UNIT IV MOBILE TELEMEDICINE

Tele radiology: Image Acquisition system Display system, Tele pathology,

Medical information storage and management for telemedicine- patient
information, medical history, test reports, medical images, Hospital information
system
IMPORTANT BIG QUESTIONS
 Explain about Tele radiology and Image Acquisition Display system
 Demonstrate Hospital information system with an example
 Explain about the various types of test reports and medical images
 Explain about telepathology and medical information storage systems
 Explain the functions, advantages and disadvantages of various types of
Telepathology system
 Identify the basic parts of a teleradiology system. .List their uses and design
requirements

TELE PATHOLOGY
Pathology is the medical specialty concerned with the study of the nature and causes of diseases in tissues and
organs. The diagnosis is made by the pathologist by examining cell and tissue sections using a microscope. In
telepathology, the images of tissue are displayed and evaluated on a monitor rather than viewing the specimen
directly under a microscope.

Time-consuming labour- and cost-intensive exchanges of specimens by post or other means of transportation can
now be avoided through telepathology.

Types of Telepathology Services

In telepathology, there are two ways to obtain teleconsultation:
(i) Diagnosis from still microscopical images and
(ii) Dynamic system using robotic video microscopy.

Generally, the second method is the most appealing system but for requirement of a very high speed
telecommunications links between the telemedicine centre and the expert.
The first method is less complex and cheaper than the second, but sometimes there is a significant reduction in the
data when high resolution images are transferred. Therefore, hybrid systems have been evolved that combine limited
robotic capabilities with high resolution still images

Categories of Telepathology
A telepathology system, like telemedicine, has two modes of delivery: static systems and dynamic systems. A
hybrid system can also be apply which incorporates both static and dynamic imaging modalities

Static Telepathology
In a static telepathology system, a small number of slide images of interest are selected by the doctor. These images
are then captured in a digital format on an image frame grabber board and sent to the specialist located at a remote
site. The image transfer is usually done by email or by a File Transfer Protocol (FTP).

The static telepathology practice is in a way store-and-forward mode. The system is simple, inexpensive, and can be
used without any special telecom equipment other than a standard PC modem and Internet facility.

The optical resolution of a microscope depends on the Numerical Aperture (NA) of the objective lens used and the
wavelength of light, and is commonly expressed as 0.6l /NA. In addition, the resolution of a microscope also
depends on the magnification of the objective lens used.

Dynamic Telepathology
In a dynamic system, a real-time live images of a specimen are transmitted from the microscope to the monitor at the
remote site (Weinstein, et al., 1992). The pathologist at the remote site can control the microscope operation while
viewing, and uses the necessary tools to select diagnostic fields by moving microscope stage and adjust focus,
magnification with change of objectives and illumination on the microscope.
Dynamic telepathology is performed between centres using the same operating system. The minimum bandwidth
requirement is 128 Kbps for satisfactory image transfer. The equipment for dynamic telepathology and the computer
programs is generally high and therefore only large hospitals and academic institutions are able to afford them. A
typical real-time telepathology system.

In the telepathology client set up, there are two main windows which are displayed on the screen:
i)Image window:
To display the microscope image captured by the camera.
(ii) Control window:
For making adjustments of the various microscope features such as stage position, objective focus, objective
magnification and target illumination.

Hybrid System
A hybrid system can be formed by combining the efficient bandwidth utilisation and reliable transmission of static
system with the real-time control and imaging of the dynamic system.
A hybrid telepathology network based on store-and-forward communication using iPATH and videoconferencing
using Skype. The iPATH network (Internet Pathology suite) is an open access platform designed for discussing
medical information in a store-and-forward format and has been used successfully in many countries.

Equipment for Telepathology

A telepathology system consists of:
(i) Telepathology workstation where pathologist receives images and audio information from remote areas. It
consists of a computer with graphics card and a colour monitor, and software to manage images, including image
acquisition and data file storage. The colour monitor should have at least 1024× 1024 pixels with 14-bit colour depth
or better and 17 inches or larger in size. A sound card with speakers and microphone is also necessary for video
teleconferencing
(ii) Image management system (image acquisition, database file storage)
(iii) High resolution video camera with resolution better than 1000  ×750 pixels to capture images of pathologic
specimens
(iv) Telecommunication set up to transmit images to the remote site for transfer of data, images and audio in
telepathology, different types of networks are available.
If an automatic microscope is employed, robotic mechanical features and a control software have to be added to
remotely manipulate X and Y positions of the scanning stage, for zooming and focusing of lenses’ magnification
control with the selection of objectives and illumination. Keyboard, mouse and special joystick are used to remotely
manipulate the functioning of the microscope.

Other important features that are available at the remote control include an electronic zoom and pan capability. It
also, has an annotation function that enables the operator to superimpose desired information.
 Tele-Radiology
Radiology is a medical specialty that uses imaging to diagnose and treat diseases within the body. It may use x-rays
and other imaging methods for this purpose. Teleradiology is the electronic transmission of radiologic images from
one location to another for the purposes of interpretation and/or consultation through digital, computer-assisted
transmission, typically over standard telephone lines, Wide Area Network (WAN) or a Local Area Network (LAN).
The main advantage of teleradiology is that it allows more timely interpretation of radiologic images and gives
greater access to secondary consultations and to improved continuing education

The goals of teleradiology include:

(i) Providing consultative and interpretative radiologic services
(ii) Providing timely availability of radiologic image interpretation in emergent clinical
care situations
(iii) Enhancing continuing educational opportunities for practicing radiologists

all types of modern popular modalities covering x-rays, computed tomography, magnetic resonance imaging, and
ultrasound. photography, endoscopy and microscopy which are used for specialised applications. Thus, the term
teleimaging would be a better term to describe the area of image transfer
in telemedicine.
A common method of image transfer is to use a CODEC (coder-decoder) which transforms analog images to digital
information and compresses the data. At the remote site, another CODEC is used to decompress the signal and to
convert it into analog form for real-time viewing on a monitor. During the past two decades, there has been a rapid
increase in the use of teleradiology to link hospitals and affiliated satellite facilities, primary hospitals, and imaging
centres.

Types of Imaging Modalities

x-rays
x-rays are the oldest and most frequently used form of medical imaging. The images are taken by passing x-rays
through a portion of the body under investigation and recording the amount of x-radiation that is not absorbed in the
body.
Computed Tomography (CT)
An image of the tissue density is computed by the CT scanner and represented as a slice of the patient’s body. In
modern CT scanners, three-dimensional (3D) image can be computed from multiple scans. A head CT scan may
consist of 10 to 12 individual cross-sectional images. These can be laser printed on to high quality transparency film.
Each image is a 512××512 data matrix containing 256 shades of gray.

Magnetic Resonance Imaging (MRI)

MRI machine, the patient lies on a table which gets into a kind of tunnel. Here, the patient is surrounded by
extremely powerful electromagnets which act to align the atomic nuclei in the body. When a radiofrequency current
in the pulsed form is externally applied to the patient, the protons are disturbed,
and spin out of equilibrium. The use of MRI machines has become popular in the hospitals because the patient is not
exposed to x-radiation and also, additional medical information is available as compared to x-ray and CT systems.
Image resolution in MRI conforms to 128×128 or 256×128 matrix size.

Ultrasound Imaging Systems

In an ultrasound examination, a transducer (probe) is placed directly on the skin of the patient or inside a body
opening. A thin layer of gel is applied to the skin so that the ultrasound waves are transmitted from the transducer
through the gel into the body. The advantage of ultrasound lies in their ability to detect soft tissue, such as tumours
and lesions. No surprise, that ultrasound today is the preferred non-invasive diagnostic imaging modality practiced
in most of the medical specialties, which include cardiology, internal medicine, obstetrics and gynecology.

Nuclear Medicine Imaging Systems

Nuclear medicine imaging is based on the principle of injecting the patient with a radioactive substance and
detecting the gamma rays that are emitted, which represent, for example, the flow of blood through blood vessels.
These are: (i) Conventional Gamma Camera, (ii) Single Photon Emission Computed Tomography (SPECT), and (iii)
Positron Emission Tomography (PET).

Gamma camera:
gamma cameras map the function and processes of the various parts of the body. Gamma cameras are mostly used to
carry out functional scans of the brain, thyroid, lungs, liver, gallbladder, kidneys and skeleton.

SPECT:
SPECT imaging is carried out by employing a gamma camera which acquires multiple 2D images from various
angles. A computer then performs tomographic reconstruction by using algorithm to the multiple projections, thus
giving a 3D data set. The examples include tumour imaging, infection, thyroid imaging, bone scintigraphy and study
localised function in internal organs, such as functional cardiac or brain imaging.

PET:
It is based on the principle that when positrons are emitted from the radioactive substance, they are destroyed by
interaction with electrons. A PET scan is helpful in evaluating important body functions, such as blood flow, oxygen
use, and glucose metabolism, to understand as to how well organs and tissues are functioning.

Steps Involved in Teleradiology

The following are the steps in the teleradiology process:

(i) Producing digital images: When the output of the imaging device is not available in the digital form, the first
step lies in digitising, say a radiology film. For this purpose, a film digitiser is used to convert radiographs (x-ray
films) into digital form.

(ii) Interfacing patient information: Providing the health record information required to correctly identify the
patient and his complete medical history to the radiologist.

(iii) Compressing images and other data: For quicker and efficient transfer of data and images from one site to
another, compression is a software technique by which certain pixels in the digitised image are dropped to decrease
transmission time.

(iv) Transmission of images: The images are transferred from one site to another over telephone lines, ISDN, T1,
Ethernet/LAN, satellite or coaxial lines, etc. The choice of communication method would depend upon the size of
the file and bandwidth of line of transmission suitable for the teleradiology system.

(v) Reconstruction of images: This is done at viewing site for display, evaluation and review.

Components of a Teleradiology System

i) An image sending station
(ii) A transmission network
(iii) A receiving/image review station

Image Sending Station

In teleradiology, the sending station
typically would have an image (film) digitiser and a network interface device which most
commonly has been a phone modem. Film digitisers can be categorised into three types:
(i) Camera digitiser
(ii) Charged Coupled Device (CCD) scanner/digitisers
(iii) Laser scanner digitisers
Once the film digitiser has converted the image to a digital format, the data is sent to the computer and to the modem
upon command of the equipment operator.
The three most important specifications for a teleradiology sending station are resolution, compression, and
transmission speed. The image resolution is determined by the number of pixels in an image and the range of density
numbers per pixel. With higher resolution, the number of pixels and consequently the file size increases and so does
the time required to transmit that file increases.

Compression:
Data compression is used to increase transmission speed and reduce storage requirements for a particular size of data
file. Compression algorithms use a variety of techniques with JPEG being quite popular. JPEG is the only
compression technique permitted by DICOM 3.0, so a fully compliant DICOM 3.0 workstation is not likely to
display a wavelet compressed image.

Transmission (modem) speed:

A modem is the interface unit between the image digitiser and the transmission network. It is the data rate transfer
speed of the modem which determines the transmission speed of transfer of the image. The speed of modem is
expressed in bits per second (bps) or baud rate. Ideally, the teleradiology sending station should have very high
resolution, little or no compression, and very high transmission speed. A sending station should be so selected that it
has a reasonably fast modem with data rates 19,200 bps and above. Also, the image resolution should be operator-
selectable between 512×512 bits and 2048×2048 bits. The compression levels should be user selectable.

Transmission Network
The images can be transmitted by means of conventional modes such as ISDN, switched-56, microwave, ATM,
satellite, and T1 telecommunication links. However, the high-speed lines, including, cable modems, and xDSL, have
become popular as prices continue to drop for the broadband Internet service. The most commonly used
transmission networks currently in use for teleradiology are those provided by the Internet service providers. This
network utilises both wire and fibre optics as a medium of transmission. Internet compatibility is increasingly a
feature of modern teleradiology systems, enabling platform-independent transmission of images anywhere in the
world.

Receiving/Image Review Station:

Network interface which is a modem
(ii) Personal computer with hard disc drive as storage medium
(iii) One or two display monitors
(iv) Hard copy printer

Modem:
To ensure maximum transmission speed, the speed of modem at the receiving station should be equal to or greater
than maximum speed of the modem at the sending station.

Computer hardware:
The minimum requirements of a teleradiology systems are:
(i) At least four megabytes of RAM with expansion capabilities
(ii) High capacity hard disc drive
(iii) High end pentium processor based PC.

Image enhancement software:

Image enhancement software is the essential component of a teleradiology system. Besides gray scale window/level
and magnification controls of the image, other important software enhancement features that are normally included
are colour, gray scale mapping, positive-negative reversal, edge enhancement, image flip/rotate and histogram
capability.

Display monitors:
The two most common requirements for display monitors at the receiving station are monitor resolution and screen
size. Resolutions usually available range from 512*512 pixels to 2048*2048 pixels. For teleradiology applications,
monitor resolution is usually recommended is 1024×1024 or above.
Split screen capability is a desirable feature in a teleradiology display station. It facilitates the display
of two or more different images on the same monitor screen at the same time.

Archiving and retrieval:

Teleradiology systems should provide storage capacity sufficient to comply with all relevant regulations regarding
medical record retention and retrieval. Images stored at either site should meet the jurisdictional requirements of the
transmitting site. Each facility should have policies and procedures for archiving and storage of digital image data
equivalent to the policies for protection of hard-copy storage media to preserve imaging records.
To summarise, the following factors should be kept in view while setting up a teleradiology system:

(i) All equipment should be DICOM standard compatible. DICOM defines the communication of images between
local and distant sites as well as between equipment from different manufacturers. If it becomes necessary to change
any of the equipment, operations will be unaffected so long as everything is DICOM compatible.

(ii) As far as possible, the HL7 standard should be used for health data communication. This is would be helpful in
ensuring that the reports are properly transmitted back to the Electronic Medical Record (EMR) of the patient at the
originating site where the patient had the original radiology examination.

(iii) Teleradiology work must meet current standards for digital radiology. Two relevant guideline for the practice of
digital radiology, including teleradiology are the ACR-AAPM-SIIM Practice Guidelines for Digital Radiography .
and the ACR-AAPM-SIIM Technical Standard for Electronic Practice of Medical Imaging.

(iv) Transmission and receipt of images should be according to all applicable state and federal laws including Health
Insurance and Portability and Accountability Act (HIPAA).

Types of Teleradiology Systems

On-call:
Typical ―on-call‖ teleradiology systems are most frequently used for after hour, ―on-call‖ applications.
Off-site:
―Off-site‖ systems are set up mostly by radiology specialists and hospitals to establish central database with a view
to expand interpretation network. Such a system would be especially beneficial for meeting the requirement of
shortage of radiologists in the rural medical facilities.
In-hospital:
―In-hospital‖ systems are meant to be used to transfer images within the same facility (i.e., from the radiology
department to intensive care unit, emergency room, operation theatre, and clinics) over a LAN.

PICTURE ARCHIVING AND COMMUNICATION SYSTEM (PACS)

A Picture Archiving and Communication System (PACS) consists of computers and networks designed for storage,
retrieval, distribution and presentation of medical images. PACS handles images from various imaging modalities
such as radiography (plain x-rays), ultrasonography, computed tomography, magnetic resonance imaging, positron
emission tomography and mammography. PACS replaces hard copy based system of managing medical images,
such as film archives. Modern radiology equipment generates and feeds images directly to PACS in digital form.
Alternatively, most hospital imaging departments use film digitisers to get the image in the digital format. PACS
offers several advantages such as improved work flow, improved throughput, rapid, remote, and simultaneous
access to image data, electronic archiving, and cost-effectiveness, leading to overall better patient care and higher
productivity.

PACS basically is an inter- and intra-institutional system which depends upon broadband telecommunications
network for its operation. The system is also known as medical-imaging network or Medical Image Management
System (MIMS) that enables different hospital departments to conveniently store, retrieve and transfer patient
records, hospital accounts, etc. Modern technology allows PACS to store the image of the patient examination
digitally along with the radiologist’s report, which can also be stored in the form of digitised voice.

PACS has proved especially useful when a physician and a radiologist need to have a discussion about a case.
Instead of travelling to a designated place to have a personal meeting, PACS can enable them to use a multimedia
communication system, where the medical images can be retrieved and displayed on their respective screens. The
medical case can then be discussed over voice communications and proper diagnosis worked out while looking at
the shared images on the computer.

A PACS has a number of physical components which are shown in the block diagram
form in Figure 13.6.

The Acquisition Devices

The first step in PACS is the acquisition of the image which may be in the form of analog (x-ray film) or digital
form. The analog x-ray needs a digitiser to convert the image into digital format. Digital modalities such as
computed tomography, magnetic resonance imaging, nuclear medicine, ultrasonography, digital radiography, digital
angiography, digital fluoroscopy, and digital mammography give output in the direct digital form.

The Network
The data connection between the various components of the PACS is provided by the network which acts like a
highway for the entire system. Some common network technologies are given in Table 13.3, which lists out the
maximum image transfer rate possible for transferring digital images from various devices. Intermediary computers
associated with the network transfer images from different modalities to the PACS or transfer information to and
from the Radiological Information System (RIS).

The Database Server

The database server is the ―brain‖ of a centralised PACS. It is responsible for keeping track of the information,
images, image attributes, and image locations. The server is a central computer comprising multiple high-speed
central processing units and a large amount of random-access memory and cache memory. The database server is
also sometimes referred to as the image server.

The Archival System

The archival system is the heart of a PACS. It is responsible for electronic archiving of image data, with both long-
term and short-term archiving. Accordingly, there are several features relating to short-term and rapid-access, long-
term and possibly slower access storage of image data. Due to cost consideration, there is a division of the system
into short-term and long-term archives, as the technology for the rapid access is earlier quite expensive. However,
with the development of low cost rapid-access storage technologies, the distinction between short-term and long-
term archives has fade away.

The Radiological Information System

The Radiological Information System (RIS) is responsible for maintaining patient demographics, scheduling, and
interpretations of examination results . At the same time, some RISs have been developed and used independently of
PACS primarily based on HL7. However, most PACS depend upon the RIS as the primary source of patient
information. Intimately integrated PACS and RIS are offered by most of the suppliers.

The Display Workstation

The display workstation provides a dynamic presentation of the image data to the clinician. The software facilitates
access to various system functions necessary for viewing an image such as retrieval, image display, and various
image manipulation functions such as window leveling and zooming. LCD with graphical user interfaces is the most
common type of display workstation used in PACS.
The basic objective of PACS was originally planned to have filmless radiology departments. However, many PACS
operations continue to use the films as digital images are often printed on film or laser printers for various reasons.
High-resolution digital printers are now available that are eventually eliminating film printing in PACS to maintain
its cost-effectiveness.
IMAGE ACQUISITION AND IMAGE DIGITIZATION
Although any type of medical image may be transmitted by teleradiology, all images must be in a
digital form before transmission can occur. Conventional hardcopy images from any modality can be
digitized by special high resolution laser or charge-coupled device (CCD) scanners. Simplistically,
film scanners for teleradiology function similarly to fax machines by scanning analog data and
converting it into digital form. Charge-coupled device scanners using the same technology as video
camera shave tiny photocells that acquire data from a trans illuminated film. Laser scanners offer
better signal-to-noise ratios than CCD scanners, leading to superior contrast resolution. They are,
however, more expensive. Additional studies are required to determine whether the superior
contrast resolution offered by laser scanners is diagnostically significant.

Many images are inherently digital: computed tomography, magnetic resonance, ultrasound, nuclear
medicine, computed radiography, digital radiography, and digital fluoroscopy. All can be directly
linked to a teleradiology system if they are in a standard format . Fortunately, more and more
imaging devices are complying with the ACR-NEMA (American College of Radiology and National
Electrical Manufacturers Association)DICOM 3 standard (Digital Imaging and Communications in
Medicine—version 3). The DICOM 3 standard is important to teleradiology because a direct digital
connection can be made from the image source to the teleradiology server and then from the
teleradiology receiving computer to a diagnostic workstation.

In practice, many digitally acquired images cannot be directly linked to teleradiology systems
because they are acquired on older equipment that is not DICOM compliant. Different
manufacturers of imaging equipment historically used proprietary file formats and communications
protocols, which prevent direct interfacing to communications networks. One of the most commonly
used methods is to simply take the hardcopy rendition of a digital modality and digitize the image
with a laser or CCD digitizer. Another alternative is to use a video frame grabber wherein the video
signal output that is sent to an imaging console is converted to digital form . Such devices are
commonly used to connect ultrasound machines to PACS, even today. It is also possible to use a
protocol converter, which is a special computing device that converts proprietary image data to the
DICOM 3 com-pliant format.

IMAGE COMPRESSION
File sizes for typical digitized medical images are large (Table 26.1). Trans-mission of this volume of
data requires significant bandwidth (the capacity of a communication medium to carry data).
Therefore, these file sizes maybe too large for teleradiology to be effective, both practically and
economically. To reduce the amount of digital data to be transmitted, the digital data can be
compressed prior to transmission.

Compression can be “lossless” (reversible), with compression ratios typically in the range of 3 : 1, and
the original dataset can be fully regenerated, or “lossy” (irreversible), where much higher
compression ratios are possible. Compression ratios of at least 10 : 1 are generally required before
data compression can have a significant economic effect. Although lossy compression requires some
loss from the original dataset, several studies have shown that compression ratios of 20 : 1 or higher
can be achieved without sacrificing diagnostic image content.

Both JPEG and wavelets can be used in either a lossy or lossless mode.JPEG compression is the only
technique currently supported by the DICOM 3 standard. JPEG’s principal advantages are that it is
inexpensive, widely acceptable to most computing platforms, and implemented in both hardware
and software.

A major advantage of wavelet compression over JPEG compression isthat it permits substantially
higher compression ratios while maintaining image quality. This has practical implications for high-
volume teleradiology, particularly from international sites, where the cost of data transmission
becomes a significant factor in the overall cost of the teleradiology system. Several studies have now
confirmed that compression ratios of up to 20 : 1are diagnostically acceptable.

IMAGE TRANSMISSION
Transmission of digitized data requires communication equipment. The nature of the equipment
depends on the communication medium being used. This may be a modem for conventional
telephone lines, a terminal adapter for an ISDN line, a channel service unit (CSU) for a T1 line, a DSL
modem, or a cable modem.

IMAGE INTERPRETATION
Once images are received from the wide area network (WAN) at the interpretation site, they can be
sent directly to an interpretation workstation or to an image server that permits distribution within
the institution . Archiving or storing the images for long periods may not be required, as is necessary
for PACS.

APPLICATIONS OF TELERADIOLOGY
 Medical Information Storage and Management for Telemedicine
Databases and Database Management Systems
It is important to distinguish between the clinical data—that is, the computer-based patient record, or CPR computer
based patient records —and the system that captures and processes those data—that is, the CPR system. CPR
functions relate to the collection of data, such as patients' medical problems, diagnoses, treatments, and other
important patient information, including follow-up data and quality measures. CPR system functions relate to
storage capacity, response time, reliability, security, and other similar attributes, but the system relies on the
collection of clinical data, the core CPR, to support virtually all of its activities.

Databases
The most desirable database model for CPR systems involves either a distributed database design—that is, a system
with physically distributed computers and databases but with logical central control of the entire record; or a
centrally integrated physical database design—that is, a centrally located, complete CPR within a single computer-
stored database or some hybrid or mix of these two approaches. In any case, the key requirements are central
control and organizational integrity of the entire record for each individual patient. Central control permits
authorized persons using a terminal located anywhere in the information system to access the entire integrated
patient record or any of its parts, regardless of the locations of any other departmental subsystems where the various
data items may have originated. (Access is allowed only on the basis of parameters specific to authorized users.)
Although the feasibility of the distributed database design has recently gained support from the development of
networking technologies, most current clinical information systems that might qualify as CPR systems use a
centralized design. The CPR systems of today cannot as yet acquire and retrieve all patient care data directly.
Instead, they rely on data transmitted to the CPR system through interfaces with departmental subsystems; the data
are subsequently entered into the CPR using applications programmed on the CPR system. One major factor that
differentiates current CPR systems is the extent to which they use local area networks, or LANs, to access
departmental subsystems and stand-alone databases containing portions of the CPR. Today's CPR systems place
great emphasis on providing at least a ''view" of a complete, centralized patient record . If the patient's clinical data
are physically distributed among several computers in a network, a comprehensive view of the record of a given
patient can be achieved only by retrieving and assembling the pertinent data from each computer on the network
where patient data reside. Although this scenario has a number of advocates and some advantages, it also has several
severe problems .

A careful analysis of the two contrasting models may be helpful in understanding the main problems. In the
distributed system, the patient record is physically distributed among several computer systems but at the same time
is functionally integrated. This means that a variety of distributed patient care applications will generate and use
patient care data in the distributed CPR. It also means that individual records may require multiple data structures
(or data files), which tends to lengthen data retrieval times. Another problem with a distributed system is that data
synchrony—that is, the correct sequencing of a patient's time-stamped data that are entered into the system at
the same time but from different sources—must be guaranteed at both the applications and the database management
system (DBMS) levels. Perhaps the most significant problem with the distributed database approach, however, is
the increased potential it carries for circumventing CPR confidentiality mechanisms. Because portions of the
patient's record are distributed among several different computers, ensuring confidentiality becomes more difficult.
Every computer has its own vulnerabilities, and each one that is added to a network represents another node that
must be protected and another potential entry point for unauthorized access (National Research Council, 1991).

Database Management Systems

A major technological issue is the complexity of the data that will eventually reside in the CPR. The CPR of the
future will consist of many different kinds of data, including text, graphics, images, numerical data, sound, and full-
motion video. To design a functionally integrated database system that accommodates such diversity is a sizable
technical challenge.

The CPR is so complex that no single database management system is capable of optimally storing and retrieving
the full range of patient data. As a result, CPR system developers have used a variety of complementary DBMSs to
address these complexities. This multiple- DBMS approach is most common when the CPR system uses the
distributed database scenario; in that case, each subsystem often uses a different DBMS. Because the CPR is
distributed across many connected subsystems, each subsystem will probably use a DBMS that is particularly suited
to the kind of data most frequently stored in that subsystem. The collection of appropriate databases that results
offers advantages of efficiency in manipulating and storing the CPR complex data. Some CPR system developers
have even created their own proprietary database management systems, tailored to the CPR's
particular complexities.
The selection or creation of the DBMS that will support the CPR is among the first and most crucial steps in
developing a CPR system. Several database management systems or architectures have evolved in recent years. Four
important ones developed by commercial vendors are hierarchical, relational, text-oriented, and object-oriented
databases. Each of these architectures has its own particular strengths and weaknesses. Architects of current CPR
systems (both commercial and private) have mainly used hierarchical, relational, or text- oriented models. Viable
object-oriented database management systems have been introduced only recently and are not yet in widespread use.

Security
Data Quality

Security
Flexibility

Efficiency

RISK MANAGEMENT CONCERNS AND MITIGATION STRATEGIES

Although the benefits of telemedicine for both patients and clinical providers are many and the financial
case is generally compelling, risk managers and insurance professionals recognize a multitude of
potential risks associated with telemedicine services. Risk management needs to accurately assess,
mitigate and finance these risks.
Many of the risks related to telemedicine are not new to health care, but certain characteristics of
telemedicine have created new twists on old exposures. One example is the geographic separation of the
patient and provider.
Health care entities have addressed important telemedicine risk issues as usage has increased, but there is
much work still to do and many questions remain unanswered.
 Patient Information
 A patient record is the repository of information about a single patient. This
information is generated by health care professionals as a direct result of
interaction with a patient or with individuals who have personal knowledge
of the patient (or with both). Traditionally, patient records have been paper
and have been used to store patient care data.

Patient-Specific Data
Demographics (age, gender, race, ethnicity, source of admission)
Problems (diagnoses, symptoms, reasons for health care encounter)
Severity of illness score (APACHE, Medis Groups, Nursing Severity Index)
Interventions (risk assessments, procedures, medical interventions, nursing interventions,
laboratory tests)
Nursing care intensity
Outcomes (mortality, morbidity, health services utilization, functional status, quality of life)

A computer-based patient record (CPR) is an electronic patient record that resides in a system
specifically designed to support users by providing accessibility to complete and accurate data,
alerts, reminders, clinical decision support systems,3 links to medical knowledge, and other aids.

Types of Patient Records

A primary patient record is used by health care professionals while providing

patient care services to review patient data or document their own observations,
actions, or instructions.
A secondary patient record is derived from the primary record and contains
selected data elements to aid nonclinical users (i.e., persons not involved in direct
patient care) in supporting, evaluating, or advancing patient care.

A patient record system is the set of components that form the mechanism by which
patient records are created, used, stored, and retrieved. A patient record system is
usually located within a health care provider setting. It includes people, data, rules
and procedures, processing and storage devices (e.g., paper and pen, hardware and
software), and communication and support facilities.

Computer-based Patient Record

• IOM Recommendations

• Attributes

• Barriers

• Status

IOM Recommendations

• Health care professionals and organizations should adopt the CPR as the standard for
medical and all other records related to patient care

• To accomplish this the public and private sectors should join in establishing a CPR
Institute (CPRI) to promote and facilitate development, implementation, and
dissemination of the CPR
 • Both the public and private sectors should expand support for the CPR and CPR system
implementation through research, development, and demonstration projects

• The CPRI should promulgate uniform national standards for data and security to
facilitate the implementation of the CPR and its secondary data bases

Attributes of CPRs and CPR Systems

• The CPR contains a problem list that clearly delineates the patient’s clinical problems
and the current status of each (e.g., the primary illness is worsening, stable, or
improving)

• The CPR encourages and supports the systematic measurement and recording of the
patient’s health status and functional level to promote more precise and routine
assessment of the outcomes of patient care

• The CPR state the logical basis for all diagnoses or conclusions as a means of
documenting the clinical rationale for decisions about the management of the patient’s
care. This documentation should enhance use of a scientific approach in clinical practice
and assist the evolution of a firmer foundation for clinical knowledge

• The CPR can assist, and in some instances, guide the process of clinical problem solving
by providing clinicians with decision analysis tools, clinical reminders, prognostic risk
assessment, and other clinical aids

• The CPR supports structured data collection and stores information using a defined
vocabulary. It adequately supports direct data entry by practitioners

Technological Building Blocks

• Data exchange and vocabulary standards

• Systems communications and network infrastructure

• System reliability and security

• Linkages to secondary databases

• Databases and database management systems

• Workstations

• Data acquisition and retrieval

• Text processing

• Image processing and storage

Technological Barriers

• Human interface and system performance

• Text processing

• Confidentiality and security

• Health data-exchange standards

Nontechnological Barriers

• Unpredictable user behavior

• Lack of leadership for resolving CPR issues

• Lack of training for developers

• Lack of consensus on the content of the CPR

• Development costs

• Disaggregated health care environment

Status of Issues Related to CPRs

• CPRI formed

• Healthcare Information Portability and Accountability Act (K2)

• IOM report on confidentiality and security

• Health data-exchange standards

Problems with Access, Availability, and Retrieval

Record unavailability and difficulties in accessing records when they are available
are frequent problems for patient record users documented in their study that
medical records were unavailable in up to 30 percent of patient visits. They
attributed this rate of unavailability to several possible causes: patients being
seen in two or more clinics on the same day, charts not being forwarded,
physicians keeping records in their offices or removing them from their offices,
and records being misfiled in the file room. One hospital in the GAO study on
automated medical records reported that it could not locate medical records 30
percent of the time . Even when records are readily available, the amount of time
required to retrieve necessary information from a record can frustrate users .
For researchers, access to paper records can be problematic and is generally
resource intensive . Identifying records that contain needed data, retrieving
needed records, reviewing records, collecting data, and entering data into data
sets for analysis are time-consuming, expensive tasks. Yet access to existing
computer-based records can also prove difficult for researchers because
documentation on how to use systems may be lacking. Further, data aggregation
can be hampered by lack of compatibility among systems.

Problems with Linkages and Integration

One of the major criticisms of the U.S. health care system is the discontinuity of
care among providers . This discontinuity extends to patient records, whose lack
of integration of inpatient and outpatient information is a significant deficiency.
Paper patient records offer little hope of improving the coordination of health
care services within or among provider institutions. Moreover, the inadequacy of
patient record interfaces with other clinical data, administrative information, or
medical knowledge impedes optimal use of record information in providing
patient care. Several health care systems and institutions have developed records
that overcome many of the problems associated with traditional paper records,
but even these improved records suffer from their lack of easy transferability to
other health care provider systems or institutions.

Outpatient Records
Attention is frequently focused on patient records in hospitals rather than in
outpatient settings. (An inpatient record is used by many different individuals
during an episode of illness, so its weaknesses can appear quite pronounced.) Yet
outpatient records are greater in number, are scattered among individual
physician offices, and may exhibit even greater variance in quality than inpatient
records. There are no established standards or review organizations for
outpatient records as there are for inpatient records.
Ambulatory care records frequently contain poorly organized data, lack
documentation of key aspects of care, and exhibit inaccurate diagnostic coding
(IOM, 1990c). Health care researchers and clinicians who conduct retrospective
studies using such records are likely to identify at least four weaknesses: lack of
standardization in content and format, inaccessibility (except in some hospitals
or large health plans), incompleteness, and inaccuracies .

Increasing Demand for Data

Even as patient care data become more voluminous and complex, the demand by
multiple users for access to patient care data is increasing . Information must be
shared among the multiplicity of health care professionals who constitute the
"health care team." These professionals represent the physician specialties, as
well as nurses, dentists, therapists, pharmacists, technicians, social workers, and
other health care providers. Patients may also require access to records; some
providers advocate greater patient input into the process of care through patient
identification of preferences among treatments, patient contributions to the
record, patient reading and validation of record data, and patient control and
transport of pertinent parts of the record .
Administrators and managers of health care institutions require information to
manage the quality of care provided and to allocate resources (e.g., labor,
supplies, equipment, and facilities) according to the institution's patient case mix.
Managers of provider institutions seek to link financial and patient care
information to develop meaningful budgets, measure productivity and costs, and
evaluate market position. Long-term institutional planning for personnel
recruitment, equipment acquisition, and facilities development depends on
anticipated trends in patient population needs.
Quality assurance activities constitute another information need. Such activities
are a requirement for accreditation of hospitals by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO); in addition, third-party
payers carry out various quality monitoring and evaluation efforts. The best
known is probably the Medicare peer review organization program administered
by the Health Care Financing Administration . Public and private third-party
payers, medical professional societies, and researchers have been exploring
practice guidelines and outcomes management as tools for improving care . The
risk management programs established by many health care institutions in
response to the recent history of medical malpractice litigation add another level
of information use .
 Medical History

The medical history is a longitudinal record of what has happened to the patient since
birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks.
It gives the clinician a feel for what has happened before to the patient. As a result, it
may often give clues to current disease state. It includes several subsets detailed
below.

Surgical history

The surgical history is a chronicle of surgery performed for the patient.

It may have dates of operations, operative reports, and/or the detailed
narrative of what the surgeon did.

Obstetric history

The obstetric history lists prior pregnancies and their outcomes. It also
includes any complications of these pregnancies.

Medications and medical allergies

The medical record may contain a summary of the patient's current and
previous medications as well as any medical allergies.

Family history

The family history lists the health status of immediate family members
as well as their causes of death (if known). It may also list diseases
common in the family or found only in one sex or the other. It may also
include a pedigree chart. It is a valuable asset in predicting some
outcomes for the patient.

Social history

The social history is a chronicle of human interactions. It tells of

the relationships of the patient, his/her careers and trainings, and
religious training. It is helpful for the physician to know what sorts
of community support the patient might expect during a major illness. It
may explain the behavior of the patient in relation to illness or loss. It
may also give clues as to the cause of an illness (e.g. occupational
exposure to asbestos).

Habits

Various habits which impact health, such

as tobacco use, alcohol intake, exercise, and diet are chronicled, often as
 part of the social history. This section may also include more intimate
details such as sexual habits and sexual orientation.

Immunization history

The history of vaccination is included. Any blood tests

proving immunity will also be included in this section.

Growth chart and developmental history

For children and teenagers, charts documenting growth as it compares

to other children of the same age is included, so that health-care
providers can follow the child's growth over time. Many diseases and
social stresses can affect growth, and longitudinal charting can thus
provide a clue to underlying illness. Additionally, a child's behavior
(such as timing of talking, walking, etc.) as it compares to other children
of the same age is documented within the medical record for much the
same reasons as growth.

Test Reports
A medical test is a medical procedure performed to detect, diagnose,
or monitor diseases, disease processes, susceptibility, or to determine a course
of treatment. Medical tests relate to clinical chemistry and molecular
diagnostics, and are typically performed in a medical laboratory.

Types of tests
A diagnostic test is a procedure performed to confirm or determine the presence of
disease in an individual suspected of having a disease, usually following the report of
symptoms, or based on other medical test result. This includes posthumous diagnosis.
Examples of such tests are:

 Using nuclear medicine to examine a patient suspected of having a lymphoma.

 Measuring the blood sugar in a person suspected of having diabetes
mellitus after periods of increased urination.
 Taking a complete blood count of an individual experiencing a high fever to
check for a bacterial infection
 Monitoring electrocardiogram readings on a patient suffering chest pain to
diagnose or determine any heart irregularities

Screening
Screening (medicine)

Screening refers to a medical test or series of tests used to detect or predict the
presence of disease in at risk individuals within a defined group such as a population,
family, or workforce. Screenings may be performed to monitor disease prevalence,
manage epidemiology, aid in prevention, or strictly for statistical purposes.

Examples of screenings include measuring the level of TSH in the blood of a

newborn infant as part of newborn screening for congenital hypothyroidism, checking
for Lung cancer in non-smoking individuals who are exposed to second-hand
smoke in an unregulated working environment, and Pap smear screening for
prevention or early detection of cervical cancer.

Monitoring
Monitoring (medicine)

Some medical tests are used to monitor the progress of, or response to medical
treatment.

Most test methods can be classified into one of the following broad groups:
In vivo diagnostics which test in the body, such as:

 Manometry
 Administering a diagnostic agent and measuring the body's response, as in
the gluten challenge test, contraction stress test, bronchial challenge test, oral
food challenge, or the ACTH stimulation test.

In vitro diagnostics which test a sample of tissue or bodily fluids such as:

 Liquid biopsy
 Microbiological culturing, which determines the presence or absence of
microbes in a sample from the body, and usually targeted at
detecting pathogenic bacteria.
 Genetic testing
 Blood Glucose testing
 Liver function testing
 Calcium testing
 Testing for electrolytes in the blood, such as Sodium, Potassium, Creatinine,
and Urea [

In vitro tests can be classified according to the location of the sample being tested,
including:

 Blood tests
 Urine tests, including naked eye exam of the urine
 Stool tests, including naked eye exam of the feces
 Sputum (phlegm), including naked eye exam of the sputum

Laboratory Tests
 Detection Methods
o Microscopy
o Culture
 o Antigen test*
o Identification Methods
o PCR*
o Viral load*
o PFGE
o Genotyping
o Serology
 Antimicrobial susceptibility
Ancillary tests

Sample test reports

Antigen Test

Polymerase Chain Reaction (PCR)

Method used to amplify a specific region of a DNA strand.
Human Parvovirus B-19: Disease and Immune Response

Antibody Testing
Hepatitis C

Medical Imaging
• Non-invasive visualization of internal organs, tissue, etc.
– Is endoscopy an imaging modality?
• Image – a 2D signal f(x,y) or 3D f(x,y,z)
– Is a 1D non-imaging sensing techniques an imaging modality?

Major Modalities
• Projection X-ray (Radiography)
• X-ray Computed Tomography (CT)
• Nuclear Medicine (SPECT, PET)
• Ultrasound
• Magnetic Resonance Imaging

1.Projection X-ray Imaging

2.

3.
4.
5.
 HOSPITAL INFORMATION SYSTEM
(HIS)
A hospital information system (HIS), variously also called clinical
information system (CIS) is a comprehensive, integrated information
system designed to manage the administrative, financial and clinical
aspects of a hospital. This encompasses paper-based information
processing as well as data processing machines.
MODULES
 PATIENT MANAGEMENT SYSTEM (PMS)
 PATIENT’S BILLING AND ACCOUNT RECEIVABLE (PBAR)
 MEDICAL RECORD OFFICE (MRO) SYSTEM
 CLINICAL INFORMATION SYSTEM (CIS)
 LABORATORY INFORMATION SYSTEM (LIS)
 BLOOD BANK INFORMATION SYSTEM (BBIS)
 PHARMACY INFORMATION SYSTEM (PhIS)
 RADIOLOGY INFORMATION SYSTEM (RIS)
 EXECUTIVE INFORMATION SYSTEM (EIS)
 FORENSIC INFORMATION & MORTUARY MANAGEMENT SYSTEM (FIMMS)
PATIENT MANAGEMENT SYSTEM (PMS)
 Manage Patient Activities:
 Appointment/Scheduling
 Registration
 Admission
 Discharge
 Transfer
 Management Of The Deceased
PATIENT’S BILLING AND ACCOUNT RECEIVABLE (PBAR)

 MANAGE PATIENT BILLING AND ACCOUNT RECEIVABLE

ACTIVITIES:
 Bill Generation
 Bill Management
 Bill Payment
 Collection Management
 Refund Management
 Account Reconciliation
 Report Generation
MEDICAL RECORD OFFICE (MRO) SYSTEM

 MONITOR, CONTROL & MANAGE MEDICAL RECORD OFFICE

ACTIVITIES:
 File Management
 Medical Report
CLINICAL INFORMATION SYSTEM (CIS)

 TO CARRY OUT THE CLINICAL ACTIVITIES:

 Doctor Documentation
 Nurse Documentation
 Amo Documentation
 Clinical Physician Order Entry (Cpoe)
LABORATORY INFORMATION SYSTEM (LIS)
 Receive Orders & Collect Specimen
 Process Orders
 Create Testing Work Orders
 Lab Equipment Interface
 Actual Testing
 Generate & Transmit Results
 Generate Management Results
BLOOD BANK INFORMATION SYSTEM (BTIS)

 BLOOD DONATION MANAGEMENT

 Blood Procurement
 Blood Safety
 Blood & Blood Component Production
 Blood & Blood Component Storage & Distribution
 Blood Transfusion Management
 Quality Management
PHARMACY INFORMATION SYSTEM (PhIS)
 Medication Order And Supply Management
 Clinical Pharmacy Management And Manufacturing
 Inventory Management
RADIOLOGY INFORMATION SYSTEM (RIS)
 Receive Subject And Process Order
 Exam Management
  Transcribe, Validate And Distribute Report
 Support Generation Of Management Report
 Support Administrative Function
EXECUTIVE INFORMATION SYSTEM (EIS)
 To Retrieve Selected Report Based On User Criteria
 To Display Selected Report
 To Print Reports Where Necessary
 To Export Graph/Data To Excel/Word Application
FORENSIC INFORMATION & MORTUARY MANAGEMENT
SYSTEM (FIMMS)
 Management Of The Deceased Person
 Release Of Claimed/Unclaimed Bodies
 Storage Of Body & Body Parts
 Medico-Legal & Clinical Autopsies
Modules of HIS
 OPD billing module
 —IPD billing module

 —Store module

 —Housekeeping module

 —Admin. Module

 —Nursing or ward module

 —Diet module

 —Purchase module

 —Medical Record

 —LIS AND RIS

—Nursing or ward module

NURSING MODULE IS BEING CONNECTED TO THE

FOLLOWING
Radiology Information System (RIS)
 Process patient and film folder records
 Monitor the status of patients, examinations, and examination resources.
 Schedule examinations
 Create, format and store diagnostic reports with digital signature
 Track film folders
 Maintain timely billing information
 Perform profile and statistic analysis