Connecting hospitals through a distance learning center and permanent remote support network - A Sicilian project to improve patient care. Vincenzo Lanza,MD Department of Anesthesia, Ospedale Buccheri la Ferla Fatebenefratelli, Palermo, Italy. Address correspondence to Vincenzo Lanza, Chief of Anesthesia department, Ospedale Buccheri la Ferla Fatebenefratelli, Via M.Marine, 197, 90123-Palermo, Italy. E-mail: lanza@unipa.it Abstract Providing health care outside major hospitals is difficult enough in urban settings, but is even more problematic in isolated places such as small towns. Sicily is an especially challenging case because it is a large island off the main track of mainstream Europe and contains many rural villages as well as numerous smaller islands. Although the major cities in Sicily currently have some well-equipped hospitals with expert staff, rare or complex diseases (e.g. neuropathology) still require support from national or international sources. There is no infrastructure for communication with such distant health-care centers, necessitating the transport of patients over long distances. The goal of the present project is to establish such a communication network to enable medical staff in remote locations, even at a patient s home, to access databases (e.g. pharmacological), consult with clinicians on diagnosis, and even transmit monitored patient vital signs in real time. It is possible to create such a network gradually so that each step would be in operation even before the entire project is completed. This paper describes the knowledge-base, human resources and technical requirements for each step. Background The problem of poisoning is widespread in Sicily because of the use of pesticides in greenhouses. The Health Minister of the Sicilian Region has recently created a task force to draw attention to the dangers inherent in the use of pesticides (1), but the use of these dangerous substances without protective garments persists in many isolated places. There are at least two specialized poison treatment centers in Sicily but emergency Call Centers in other regions are often employed even though they are only able to provide a minimum of general information. An off-line toxicological database without medical staff can serve poisoning cases of the most usual kind in the area, depending on their level of severity, as well as a search engine for patients who are pregnant or nursing and guidelines for the use of medications during pregnancy. A verbal message can guide users not familiar with the Internet or direct them to a call center accessible by mobile telephone. In more complex cases medical staff can be available for telephone consultation or videoconferencing online. The physician on duty or an intensive care specialist at a major hospital can offer clinical-diagnostic support. Two centers can alternate online service 15 days each. Such a system would avoid unnecessary transport of patients over long distances. Table 1 shows the working plan to create the online Internet pregnancy consultation system. Figure 1 shows a flowchart. Collection of data on the obstetric population and drugs used during pregnancy one Statistical evaluation of the use of drugs during pregnancy Creation of a questionnaire to distribute to other hospitals one Increase statistical information in the region Analysis of the data collected three Produce a final report on the data published on the Web Creation of a database containing the information collected, accessibile by the regional health department Creation of a database containing information on the frequency and characteristics of the adverse effects of medications, toxic substances and illegal (recreational) drugs during pregnancy and nursing two three Organized and immediate availability of the data Integration of the data with clinical events and possible statistical correlations (regularly updated) Creation of a web site for rapid consultaion of the database ondine, includine a section for patients. two Publicizing the data to health care workers and educating the public. Table 1 Working plan to build the online Internet pregnancy consultation system
Figure 1. Flowchart The basic data needed for clinical-diagnostic consultation are radiological images, hemodynamic parameters, and laboratory values. Radiographic images in digital format can be transmitted easily online. In some cases this may require a portable x-ray device and technician. The transmission of radiological images can facilitate their interpretation by a radiologist at the hospital in real time, who may then request further images and indicate appropriate therapy. Many patients are brought to hospitals with suspected pneumothorax or pneumonia, while a simple x-ray can eliminate such possible diagnoses. If a local hospital can perform CT scans such images can also be transmitted for neurosurgical consultation. Photographs of the patient may also be useful, and current technology allows echo-sonograms to be transmitted online. A test of remote consultation was performed in Palermo in 1996, in which a simulated chemical disaster demonstrated the transmission of patient images to a remote hospital using an ISDN line (128Kbit/sec), and subsequent valid therapy recommendations (2). A portable multi-parameter monitor connected to a patient can transmit a series of information such as ECG, arterial pressure, etc. to evaluate the patient s clinical condition during diagnosis or treatment especially when timely treatment is important (e.g. cardiac ischemia). Instrumentation may be interfaced using the widespread medical protocol HL7. Multidisciplinary support is possible by telephone if needed. Laboratory instrumentation can perform blood-gas analyses, glycemic and white cell count, etc., the values of which can be transmitted using HL7, displayed graphically as illustrated in Fig. 2 Patients at home can be monitored remotely by the local physician first, and then the data can be retransmitted to a distant hospital. For example, patients would primarily be ventilated or undergoing other oxygen therapy (scheduled monitoring of ECG, arterial pressure, etc.), or diabetics undergoing insulin therapy (monitoring of hemodynamic parameters).
Figure 2 - Display at the remote center: (from above) blood gas analysis, glycemic and other blood values, clinical diary, therapy, x-ray and other images (may be enlarged to full-screen).. Technical Infrastructure A reasonably fast connection to the Internet is required, at least two effective megabits, which can be obtained through a GARR network (The Italian Academic & Research Network) (http://www.garr.it/) such as available through the University of Palermo Computing Center. A network server will contain the database which must be updated regularly with the latest information on drugs, toxic substances and antidotes. During initial testing the network should be monitored by all major hospitals involved. Clinical-diagnostic support in real-time will require WiMAX technology (Worldwide Interoperabilty for Microwave Access), which is a wireless transmission standard using the current wireless network in modern portable computers allowing them to connect to the Internet in airports or other so-called Hotspots. The standard currently adopted uses the 802.11g transmission protocol, allowing a field of action of 100 meters at a frequency of 2.4GHz, and a speed of 54 Mbits/sec. In contrast, WiMAX uses protocol IEEE 802.16 at a frequency of 10 GHz and a transmission speed of 75 Mbits/sec. The range of action is up to 50 Km. (More realistically, the range is 5 Km when inside a building and 15 Km outdoors. This new technology has been embraced by software makers (e.g. Microsoft), as well as cell phone manufacturers, etc., which will result in the integration of land, cellular and satellite communications. The transmission of moving images entails the streaming of data (upstream and downstream), at more than one effective megabit/sec., to support remote consultation.. Table 2 shows the speed of normal telephone lines If there are difficulties expected in connecting locations, as between Sicily and smaller islands, then the use of bidirectional satellite or WiMAX is highly recommended
Type of data File size 28.8 KBPS MODEM ISDN - 128 KBPS DSL - 384 KBPS Use of a web 2.5Mb 12 minutes 2 ½ minutes 52 browser to download 25 pages with graphics Video clip of 20 8Mb 37 minutes 8 ½ minutes 2 ¾ Download a program (Internet Explorer) minutes 25Mb 120 minutes 26 minutes 8 2/3 minutes Table 2 The speed of normal telephone lines DSL - 1.5 MBPS 13 43 2 1/5 minutes The hardware needed for remote consultations in realtime include four videoconferencing stations connected to the server for the development of software to integrate patient data in the single database. The data is classified as: patient monitoring (ECG, invasive and noninvasive arterial pressure, respiration, EEG, temperature, ventilation volume and pressure; laboratory exams (blood ph,po2,pco2,hb,hbco, GPT,GOT,CPK,LDH, etc.), patient images (x-rays, etc., digitally compressed) and video (a videocamera connected by USB II at the remote site and a videoconferencing system at the major hospital), to create a detailed patient file. A ventilator and monitor capable of transmitting parameters to a Patient Data Interface (PDI) in HL7 is therefore required. It must be connected to a computer server where it will be possible to visualize and memorize the parameters in the database. Hence, three computers are necessary: one for capturing the monitoring data from the patient, a second containing the patient database, and a third for data-entry by the user. Figure 3 shows the screen display from a remote monitoring system. Portable laboratory devices feature a serial port interface or Ethernet network connection with data transmission by ASTM or HL7 protocol. The hardware needed at the fixed site include: three computers, two of which are configured as servers; two switches, one of which is wireless; one digital camera; a videocamera; the hardware necessary for an Internet connection, according to what type of connection is chosen. At each site at a major hospital: one computer; one digital camera; the hardware necessary for an Internet connection (fig.4) Figure 3 Display using PDI.
Figure 4. Structure of Hospitals connection The software needed includes programs for the acquisition of data transmitted by the instrumentation, the creation of a database containing the patients files, and management of the database. Suppliers of PDI monitoring instruments also provide the software that enable the acquisition of parameters every five into a database. Direct acquisition is also possible if parameters must be visualized as a continuous wave. In some cases remote consultation may only need sampling of parameters every minute to monitor the patient (fig.5). The software developed should have a flow chart: Every 50 : query PDI with the monitor identifier: wait 10 : data arrives and values are extracted: memorization in a database table and creation of a record containing the patient identifier. The data are also present in graphic form which can be analyzed in detail (fig.6). Figure 5 Vital signs captured at one-minute intervals and memorized in a database. Time= beginning of monitoring.0,1,2,3 etc. = minutes after the beginning of monitoring.
Figure 6 The figure 5 data presented in graphic form Both ASTM and HL7 protocols should be used for the acquisition of data from laboratory instrumentation. The software must capture the data as soon as it is produced, and memorize the data along with the patient s unique identifier (the same identifier as for the monitoring). Creating such software requires the work of a programmer and a physician for a month. The capture of images is achieved using the classic copy and paste functions of Windows. This approach enables the acquisition of images from any Windows application in a table as a binary object included in the patient s file. Tools such as Lead Tools can be used to compress the images. Patient history and therapy must be entered manually by a health professional. The software needed for image capture and data-entry require three months of work by a programmer and a physician. References 1) Gazzetta Ufficiale della Regione Siciliana. Venerdì 23 luglio 2004 -n. 31. http://gurs.pa.cnr.it/gurs/gazzette/g04-31/g04-31- p29.htm 2) Chemics96: Simulation of chemical accident in telepresence and teleconsultation. http://anestit.unipa.it/tossic/cheming.htm