%, presence of swelling or deformity of 98%, diminution of joint movement of 95%, presence of tenderness of 97%, weight bearing and gait of 99%, and radiological diagnosis of 98%. The severity of illness or injury was overestimated in one case and underestimated in five cases. Treatment was over-prescribed in one case and under-prescribed in three cases. The final diagnosis was correct in all but the two cases in which mistakes were made in the teleradiology. Overall, there was good accuracy using teleconsultations.

Transfer of telemedical support to Cornwall from a national telemedicine network during a solar eclipse

During late 1998 and early 1999, planning officers in Cornwall predicted a huge increase in summer visitors to the county to observe the August solar eclipse. There was the possibility that a mass gathering in Cornwall could overload existing arrangements for handling accident and emergency patients. We therefore set up a telemedicine system to support the county's minor injury units (MIUs) from hospitals throughout the UK. Six main hospital accident and emergency departments outside Cornwall with existing links to their own MIUs were twinned with 10 of the 11 MIUs in Cornwall before the expected date of the gathering. The network was live for nine days, starting four days before the eclipse, and 2045 patients were seen in the 10 MIUs. There were 93 telemedicine calls from the 10 MIUs, involving 91 patients. Overall, 4.6% of the patients required a telemedicine consultation. Fifty-seven calls were made during working hours. Thirty-four patients were referred for further management, of whom 18 were referred on the same day. The transfer of telemedical support to a national network was successful.

How do teleconsultations for remote trauma management change over a period of time?

We obtained follow-up information about the new patients seen at a minor accident and treatment service (MATS) staffed by emergency nurse practitioners (ENPs). A previous study, of 150 teleconsultations in a six-month period starting in April 1996, was used for comparison. In the present series, 150 teleconsultations occurring in a four-month period starting in April 1999 were studied; the patients constituted 5.6% of the 2658 new attenders or 3.8% of the 3936 total attenders. In comparison with the study three years before, falling teleconsultation rates were partly offset by increasing numbers of attenders and an extension of the ENPs' roles and skills. Teleconsultation rates rose when the number of consultant-run clinics was curtailed and ENP-run clinics replaced some of them. Eligibility to request and report more radiographs reduced the need for teleconsultations, and subsequently teleconsultations for help with interpretation of radiographs fell as the ENPs became more experienced. Specialty residents trusted ENP judgement and accepted telephoned direct admission of cases to their wards. Fewer teleconsultations were required for soft-tissue injuries. Telemedicine is an excellent educational tool.