In Europe but especially in other parts of the world, including the third world, the costs for health care delivery to each individual in every imaginable situation have risen to an astronomical level. The need for affordable diagnostic systems which can be used in difficult-to-reach as well as underserved regions has become urgent. In response to this demand, nine partners decided to launch TeleInViVo, a two-year project, funded by the European Commission under the Telematics Technologies Programme. The aim is to develop a transportable, integrated telemedicine workstation, utilising 3D ultrasound, connected with a lightweight, portable ultrasound system for use in rural, isolated, or crisis situation areas. The workstation includes both computing and telecommunication capabilities, and is able to support a variety of applications ranging from gynaecology and urology, over endocrinology, surgery, orthopaedics to cardiology and abdominal scans.
The different imaging modalities differ significantly in cost and portability of the equipment involved and in their potential to harm or cause undesirable side effects. The TeleInViVo team considers ultrasound to be particularly attractive since its relatively low cost for manufacture, portability, and non radiating capacity make it the only economically and practically affordable imaging equipment at the moment. The basic idea behind the 3D ultrasound telemedical workstation is to scan the data instead of the patient. In order to create a diagnosis, the physician normally has to directly interact with the patient but the use of 3D ultrasound allows to generate a virtual 3D digital patient tomographic model at the location where the patient is present and transfer it over a network to essentially every other location of the world for remote examination.
The doctor in the field scans the sick or injured part of the patient's body and transmits the acquired 3D data set via phone line, ISDN, Internet or satellite to the distant expert. Such transportation of data can be on-line, i.e. while both doctors are connected, or off-line, e.g. overnight. In the latter case waiting times are minimized, whereas in the first case additional scans can be ordered by the remote expert during the consultation and transferred to him immediately for fine-tuning the diagnosis. Afterwards, both physicians are linked on-line to perform "virtual echography" on the patient's 3D images on screen in real time, even through narrow-band channels.
The innovative idea of the system lies in the fact that after the transfer of the 3D ultrasound data and during the on-line co-operation only control signals (e.g position of mouse, activation of buttons etc.) have to be transferred over the network. The control signals resulting from actions introduced by one user are transferred to the remote location, where the second workstation locally calculates the corresponding image. Thus, no bulky image data have to be transferred over the network, only a few bytes of control signals. Nevertheless, the two doctors see exactly the same image on the screen. The delay between the two locations depends only on the latency of the intermediate network, which can be as low as that of a usual telephone line or even a GSM handy!
An early prototype version using a similar principle, called the MUSTPAC-1, was developed for NATO military peacekeeping forces for use under field conditions during the Bosnia War in the summer of 1996. Compared to that early prototype, the current version of TeleInViVo offers dozens of novelties in software and hardware, including compact and integrated design of computer and ultrasound devices as well as CE certification of the software system.
The TeleInViVo team started in July 1998 with a development phase to set up the soft- and hardware equipment according to the user specifications. The Fraunhofer Institut für Graphische Datenverarbeitung (IGD) and the Zentrum für Graphische Datenverarbeitung (ZGDV) in Germany collaborate with the Centro de Computação Gráfica in Portugal and the Centro de Alta Tecnologia en Analisis de Imagen (CATAI) in Tenerife. The two industrial partners involved are Pie Medical B.V., a Dutch ultrasound specialist, and Dr. Staerk Computer Systeme GmbH, a German hardware provider. Both of them are directly interested to commercialize the TeleInViVo system as a medical teleconference emergency workstation to be used almost anywhere at anytime with less travelling time needed for doctors and inconvenient transportation problems eliminated for patients.
Seven field test sites are planned to validate the system. The major hospital in the Azores Islands is situated at the city of Ponta Delgada. The TeleInViVo system will serve to provide emergency support throughout the archipelago and to ships at sea using satellite or mobile communications. In the Canary Islands, TeleInViVo will be used remotely for the prevention and treatment of prenatal malformations, high risk pregnancies, as well as for the control of infertility and in vitro fertilization, and for emergency cases in general. The hospitals in both the Azores and Canary Islands will have a mobile station. A fixed station for medical diagnosis support will be situated at the Coimbra University Hospital in Portugal. Coimbra Hospital will also function as a centre of expertise to provide remote consultations to the other sites.
The UNESCO will assess the system both in Uganda and Kazakhstan, at two different sites for each country. In Uganda, the TeleInViVo system has been integrated in a new rural Multipurpose Community Telecentre (MCT) pilot project to provide affordable access to innovative tools for information and communication technology development in the villages. In Kazakhstan, the polluted Aral Sea region has to be considered as a rural and remote area, suffering under a staggering ecological disaster, and also as a developing region in terms of alarming health care indices. As such, the 3D ultrasound telemedical workstation will be tested in various socio-economic conditions in order to be adapted to meet the specific needs of developing countries and regions in transition.
The core of the system consists of the Interactive Visualizer of Volume Data (InViVo), a robust and fast volume processing solution. The software allows to mix volume and surface rendering in order to generate varying degrees of transparency. The physician can take arbitrary slices through the data, and apply tools for filtering, measuring, segmenting and for planning trajectories. The InViVo software is available in different versions, in order to support all current visualization modalities. InViVo-Vis is the basic visualization system for CT and MRI datasets that has been upgraded for ultrasound applications to the InViVo-3DUS, with special ultrasound filters, and to InViVo-Scan, a free-hand 3D ultrasound extension to every existing conventional ultrasound scanner, which provides full 3D capabilities.
After the initial field tests, the system will be submitted to the modifications, requested by the end user hospitals. In March, there has been a first public trial between Tenerife and Germany as well as between Tenerife and Portugal. Data sets of ultrasound and MRI were transmitted on-line and over the Internet between the sites whereas a teleconsultation was performed via ISDN phone to discuss images showing a placenta with a cyst. The demonstration was a full success! The TeleInViVo project will take an end in June 2000. By then, the partners expect to present a killing application product in the form of a well affordable and excellently functioning 3D ultrasound telemedical workstation for use in Europe as well as in other parts of the world, to offer health care support in regions where conventional medical services fail to be effective. Please, find more detailed information at the home page of the TeleInViVo project.