Telemedicine will be one of the basic stages in upgrading of medical
services in all public or private hospitals in Russia in the third
millennium. This fact calls for no proof and is not seriously argued
against, as a rule.
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
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
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
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
The realization of a pathomorphologic fragment of the medical
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
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
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
Operational methods of a pathomorphologic fragment of the video
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:
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.
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
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
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
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
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
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
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 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
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.
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
A practice in medical video networks allows to develop methods of
telemedical consulting, which will be used in working with remote