fruits of love in the concept of modern electronics jumper to telemedicine in modern electronics next go totelemedicine electronics circuit and Telemedicine Robots ( Ringing On Boats ) AMNIMARJESLOW GOVERNMENT 91220017 XI XA PIN PING HUNG CHOP 02096010014 LJBUSAF The E-Medicine Pro Life 2020

                                 


              
                                    The Flash Back of Telemedicine
                    ( Fruit of Love in modern Electronics )

    
                         
                             
      A doctor’s diagnosis “by radio” on the cover of the February, 1925 issue of Science and Invention magazine

The 1920s was an incredible decade of advancement for communications technology. Radio was finally being realized as a broadcast medium, talkies were transforming the film industry, and inventors were tinkering with the earliest forms of television. 
The Teledactyl (Tele, far; Dactyl, finger — from the Greek) is a future instrument by which it will be possible for us to “feel at a distance.” This idea is not at all impossible, for the instrument can be built today with means available right now. It is simply the well known teleautograph, translated into radio terms, with additional refinements. The doctor of the future, by means of this instrument, will be able to feel his patient, as it were, at a distance….The doctor manipulates his controls, which are then manipulated at the patient’s room in exactly the same manner. The doctor sees what is going on in the patient’s room by means of a television screen.
                   
                                                     
                      
Quite impressively, the teledactyl was imagined as a sensory feedback device, which allowed the doctor to not only manipulate his instruments from afar, but feel resistance.

Here we see the doctor of the future at work, feeling the distant patient’s arm. Every move that the doctor makes with the controls is duplicated by radio at a distance. Whenever the patient’s teledactyl meets with resistance, the doctor’s distant controls meet with the same resistance. The distant controls are sensitive to sound and heat, all important to future diagnosis.
As our civilization progresses we find it more and more necessary to act at a distance. Instead of visiting our friends, we now telephone them. Instead of going to a concert, we listen to it by radio. Soon, by means of television, we can stay right at home and view a theatrical performance, hearing and seeing it. This, however is far from sufficient. As we progress, we find our duties are multiplied and we have less and less to transport our physical bodies in order to transact business, to amuse ourselves, and so on.The busy doctor, fifty years hence, will not be able to visit his patients as he does now. It takes too much time, and he can only, at best, see a limited number today. Whereas the services of a really big doctor are so important that he should never have to leave his office; on the other hand, his patients cannot always come to him. This is where the teledactyl and diagnosis by radio comes in.

It wasn’t just the field of medicine that was going to be revolutionized by this new device. Other practical uses would involve seeing and signing important documents from a distance:

                   The man of 1975 signs important documents by videophone (1925)

Here we see the man of the future signing a check or document at a distance. By moving the control, it goes through exactly the same motions as he would in signing he document. He sees what he is doing by means of the radio teleview in front of him. The bank or other official holds the document in front of a receiving teledactyl, to which is attached a pen or other writing instrument. The document is thus signed.

                                This diagram also explained how the teledactyl worked:

                         Diagram explaining how the teledactyl was supposed to work (1925)

                       XXX  .  XXX  Telemedicine: Types of Modern eHealth Care

Telemedicine

The use of medical information exchanged from one site to another through electronic communications with the goal of improving a person's health status. 'Telemedicine,' and, 'telehealth,' are many times considered to be interchangeable terms which encompass a wide definition of remote health care.

'Telemedicine,' is the use of medical information exchanged from one site to another through electronic communications with the goal of improving a person's health status.Today, telemedicine includes a growing number of applications and services using two-way video, smart phones, email, wireless tools and additional forms of telecommunications technologies. More than 40 years ago, with demonstrations of hospitals extending care to people in remote areas, the use of telemedicine spread quickly and is now becoming integrated into the ongoing operations of hospitals, home health agencies, specialty departments, private doctors offices, and people's workplaces and homes.Telemedicine is not a separate medical specialty. Services and products related to telemedicine are many times part of a larger investment by health care institutions in either information technology or the deliver of care. Even in the reimbursement fee structure there is usually no distinction made between services provided on site and services provided through telemedicine and often no separate coding required for billing related to remote services. 'Telemedicine,' and, 'telehealth,' are many times considered to be interchangeable terms which encompass a wide definition of remote health care. Consultations through:

• Video-conferencing
• Nursing call centers
• Transmission of images
• Continuing medical education
• Remote monitoring of vital signs
• e-health including patient portals
• Consumer-focused wireless applications

About This Image: Chart showing ways telemedicine consultation is provided throughAmong other applications, are all considered to be parts of telemedicine and telehealth. While the term, 'telehealth,' is at times used to refer to a broader definition of remote health care that does not always involve clinical services, the terms are used in the same way one would refer to medicine or health commonly. Telemedicine is closely allied with the term, 'health information technology (HIT).' However, HIT more commonly refers to electronic medical records and related information systems, while telemedicine refers to the actual delivery of remote clinical services using types of technologies.Services Provided by TelemedicinePerhaps telemedicine is best understood in terms of the services provided and the mechanisms used to provide those services. For example:Primary care and specialist referral services might involve a primary care or allied health professional providing a consultation with a person, or a specialist assisting a primary care doctor in rendering a diagnosis. It may involve the use of live interactive video, or the use of store and forward transmission of diagnostic images, video clips, or vital signs along with patient information for later review.Remote patient monitoring, to include home telehealth, uses devices to remotely collect and send information to a home health agency or a remote diagnostic testing facility for interpretation. The applications might include a particular vital sign such as a heart ECG or blood glucose, or a number of indicators for people who are at home. The services may be used to supplement activities by a visiting nurse.Consumer health and medical information includes the use of the Internet and wireless devices for people to obtain specialized health information, as well as on-line discussion groups, to provide peer-to-peer support. Medical education provides continuing education credits for health care professionals and special medical education seminars for groups located in remote areas.Telemedicine Delivery SystemsNetworked programs link hospitals and clinics with community health centers and clinics in suburban or rural areas. The links might use dedicated high-speed lines, or use the Internet for telecommunication links between the sites. An estimate of the number of existing telemedicine networks in America is roughly 200; they provide connectivity to more than 3,000 sites. Point-to-point connections using private high-speed networks are used by hospitals and clinics that deliver services directly or outsource specialty services to independent medical services providers. Outsourced services may include:

• Radiology
• Mental health
• Stroke assessment
• Intensive care services

Monitoring center links are used for pulmonary, cardiac, or fetal monitoring, home care and related services that provide care to people in their own homes. Many times, usual land-line or wireless connections are used to communicate directly between the patient and the center, although some systems use the Internet. Web-based e-health patient services sites provide direct consumer services and outreach over the Internet. With telemedicine, these sites provide direct patient care.
About This Image: Chart showing some of the benefits of telemedicineThe Benefits of TelemedicineTelemedicine has been growing at a rapid rate because it offers 4 fundamental benefits.These benefits include the following:Improved Quality: Studies have consistently revealed that the quality of health care services delivered through telemedicine are as good as those provided in traditional in-person consultations. In some specialties, especially in mental health and ICU care, telemedicine delivers a better product with greater outcomes and patient satisfaction.Cost Efficiencies: Reducing or containing the cost of health care is one of the most important reasons for funding and using telehealth technologies. Telemedicine has been shown to cut the costs of health care while increasing efficiency through improved management of chronic diseases, reduced travel times, shared health professional staffing, and fewer and shorter hospital stays.Improved Access: For more than 40 years, telemedicine has been used to bring health care services to people in distant areas. Not only does telemedicine improve access to people, it also permits doctors and health facilities to expand their reach beyond their own locations. Considering the provider shortages around the world, in not only rural but urban areas, telemedicine has an incredible capacity to increase services to millions of people.Patient Demand: People want telemedicine. The largest impact of telemedicine is on the person, their family members and their community. Using telemedicine technologies reduces stress on the person and cuts travel time. Over the past 15 years, study after study has documented patient satisfaction and support for telemedical services. The services offer people access to providers that might not otherwise be available, as well as medical services without needing to travel over long distances.Telemedicine Fields Include:Teletrauma care - Telemedicine for trauma triage: using telemedicine, trauma specialists can interact with personnel on the scene of a mass casualty or disaster situation, via the internet using mobile devices, to determine the severity of injuries. They can provide clinical assessments and determine whether those injured must be evacuated for necessary care. Remote trauma specialists can provide the same quality of clinical assessment and plan of care as a trauma specialist located physically with the patient.Emergency telemedicine - Common daily emergency telemedicine is performed by SAMU Regulator Physicians in France, Spain, Chile and Brazil. Aircraft and maritime emergencies are also handled by SAMU centers in Paris, Lisbon and Toulouse.Teleaudiology - The utilization of telehealth to provide audiological services and may include the full scope of audiological practice.Telesurgery - Remote surgery - Performance of surgical procedures where the surgeon is not physically in the same location as the patient, using a robotic teleoperator system controlled by the surgeon. The remote operator may give tactile feedback to the user. Remote surgery combines elements of robotics and high-speed data connections.Teleophthalmology - A branch of telemedicine that delivers eye care through digital medical equipment and telecommunications technology. Today, applications of teleophthalmology encompass access to eye specialists for patients in remote areas, ophthalmic disease screening, diagnosis and monitoring; as well as distant learning.Teledermatology - A sub-specialty in the medical field of dermatology and one of the more common applications of telemedicine and e-health. In teledermatology, telecommunication technologies are used to exchange medical information (concerning skin conditions and tumors of the skin) over a distance using audio, visual and data communication.General health care delivery - The first interactive telemedicine system, operating over standard telephone lines, designed to remotely diagnose and treat patients requiring cardiac resuscitation (defibrillation) was developed and launched by an American company, MedPhone Corporation, in 1989.Telerehabilitation - The delivery of rehabilitation services over telecommunication networks and the Internet. Most types of services fall into two categories: clinical assessment (the patient's functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy.Telepathology - The practice of pathology at a distance. It uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purposes of diagnosis, education, and research.Teleneuropsychology - The application of telehealth-based communications (i.e., video teleconferencing) to neuropsychological services. This includes remote neuropsychological consultation and assessment, wherein patients with known or suspected cognitive disorders are evaluated using standard neuropsychological assessment procedures administered via video teleconference (VTC) technology.Telecardiology - ECGs, or electrocardiographs, can be transmitted using telephone and wireless.Teledentistry - The use of information technology and telecommunications for dental care, consultation, education, and public awareness in the same manner as telehealth and telemedicine.Teleradiology - The ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, MG) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving-image review station.Telepharmacy - The delivery of pharmaceutical care via telecommunications to patients in locations where they may not have direct contact with a pharmacist. It is an instance of the wider phenomenon of telemedicine, as implemented in the field of pharmacy. Telepharmacy services include drug therapy monitoring, patient counseling, prior authorization and refill authorization for prescription drugs, and monitoring of formulary compliance with the aid of teleconferencing or videoconferencing.Telenursing - Refers to the use of telecommunications and information technology in the provision of nursing services whenever a large physical distance exists between patient and nurse, or between any number of nurses. As a field, it is part of telehealth, and has many points of contacts with other medical and non-medical applications, such as telediagnosis, teleconsultation, telemonitoring, etc.Telepsychiatry - Utilizes videoconferencing for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical programs, diagnosis and assessment, medication therapy management, and routine follow-up meetings.

Quick Facts: Telemedicine

• The American Telemedicine Association, ATA, defines telemedicine as "the use of medical information exchanged from one site to another via electronic communications to improve patients' health."
• Studies have consistently shown that the quality of healthcare services delivered via telemedicine are as good those given in traditional in-person consultations.
• The CDC reports that 84 percent of seniors have at least one chronic condition. Using the latest communications technology empowers healthcare providers in treating these patients and helps educate patients about their care.
• Mortality rate dropped from 13.6% to 11.8% after tele-ICU was implemented, and length of stay in the ICU fell from 13.3 days of 9.8.
• The U.S. Veterans Administration reports reductions in utilization of between 20% and 56% when care coordination and home monitoring are employed.
• Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care.
• California prison officials provided roughly 9,000 telehealth consultations in 2004, saving taxpayers more than $4 million in transportation and escort costs.
• For over 40 years, telemedicine has been used to bring healthcare services to patients in distant locations.
• 55 percent of urban and rural physicians reported that cost of telemedicine equipment is the main barrier to accessing this technology.
• Barriers to telehealth use include concerns about costs and return on investment, clinician resistance, lack of broadband connectivity, and interstate practice issues.
• 21 percent of physicians reported that broadband capability was a barrier in their use of telemedicine. In addition, about 60 percent of rural areas have broadband compared to 70 percent of urban areas.

                            XXX  .  XXX 4%zero Telemedicine in circuit electronic

                      


                                            Telementoring and Telesurgery




Introduction

Over the last two decades, minimally invasive surgery (MIS) has emerged as an attractive alternative to traditional open surgical procedures. MIS has been shown to provide excellent surgical outcomes with the added benefit of decreased procedure-related morbidity. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery times are all proven advantages for laparoscopic procedures.  However, many MIS procedures are more technically challenging than the traditional open counterpart, and the learning curve to proficiency is markedly steeper than standard open procedures. Several factors including establishing adequate access, two dimensional vision, decreased depth perception, restricted instrument maneuverability, decreased dexterity and dampened tactile feedback are all unique limitations that make laparoscopic surgery challenging for surgeons trained in traditional open approaches. To the laparoscopically naïve surgeon, this translates into a loss of confidence in performing a procedure in which they were previously skilled. Appropriate training and education are therefore essential for a surgeon to develop the necessary skills required in order to comfortably perform a surgery adequately and safely. Unfortunately, resources are limited. Time, monetary and geographical constraints often limit the ubiquitous dissemination of new surgical knowledge, skills and techniques. The inability to provide adequate training opportunities and support for surgeons in the community continues to be the limiting factors determining the success and widespread availability of laparoscopic surgeries.

Thankfully, with the ever-increasing push to incorporate technological advances into the medical field, we are now able to overcome these barriers. In this chapter we outline how the recent progress in technology and telecommunication has led to the advent of telemedicine – an ingenious solution to our current problem, which will allow for the widespread availability of MIS and improve patient care.

2. What is telemedicine?

Defined as “medical care at a distance”, telemedicine is a broad term referring to a physician’s ability to practice medicine and directly influence patient care without being physically at the bedside. The underlying principle of telemedicine involves advanced telecommunication systems for data acquisition, processing and display allowing the physician or health care worker to transfer their expertise from a remote location. This opens the door for a wealth of applications, transcending geographical barriers when participating in patient care. Of particular interest to our discussion are the two main branches of telemedicine for surgeons – telementoring and telesurgery.

3. Telementoring

As cutting edge technology evolves, new surgical techniques are developed. This has occurred with the development of laparoscopy, laser, and robotic surgery. Surgeons already established in their community or academic practices have limited time to re-train or take sabbaticals to learn new skills necessary to carry out novel complex operative procedures. In part, this may have contributed to prolonged operative times and alarmingly high complication rates associated with the early development in laparoscopic radical prostatectomy (LRP) . In general, the ability to efficiently train a surgeon to become facile at LRP has requires fellowship training, or recruitment of an experienced surgical mentor. However, when local expertise is not available, it is a challenge to recruit a mentor to teach novel operative techniques, as there rarely exists an established remunerative or academic reward to lure the mentors away from their regular patient-care and academic activities in order to travel and teach others. Therefore, telementoring has been developed to allow long-distance training utilizing mentors from a different hospital, city or continent.

Telementoring involves procedural guidance of one professional by another from a distance using telecommunications. This has involved interactions involving audio dialogue, video telestration (video tablet and pen), and even guidance of a camera or laparoscope with a surgical robot such as Aesop^TM (Computer Motion, Santa Barbara, CA). In order to send audiovisual data, connections using WAN (wide area network), LAN (local area network), integrated services digital network (ISDN) or internet protocol (IP) links have been utilized. Security has been established through virtual private networks (VPNe) to prevent others to access and manipulate connections.

At first, telementoring was developed by surgeons from the Johns Hopkins University group utilizing rudimentary teleconferencing audiovisual equipment and a video sketch pad to provide telestration (Cody Sketchpad, Chryon Corp., Melville, NY). Trainees were provided mentorship from the staff surgeons situated 1000 feet away . This developed into telementoring studies involving the USS Abraham Lincoln Aircraft Carrier Battle Group. Five laparoscopic inguinal hernia repairs were performed under telementored guidance from land-based surgeons from Maryland and California . This established the ability to perform long-distance telementoring across bodies of water in times of war. Furthermore, Kavoussi’s group utilized the Aesop^TM robot as well as the Socrates telestration system (Intuitive Surgical) to telementor 17 urologic operations (including laparoscopic nephrectomy) between Baltimore, Maryland to Rome, Italy. However, the procedures were associated with a half second image delay between sites, and a high technical failure rate (5/17) due to an inability to establish connections through their 4 ISDN lines during times of heavy traffic .

In its early development, most of the procedures utilizing telementoring have required that an experienced surgeon was situated at the patient’s operative tableside. Accordingly, in March 2003, our group from London, Ontario, Canada harnessed SOCRATES^TM and AESOP^TM telerobotic technology through 4 ISDN lines to successfully telementor laparoscopic nephrectomy and pyeloplasty with the mentor situated over 200 km away. Since our intent was to test the ISDN connections and the robotic platforms, we ensured that the bedside surgeon was equally as experienced as the mentor, and could complete the operation in case of communicative technical failure.

Subsequently, our group has prospectively tested telementoring in a ‘real-world’ situation, with a truly ‘inexperienced’ trainee with a ‘complex’ new procedure. As we have stated in the past, LRP is one of the most technically challenging operations in urology, with a steep learning curve associated with prolonged operative times, complications and poor oncologic outcomes during the early development of the procedure [4]. It has been stated that surgeons need to complete 50-300 cases in order to obtain operative proficiency for LRP. For the first time, we described the experience utilizing long-distance telementoring to facilitate the performance of the LRP with a trainee surgeon naïve to LRP. It should be mentioned, however, that although the trainee had never performed LRP, he had a high volume laparoscopic surgical practice. Utilizing an ISDN telecommunications network, the LRP-naïve trainee observed 6 LRP performed by a trainer located 200 km away from Hamilton to London Ontario (group1) (Figure 1). Using the same network, the trainee performed 6 LRP under the supervision of the remote trainer (group 2). The next six LRP procedures were performed by the trainee independently (group 3). The trainer and trainee were able to communicate back and forth using audio equipment and visual demonstration of anatomy and techniques were communicated via a pen and tablet video screen. The audiovisual feeds were facilitated by simple Polycom technology and ISDN lines. Due to weather issues, telecommunications failed in 1 case. Audiovisual communication was excellent and although visual delays were experienced, this did not greatly impact upon the success of the cases. The median operative times for the three groups were 200 min, 285 min vs. 250 min respectively (p = NS between groups 2 and 3). Median blood loss was not different between groups and no blood transfusions were performed. No anastomotic leaks, open conversion or intraoperative complications occurred. Of the patients with confined disease (pT2), only one patient had a local positive surgical margin (group 2) with all patients having undetectable disease at 1 year. At the 1 year follow-up mark, 11/12 patients in group 2 and 3 have achieved complete urinary continence. Of 8 patients in the groups 2 and 3 that underwent bilateral nerve sparing, 38% of patients achieved potency by 12 months. It was concluded that telementoring could be performed to teach complex operative procedures such as LRP to surgeons. Similarly, Schlacta’s group from our centre had successfully trained less-experienced community-based general surgeons (through direct local and telementoring) to perform laparoscopic colon surgery. Although 33% of cases were converted to standard open procedures, the group concluded that there was excellent incorporation of laparoscopic colon surgery into this community-based practice [9].

We conclude that performance of telementoring is feasible and that it is possible to teach complex operations with current technology. We also believe that telementoring does not need to be limited to MIS procedures. Although the majority of hospital administrators are facile with teleconferencing, and telemedicine has been explored by a number of physician groups for patient care and education, surgeons have been slow to adapt to the same technology. We have shown that telementoring using ISDN lines is feasible and relatively inexpensive, utilizing existing communication lines. However, its eventual adaptation in healthcare will depend on further education and an evolution in surgical thinking.

Figure 1.

Telementoring set-up. The set up in our telementoring procedures involved 4 ISDN lines as well as audiovisual Polycoms, and video screen telestrator. The AESOP laparoscope holding robot was used during early, but not later clinical use. The mentor is pictured on the left while the trainee along-side the OR table is pictured on the right hand side.

4. Telesurgery

Telesurgery involves a surgical procedure with the surgeon being situated remotely from the patient. The history of telesurgery dates back to the first commercial application in laparoscopy. The Automated Endoscopic System for Optimal Positioning (AESOP^TM) was FDA approved in the United States in 1993 and was used solely to guide the laparoscope. When it was initially introduced, the surgeon controlled the robotic arm either manually or remotely with hand or foot switches. Later versions were modified and equipped with voice controls. Although the use of has been associated with ‘telementoring procedures’, its development gave way to the complex three armed robotic technology that integrated instrument manipulating arms as well.

The manufacturer of the AESOP^TM, Computer Motion Inc., would later introduce the three armed ZEUS^TM robotic system onto the U.S. market in 1998. Concurrently, Intuitive Surgical (Sunnyvale, California) released yet another 3-arm surgical robot, the da Vinci. Developed from technology designed by NASA, the da Vinci was originally intended for use by the U.S military, but was quickly adopted for civilian use. In 2003, a merger between Computer Motion Inc. and Intuitive surgical paved the way for the da Vinci robot, along with it’s newly FDA approved EndoWrist^TM technology, to dominate the surgical robot market worldwide. The large majority of published literature on robotic-assisted surgery to date, has employed the use of the da Vinci system. Currently, it is the only commercially available surgical robotic system.

The da Vinci consists of separate components. The surgeon sits at the console where he/she is able to visualize the surgical field in 3D and operate several hand and foot controls. The surgeon’s motions are processed by a computer system and relayed to the robotic arms. The robot has three arms. The central arm holds the camera and 2-3 outer arms hold the surgical instruments, which articulate at the EndoWrist^TM. This allows the instruments to move with seven degrees of freedom and two degrees of axial rotation, eliminating many of the difficulties associated with standard laparoscopic procedures.

Initially, commercial surgical robots were intended to perform minimally invasive cardiac procedures. However, since the initial description for robot assisted closed-chest coronary artery bypass grafting at our centre in 1999 , applications for robotic surgery have been rapidly growing. Since its inception, robotic surgery has not only expanded to other cardiac surgical procedures such as left internal mammary artery take-down and mitral valve repair, but also several gastrointestinal, gynecological and urological procedures. These included: cholecystectomy, Nissen fundoplication, Heller myotomy, pancreatectomy, hepaticojejunostomy, gastric banding, distal gastrectomy, Roux-en-Y gastric bypass, colectomy, tubal re-anastamosis, hysterectomy, nephrectomy, pyeloplasty, adrenalectomy, aneurysm repair and radical prostatectomy, among others. Due to the increased precision and dexterity that the robot contributes to the case, the robot has been exploited for radical prostatectomy more than any other procedure, since it has allowed laparoscopically naïve surgeons to perform laparoscopic suturing to perform critical anastomotic maneuvers with relative ease. We have shown that the robot improves the performance of experienced laparoscopic surgeons as well .

Of relevance to telesurgery, these robotic platforms were designed using connections that permitted surgery to be performed with the surgeon at a console remote from the bedside robot and patient. In fact, the original intent was to permit the surgeon to perform surgery just as easily in another room, another building, another continent, or in outer space. Indeed, any surgical procedure with the surgeon sitting remotely from the patient could be considered remote telesurgery. However, it is the possibility of performing long-distance telesurgery that stirs the imagination.

Most notably, in 2001, Marescaux et al. revolutionized surgery by performing a trans-Atlantic robotic assisted cholecystectomy using the ZEUS^TM robot . The surgeon and console were located in New York, and the patient and effector arms were in Strausbourg, France. Asynchronous transfer mode (ATM) technology was used to establish connections via high-speed terrestrial fiberoptic networks with a bandwidth of 10Mb/s. These connections were reserved exclusively for the procedure that ran a round-trip distance of 14000 km. Although there was a lag time of 155 ms, the laparoscopic cholecystectomy was completed without incident over 54 minutes. It should be noted that although audiovisual interactions and robotic arm movements were performed through the trans-Atlantic connections, the application of ‘electrocautery’ to dissect the gall bladder, placement of clips, introduction of the ports, and closure of port-sites had to be performed by the bed-side assistants. As well, laparoscopic cholecystectomy is a relatively simple laparoscopic procedure and could have been easily completed by the bed side surgeons with greater ease and in less time. Although the cost of this solitary operation was astronomical, it demonstrated that ‘real world’ long-distance telesurgery was feasible, and if the lag time could be limited to <155 ms, surgeons could perform simple procedures from their home base, even if the patient was on a battlefield or in the far reaches of space.

The next natural step in the evolution of telerobotics was to employ this technology to help train and certify surgeons in ‘real world’ distant or remote communities. This would allow an expertly trained surgeon at a central location to provide assistance and collaboration during a new or challenging procedure to a less experienced surgeon in the community. This would also provide community surgeons in remote areas a means to gain advanced laparoscopic skills, as well as provide patients access to tertiary care level surgical procedures without having to travel.

Although this concept seems intuitive, reports of these practical applications are rare and the anticipated adoption of this technology into the current day clinical practice remains sporadic. Reasons for this may include: the amount of time and organization involved at both sites, financial burdens of the technology and equipment, and a lack of a dedicated and safe network with sufficient bandwidth to transmit such data.

Another group in Ontario, Canada has demonstrated their successful integration of telesurgery into clinical practice. Anvari et. al.  used telesurgery on a routine basis to both assist and mentor surgeries requiring advanced laparoscopic skills at a remote hospital over 300 miles away. Commencing in February 2003, one year after the trans-Atlantic cholecystectomy by Marescaux, Anvari was able to provide a “Telerobotic Surgical Service”; using telesurgery, he successfully completed 21 laparoscopic procedures over a two-year period. All surgeries were successful with no major intraoperative complications, including no open conversions. Surgical outcomes were equivalent to those of the same laparoscopic procedures performed at a tertiary center. The array of surgeries performed included: 13 fundoplications, 3 sigmoid resections, 2 right hemicolectomies, 1 anterior resection, and 2 inguinal hernia repairs. The amount of time spent by each surgeon performing the surgical dissection in each case was equally allocated between mentor and trainee. Furthermore, both surgeons were able to operate together using the same surgical footprint, swapping roles seamlessly throughout the procedure.

The group utilized a commercially available network (15 Mbps of bandwidth) to connect the two hospitals. An overall latency of 135-140 ms was incurred, but surgeons were able to compensate with this delay. The Zeus^TM surgical system used in all cases, with the console in Hamilton and the operating arms at the operative bedside in North Bay, Ontario.

Overall, the work by Anvari demonstrated that routine telesurgery is feasible, although the full extent of its role as an adjunct to telementoring remains to be determined. As the cost of surgical systems decrease and reliable data networks become more available, barriers preventing the routine use of telesurgery may fall, allowing a more broad involvement in future surgical practice.

5. Limitations of telesurgery

Although successful clinical telerobotic surgery has been accomplished, most cases were simple and did not require extensive dissection, suturing and knot tying. Delays incurred through transmission of telesurgical data through the communication circuits and codecs result in slowing of surgeon movement to account for asynchrony in motor output and visual input. It was not clear whether there was a temporal delay (latency) incurred by distance that would preclude the ability of the surgeon to compensate for visual-motor asynchrony, leading to excessive errors and abandonment of relatively complex proceduresUtilizing a Zeus^TM robot and real-time, internet protocol virtual private network (IP-VPNe) as well as satellite links, 18 porcine pyeloplasty procedures were performed by our group. The pyeloplasty procedure was used as our operative model, since it requires fine operative suturing with requirements of knot tying to accomplish ‘water tight’ anastomotic competence. The IP-VPNe network consisted of two redundant 17 Mbps IP connections at the surgeon console and two redundant 17 Mbps connections at the operative subject side cart (in London, Ontario), providing highly available WAN access to the Bell Canada VPNe Core network within our test laboratory. The WAN connections were then looped back at the Bell Canada central office in Halifax Nova Scotia, which added 4150 km round trip distance between surgeon and surgical subject sides (both in London, Ontario) (Figure 2). The satellite network was privately partitioned with 10 Mbps bandwith. The routing was a round trip connection from London to Toronto, Ontario, to a telecommunications satellite (Telesat Canada) operating in the Ku band (12-14 GHz) and back to London Ontario, traversing a distance of 71,000 km .

Figure 2.

Hardware set-up of the London-Halifax and satellite telesurgery loops. These loops were used to facilitate telesurgical experimental procedures. This permitted all experiments to be performed in one location, despite telesurgical routes over 4000 km long. Left hand side of figure outlines surgeon console and associated connections, right hand side illustrates telesurgical accessory surgeon console and patient side cart with associated connections.

Network latencies encountered during the trial were 66.3 +/- 1.5 ms for landline and 560.7 +/- 16.5 ms for satellite. During the procedures through landline, VPNe and satellite, fluid robotic motion and faithful visual rendering of the operative field was achieved. Network bandwidth was measured, requiring only 23 Mbps of budgeted 45 Mbps required during the procedures. Operative duration with real-time connection (41.3 +/- 15.0 min) was not significantly different vs. VPNe landline (47.0+/-24.1 min) vs. satellite (51.8+/-4.7 min). The anastomotic competence of the pyeloplasty procedures were excellent in all groups as well . Although it was subjectively more challenging to perform pyeloplasty in the landline and satellite groups, it was shown that complex operative procedures requiring delicate suturing and knot tying could be accomplished using long-distance landline and satellite connections. The fact that operative times and errors were similar between groups indicate that surgeons experienced in telesurgery and robotics are capable in adapting to an operative environment in which latency and network jitter affect the human-machine interface.

Using the same 4150 km ‘London to Halifax to London’ loop, the ability to perform telesurgery in the same porcine pyeloplasty model was assessed 1 year later using the advanced da Vinci robotic platform. A maximum of 23 Mbps of budgeted 45 Mbps were required for telesurgical operations, but 3-D stereoscopic vision was lost from the long-distance cases vs. the direct connection controls. Network latencies were similar at 66.1+/- 1.5 ms. Network jitter ranged from 0-5 ms and no network failures occurred. With the da Vinci procedures, operative times were significantly faster than with the Zeus^TM procedures, but it was also apparent that with the use of more efficient robotic technology, the long-distance IP-VPNe operations took significantly more time vs. direct cable links (20.7+/-4.7 min vs 10.9+/-1.1 min, p<0.01). As well, there were no anastomotic discrepancies in any cases performed (total 12) . We concluded that as robotic technology advanced, surgeries became more facile and the detriment of network latency and jitter were more apparent in our later trials. However, the impact of losing 3-D vision through the VPNe network as it related with operative time is not known.

6. The limits of bandwidth and latency

Our labs performed a series of experiments to quantify maximal tolerable latency during typical surgical maneuvers. Using randomized latencies, task times were significantly higher compared with zero delay at latency times of 500 ms and above (p<0.01; Figure 3) . As noted earlier, the root cause of this delay are related with the encoding and decoding processes rather than the physical separation distance between operating sites. Already, we have seen significant progress in codec speed and capacity rates facilitating transmission of dual high definition signals.

Communities without broadband access may need to rely upon satellite communication to support telemedicine. In order to quantify telesurgery applications, our group performed porcine internal mammary artery (IMA) dissection using both IP and satellite networks described earlier . There was no significant difference in the time to perform IMA dissection (p = NS). Using a multi-criteria Global Rating Scale, we found that there was also no significant difference in the quality of surgical performance. Bandwidth of the satellite feed was progressively pared down to identify a failure point for the video signal. Telesurgery was no longer possible at bandwidth of approximately 4 Mb/s or less, as determined by the operator and an experienced robotics observer team (Figure 4)[19].

Figure 3.

Overall time for task completion of dry lab objects for sequential and random delay trials at differing latencies. Random trial times were significantly greater compared to zero latency at 500 ms and beyond (repeated measures ANOVA, * p < 0.001)

Figure 4.

Satellite and encoder bandwidths were sequentially decreased to identify a minimum level for telesurgery. The bandwidth ‘pipe’ is shown as concentric circles (9–0 Mb/s). Changes in bandwidth combinations using 7 pigs are seen radially in the 43 spokes. ■, satellite bandwidths at which surgery was no longer possible (approximately 4 Mb/s)

7. Pitfalls

Although the performance of complex operations from a distance has been shown to be feasible using existing technology, the provision of VPNe lines capable of supporting 48 Mbps was expensive ($30,000/ month). There are also issues regarding the medico-legal aspects of performing telesurgery. For example, who assumes the primary medico-legal responsibility for the long-distance procedure? Is it assigned to the bedside surgeon or the experienced surgeon based from afar? What happens if the telecommunication system fails? Are encrypted VPNe systems truly protected from individuals that are capable of ‘hacking’ into IP lines? There are other issues that exist for the telementor. How do we decide who is credentialed to be a mentor and how do we assign responsibility if the case goes awry? If the most experienced surgeon needs to assume responsibility, then it may be impossible to find any experts that would take on the responsibility of primary patient care without established and reliable financial or academic reward.

8. Future of telesurgery

Technologically, telesurgery will become more facile as network latency becomes reduced through the use of more efficient codecs and the advancement of surgical robotics. However, the development of telesurgery is contingent upon surgeon acceptance, need, and development of routine use, which would be associated with reduce costs. In fact, there may come a time that a surgeon performing robotic surgery may find a colleague to assist in a challenging operation through telesurgical operation of a fourth robotic arm. It would be as simple as dialing up a senior colleague to facilitate the operative procedure. Using telesurgery, that senior colleague may be dialed into an operation that is taking place a thousand miles away.

9. Conclusion

In conclusion, telementoring has been shown to be feasible, inexpensive and an effective tool to facilitate the development of surgical training in remote locations. Currently, its major limitations reside within limited access to trainers, perceived need, and the slow trickle of technology into the operating room. Long distance telesurgery, despite network latency and jitter, has been shown to be feasible, effective but very expensive. It requires significant amount of resources, including a robot in the remote centre, and bedside assistants that are capable of providing a fallback plan in case of technical failure. Ongoing clinical needs and evolving robotic and telecommunication technology are currently being evaluated.

                                                   Telemedicine Applications


The current trend in aging population will likely result in a future increase of chronic diseases occurrences as well as a future increase of chronic diseases comorbidities. In this context, telemedicine can improve the management of these diseases by using information and communication technologies. The advantages cover more regular follow-ups and fewer unnecessary travels. To guarantee quality in the patient's care, a typical telemedicine application combines three systems: the patient system for the medical monitoring, the data transmission system between the two structures (e.g., the patient's home and a healthcare facility) and the data processing and archiving system, which is generally located in the hospital. In this contribution, we focus on four main chronic diseases, i.e. cardiovascular diseases, diabetes, respiratory diseases and kidney diseases. We surveyed the main current telemedicine applications for these diseases. The analysis revealed that the applications shared some common functionalities for each of three systems. It also revealed that each application relied on its own implementation of these common functionalities. This situation creates two intrinsic limitations for the use of telemedicine applications in a context of comorbidities. The first limitation is the unnecessary duplication of portions of the implementation. The second limitation is that information produced when monitoring one disease cannot be systematically reused for another one. The implementation of a common data transmission system and a single integrated data processing and archiving platform would provide a unified environment for covering several chronic diseases and their comorbidities.
             

              
                          
                                                          TELE PSYHUMAN



                       XXX  ,  XXX 4%zero null 0 Telepointer technology in telemedicine

Telepointer is a powerful tool in the telemedicine system that enhances the effectiveness of long-distance communication. Telepointer has been tested in telemedicine, and has potential to a big influence in improving quality of health care, especially in the rural area. A telepointer system works by sending additional information in the form of gesture that can convey more accurate instruction or information. It leads to more effective communication, precise diagnosis, and better decision by means of discussion and consultation between the expert and the junior clinicians. However, there is no review paper yet on the state of the art of the telepointer in telemedicine. This paper is intended to give the readers an overview of recent advancement of telepointer technology as a support tool in telemedicine. There are four most popular modes of telepointer system, namely cursor, hand, laser and sketching pointer. The result shows that telepointer technology has a huge potential for wider acceptance in real life applications, there are needs for more improvement in the real time positioning accuracy. More results from actual test (real patient) need to be reported. We believe that by addressing these two issues, telepointer technology will be embraced widely by researchers and practitioners.

TelepointerTelemedicineCursor pointerHand pointerLaser pointerSketching pointer

Introduction

Fast and accurate long-distance communication have been very fundamental factors to humankind advancement. Telemedicine is one of the areas that benefited from the recent innovation in network and communications, which proved to be crucial in saving many lives . A basic system of telemedicine typically involves communication between two or more persons that are located in different places. Some examples of telemedicine-based applications are education, surgery, consultation and many more.

Without doubt, the best mode of communication is face-to-face communication due to natural presence of gesture, interaction, deictic instructions, face expression and voice intonation, which helps in explaining the real meaning of the speech. However, long-distance communication lacks of natural presence contrary to face-to-face communication, which usually leads to misunderstand and misinterpretation of the information, especially when dealing with deictic gestures. To improve the communication quality, telepointer technology has been widely used to help the speaker in conveying the real meaning of the words. It is used as the support tool which is capable of boost up the power of distance communication through a sense of presence.

Telepointer technology can be defined as “an interaction style for presentation system interactive television, and other systems, where the user is positioned at a remote site from the display” . The main function of a telepointer is to point at the specific display so that its motion could represent the human gesture. Meanwhile, display devices allow the collaborator to view the same scene as seen by the other parties. Greenberg et al. stated that “telepointers are a natural focus of attention for group participants, and they can be leveraged to show information vital for smooth collaboration: interaction modes, system state, identity, actions of others, and so on.“ In other words, telepointer can be used 1) to point to an object or region of interest and 2) to create a pattern to signify something depending on movement, location and temporal information at the remote display.

Nowadays, a lot of applications use a camera-based physical gesture to improve the communication quality, especially hand gestures that can be used for pointing, overlaying hands and sketching . Telepointer can be broadly classified into two categories; low level and high level. Low level system refers to a pointer which provides the coordinate information only such as cursor and laser pointer. Meanwhile, high level system provides more than just coordinate information by providing instruction and complicated data such as hand gestures, sketching, drawing and overlaying hands.

A variety of technologies have been developed to facilitate telepointer gesturing, such as GestureMan , DOVE-Drawing over Video Environment , Mixed Ecology  and Head mounted display (HMD) . GestureMan employs a robotic system that represents the gesture through a laser pointer. DOVE system creates the sketching gestures by overlaying pen-based gestures on a tablet personal computer (PC) and Mixed Ecology employs unmediated gestures. HMD based on augmented reality by superimposed pointer on a video channel.

Basic system telepointer

Telepointer is vital elements in remote collaboration and computer supported co-operative work (CSCW). CSCW is a combination of hardware and software resources to allow groups to collaborate either in static or mobile environments. Static refer to fix confined workspace while mobile refer to moving workspace either remote or local user or both. Hence, technical setup and hardware system almost inherit from both areas. A simple mechanism is used to set up a telepointer system which consists of a video display; a pointer device; a computer; and a camera as a means of communication with the collaborator. A camera is used to capture the visual information at the local site which is then transmitted to the remote site. The local site will have a pointing device (e.g.: cursor mouse) to point to a particular object on the computer display which should be synchronous between the local and remote sites. As a result, the other parties will be able to view the exact scene as viewed by the sender in order to reduce false information. Figure 1 shows the typical telepointer system applied in telemedicine.

                 

Figure 1

Typical telepointer system applied in telemedicine and laser as a pointing device (adapted from Ereso , et al.).

Motivation

A telepointer system offers many advantages such as 1) to provide coordinate information of the target object, 2) create the sense of presence and 3) increase the audience attention by using the multiple form of the telepointer such as colour, size and image . It is difficult to rely on verbal instruction alone while giving the instruction through the internet. By adding the pointer information, the collaborator will be able to understand the command easily. Previous researches have demonstrated that a telepointer system has been well accepted as the support tool for sending gesture information and enhance the performance of the collaborator. In addition, it also reduces the travel cost since both collaborators are not required to be at the same place for undergo their activities.

Sharing and exchanging knowledge about the treatment and diagnosis of a disease is a common practice in the medical world. It is crucial in the medical field to have effective communication mode such as discussion and consultation in order to come out with the best treatment. Lack of expert and specialist in rural areas is of great concern for the government, especially when diagnosing a rare disease and difficult symptoms. Therefore, telemedicine can be used to overcome this shortcoming. The problem becomes more complicated for an online-based surgery where a specialist needs to assist a general surgeon in a remote site who may lack the required skills. An example of successful telesurgery was given by Brévart et al.  where an emergency surgery needs to be performed to a two-year-old boy, who had a severe vertex epidural hematoma (VEDH).

As reported by McLauchlan et al., only 32% of the junior doctors managed to successfully diagnose a trauma case based on X-ray’s data, while 80% of the senior doctors correctly diagnosed the same disease. This issue can be attributed to low confidence among the junior doctors where a second opinion is needed to help them in doing the diagnose . Hence; a telemedicine can be employed as a support tool for facilitating the knowledge sharing. A lot of researches believe that the telepointer technology has a great potential in the medical field, since it 1) improves the performance of doing a task, 2) increase the accuracy of the diagnose and 3) avoid the tragedy during the golden rescue minutes due to lack of specialist. According to Sachpazidis et al., the telepointer is an important feature in collaborative applications, especially in medical collaboration. It helps a lot during long range diagnosis, consultation and mentoring by enhance the medical services and computer-mediated instructions.

However, there are two main limitations to the telepointer. Firstly, network condition will heavily affect the quality of transmit signal. Several studies  show that a major contributor to error of pointing is due to delay, which result in jitter and latency. A delay to the pointer system may cause a fatal consequence, especially in tele-surgery where a wrong location may be pointed. Secondly, current telepointer systems lack of tracking capability. Tracking allows the system to be updated by using prediction data in case of short-period signal loss.

The paper is organized into 5 sections. A brief description of Telemedicine is given in Section 2. Section 3 outlines the telepointer technologies in telemmedicine. Issues and challenges in section 4. Conclusion and future works are summarized in section 5 respectively.

A brief description of telemedicine

Initially, telemedicine was inspired by evolution of the space technology which happened around 1960s. The system was first used to monitor astronauts’ physiological parameters by using real time wireless approach during the outer space expedition. Presently, clinical medicine that allows patient medical information to be shared through interactive multimedia has been the driving force of telemedicine application development. Rizou et al.  defines a telemedicine system as “Telemedicine is the use of electronic information and communication technologies to provide and support health care when distance separates the participants (physicians, providers, specialists and patients)” as illustrate at Figure 2. Thus, we can infer from the definition that a telemedicine system has a very limited capability to interact physically with all the involved parties except through a telecommunication mean.

              

Figure 2

Participants of telemedicine communicate at distance thru through internet network (adapted from).

Telemedicine can be broadly divided into two types of communication mode; online and offline. Offline method is the simplest approach, which requires less sophisticated equipments and technical facilities. Basically, the system just records the patient data first and then transferred to the interested party. For a teleconsultation system, medical data such as images, sound, and text are collected and stored, which is then forwarded to the medical specialist. The specialist will then diagnose the data at any convenient time and of course within the allowable time frame. Commonly, offline method was only applicable for non-critical diseases such as small skin issue and minor pathology problem. Besides, it is used to obtain a second opinion to strengthen the first doctor deduction. Several examples of popular offline communication mediums are email , iphone , Multimedia Messaging Service (MMS) , and Short Message Service (SMS)  which do not require a telepointer system in place.

Contrary to the offline method; online approach involves two ways of communication simultaneously by sending and receiving the feedback instantaneously. It provides more convenient and satisfaction  due to additional sense of presence. It is normally employed for the critical cases (heart disease, diabetes mellitus, cardiac), which requires face to face communication. The usual modes of online communication are video conferencing technology that integrates both multimedia elements of video and audio , desktop to desktop . The setup requirement of online method is more extensive because of the extra technical equipments required such as video camera, video conferencing equipment, telepointer, computer and high-speed network.

Telemedicine has also been applied to both clinical and nonclinical applications. Clinical term refers to the task that requires direct diagnosis and treatment of the patients such as general healthcare delivery (nursing, follow up, trauma, rehabilitation, pharmacy) and specialist care delivery (cardiology, pathology, dermatology, surgery). On the other hand, nonclinical is any task that does not involve treatment and diagnosis of the patient yet still related to the patient care such as distance learning for sharing knowledge and information, pre-operation meeting, medical appointment and many more. Both clinical and nonclinical job can be enhanced by implementing a telepointer system for more efficient communication.

There are several subbranches under the telemedicine system such as teleconsultation, telementoring, teleproctoring, telesurgery, telediagnose, telepresence, teletrauma and many more. All of these branches can be perceived as a cheaper alternative to the traditional methods  except for the telesurgery. Telesurgery is the most sought over service and requires the most advance facilities to operate on. The surgeons will remotely control the robot action that located in the operation theatre by using a computer interface. One of the earliest successful telesurgery was achieved by operation Lindbergh in 2001 . It was the first surgery where the operating surgeon was removed from the operating room to perform minimally invasive surgery on a human patient. The surgeon was in New York City while the patient was in Strasbourg, France. The setup cost was very expensive, which can go up to $100,000 per terminal . However, most hospitals or clinics that need the system most are located in rural area of poor and developing countries, where majority of them cannot afford these terminals due to limited health care budget . Besides, the system is still in early development phase, which can be very risky because of the 1) failure possibility due to clinician lack of skills, 2) technical error of the communication system and 3) quality inconsistency across geographic or economic boundaries. Hence, a good network and communication technology is a vital component for a successful telesurgery system.

As we stated before, a good communication system is very critical for an accurate telemedicine system since it will act as the medium for delivering and exchanging information from one place to another place. Performance of a telemedicine system always dependent on the network bandwidth which gives the upper limit of information transferred. In order to receive instantaneously accurate information, a telemedicine system required a high bandwidth network to transmit complex medical information in a real-time. The main downside of such a system is a higher installation and maintenance cost. For example, Nagata and Mizushima  has shown that a medical image in Joint Photographic Experts Group (JPEG) format of 1000 x 1000 pixels requires 10 to 65 seconds to be uploaded to four different clients, while an image of 640 x 480 pixels had a much faster response time (2-5 s) with 1.5Mbit/s connection. Besides, choice of the equipments, transmission media and network bandwidth are dependent on the remote hospital location. As for example, a telemedicine system in Madagascar cannot operate on a high bandwidth system due to limited technologies . They can only manage a system with low cost equipments for 25 kbit/s bandwidth connection. Therefore, only small-sized data such as electrocardiogram (ECG) and blood pressure can be transmitted for a real time teleconsultation.

Telepointer technology in telemedicine

Current technology in telemedicine allows the patient image to be transmitted in real time to the expert by using a camera. A two-way communication is established via an audio-visual tool, which enables the general clinicians and the expert to view the same video as displayed simultaneously on the expert’s terminal. There are several approaches in telepointer where the most popular methods utilize a laser pointer, cursor movement or sketching to generate a mutually visible remote pointer in the shared workspace. Figure 3 shows the division of the telepointer technology used in telemedicine, which will be discussed in the following subsections.

Figure 3

Division of the telepointer technology used in telemedicine.

Cursor pointer

Cursor pointer can be regarded as the simplest pointer. It is just a small graphical pointer on the screen display, which normally takes an arrow form. Location and movement of the cursor are controlled by an external computer device such as mouse or touchpad. Numerous studies have explored the usage of the cursor pointer for the remote collaboration  and have been proven to be very important in enhancing the performance of the collaborative tasks. Kirk and Fraser  found that the performance of overlaying hand approach was better than the actual sketch devices (for example, cursor pointer, pen) in terms of the effectiveness. However, sketch device has a superior performance compared to a simple laser pointer.

In telemedicine, cursor pointer plays the main role in showing and stressing the details of the examined image. It can be used to highlight any specific location and distribution of a lesion which has been applied in the majority of the teleconsultation systems. In , Julsrud et al. explored the capability of a cursor pointer system for congenital heart disease consultation. They have performed an initial test of 54 sessions of teleconsultation comprised of 38 patients with various types of congenital heart disease. The results were promising since 72 (67%) respondents out of 108 observations believed that a cursor pointer was helpful during the consultation. Hence, the study suggested that the implementation of a cursor pointer will enhance the consultation process, especially for congenital heart disease. Moreover, the system has also been implemented in teleradiology consultation  as shown in Figure 4(A). A similar approach has been adopted in telementoring of gynecological surgery where a cursor pointer is used to highlight the structure and landmark anatomy on the monitor of the operating room . For this case, the cursor movements have been synchronized between the local and the remote sites.

Figure 4

(A) cursor pointer applied in teleradiology (adapted from) (B) laser pointer applied in telementoring (adapted from) (C) telestrator applied in laparoscopic (adapted from) (D) hand pointer (adapted from.

Generally, a cursor pointer system in telemedicine can be classified into two modes of communication scheme; 1) master and slave and 2) groupware. Both schemes apply the concept of “What you see is what I see”. It means that each user could see what the other parties were pointing. Master and slave scheme involves two parties where the collaboration only occurs if one person situated at the local site while the other person at the remote site. This scheme was designed to prevent any competition while operating the telepointer such as the cursor and laser pointer . Hence, only one person will be granted the authority to control the cursor pointer at one time. The slave site can become the master just by pressing a special button to reverse the authority. Groupware scheme involves more than two parties where each user can see their own action and other users’ cursor pointer. Anyone can control the other parties’ pointers. In the work by Lee et al., they faced inconsistency issue with the cursor pointer when too many users activate the system simultaneously. This issue can be solved by using a simple solution such as token passing scheme.

Some studies have focused on improving the attention and gaze awareness among the collaborators by enhancing the visual properties of the cursor. By default, a cursor pointer is usually small and sometimes its movement may not be noticeable by others. It will be worse if the display is situated far away from the user. Alternatively, Sachpazidis et al. proposed changeable graphical symbol to represent the cursor when it is in active mode. The changeable scheme has also been implemented in the hand cursor system. A blink of yellow flash is added below the cursor to indicate the authority transfer to the remote site. If the transfer is successful, the cursor colour will be changed to grey. Usually, a cursor pointer has an embedded capability to zoom in and out just by clicking the right and left side of the mouse. In the system developed by Nagata and Mizushima , the cursor shape was changed to an arrow, and the user can define their own cursor colour. For a groupware application, cursor pointers of each participant are marked by their name and host address of the remote computers .

Real time communication software have been developed to improve high-level telemedicine system. Some examples of existing methods are; 1) wavelet-based interactive video communication system (WinVicos)  2) TeleDicom  3) REmote Patient Education in a Telemedicine Environment Architecture (REPETE) . All of these methods used sophisticated communication software, which consists of all minimum requirements for a collaboration scheme such as audio, interactive video conference system, still images and a telepointer. All of these softwares used cursor as a pointer for deictic referencing and gesturing. However, Huang et al. claimed that a simple cursor pointer was insufficient for an effective collaboration.

Laser pointer

The first laser pointer was invented in 1960  with the intention of replacing the traditional pointer such as a hand-held wooden stick for more flexible presentation. The main advantages of the device are long range pointer capability and ability to function well in a low ambient surroundings. It produces a bright spot of light to attract audience attention. It can be broadly classified according to its power consumption, either low or high. A low power pointer usually requires 1mWto 500 mW while a high power device can consume power from 1000 mW up to 3000 mW.

Laser pointers have three primary colours; red, green and blue. Each colour have a different range of wavelength with red laser has the highest wavelength, followed by green and blue. Red and green colours are most suitable to be implemented in a task that requires the attention from the audience . Unfortunately, red laser have similar colour to blood and human tissue, which makes it not suitable for pointing in clinical applications. Hence, the usual practice is to implement green laser, which have a good contrast to blood and tissue colour. Paper by Schneider, et al. claimed that green laser performed well enough in the operative field for clinical remote consultation.

During its early development, laser pointer system is usually coupled with the monitor interface. It just not acting as a pointer, but able to navigate the display as well as function as a mouse . The advantages telepointer usage in telemedicine are 1) it can directly point to the interest object, 2) it requires a very low bandwidth, 3) it is not an invasive procedure, 4) it can be easily incorporated into the modern operating theatre and 5) low cost installation.

Nowadays, laser technology is used widely in telemedicine not just for pointing purpose since a high power device have been used in surgical operation to cut through tissue, seal and cauterize wounds while a low power device can be used to treat injury and speed-up the healing process. Usually, for a pointer application, a diode laser pointer will have a power less than 1 mW power . It has been used to improve teaching efficiency during surgical education of a laparoscopic surgery. Ursic et al. used a common pen-sized laser pointer to mark on the video screen to support and accelerate interaction between the surgeons and their assistants. Laser pointer can also pinpoint the correct entry points as demonstrated by Racz and Kao . Moreover, it is used to guide the trainees while learning the anaesthesia procedures. The surgeon also benefitted from the system since a laser pointer can act as the user input to a robotic system before they perform the medical procedure autonomously . Similarly, laser pointers have also been applied in Computer Assisted Orthopaedic Surgery for locating landmarks intra-operatively . Figure 4(B) shows laser pointer marks on patient body which applied in telementoring.

Preliminary research for the remote laser pointer was started by Yamazaki et al. when they realized a fixed computer does not support the interaction between space and the real objects. Output of this research has allowed them to come out with a new idea specially for remote medical instruction. They developed a system that allows the remote expert to control laser pointer movement by using a mouse cursor, which acts as a pointer that can be directed to any particular area of interest on the patient’s body . By using cameras, the system enabled both local and remote sites to share the same visual data. A similar approach was employed by Ko and Razvi  and Schneider et al., in which a laser pointer was integrated to a camera that will point out the relevant anatomical points of interest as directed remotely by an expert. In , Ereso, et al. developed a system that allowed the camera to track the hand of the local surgeon. However, none of the previous publications provide much detail on the image processing part of the laser pointer.

There are other technologies that are able to support two ways communication directly such as tabletop , Wearable Active Camera/Laser (WACL) , and HandsOnVideo . However, most of these systems require a complex technical setup and can only function well under limited environments for the gesture and interaction to be recognizable. Moreover, it is a difficult task for the surgeon to maintain the stability of the camera during a surgery, which might distract their concentration. Besides, it is difficult to make an accurate diagnosis and observation on the remote site when the captured image is blurred due to unstable camera effect. Furthermore, laser pointer movement depends only on the cursor movement by the expert which might lead to an error, especially while clicking the interface or taking a glance at the patient’s body. This error will lead to the inaccurate area of interest.

Results in  have shown that the presence of a laser pointer device can increase the performance speed of the surgeons. As an example, such a device can enable inexperienced surgeons to identify correctly the intended location of the surgery and enhance their chance of doing the job right on the first trial. Without the support by a laser pointer system, the novice surgeons took a longer time to complete the task and even some of them need a second trial.

Sketching

Sketching is a basic skill in painting and drawing. In a telepointer system, sketching can be regarded as a gesture system with the added ability of pointing. The user is given the freedom to draw anything without any restriction such as any shape, line and even writing a word. Normal implementation of a sketch pointer is by sharing the drawing activities or “virtual sketchbook” among the collaborators . Video input is used to provide a common drawing surface where each collaborator can view the combined image of all the sketches made by the collaborators. The work by Ou et al. proposed a method to integrate visual information and gesture beyond the static surface like a sketchbook. They implemented a system of dynamic surface in the collaborative physical task environment. Their system can support pointing and gesture activity by using the sketch pointer on a video stream. Stylus, touch screen and telestrator are used as a drawing tool that allows its operator to sketch an overlay over an image generated by the camera.

Telestrator has a special ability that allows the user to draw on the television screen by using a particular stylus pen. It was invented in the late 1950s and widely used in advanced application of telemedicine such as telesurgery , teleproctoring and telementoring . Telestrator managed to improve performance of a clinician who has the fundamental knowledge about the surgery yet limited or no experience in the operation room. Ali et al. stated that telestrator is an important teaching tool, especially for minimally invasive surgery or also known as laparoscopic. Telestrator commonly used as annotation tools for directing the surgeon by highlighting the point of interest that allows better demonstration of the anatomical structure. It can also be used to lead the surgeon where to place the instruments, other than pointing out any operative threat that he might not aware. An example of such a system is used in telementoring of an adrenalectomy laparoscopic  as indicate in Figure 4(C). A surgeon who is an expert in open surgery and skiilful in laparoscopic procedure but limited experienced in laparascopic adrenalectomy has been guided by another expert from a remote place to perform the laparoscopic successfully. He needs to identify and recognize all the difficult structures, such as vena cava, adrenal veins, and in spleen medialization in order to complete the operation. Here, telestrator is used to guide the surgeon to identify and recognize the difficult structures. The result showed that the operating time was shorter compared to the other authors report and at the same time no complication to the patient is reported. We strongly believed that the implementation of a telestrator enhances the learning experience and accelerates the learning curve of for the laparoscopic procedure.

Conventional telestrator have a limitation on the number of participants. It operates on one-to-many relationship where only the remote site is allowed to manipulate the pointer while the local site can only view the output. The system will feed the information back to the remote site through audio information. This restriction makes a telestrator system unsuitable for a groupware application that requires multiple input from all the users. Besides, communication architecture of a conventional telestrator does not allow the users to recover back the original video. As the technology evolves, new form of multimedia framework for the telestrator was developed. Qiru and Dong  presented an approach that provides a platform for n-way Interactive Visual Content Sharing and Telestration (IVCST). The architecture of the system allows multiple users at remote sites to sketch on a shared visual content. Each user is identified by using a name tag and different sketch colour. A conventional telestrator system utilizes 2-dimensional visual system which overlaps the pointer with the points of interest. This approach reduces the accuracy of the telestrator from the user point of view. To lessen this effect, Ali et al.  investigated a 3-dimensional system for potential integration with the telestrator system. Early results showed that the system is feasible for further development since it receives positive feedback from the doctors. In addition, it provides more diverse spatial information such as 3-dimensional sense of presence and can be used for depth perception, which results in more accurate pointing position.

The popularity of a stylus pointer in touch screen tablet and personal digital assistant (PDA) technology were increased due to wide spread usage in telepointer and telemedicine applications. Both technologies allow the remote user to be at more dynamic position compared to the telestrator technology which requires the remote user to be at a static place. The main advantage of a pen-based pointer compared to other telepointer modalities (cursor, laser pointer) is the user friendly factor since it imitates the way human write on a piece of paper. Kim et al. claimed that “pen-based computing provides people with an intuitive way to use a computer” because the user can leverage their writing skill without having to learn how to operate the keyboard and mouse. Therefore, a patient with low computer skill can still be able to provide gesture feedback to the doctor during a teleconsultation session. Dante  examined the usability of a pen-based pointer among the novice older users. The results revealed that majorities of the participant were satisfied with the pen-based pointer compared to the cursor since they can focus their hands and eyes at the same location. Meanwhile, cursor pointer requires them to focus on two different parts; 1) a mouse for moving the cursor and 2) view the display in order to locate the cursor on the screen. Hence, it is suitable for the patient with Parkinson’s disease . In the work by Tu et al., they explored the feasibility of using pen and finger-based pointer for the touch screen application. They found out that both pointers have their own advantages depending on the types of applications.

Hand pointer

Hand pointer is a subset of the hand gesture system that mainly utilizes finger as a pointer. Fussell, et al. classified the hand gesture system into four categories; 1) deictic (pointing), 2) iconic, 3) spatial or distance and 4) kinetic motion. It is considered as a nonverbal communication method since it is portrayed by human action and body language. There are many forms and shapes of the hand gesture that dependent heavily on the culture and norm of the society. Several examples of the human gesture technology are implemented in head tracking  and eye tracking  systems where the users are allowed to interact directly with the computer without using the mouse.

Hand pointer system is an active research area, especially for remote collaboration on a physical task Basically, the input data or the hand gestures are captured by a camera that will be projected to a local workspace and displayed on the monitor. This set up requires the user to be at certain location, which limits the user mobility. Therefore, Alem, et al. and Huang, et al. a wearable system that allows the user to move freely since the camera is not fixed anymore as illustrate in Figure 4(D). Their systems operate on one to one relationship. Both remote and local sites are allowed to send the gestures, but only the local site can view the projected image. Alem and Li  then investigated the possibility of combining hand gesture and cursor pointer together for video-mediated collaboration. The results revealed that both gestures had almost similar performance since all participants performed the tasks well with only minor mistakes. However, most of the participants preferred a hand gesture pointer instead of the cursor pointer because a gesture is more flexible and can represent more symbols. On the other hand, a pointer can only represent a deictic point and can be misunderstood easily by the other parties.

Current hand pointer applications are still in early stage for teleconsultation usage due to high requirement of the telecommunication bandwidth to convey the images. Hence, it requires an expensive installation cost, which is not feasible for rural area implementation. Moreover, a hand pointer system also requires a more accurate algorithm to perform well such complex modeling of the scene. Paper by Argyros and Lourakis  proved that the preprocessing steps required is very challenging such as detection, tracking and recognizing the hand gestures. Gallo and Ciampi  improved the system robustness by using a hand glove for more recognizable gestures. However, usage of a glove is unpractical for a telemedicine application due to heavy and bulky size of the glove that hinders the doctor ability to write the diagnosis report at the same time. Besides, the high-tech glove contains a lot of electronic components that require careful handling. The user needs to be trained on how to operate the devices optimally for a safety reason.

However, the usage of a hand pointer system in telemedicine is encouraging, especially for human-computer interface (HCI) applications. An example of hand pointer implementation in telemedicine is to perform sterility procedures in order to avoid bacteria and virus contamination. Hand pointer is manipulated to direct the inexperienced doctor to perform the procedures as shown by Grätzel, et al, Grange, et al. and Wachs, et al.. The gesture assisted system works as follows 1) “push-to-click” is represented by hand pressing movement 2) “wait-to-click” is inferred from the absence of hand movement for a particular length of time. 3) “turn left” command is performed by moving the hand towards left direction. In , the authors improved the hand pointer system for dynamic environment usage by considering both hand motion and posture simultaneously for realistic gesture representations. A hand pointer system is also used to zoom in or out the camera perspective remotely by manipulating all five fingers movements . According to Wachs, et al., this technology managed to improve surgeon performance by reducing unnecessary movements while discussing with his assistant and browsing through the patient data. Therefore, we strongly believed that a hand pointer system will be further developed given such a vast potential application. Table  shows the comparison of each pointer technology.

Table 1

Comparison between pointer technologies in telemedicine

Telepointer	Pointer manipulation/ Relationship	Hardware requirements	Advantage	Disadvantage
Laser	One to many	•Mounted laser pointer	•Expert can point directly to the specific point on the patient	•Not sufficient enough to lead the direction
		•Video camera
		•Computer devices
			•Save the search time with more accurate location
		•Video display
			•Easily incorporated into the modern operating theatre
			•Low cost installation.
Cursor	One to one	•Computer devices	•Easily incorporated into the modern operating theatre since computer is important devices at hospital for management and etc.	•Small graphical pointer on the screen display
	One to many	•Videoconferencing devices
				•Movement may not be noticeable especially in large screen
				•Doctor at local side needs to look repeatedly at the projected image to see the exact location of the expert’s pointer
			•Low cost installation.
				•Having to learn how to operate the mouse
				•Insufficient for an effective collaboration
Sketching	One to many	•Portable computer devices (PDA / Tablet)	•Freedom to draw anything without any restriction	•Doctor at local side needs to look repeatedly at the projected image to see the exact location of the expert’s pointer
		•Videoconferencing devices	•Multiple shape and size of pointer increase viewer awareness
		•Telestrator devices
		•Stylus pen
Hands	One to one	•Computer devices	•Can form many shapes of hand gestures	•High cost for installation
		•Face video camera
				•High bandwidth
				•Complex algorithm
		•Overhead video camera
		•Screen video camera
		•Wearable devices

Issues and challenges

In the previous subsections, we have discussed the main role and current technology available for the telepointer system. Although it has the ability to increase the quality of health care, issues such as clinician’s concentration, insufficient gesture information and real-life applications should also be addressed.

Clinician’s concentration

The usage of a cursor pointer on the projector screen or display device is a common practice in medical applications. Because of this practice, a clinician needs to divide their focus between looking at the pointer on the display device and the patient. A clinician needs to look repeatedly at the projected image to see the exact location of the expert’s pointer. Difficulty arises when the expert asks the clinician to search for a specific point on the patient body. This may cause a serious problem, especially during a telesurgery where the focus of attention should be on the patient instead of the display device. Therefore, a telepointer system which is capable of transferring digital gestures to the physical workspace is more suitable for this type of telemedicine application.

Insufficient gesture information

Laser pointer has the ability to point directly to the specific point on the patient. Thus, it will reduce the search time and a more accurate localization can be obtained. Furthermore, pattern of the laser spot movement can also represent some form of instruction. However, a clinician claimed that normal telepointer without any gesture information is not sufficient enough to lead the direction in complex teleconsultation process . Moreover, laser pointer movement depends only on the cursor movement by the expert who might lead to an error, especially while clicking the interface or taking a glance at the patient’s body. This error will lead to an inaccurate area of interest.

Real-life applications

A telemedicine system requires more accurate and precise technology since it deals with living things. Most paper  only considered static patients. However, this assumption does not represent precise real-life applications since human does move a lot. Certain parts of the body such as mouth and eyes move unintentionally as reported by Jon and Bowden . In surgery, internal organs also move unconsciously such as heart pumping, colons contraction and lungs expanding motion. Real-life applications must consider the ability of the pointer to track and point to the accurate spot on the object at a local site. It should reflect the same point as pointed out by the expert at the remote site regardless of the object movement at a local site. Salient features are needed to track the moving components. Tracking process will be more complicated due to poor texture on the human skin and tissue, which will degrade the performance of the salient feature’s detection.

Conclusions & future works

In this paper, we have discussed state of the art of telepointer technology in telemedicine. Based on recent publications, we can infer that telepointer system is a very valuable support tool for telemedicine applications that improves communication quality between 1) clinicians and other clinicians, 2) clinicians and patients, and 3) medical students and expert clinicians. Telepointer system is a nonverbal communication mode that enhanced the communication capability of the remote user so that more accurate information will be delivered. There are many types of telepointer hardware such as cursor, laser, hand and sketching tool where every tool has their own unique advantages and disadvantages. In addition, we have identified the environments and surroundings where the tools will perform the best. For the teleconsultation purpose, cursor pointer and sketching were usually used as the support tool by the specialists to convey the instruction to the junior clinicians. On the other hand, laser pointer is used to enhance the communication between clinicians and patients.

Currently, several works in CSCW field  have focused on robustness improvement of the system to unstable network. We also found out that there is a limited study in telepointer performance with respect to the localization, actual patients and outdated instruments, which result in the limited report on real object implementations.

As for future improvement, we believe there are two areas that will enhance the current system significantly. Firstly, the system can be implemented in a parallel processor instead of sequential approach for faster processing speed. Most of the existing telepointer hardwares utilize central processing unit (CPU) as the main processor, which performs moderately slow if the image resolution is high. High performance processor is required for real-time applications, especially in telesurgery where the decision must be made instantly. Therefore, a graphics processing unit (GPU) is a good alternative to CPU for real-time telemedicine system. GPU consists of hundreds of smaller core, while current CPU technology typically has four to eight cores. This feature makes GPU as a powerful computing tool for medical image information. Besides, image resolution and interpolation can be executed at a faster speed. Due to bandwidth limitation, most of the captured images need to be transmitted at a low resolution.  implemented their down sample method in GPU so that the captured images can be transmitted at a lower resolution. Then, the down sample can be enhanced through image sharpening, which also requires heavy computational load. As a result, their method can perform five times faster than the conventional compression method. By having greater computational ability, hybrid telepointer with high resolution will be utilized more in the telemedicine field. One obvious advantage of using higher-resolution image is better localization of the pointer information such that more accurate pointing can be obtained.

Secondly, a telepointer system can be improved by using a more robust algorithm, especially for the image-processing part. A statistical approach will result in better learning compared to heuristic approach . It will reduce the bottleneck effect when the decision rules are out of the input set such as during illumination changes. Statistical approaches are based on a collection of quantitative data manipulation and interpretation on its statistical properties to discover the pattern, relationship and distribution of the data. Most of the medical images contain nonrigid object and it is hard to model it by using fixed modelling. Statistical method offers the ability to learn from a bundle of data and come out with more robust formulation. This approach has been used in many high level applications  and has been applied in various medical systems By using this approach, a better pointer tracking system will be developed to keep track the movement of the pointer device at the remote site. At the same time, the local site pointer can be tuned to follow the remote site movement in order to obtain more accurate feedback data.

Abbreviations

DOVE: 

Drawing over video environment

HMD: 

Head mounted display

PC: 

Personal computer

CSCW: 

Computer supported co-operative work

VEDH: 

Severe vertex epidural hematoma

JPEG: 

Joint photographic experts group

ECG: 

Electrocardiogram

MMS: 

Multimedia Messaging Service

SMS: 

Short message service

WACL: 

Wearable active camera/laser

IVCST: 

Interactive visual content sharing and telestration

PDA: 

Personal digital assistant

HCI: 

Human-computer interface

CPU: 

Central processing unit

GPU: 

Graphics processing unit

WinVicos: 

Wavelet-based interactive video communication system

REPETE: 

REmote patient education in a telemedicine environment architecture.

                                        Telehealth Today, Not Tomorrow

Telehealth Today, Not Tomorrow

According to the American Telemedicine Organization, telemedicine is the use of electronic communications and information technologies to provide clinical services when participants are at different locations. Closely associated with telemedicine is the term telehealth. This term is often used to encompass a broader application of technologies to distance education, consumer outreach, and other applications wherein electronic communications and information technologies are used to support healthcare services.  Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.

The delivery of remote health services is used for a variety of purposes:

• Direct patient care such as sharing audio, video and medical data between a patient and a health professional for use in rendering a diagnosis, treatment plan, prescription or advice. This might involve patients located at a remote clinic, a physician’s office or home.

• Remote patient monitoring uses devices to remotely collect and send data to a monitoring station for interpretation. Such “home telehealth” applications might include using telemetry devices to capture a specific vital sign, such as blood pressure, glucose, ECG or weight. Such services can be used to supplement the use of visiting nurses.

• Specialist referral services typically involve a specialist assisting a general practitioner in rendering a diagnosis. This may involve a patient “seeing” a specialist over a live, remote consult or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later.

• Medical education and mentoring, which range from the provision of continuing medical education credits for health professionals and special medical education seminars for targeted groups to interactive expert advice provided to another professional performing medical procedure.

• Consumer medical and health information includes the use of the Internet for consumers to obtain specialized health information and on-line discussion groups to provide peer-to-peer support.

Remote health care relies on several means for the delivery of data:

• Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas through either hub-and-spoke or integrated networked systems. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites. It is estimated that there are about 200 telemedicine networks in the United States involving close to 3,500 medical and healthcare institutions throughout the country.

• Point-to-point connections using private networks are used by hospitals and clinics that deliver services directly or contract out (out sourced) specialty services to independent medical service providers at ambulatory care sites.

• Health provider to the home connections involves connecting primary care providers, specialists and home health nurses with patients over single line phone-video systems for interactive clinical consultations. Such services can also be extended to a residential care center such as nursing homes or assisted living facility.

• Direct patient to monitoring center links are used for pacemaker, cardiac, pulmonary or fetal monitoring and related services and provide patients the ability to maintain independent lifestyles.

• Web-based e-health patient service sites provide direct consumer outreach and services over the Internet.

With the looming physician shortage, this technology delivers much needed access for small and rural healthcare providers.  CMS (Centers for Medicare & Medicaid Services) has taken notice and developed a new credentialing and privileging process for practitioners delivering healthcare services remotely.  In the presence of faster and more reliable networks, wireless devices, high-definition digital images and video, telehealth could be the fulcrum for this long overdue multi-pronged approach.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates stand head and shoulders above the competition.

 

 

                              XXX  .  XXX 4%zero null 0 1 2  Telemedicine Robots

 

 

Robots and robotics have been a fixture in healthcare for decades. New telehealth and mHealth tools are giving them a chance to shine

 

 

Long a staple of science fiction, robots are now proving their value as a telemedicine resource.
Originally designed to ferry supplies around the hospital or give surgeons a steadier hand for delicate medical procedures, robots are now finding their way into the care continuum, thanks to a variety of designs that can turn them into walking, talking healthcare kiosks. Healthcare robots can take orders from and deliver items to a patient, act as an around-the-clock sitter, assist frail and elderly patients out of a bed or chair, or provide a video connection to a distant doctor.
“There’s a lot of opportunity for this technology in healthcare,” says Daniel Theobald, Vecna’s Co-Founder and Chief Innovation Officer and a leading expert on robotics in healthcare. “If you look around now you’ll see them.”
Robots have proven especially helpful in telemedicine. Companies like VGo and InTouch have developed robots that serve as the doctor’s stand-in in remote clinics, community health centers, schools, cruise ships, sporting events, even smaller hospitals.  They’ve even been used to provide home-bound or quarantined children with an avatar of sorts, enabling them to attend school and interact with classmates from afar.
The challenge going forward is finding where robots fit best in healthcare, and balancing the expectations with reality.

Origins of Robots in Healthcare

Taking a page from the retail industry in the late 1990s, healthcare first turned to robots to automate the supply chain. Guided by GPS technology, small and squat mobile units were designed to deliver supplies, replacing the need to dispatch a nurse or other staff member to restock cabinets.
"This new robotic breed is boasting features increasingly found in smartphones, gaming consoles and other consumer electronics, from advanced sensors and motion detectors to powerful microprocessors and voice activation,” the Wall Street Journal reported in 2012. “The service robots are self-aware, intelligent and able to navigate changing environments, even chaotic hospital settings."
Those robots, says Theobald, are designed to improve the supply chain and make the nurse’s life easier.
“The biggest cost in hospitals that people don’t think about is logistics,” claims Theobald, whose company produces the QC (Quality Care) Bot. “It can take up to about a third of your budget just getting the stuff you need and getting it to where it needs to be.”
“Nurses walk about five miles a day,” he explains. “That’s about a quarter to a third of their time. Imagine what would happen if we could cut down on that walking and allow them to do their jobs more efficiently.”
Two types of robots are generally found in this environment: supply and maintenance robots such as the QC Bot and Aethon’s Tugs robot, and mobile medical carts — often called computers-on-wheels or COWs. The latter are often dispatched to patient rooms to deliver patient orders or give doctors and nurses mobile access to medical instruments and the electronic medical record.
The first health systems to take full advantage of robots were pediatric hospitals that either ordered specially designed machines or dressed them up as characters to entertain their patients. More recently, these organizations used robots to help children adjust to the hospital and their care plan.
“There’s something important and almost magical about a robot,” Theobald observes. “Children will be much more open with them. It make a difference in their care.”
In California, Children’s Hospital of Orange County dispatched robots to Hoag Hospital Newport Beach to help with children admitted to the Emergency Department. The four-foot-tall robots enable CHOC pediatricians to assess the children — and talk to their parents — before transfer.
“The children think this technology is cool,” adds Jason Knight, MD, Medical Director of CHOC Children’s Emergency Transport Services, who uses his home computer, laptop, or iPad to use the robot. “When I introduce myself via the robot as a pediatric specialist, it always puts the parents’ minds at ease because from that point forward, CHOC is involved with their child’s care.”

                   

 

Many different uses for robots

Robots are actually showing up in several healthcare scenarios. A blog in Medical Futurist outlines the nine most common uses:

1. Room disinfection. A robot using UV light can sterilize a room more efefctively than housecleaning, reducing the chances of a hospital-acquired infection like MRSA or C.diff.
2. Reception. A robot can register patients, access medical records and provide detailed directions – in a y number of languages.
3. Surgical assistance. Robotic arms, guided by a doctor, can perform basic surgical procedures in small or delicate areas, even when the doctor is miles away.
4. Remote clinical encounters. Robots can serve as a doctor’s eyes and ears in clinics, community centers, retail locations and the patient’s home.
5. Supply chain management. Robots can carry up to 400 pounds of supplies from one department to another, be programmed to respond to shortages, even deliver food and amenities to patient rooms.
6. Assisting mobility-impaired patients. Some robots can assist patients getting in and out of beds or wheelchairs, while exoskeletons can improve mobility for patients with partial paralysis or other physical impairments.
7. Drug delivery (think Fantastic Voyage, without the human cargo). Miniaturized robots can be deployed inside the body, delivering targeted doses of medication to specific locations, such as an organ or tumor.
8. Blood drawing. Newly developed robots can pinpoint the ideal vein and withdraw blood in half the time it takes a nurse to do the same thing.
9. Patient engagement. Robotic animals can help soothe the nerves of traumatized patients, especially children, or help them open up to care providers.

“As robots take care of our more intimate needs, such as personal caregiving, human to robot and robot to human interactions will become a central focus of study and philosophical discussion,” healthcare IT blogger Bernadette Keefe, MD, wrote in a 2016 post for the Mayo Clinic.
“There is much unknown regarding the ultimate acceptability of robots in intimate settings, or at work,” she concluded. “Comfort with robots may depend on multiple variables, such as the individual, culture, particular application, or industry. Trust is at the core of the use of autonomous robots in healthcare, and safety must be proven."

Robots in critical care

In clinical settings, a robot can sometimes serve as the doctor’s representative, especially in cases where a specialist is required.
One of the first to be used in that setting was the RP-VITA, developed by iRobot (makers of the Roomba) and InTouch Technologies and given 501(k) clearance by the Food and Drug Administration in 2013. The five-foot-tall “autonomous navigation RP robot” was designed to combine mobility with an audio and video communication platform and instant access to patient medical records, as well as a navigation system that could map the environment for future reference and sense objects and people in its path.
"FDA clearance of a robot that can move safely and independently through a fast-paced, chaotic and demanding hospital environment is a significant technological milestone for the robotics and healthcare industries," iRobot Chairman and CEO Colin Angle said in 2013.
In one particular case, robots are proving their value. That’s in the emergency department, where a robot can connect patients and staff to a specialist miles away.
At Lompoc valley Medical Center, “Dr. Robot” is deployed in the Emergency Department to provide specialty care for stroke patients. Officially called a Remote Presence Virtual Independent Telemedicine Assistant, or RP-VITA, the five-foot-tall robot comes equipped with a high-definition video communications platform that allows the specialist to examine and communicate with the patient and on-site care team.
An April 2016 article in Lee Central Coast Newspapers describes how the telemedicine robot is used for someone suspected of suffering a stroke:
Once the patient is admitted, the hospital’s 12-member stroke alert team springs into action. This includes contacting the on-call neurologist, who is located in or near Los Angeles.
At the same time, the robot is dispatched from its docking station to the patient’s room.
The neurologist logs in through an encrypted connection, reviews the patient's scans and, using cameras attached to the robot, examines the patient, even zooming in to chekc the patient's pupils. He/she can also check data on bedside monitors and talk to both the patient and attending doctors and nurses.
“Because some crucial medications can be especially dangerous under certain circumstances, [Steven Reichel, MD, medical director of the LVMC emergency department] said it is nice having a specialist essentially in the room to provide an instantaneous second opinion, which becomes part of that patient’s medical record,"  the story notes.
One small hospital even credits robots with saving the facility from closing.
That’s the opinion put forth by Bryan Coffey, CEO of Hamilton County Hospital, a 25-bed critical care hospital in rural Kansas serving a population of about 2,700 people. In a 2014 white paper, Coffey said he took over the hospital in June 2013, when the hospital had no doctors, and immediately hired one physician and one cardiologist.
He then brought in an InTouch telemedicine robot.
“[We] started seeing a 180 (degree change). There’s been a 40 percent increase in (patient) volume and we’re consistently, month over month, 15 percent in growth,” Coffey told a local newspaper. 
The hospital now uses the robot for ER as well as primary care visits and is adding service lines to connect patients through the robot to specialists, including dermatologists, pediatric doctors, and OB doctors.
“We have gone from a stagnant ‘stabilize and ship’ CAH to a vibrant provider of healthcare for our community … despite the fact that we are 55 miles from the nearest town with a Wal-Mart store,” Coffey wrote.
“The robot opens up opportunities for clinical affiliations which have increased interest from mid-level providers as well as some second and third year residents in medical school as they would no longer be the only town doctor,” he concluded.  “We have gone from a hospital that was looking to close its doors in early 2013 to a vibrant growing and profitable hospital by 2014. So, if you are wondering how you can afford this robot, I would ask you how can you not afford to have this robot?”

                       

 

Robots in the operating room

Robots have been used to assist in delicate surgical procedures since 1985, when a robot surgical arm called the PUMA 560 was first used to perform a non-laparoscopic surgery.
The technology took a leap forward in 2000 with FDA approval of the da Vinci Surgical System, which has performed some 20,000 surgeries to date. In 2001, a team of New York-based physicians made history by using a robot named Zeus to perform a complete laparoscopic cholecystectomy on a patient in Strasbourg, France.
“It’s the same as if I were sitting in the operating room,” Mehran Anvari, a physician at St. Joseph’s Hospital in Hamilton, Canada who used the Zeus robot for more than 20 operations, including hernias and colon surgery, told BBC News in 2014. “I have both my hands on the robot the same way I would have instruments in both hands. … Basically, it’s the same as if I were next to the patient, just using telecommunication and robotics. It doesn’t feel different.”
Guided by the idea of using robots to perform surgeries in remote locations – such as space – healthcare providers and entrepreneurs have been working since then to refine the process.
In 2014, New York’s Mount Sinai Health System Icahn School of Medicine conducted two separate studies on the feasibility of telerobotics, with a doctor in one location controlling a robotic instrument in a surgical procedure at another site – ultrasounds in one study, echocardiogram exams in the other.
In the second study, Mount Sinai researchers collaborated with Kurt Borman, MD, of Umea University in Sweden to conduct robotic echocardiogram exams of several patients in remote clinics more than 100 miles from Borman's hospital.
According to Borman, the robot-assisted exams helped reduce diagnostic process time from 114 to 27 days, while a patient's wait time to see a specialist was reduced from 86 to 12 days; in addition, 95 percent of the patients involved in the remote consults said the results were superior to an in-person encounter.
"As a result of our pilot study, we were able to establish a safe and efficient e-health solution to improve the comprehensive, convenient examination of suspected heart failure patients in a rural community of northern Sweden and improve their physician care team's communication," said Narula, who published both studies in the August issue of the Journal of the American College of Cardiology-Imaging. "This pilot may serve as a future model for use of e-consults and robotic imaging in similar rural communities to improve access to specialists and the latest diagnostic technology globally."
And in 2015, the Florida Hospital Nicholson Center in Celebration conducted studies to determine if clinicians could conduct surgery via telemedicine. They found that while the technology is far more precise than it used to be, it’s not yet ready to sit in for the surgeon.
"The networks that exist today in well-equipped hospitals are more than capable of supporting telesurgery," Roger Smith, PhD, the Nicholson Centers Chief Technology Officer, said at the time. "But we've got a long way to go before that will happen."

 

Expectations and limitations

In 2011, Boston Children’s Hospital was one of several hospitals around the country to send robots home with newly discharged children in an early remote patient monitoring study. The robots, which cost roughly $6,000 apiece, were designed to interact with the children at home and enable caregivers to keep tabs on the kids’ health.
"Eventually, I see a whole fleet of these robots being sent home with patients,'' Hiep T. Nguyen, Associate Professor at Harvard Medical School and Children’s Director of Robotic Surgery Research and Training Center, told the Boston Globe. "With this technology, we're going to be able to replace hospital monitoring with home-based monitoring.''
It may be going there, but it hasn’t gotten there yet. Most of the programs were scrapped because the robots proved too expensive and didn’t provide enough clinical information back to caregivers to improve care management. In addition, providers are now looking at smaller, less invasive and more comprehensive RPM programs that use wireless devices and wearables.
“The pace of automation and robotics technology outruns the ability to get it into the hands of the clinicians,” Paul Sturrock, MD, a colon and rectal surgeon at UMass Memorial Medical Center and assistant professor at the University of Massachusetts Medical School, wrote in a 2016 blog. “In a healthcare environment, not only are the costs scrutinized -- the cost benefits are scrutinized even more. We are constantly evaluating these things and seeing what actually provides benefits to the patients and the advantages for doctors beyond being able to get their procedures done more efficiently.”
The upshot: Robots and robotics will work in certain situations where they provide services that reduce waste – both in time and money – help patients and improve workflows for doctors and nurses. As for the predictions that a robot might someday replace the doctor? Not just yet.
“We’ve all grown up with (robots) and we all believe they can do amazing and wonderful things,” iRobot Co-Founder and CEO Colin Angle pointed out during a panel discussion at the Digital Health Summit at the 2013 CES conference in Las Vegas, “but we always get ahead of ourselves.”

Doctors Can Use Robotic Telemedicine to Assess Coma Patients

A new study shows that a remote specialist can be just as effective at reporting a comatose patient’s condition than a medical professional in the room

                     

          Robotic telemedicine can be used to assess patients with stroke

There are moments when I can still smell the heat from the machines humming around us. To distract myself from the overwhelming complexity of the tubes, wires and rainbow of flashing lights, I timed my own breathing with the rise and fall of his ventilator. And I watched. I watched every swell of his chest, each tiny twitch of his hands. I monitored the lineup of screens with numbers increasing and decreasing, learning from the nurses what was good and what needed to be addressed. When there was a change, any change, it didn’t matter how big or small, I reported my findings to the medical staff. The only time I left his side was at night—not by choice, by hospital policy. A friend allowed me to stay at her empty condo only a few miles away. It saved hours of traveling and being gone from my son for too long. Not many families in our situation are this fortunate.

the first to question if medical providers need to be in the same room as a patient, or if robotic telemedicine can be used to successfully complete an assessment of someone in a comatose state.

The patients underwent assessments utilizing two closely related scales: the Glasgow Coma Scale (GCS) and the Full Outline of Un Responsiveness (FOUR) score. The GCS measures eye opening, verbal response and motor response, with scores ranging between 3 (severe) and 15 (mild). The FOUR score is a 17-point scale (with potential scores ranging from 0 to 16) that assesses eye response, motor response, brainstem reflexes and respiration.
A pair of neurologists was assigned to each patient. One was assigned to the bedside of a patient in the ICU and the other was assigned to an office in the neurology center where they had access to a computer workstation. They conducted their neurological assessments simultaneously, one doing a normal bedside assessment and one through robotic telemedicine. Each pair submitted their score independently. The differences between total bedside and remote GCS and FOUR scores were trivial. The mean GCS total score at bedside was 7.5, while the one conducted remotely scored a 7.23; a difference of 0.25. Similarly, the mean FOUR total score at bedside was 9.63 compared to the remote score of 9.21; a difference of only 0.40.

Robotic telepresence, like that used in the study, is the most sophisticated type of telemedicine technology deployed today. In addition to an audio-video connection, these tall, vertical units, which resemble antique street lights in their contoured shape, are remotely controlled using a desktop, laptop or mobile device. They can be pre-programmed to drive on their own or the drive mode can be overridden and controlled by an individual, located in the same building or hundreds or thousands of miles away, with a joystick or keyboard. Medical professionals on site can plug peripherals into the units to directly extend the remote doctor’s capabilities beyond just audio-visual. For example, a nurse could plug a stethoscope into the robot and then place one end the stethoscope on a patient’s chest, so that the neurologist at the workstation could hear the breath or heart sounds directly as if they were at the bedside.

“Patients were being transferred from small, rural community hospitals to larger centers when there were neurological emergencies, like strokes, often arriving too late for there to be any treatment delivered.”
Many of the treatments for patients in comas can be started at a remote hospital if the emergency department physician works in concert with a neurologist or neurosurgeon via telemedicine. This provides an earlier diagnosis and treatment plan, and can even make a transfer completely unnecessary.

“It’s a very important state and there are very strict criteria to make that diagnosis. We believe that the assessment could successfully be done via telemedicine,” he says.

He also believes a nationwide rollout of telemedicine programs could vastly improve our health care system. There are several bills introduced in legislature that could help streamline this process and reduce the barriers for physicians to practice telemedicine in underserved regions in multiple states.
For patients, telemedicine means the best possible care, as early as possible, no matter where they are located. For families, like mine, it means hope—even when the odds must be defied.