Network investment aids European telehealth projects

Countries in central and eastern Europe are widely regarded as ripe for investment in healthcare IT. Provision of such services, however, depends on an adequate telecommunications infrastructure. Proposals for hospitals to hook up to high-speed interuniversity cabling may provide the answer.

Serbia and Montenegro is one country that is making the most of its academic network infrastructure to launch much-wanted e-health projects. Plans are under way to link all hospitals and healthcare institutions to the country's expanding national research and education network (NREN), said Prof. Zoran Jovanovic, director of Belgrade University Computing Center. About 20 towns and cities should have access to the gigabit network by early 2005.

"What we are doing in our country is trying to reuse the money that has already been spent on the NREN, so we do not have additional communication costs," he said. "Typically, the research and education networks are not overloaded, so when we connect all these hospitals to the gigabit network there will not be a communication bottleneck."

A project instituted at the Belgrade Children's University Hospital takes advantage of the network availability. Researchers have constructed a system that will provide Web-based access to virtual reality-modeled 3D medical images. The project's goal is to let users with access to the hospital's high-speed intranet manipulate the 3D data sets so that advanced image-based surgical planning can be performed without the need for dedicated 3D workstations.

The system's architecture was designed to minimize time spent loading and transferring large 3D data sets. Only 2D images are transmitted from server to client. Because of the network's speed, data retrieved from the hospital's PACS or hospital information system do not have to be compressed. A geometry engine turns data requested by the client into virtual reality models. A separate field engine controls the Java-based tools that doctors use to manipulate the 3D image (Figure 1).

The Web-based system has considerable potential in a number of clinical applications, Jovanovic said. Research performed with colleagues at the University of California, Los Angeles has revealed opportunities for using virtual reality modeling tools to simulate blood flow around brain aneurysms (Figure 2). Teleconsultations could become possible if external users were given restricted Web-based access to the host hospital's medical records.

"We hope that in the future this tool will be used for telemedical cooperation between hospitals and included in everyday practice at the Belgrade Children's University Hospital," Jovanovic said.

Good network infrastructure is also assisting e-health projects in the Czech Republic city of Brno, according to Michal Schmidt, product manager with the healthcare division at Czech IT company ICZ. All universities in Brno are connected by a privately owned fiber-optic network, which is linked to the country's NREN through the computer center at Brno's Masaryk University. Most hospitals, local governments, and courts in the Czech Republic's second largest city are also linked to the 90-km optical network.

Network capacity has increased substantially in the past decade, Schmidt said. A multimode fiber initially provided a 100-Mbps service, but that has been replaced by a gigabit Ethernet backbone. The network is now used to provide hospitals and healthcare institutions in and around Brno with a metropolitan PACS.

A project known as MEDIMED aims to establish a medical multimedia data archiving and communication center for six participating hospitals, Schmidt said. The center, based at Masaryk University, offers three levels of service. Hospitals opting for a "primary PACS" receive full support from image acquisition to archiving (Figure 3). The center also provides long-term archiving for hospitals running their own PACS with short-term onsite storage. A third service option will facilitate exchange of DICOM data from hospitals outside the Brno region. Cooperation with two hospitals in Prague has already been established.

"Masaryk University is a neutral exchange point for Brno hospitals. It is like an application service provider," Schmidt said. "This choice meant cooperation between hospitals, and not unhealthy competition."

Fiber-optics are clearly an advantage in transferring image data. But not all e-health projects in central Europe have the advantage of running on an NREN. In some cases, more basic network infrastructure has sufficed.

NATIONWIDE LINKS

Telecommunications have played a pivotal role in Croatia's plans to upgrade its healthcare services ever since the country gained independence in 1991, said Adil Dzubar, general manager of Vamstec, a Zagreb-based medical image management company. Croatia is a long, thin, boomerang-shaped country, with over 1000 islands. Travel between major towns and cities to remote villages and island communities can be arduous. Villagers' access to city-based medical specialists was complicated further in the aftermath of war because of the poor state of roads and an occupation that cut off the southern part of the country from the north. Telemedicine solutions therefore received serious attention from an early stage of the republic's birth.

Croatia's first networked healthcare project in 1993 focused on telepathology. The need for teleradiology became more pressing in 1997, following installation of 15 CT scanners in small regional medical centers. Networked communications offered a means of sharing expertise between experienced radiologists at large medical centers and their colleagues performing CT in local hospitals. Hospital authorities developed a plan to link all 35 CT scanners in Croatia's state-run hospitals (including 13 in Zagreb itself) with a centralized referral center, forming a nationwide neuroteleradiology network.

"At the time we started this proj-ect, most radiology departments didn't even have a single PC," Dzubar said. "We decided to try and build a system that could be used locally too, because we couldn't predict how much the telemedicine application would really be used."

Project planners were restricted to using standard telephone lines for all telecommunication. They determined that the system would be able to handle all medical images, whether generated by CT, MR, ultrasound, digital subtraction angiography, radiography, endoscopy, or microscopy equipment. Although experience with the telepathology network suggested that most teleradiology would operate on a store-and-forward basis, they chose to provide for interactive communication as well.

Installation of the national neuroteleradiology network began in 1998. The completed network linked all CT and MR scanners at 38 hospitals in 19 cities. Radiological workstations at each networked location were fitted with two software applications: a miniPACS capable of storing medical images and reports, and a communications module. Video digitizer boards were also incorporated to "DICOMize" all images for transfer as secondary capture, given that none of the 35 CT units were DICOM-compliant.

Results of all CT examinations were transferred automatically into the miniPACS for reporting. Radiologists seeking a second neurosurgical opinion used the communication module to send the entire CT study plus their own report to the Clinical Hospital Center in Zagreb. Specialists at the national neurosurgery referral center could open the examination using the same miniPACS application, add their opinion on the images, and return those comments to the remote center. An interactive "whiteboard" application supported faster communication in urgent cases.

"Within three years of using this system, we saved something like 400,000 km of patient travel as well as numerous patient lives," Dzubar said.

An additional telemedicine project was inaugurated in 2001 to serve the needs of Croatia's island dwellers. Croatian islanders are, on average, older than mainland inhabitants, so healthcare practitioners treat a significant number of chronically ill patients. None of the islands have a hospital, and a program in which regional clinical hospitals provided islanders with weekly specialist medical care ceased in the late 1990s. Yet travel to the mainland during winter months can be difficult, and healthcare services are stretched even further in the summer when the islands receive a large influx of tourists.

Project planners this time chose a Web-based telemedicine solution to connect 13 local doctors' practices on nine islands with 30 mainland medical specialists. Communications are mainly text-based, although images generated at the general practitioners' offices can also be transferred. These may include photographs from digital cameras, ECG scans, and in some cases ultrasound images.

Doctors at the Clinical Hospital Center in Zagreb perform 70 to 100 teleradiological consultations every month. The project has also spawned further IT upgrades, with some sites moving from a miniPACS to department-wide integrated RIS/PACS solutions. DICOM connectivity is stressed in all new modality purchases to ease PACS integration.