Telemedicine System Telemedicine is the remote communication of

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Telemedicine System Telemedicine is the remote communication of information to facilitate clinical care. Jayanta

Telemedicine System Telemedicine is the remote communication of information to facilitate clinical care. Jayanta Mukhopadhyay Dept. of CSE, IIT Kharagpur

Exchange of Information at a Distance n n n Voice Image Video Graphics Elements

Exchange of Information at a Distance n n n Voice Image Video Graphics Elements of Medical Records Commands to a surgical robot

Examples • • • Data related to a patient’s personal information Data related to

Examples • • • Data related to a patient’s personal information Data related to a patients medical information Data for patient management in Telemedicine Data related to the doctors Data for system management

Technologies Involved n Medical Instrumentation Sensing Bio-medical Signals, Medical Imaging, Measurement of Physical Parameters

Technologies Involved n Medical Instrumentation Sensing Bio-medical Signals, Medical Imaging, Measurement of Physical Parameters e. g. Body Temperature, Pressure etc. n Telecommunication Technology Trans-receiver on different communication channels and network such as, on wired network, wireless medium etc. n Information Technology Information representation, storage, retrieval, processing, and presentation.

Medical Information and data Data: “Signature” of Information n Information: Processed data n System

Medical Information and data Data: “Signature” of Information n Information: Processed data n System Transduce r Signal Processor Presentation

Waveform Acquisition Model

Waveform Acquisition Model

f(t) Analog and Digital Data (t) f(n) Analog Data: f(t) t (n) Digital Data:

f(t) Analog and Digital Data (t) f(n) Analog Data: f(t) t (n) Digital Data: f(n)

Analog to Digital Conversion ● Sampling Rate ● Quantization Level t q Value=4

Analog to Digital Conversion ● Sampling Rate ● Quantization Level t q Value=4

Signal Bandwidth n How fast the signal changes? Slow variation Fast variation Bandwidth is

Signal Bandwidth n How fast the signal changes? Slow variation Fast variation Bandwidth is the measure of range of frequency components present in the signal. Nyquist sampling rate= 2* Bandwidth of the signal

Data Size: Voice Band width: ~ 4 Khz n Minimum Sampling Frequency: 8 Khz

Data Size: Voice Band width: ~ 4 Khz n Minimum Sampling Frequency: 8 Khz n Bits per sample: 8 bits (for 256 levels) n Minmum data rate: 8000 x 8 bits per second = 64 Kbps n

Data Size: ECG B. W. ~ 100 Hz. n Minimum Sampling Frequency: 200 Hz.

Data Size: ECG B. W. ~ 100 Hz. n Minimum Sampling Frequency: 200 Hz. n Bits per sample: 8 (for representing 256 levels) n Data rate: 200 x 8 bits per second = 1. 6 Kbps n

Data Size: Video Number of frames per second: 15 fps n Resolution of a

Data Size: Video Number of frames per second: 15 fps n Resolution of a frame: 480 x 640 pixels n Bits per pixel: 24 bits (for colored video) n Data Rate: 480 x 640 x 15 x 24 bits per second = 110. 6 Mbps n

Data Compression n Alternative description of data requiring less storage and bandwidth. Uncompressed 1

Data Compression n Alternative description of data requiring less storage and bandwidth. Uncompressed 1 Mbyte Compressed (JPEG) 50 Kbyte (20: 1)

Compression Standards Lossy and Lossless Compression n Data: ZIP n Audio: MPEG n Still

Compression Standards Lossy and Lossless Compression n Data: ZIP n Audio: MPEG n Still Image: JPEG, JPEG-LS, JPEG-2000 n Video: MPEG-2, MPEG-4, H. 263 n

Band-width requirements of different compressed multimedia data Type of Multimedia Data Bandwidth Usual data

Band-width requirements of different compressed multimedia data Type of Multimedia Data Bandwidth Usual data Image Voice Stereo Audio VCR quality video 3 D medical images HDTV Scientific Visualisation 100 bps~2 kbps 40 Kbps~150 Kbps 4 Kbps~80 Kbps 125 Kbps~700 Kbps 1. 5 Mbps~4 Mbps 6 Mbps~120 Mbps 110 Mbps~800 Mbps 200 Mbps~1000 Mbps

Signal Transmission Transmitter x(t)=A. sin . t) Channel Receiver y(t . A. sin(. t

Signal Transmission Transmitter x(t)=A. sin . t) Channel Receiver y(t . A. sin(. t

Channel Bandwidth How fast the system responds? n Range of fequencies transmitted by the

Channel Bandwidth How fast the system responds? n Range of fequencies transmitted by the channel. n Modulation is the process of translating signal's bandwidth into a channel's bandwidth. n

Communication Channels Communication Links Terrestrial POTS Leased lines Satellite Wireless ISDN Wireles LAN GPRS

Communication Channels Communication Links Terrestrial POTS Leased lines Satellite Wireless ISDN Wireles LAN GPRS GSM/CDMA/3 G

Early systems n 1920 (USA): Transmission of ECGs and EEGs on ordinary telephone lines.

Early systems n 1920 (USA): Transmission of ECGs and EEGs on ordinary telephone lines. n 1920 (USA): Medical advice services for sailors based upon Morse code and voice radio. n 1950’s (USA): Telepsychiatry between a state mental hospital and the Nebraska Psychiatric Institue using microwave link

Early systems n n n 1950’s (USA): NASA and the US Public Health Services

Early systems n n n 1950’s (USA): NASA and the US Public Health Services developed a joint telemedicine programme to serve the Papago Indian Reservation in Arizona. 1960’s (USA): Two-way closed-circuit television systems to facilitate both the transmission of medical images such as radiographs as well as consultations between doctors. 1970’s (USA): Paramedics in remote Alaskan and Canadian Villages connected with hospitals in distant towns and cities using the ATS-6 satellite systems

Early systems n n 1971, Japan: First time implemented in two areas: Nakatsu-mura and

Early systems n n 1971, Japan: First time implemented in two areas: Nakatsu-mura and Kozagawa-cho, Wakayama using telephone line for voice and Fax transmission and CATV system for image transmission. 1972, Japan: Between Aomori Teishin Hospital and Tokyo Teishin Hospital over 4 Mhz TV channel and several telephone lines. Other systems came up for teleradiology in several places in Japan like, Nagasaki, Tokai etc.

Applications in different forms n n n Information exchange between Hospitals and Physicians. Networking

Applications in different forms n n n Information exchange between Hospitals and Physicians. Networking of group of hospitals, research centers. Linking rural health clinics to a central hospital. Videoconferencing between a patient and doctor, among members of healthcare teams. Training of healthcare professionals in widely distributed or remote clinical settings. Instant access to medical knowledgebase, technical papers etc.

Telemedicine Systems: Developed at IIT Kharagpur n Telemedi. K n n Telemedi. K V

Telemedicine Systems: Developed at IIT Kharagpur n Telemedi. K n n Telemedi. K V 1. 0, V 2. 0, V 3. 3, V 2004, V 2005 A peer to peer application. Facilitates specific care for different diseases such as dermatology, hematology, orthopedics, pediatrics, oncology, cardiology etc. Online graphics communicator Peer to peer discussion n Annotation of patient images and profile images. n

Aim of the Telemedik System • Information management – – Patient information Medical data

Aim of the Telemedik System • Information management – – Patient information Medical data (signs, symptoms, test reports, etc. . ) Appointment scheduling Archival and retrieval of patient records • Low cost solution – Using ordinary telephone line • Service to large population – Through public health care delivery systems • Development of knowledge-based system – For decision support – For training and education

Key Principles • Avoid Adhocism : Preorganisation of Patient Data • Minimize online data

Key Principles • Avoid Adhocism : Preorganisation of Patient Data • Minimize online data transfer • Patient Management with Database support

Technical issues over Low Bandwidth Problem • Longer time for data transfer • Poor

Technical issues over Low Bandwidth Problem • Longer time for data transfer • Poor video quality Solution Store and forward policy Transferring sequence of still images

Requirement Specification Nodal Hospital • A patient getting treated • A Doctor • A

Requirement Specification Nodal Hospital • A patient getting treated • A Doctor • A remote telemedicine console having audio visual and data conferencing facilities POTS / ISDN Referral Hospital • An expert/ specialized doctor • A central telemedicine server having audio visual and data conferencing facility

Sequence of Operation PATIENT IN Day One Patient visits OPD Local Doctor checks up

Sequence of Operation PATIENT IN Day One Patient visits OPD Local Doctor checks up Patient receives local treatment and OUT not referred to telemedicine system Patient referred to the Telemedicine system (some special investigations may be suggested) Patient visits Telemedicine data-entry console. Operator entries patient record, data and images of test results, appointment date is fixed for online telemedicine session Offline Data transfer from Nodal Centre OUT

Day Two Sequence of Operation Patient 1 Patient 2 Patient 3 Patient 4. .

Day Two Sequence of Operation Patient 1 Patient 2 Patient 3 Patient 4. . . Patient queue Online conference for the patient. IN Patient, local doctors at the nodal hospital and specialist doctors at the referral hospital OUT

Hardware Configuration Video Conference Modem Referral Hospital Telephone Microscope and other medical instruments Video

Hardware Configuration Video Conference Modem Referral Hospital Telephone Microscope and other medical instruments Video Conference PSTN/ISDN/VSAT link Digital camera Scanner Telephone Printer Modem Nodal Hospital

Software Modules Offline Activities Online Activities

Software Modules Offline Activities Online Activities

Schematic Diagram for Telemedicine using Leased Line 512 Kbp s Leased Line State Switching

Schematic Diagram for Telemedicine using Leased Line 512 Kbp s Leased Line State Switching Centre Referral Centre ps b 2 M 512 al tic p O ed Leas Kbps k Line District Switching Centre Nodal Hospital

Video and Data Conferencing Doctor Patient

Video and Data Conferencing Doctor Patient

Multi-Reference in Tele-consultation A center acting as local asks for tele-consultation with a remote

Multi-Reference in Tele-consultation A center acting as local asks for tele-consultation with a remote center which can again be able to consult with another remote center. Attending local doctor Patient Remote Hospital 1 Local Hospital Remote Hospital 2 If required concerned data may be resent to remote hospital

Telemedi. K Model n n n Based on peer-to-peer network topology. Physical transmission of

Telemedi. K Model n n n Based on peer-to-peer network topology. Physical transmission of patient medical records. Symmetry in telereference. Limitations: • Duplication of records incurs increased storage cost. • May violate data consistency. • High bandwidth requirement.

Telemedicine over web Telemedicine Server Internet Step 1. Upload Information Step 4. Receive Suggestion

Telemedicine over web Telemedicine Server Internet Step 1. Upload Information Step 4. Receive Suggestion step 2. Download Information Step 3. Post Suggestions Referral Hospital Patient Console

Web based telemedicine system n i. Medi. K n n n i. Medik V

Web based telemedicine system n i. Medi. K n n n i. Medik V 2007, V 2008, V 2009. Client interfaces are mostly provided through internet browsers. Supporting care of same set of diseases as handled by Telemedi. K. Additional Diseases like HIV Pediatrics and Drug resistant tuberculosis. Online graphics communicator n Conference among multiple participating doctors.

i. Medik Model n n Based on the Central server model. Usually deployed at

i. Medik Model n n Based on the Central server model. Usually deployed at in the public network like WWW. Limitations • No physical separation of records. • Needs higher configuration. • Security threats prevail. • Less or no fault tolerance. • Requires uninterrupted connection to external links. Four Layer Architecture

Features of i. Medik n n Multi-tier secure telemedicine system. Focuses on service oriented

Features of i. Medik n n Multi-tier secure telemedicine system. Focuses on service oriented approach. Facilitates health care services through Internet. Salient features n n n Encompasses all the features of Telemedi. K. Completely browser based interface. Complies with n n HIPAA security standard EPR standard proposed by National Task Force for Telemedicine Standards, MCIT.

Architecture n Web Proxy Layer n n n Only layer that resides in public

Architecture n Web Proxy Layer n n n Only layer that resides in public domain Intercepts all requests / responses between the client and web server Presentation Layer n n n Responsible for building page template A sub part of the layer is Wireless Medical Information Access Server (WMIAS) The WMIAS builds customized web pages for handheld devices

Continued … n Business Logic Layer n n n Core of the application Performs

Continued … n Business Logic Layer n n n Core of the application Performs all database operations Database Layer n n Hosts the clinical database. Allows storage of files (Size > 100 MB), such as MR and CT data.

n The lower three layers in secure zone (inside the firewall) n Only the

n The lower three layers in secure zone (inside the firewall) n Only the Web Proxy Layer is in the Demilitarized zone (outside the firewall) n HIDS (Host Based Intrusion Detection System) can be deployed in each of the layers in secure zone to control illegal access

Summary of Patient Records

Summary of Patient Records

Visit wise patient record display

Visit wise patient record display

Patient record browsing

Patient record browsing

Mobile Healthcare n Client interfaces for PDA and mobile phone. n SMS based Emergency

Mobile Healthcare n Client interfaces for PDA and mobile phone. n SMS based Emergency messaging system. n Developing instruments with mobile interfaces.

Use of Mobile Devices in Telemedicine

Use of Mobile Devices in Telemedicine

Limitations Of Handheld Devices Limitation of computational resources a. Limited memory capacity b. Slow

Limitations Of Handheld Devices Limitation of computational resources a. Limited memory capacity b. Slow execution speed n Small screen size n Input device (Stylus) n

Solutions Client Server based approach n Data filtering n Partitioned image display for large

Solutions Client Server based approach n Data filtering n Partitioned image display for large images n Buffer management n

Wireless Medical Information Access Server Patient data browsing a. Text data b. Image data

Wireless Medical Information Access Server Patient data browsing a. Text data b. Image data n Prescribing drugs and advice n

Patient Queue in Desktop Computer Patient Queue in PDA

Patient Queue in Desktop Computer Patient Queue in PDA

Test Reports Fragment 1 Fragment 2

Test Reports Fragment 1 Fragment 2

Prescription Writing Form

Prescription Writing Form

Multimedia data in PDA n n Viewing & Marking of image Profile Marking application

Multimedia data in PDA n n Viewing & Marking of image Profile Marking application ECG Viewer application Display of Graphs and Charts

Zooming & Marking of Image

Zooming & Marking of Image

ECG Data Display

ECG Data Display

Skin Patch Viewer

Skin Patch Viewer

Graphs & Charts Family History Tree Growth Chart

Graphs & Charts Family History Tree Growth Chart

Emergency Messaging Service using i. Medik n n n Sends SMS to doctors’ cell

Emergency Messaging Service using i. Medik n n n Sends SMS to doctors’ cell phones to inform him/her about any emergency or patient referral. Follows the same multi-tier architecture EMS server resides outside the firewall intercepting incoming / outgoing messages

EMS Architecture

EMS Architecture

Message Classification Message Type Emergency (Alert) Code ALR Reminder REM Regular REG Referred Patient

Message Classification Message Type Emergency (Alert) Code ALR Reminder REM Regular REG Referred Patient REF Acknowledgement ACK Group GRP

Example of Message Length Reduction ALR 12: 32|01: 02 Attend Cardiac Patient. Blood pressure

Example of Message Length Reduction ALR 12: 32|01: 02 Attend Cardiac Patient. Blood pressure suddenly becomes very high. Some abnormality found in ECG. Priority = High Dead Line = 20 Minuts Location = Male Ward Room-102, Bed-14 Blood Pressure =180/140 Temperature = 98 Pulse Rate = 95 Hemoglobin Count = 8. 3 Original Message 262 Char ALR 12: 32|01: 02 Pri = HI Dead Line = 20 M Loc = Male Ward Room-102, Bed-14 B. P. =180/140 Temp = 98 Pulse Rt = 95 Hemoglobin Cnt = 8. 3 Attend Cardiac Pat. B. P. suddenly becomes very hi. Some abnormality found in ECG. Compressed Message 208 Char

Message Formatter n Message Indentation and Fragmentation ALR 12: 32|01: 02|Frg 1/2 Pri =

Message Formatter n Message Indentation and Fragmentation ALR 12: 32|01: 02|Frg 1/2 Pri = Hi Dead Line = 20 M Loc = Male Ward Room-102, Bed-14 B. P. =180/140 Temp = 98 Pulse Rt = 95 Hemoglobin Cnt = 8. 3 Fragment 1 135 Char ALR 12: 32|01: 02|Frg 2/2 Attend Cardiac Pat. B. P. suddenly becomes very hi. Some abnormality found in ECG. Fragment 2 103 Char

SMS Message Management

SMS Message Management

Example Emergency Message ALR 14: 12 Attend Cardiac Patient Pri = Hi B. P.

Example Emergency Message ALR 14: 12 Attend Cardiac Patient Pri = Hi B. P. Increased Loc = Male Ward Room-102, Bed-14 BP =180/140 Tmp = 98 Pulse = 95 Hemoglobin = 8. 3 Dead Line = 20 Minuts Emergency message for attending a patient admitted in hospital. ALR 20: 10 Attend a trauma pat in emerg. Pri = Hi. Unconscious. External Bleeding Dead Line = 10 M. Age = 30 Y Sex = M. RR = 24 BP = 100/190 Pulse = 120. Emergency Message for attending a patient of accidental emergency.

Emergency Messaging ALR 14: 12 Attend Cardiac Patient Pri = Hi B. P. Increased

Emergency Messaging ALR 14: 12 Attend Cardiac Patient Pri = Hi B. P. Increased Loc = Male Ward Room-102, Bed-14 BP =180/140 Tmp = 98 Pulse = 95 Hemoglobin = 8. 3 Dead Line = 20 Minuts Emergency message for attending a patient admitted in hospital. ALR 20: 10 Attend a trauma pat in emerg. Pri = Hi. Unconscious. External Bleeding Dead Line = 10 M. Age = 30 Y Sex = M. RR = 24 BP = 100/190 Pulse = 120. Emergency Message for attending a patient of accidental emergency.

Distributed Telemedicine System n i. Medik-D (Under development) § Referral Activities through a Central

Distributed Telemedicine System n i. Medik-D (Under development) § Referral Activities through a Central Server. § Hybrid Model: For some in-house patient management through the Central Server. § Hierarchical Distributed system (without any Central server. )

i. Medik. D Symmetric: Server Model n Two types of nodes - main sever

i. Medik. D Symmetric: Server Model n Two types of nodes - main sever and peripheral server. n n Multiple peripheral servers connected to one main server. Deployment of hospital EHRs at peripheral servers. n Symmetric patient referral n Data segregation partially achieved.

i. Medik. D Model: Hybrid Server Model n Combination of centralized server model and

i. Medik. D Model: Hybrid Server Model n Combination of centralized server model and distributed server model. n Supports both the scenarios n Organization that can not afford the cost of a PS. n n Example – H 2 Organization that can bear the cost of additional PS. n Example – H 1, H 3

i. Medik. D Hierarchical: Server Model n No central or main server. n Tele-consultation

i. Medik. D Hierarchical: Server Model n No central or main server. n Tele-consultation is carried out in the origin server. n Hierarchy of reference. n Each hospital hosts a separate EHR system. n Can be deployed in the public domain.

i. Medik. D Hierarchical: System Architecture n A few additional services: n n Manage

i. Medik. D Hierarchical: System Architecture n A few additional services: n n Manage telemedicine network Refer a patient. Fetch doctors information. Only reference to data is sent with temporary log in information: n n Securely. Transparently. Four Layer Architecture

Benefits of Telemedicine n Improved Access Covers previously unserved or underserved areas. n Improved

Benefits of Telemedicine n Improved Access Covers previously unserved or underserved areas. n Improved quality of care Enhanced decision making through collaborative efforts. n Reduced isolation of healthcare professionals Peer and professional contacts for patient consultations and continuing education. n Reduced costs Decreased necessity for travel and optimum uses of resources.

Deployment of Telemedicine Tripura Telemedi. K 2005 deployed in 11 hospitals – § 2

Deployment of Telemedicine Tripura Telemedi. K 2005 deployed in 11 hospitals – § 2 Referral Hospital in Kolkata § 9 Nodal Hospital in different districts.

Deployment of Telemedicine – West Bengal Telemedi. K 2005 deployed in 20 hospitals –

Deployment of Telemedicine – West Bengal Telemedi. K 2005 deployed in 20 hospitals – § 6 Referral Hospital in Kolkata § 14 Nodal Hospital in different districts. i. Medi. K installed in Calcutta Medical College in July 2009.

Conclusion Telemedicine being increasingly used for providing health care services. n Effective and efficient

Conclusion Telemedicine being increasingly used for providing health care services. n Effective and efficient in managing resources and time for delivery of health care. n Telemedicine systems are evolving: Peer to peer ► Centralized Server based ► Distributed Systems. n Looking for a great healthy future of our public health care system in our country. n