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发帖数: 910 | 1 George J. So, Xin Li, Hooshang Kangarloo, Richard Steckel, Daniel J.
Valentino
UCLA Medical Center, Department of Radiological Sciences 10833 Le Conte, Los
Angeles, California 90024
1. ABSTRACT
Recent advances in telecommunications via the Internet have significantly
improved international communication. We report a case of teleconsultation
using the World Wide Web (WWW) and related technologies on the internet to
facilitate the successful diagnosis and treatment of a rare illness that
occurred in Beijing, China. This case report demonstrates some of the
advantages and disadvantages of using such a system to gather, to retrieve
medical information, and to facilitate communication among physicians in
different countries. It also demonstrates international teleconsulation
using the internet and World Wide Web (WWW) is possible and effective in
this case which saved this young student's life.
2. INTRODUCTION
2.1 Internet Request for Help
On April 10, 1995, an "SOS message" was sent via email by two students at
the Peking University seeking for consultation for their fellow classmate
who has contracted an unknown but severe illness. The message read "Hi, This
is Peking University in China,..., a young 21-year old student has become
very sick and is dying,..., (she) felt sick in her stomach,..., and within
two days she was completely bald,..., her symptoms worsened,.., she was put
on a respirator,..., (her) doctors cannot cure her,..., can somebody help us
?"
2.2 Case Report
The message described a 21 -year old female chemistry student who had
suffered an acute onset of abdominal pain and alopecia. She was eventually
hospitalized at the Tongren Hospital, Beijing, China in December 1994 three
months prior to her admission at Peking Union Medical College Hospital (PUMC
). Multiple laboratory testings and radiologic studies revealed no specific
diagnosis. The patient slowly improved clinically and was discharged home.
Three months later, the patient again developed multiple neurologic signs,
abdominal pain, myalgia, arthritis, and abdominal pain. She was then
admitted at the PUMC. Her symptoms continued to worsen and became comatose.
Multiple laboratory and radiologic studies again yielded no diagnosis.
The SOS message was then sent to the international medical communities via
the internet to newsgroups with address suffix sci.med and also Peking
University alunmi in the United States. Since then over 2000 replies from
the medical communities in 1 8 countries have responded, and on one occasion
, over 100 e-mails was received by Peking University a day. With the
enormous number of e-mails, the Department of Radiological Sciences at UCLA
has created a web site to organize information and facilitate the diagnosis
and management of her disease (1). The consultations are managed via
internet communication between Peking University and UCLA. The history and
physical examination were translated by students at Peking University. All
laboratory tests, neurologic tests and radiographic study results were also
sent via the internet. Hypermedia information, including patient photos,
chest radiographs and head MRI examinations were set up and can be viewed by
any internet browser. Within 18 days, 84 physicians had collaborated their
efforts to made the diagnosis. It was felt that the student's illness was
likely related to acute poisoning. This diagnosis was suggested by many
medical specialists. Appropriate testing of blood, urine, nail, hair, and
cerebral spinal fluid yielded markedly abnormal elevation of thallium, and
the diagnosis of thallium poisoning was thereby confirmed.
After the diagnosis successfully made and confirmed, the different
therapeutic regimens, including prussian blue, BAL and dialysis, were
discussed. The Los Angeles Poison Control Center was contacted for
appropriate therapy. It was decided that a prussian blue regimen was
probably the most appropriate therapeutic choice, and it was subsequently
initiated. During the
patient's hospitalization, progress and management problems, such as patient
's tracheotomy complications, and rehabilitation were communicated via the
internet. The patient continued to improve slowly. At present, she has
regained her consciousness, has been extubated, and transferred out from the
intensive care unit for long term rehabilitation.
3. METHOD
We attempt to build a cost effective, and widely available system based on
the internet and World Wide Web technologies (1). The system will integrate
the following modules: case submission from primary physician or general
radiologists, database archive, specialist selection, case presentation, and
case consultation with feedbacks (Fig 1).
Using the Common Gateway Interface (CGI) to radiology information system (
RIS), hospital information system (HIS), and picture archiving and
communication systems (PACS) relational databases, electronic medical record
of a patient can be created and presented in an overview format, detailed
information can also be hyperlinked and retrieved if desired. Both hypertext
markup language (HTML) and Java language are utilized so that current
internet browsers can be used to both view and input data. Medical images
are handled using DICOM 3.0 protocols. To manipulate images interactively,
applets, created by Java language, are used. Regarding security measure, we
currently employ only passwords. The use of firewalls, encryptions and virus
protection are under evaluation. Figure 2 shows a portion of web pages
created for this case.
4. DISCUSSION
The advantages of teleconsultation using the internet are many fold. First,
the internet is a standardized network that already exists and is supported
by both government, business, and research organizations throughout the
world. Although most of the hardware are heterogeneous and largely
incompatible to each other, the internet is widely supported and is
relatively convenient to access, easy to use, upgrade and maintain, hence
dedicated, customized, and systems, relational databases of both hospital
information system and radiology information system using our approach. In
addition, it can also link to literature databases such as Medline, clinical
practice guidances as well as financial information from insurance
companies, managed care organizations or other providers.
Informal consultations among physicians are not uncommon via electronic mail
. With internet and World Wide Web technologies, a primary physician may be
able to access a large group of specialists and refer the patient to the
appropriate specialist. In addition, rural or primary medical care
facilities can also obtain expert opinions from specialized care facilities
or tertiary care providers to determine whether a patient should be
transferred to a different level of care. Another major advantage of the
internet is the possibility of for research worldwide, especially in the
study rare diseases for which the number of patients inflicted with the
disease is limited. A larger patient base of the disease can be accessed and
information on the natural history, stages and classification of the
disease, and the effectiveness of a particular treatment regimen can be
extracted. The internet can also be used as a data entering device for
medical, epidemiological studies and multicenter meta-analysis for a
specified treatment. The use of electronic form to input data simplifies the
process of collecting data and analysis of data. Research efforts can be
coordinated globally.
The application of teleconsultation using internet technologies can also be
extended to medical education. Detailed documentation of rare diseases such
as in the case presented in this paper can be used for educational purposes
in a case study format. Traditional film-based, CD-ROM, or laser disc
teaching files can only be used in one location. Multiple copies are
expensive and easy to misplace and lose. This problem can certainly be
minimized using the internet. Many institutions have already included
teaching files in their home page. Teaching files that can be retrieved via
the internet already exist and are in daily use in radiology training (2-4).
The system can also be shared globally. In addition to a teaching file
format, medical education via the daily work round can also be enhanced. A
system is currently under development so that selected images of question by
radiology residents can be accessed remotely by staff radiologists for
consultation and teaching.
Many issues still needed to be resolved in order to make teleconsultation
possible. First, patient confidentiality has to be safe guarded. In order to
achieve that, only limited numbers of physicians are allowed to access the
module, but this will also limit the expertise. Despite security measures
such as firewalls, virus protection, encryption and passwords, security
problems and break-ins still occur. A related issue is the reliability of
the internet, which for medical usage has to be available during the time
the system is used as a medical instrument. The long list of e-mails and
replies is cumbersome especially for complex illness. New interactive media,
case presentation, and referring mechanisms are needed to summarize and
oversee the general picture of the case such as disease presentation, course
of the disease and, response to therapy. As a result of the experience
gained in this trail, we began to implement a multi-media telemedicine
system using HyperText Markup Language (HTML) and Java to combine both
images and text information so that information can be reviewed by multiple
sites at the same time.
High speed access to the internet, related to commercial hookups via phone
line are relatively common in university hospitals but is still limited in
community hospitals and rural clinic. However with the development of high-
speed networks such as asynchronous transfer mode (ATM), the access to
medical information by desktops will significantly be improved.
The system is currently limited only to English speakers. One ofthe major
difficulties is that medical information for a patient must to be translated
by a third person usually with no medical training. The loss of information
and accuracy needs to be examined. This may change as the system matures to
a multilingual system. Lastly, cultural differences also played a
significant role in the acceptance of the telemedicine system for medical
usage. This may pose a greater obstacle to teleconsultation.
5. CONCLUSION
This case report has marked a real life application of telemedicine the
internet and World Wide Web. It demonstrated that international
teleconsultation and telemedicine is not only possible but also effective in
this case. With the elimination of time and distance barriers, telemedicine
via the internet may prove to be a low cost and high quality adjunct in the
very competitive health care environment. Further refinement of the
software and network technology may realize the possibility of a more cost
efficient, and higher quality system for patient care and medical education.
6. ACKNOWLEDGMENTS
The author wishes to thank all 84 physicians and professionals involved in
the making the correct diagnosis and medical treatment of ZL and support
from the UCLA Clinical PACS Group. Support was also provided in part by SUN
Microsystems, Inc. and NIH Grant P01 CA5 1198
7. REFERENCES
(1) Li X, Valentino D, So G.J., Lufkin R, Taira R.K. A World Wide Web
Teleradiology PACS. Proceedings of SPIE Medical Imaging 1996: PACS Design
and Evaluation, 1996 (To be published).
(2) Richardson M. A World-Wide Web radiology teaching file server on the
Internet. American Journal of Roentgenology 1995; 164(2):479-83.
(3) Galvin J, D'Alessandro M, Kurihara Y, et a!. Distributing an electronic
thoracic imaging teaching file using the Internet, Mosaic, and personal
computers. American Journal of Roentgenology 1995; l64(2):475-8.
(4) Richardson M, Rowberg A, Gillespy T3. An on-line digital Internet
radiology teaching file server. American Journal of Roentgenology 1994;162(5
): 123 9-42. |
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