Rafael Magdalena⁽¹⁾, Javier Calpe Maravilla⁽²⁾, Juan Guerrero⁽³⁾, Antonio J. Serrano López⁽⁴⁾, José David Martín Guerrero^(5)
(1)Electronic Engineering Dpt.. University of Valencia - Burjasot. Spain
⁽²⁾dpto Ingeniería electronica. Facultad de Fisicas - Burjassot/Valencia. Spain
⁽³⁾Departamento de Electrónica. Universidad de Valencia - Burjassot. Spain
⁽⁴⁾Dpto. Electrónica. Universidad de Valencia - Burjasot. Spain
⁽⁵⁾G.P.D.S. Departament d´Enginyeria Electrònica. Universitat de València - Burjassot. Spain

	[New Technology]	[Cardiolovascular Diseases]	[Health Informatics]

INTRODUCTION

Telemedicine is not a new and in fashion concept. Physicians have been using telephone and fax as usual tools at work, since they appeared in our lives. But nowadays new technologies are arising and seizing unexpected technological areas. Prophets in last half century were not able to foresee the star of the future: Internet, or in few words, world computer networks. Data and multimedia transmission are common today, nearly for every place at developed countries. Medicine is a discipline slow in adapting the new offers in telecommunications and computers, in spite of its trust on new technological advances in other areas, like electronics.

Telemedicine can be defined in several ways. One of these is the next one: "Telemedicine is the research, inspection and patient managing and the patient and physician training, regardless of patient or training subject location⁽¹⁾. The use of recent telecommunication and information technology advances is necessary to bring medical care independently of the patient location. So one of the benefits of telemedicine has been to avoid patients or physicians to travel.

This application relies on telemedicine concepts and present existent communication networks. NEMESIS is the Spanish acronym of New Electrocardiographic MEdical Station with Information Systems. Medical Station is highly and strictly modular, which implies that can be easily upgraded or fitted to real requirements and can be smoothly adapted to other medical areas: other physicians of different subjects can benefit of the Station just adding a specific proprietary module, or attaching commercial modules as other applications´ modules.

The developed application implements a Cardiological Medical Station that gathers the tools and utilities useful for cardiologist on their usual work. This Station is a program that can be installed on nearly every computer. It just will need additional hardware on particular cases, like video cameras or acquisition boards, all of them low-cost components. From this computer, physicians will have specific cardiological tools and generic telemedicine tools

MATERIAL & METHODS

Internet has been the selected backbone to hold our application. It offers a privileged position in the global networks´ frame. It is cheap, wide extended, easily obtainable (it only needs a phone line), available for every operating system and with powerful protocols. With very little money and a simple phone line we can have a 56Kbps bandwidth channel, most of the times enough for usual needs. If higher bandwidth is required, ISDN access starts on 128Kbps, which fulfils the application requirements, maintaining costs low. Often proprietary and dedicated networks are not flexible and very expensive.

The application has been developed on a standard PC (P200MMX 64MB RAM), a common computer in every cardiology service. Java has been the programming language selected. The choice relies on two main characteristics: platform independence and network orientation. So Java´s choosing has been neither fanciful nor capricious. Several Integrated Development Environments (IDE) would have brought a similar application with a lower time developing cost, like Microsoft´s Visual Basic; but Sun´s Java offers portability, program once and run always and on different computers. Only specific hardware dependant modules (acquisition, videoconference) are platform-dependent, but they are only small application subsets. Java is endorsed by developers community, is a multiplatform language, robust and network oriented, being the last one a main advantage on the development. The selected IDE was IBM´s Visual Age 2.0, with JDK 1.1.6 and JFC 1.1. This is a user friendly, very intuitive and powerful IDE. This JDK has Swing 1.0.2, that produces applications with appearance independent from the platform, and this characteristic has been used in order to obtain an application with the same aspect on every operating system. This JDK version supports internationalisation, which allows adapting the application to every particular country where it is used. The application is programmed in Spanish, but it is easy to translate it into English or local languages, without recompiling⁽²⁾.

RESULTS

Our medical station starts with a navigation bar, which birng easy and fast access to every module or utility wich application offers. As can be seen, application is window based, user friendly and very intuitive, in order to minimise the learning curve and to gain users, often not so keen to use new and innovative software.

fig. 1

New work strategies must be devolped in using the applicatios. The applications helps the physicians on their usual and traditional work, but new "ways of working" can be developed and created, most of them co-operative work. The use of new and powerful tools in signal processing and networking would imrpove the work and benefits of the users.

We are going to describe the several modules that comprise the application.

1. The ECG visualisation and revision tool allows picking a disk file coded according to the European Standard ENV-1064, developed by the CEN TC 251 about coding ECG for transmission. The module is ready for conversion routines from another proprietary coding schemes under request. Once the file is opened, we can visualise the existent data, the ECG wave, add a report or mark characteristic points on the ECG⁽³⁾.fig. 2

2. Acquisition module is autonomous in order to guarantee portability, because is one of the very few with low level access. Our prototype accesses a National Instruments acquisition card, the AT-MIO-16E-10 using Windows drivers provided by manufacturer. It use is fully integrated with the visualisation module, and user is transparent. It stores a standard coded ECG.

3. Transmission module is a collaborative tool between different stations. The Medical Station Network can be set as a hierarchic structure, where Primary Care Centres can acquire an ECG and send it to their Head dependant Hospital to revise and ask for diagnostic, without the needing for the patient to travel. This hierarchy can be flexible, as every Primary Care Attention Centre can select the hospital or physician to check the ECG, if allowed. This module complements the communication modules.fig. 3

4. Conference and videoconference allow different users of Medical Stations to speak among them. Communication is vital in remote resource control, and advisable in usual work at Station. The Medical Station allows specifying which utility to use, the developed one or a commercial one. This communication module complies ITU H.263 standard, in order to guarantee compatibility with most video conference commercial software.

5. Electronic mail has the same aim, i.e. ease the communication among users. Again, looking for integration and user comfort, commercial e-mail reader can be used instead of the e-mail reader brought in application.

6. A more new application on telemedicine arena is remote control of medical stations. These tools allow an authorised NEMESIS user to acquire ECG onto remote stations, aided by a non-medical assistant. Collaborative tools, such as videoconference, are vital. Cardiologist can acquire and retrieve the ECG from a distant patient, aided with videoconference to supervise the positioning of the electrodes. This remote control is only available if an authorised user is in the station, and only allowed if no user is working or using the remote station. This kind of super-user must specify the IP address of the remote computer and the password. Then access is granted.

7. Previous tools imply that some user have more privileges than other users. To guarantee the right use and avoid the abuse of these privileges users access must be controlled and verified. Identity is the key to enable the several modules. Identity log is kept for every user in order to maintain accurate record of every action. Security and safety are also observed. Integrity is checked at two levels: TCP/IP protocols guarantee data integrity by itself, and data received and stored at hard disk has a Check Redundancy Code (CRC) appended, which is checked on every write/read operation. Encryption is another user-transparent module, because it runs every time a file is sent trough the network. Public key cryptography is used, with a 40-bit RSA algorithm. Most of the programming tools are available at Sun´s Java site

8. A very helpful and useful tool is knowledge database access. These databases are broadly literature quoted, but very few are available nowadays in Spain, being most of them proprietary and local databases with no standard access provided. The developed tool is just only a web browser, with selected bookmarks covering database access in web. Bookmarks are made in pure HyperText Mark up Language (HTML), so they can be imported into other commercial browsers. Discussion forii are accessed via browser as Internet News services.

9. In this age of information society, Hospitalary Information Systems (HIS) and Computer Patient Records (CPR) are primary targets on Medical Informatics. The European Standardisation Committee (CEN) is working on these standards, but real world consists on several isolated and proprietary patient databases, most of them without graphic support and regarding only a small medical area. This tool was implemented with a proprietary format, waiting for a standard that unifies every kind of data.

10. Sending/Receiving ECG files implies a queue managing tool, most of times transparent to users but inevitable to assure the right operation of the system.fig. 4

Recent implantation of intelligent cards in Spanish Health Offices for both patient identity and physician identification has led to a new module development. This module relies on the hardware, so the commercial application provided with card reader is used. Result data is carried to patient record or physician identity⁽⁴⁾.

CONCLUSIONS

Major advantages in this application, setting aside programming techniques, are:

• Standardisation needing on several areas on public health. CEN is making a worthy effort, but most of the work is still to be done. Besides, standardised items are not operative, because of the use of olds systems.

• Renounce of many users in using new and innovative, computer based tools.

• Strict cost/benefit evaluation, with no foresees, which leads to prohibitive figures on every new developed prototype.

• Non existent interfaces to medical devices, as electrocardiographs, echocardiographs, radiological systems, which makes it hard and difficult to append medical electronic data to patients database. Some of these problems have been overcame by using data acquisition boards or external image scanners.

Previously to the complete development of the application research has been made about its use on cardiac areas at hospitals. The Local Government Health Office, who made a poll among physicians to gather information about needing and expectation, backs this research. Additional research was made looking for similar applications on medical software market. Research is made on the University Clinical Hospital of Valencia about the HIS and CPR structure. Research about standards was made too, paying special attention to CEN standards. The prototype application is running at the Cardiology Service of the Hospital Clínico Universitario of Valencia, waiting for physicians to evaluate the usability, utility and functionality of the software.

The thesis and additional work has its own web site at

filemon.uv.es/nemesis/

BIBLIOGRAPHY

Akselsen S, Eidvisk A.K., Folkow T. Telemedicine and ISDN. In: IEEE Communications Magazine 1993. Piscataway: IEEE Computer Society Press, 1993: pp.46-51.
Hortsmann C, Cornell G. Core Java 1.2 Fundamentals. Vol. 1&2, Prentice Hall. 1999.
European Committee for Standardisation Strandard communications protocol for computer-assisted electrocardiography. PrENV 1064. CEN publications, 1993.
Makris L., Kamilatos I., Kopsacheilis E.V., Strintzis M.G. Teleworks: a CSCW application for remote medical diagnosis support and teleconsultation. In: IEEE Transactions on Information Technology in Biomedicine June 1998. Piscataway: IEEE Computer Society Press, 1998: pp. 62-73.

Discussion Board

Any Comment to this presentation?

[ABSTRACT] [INTRODUCTION] [MATERIAL & METHODS] [RESULTS] [IMAGES] [CONCLUSIONS] [BIBLIOGRAPHY] [Discussion Board]

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	[New Technology]	[Cardiolovascular Diseases]	[Health Informatics]

Rafael Magdalena, Javier Calpe Maravilla, Juan Guerrero, Antonio J. Serrano López, José David Martín Guerrero
Copyright © 1999-2000. All rights reserved.

Last update: 12/01/00