Theory and practice of Store-and-Forward Telemedicine over the Internet in a nutshell

Heidelberg 21 September 1999VMWC partner Dr. Vincenzo Della Mea from the University of Udine in Italy, led a workshop on Store-and-Forward Telemedicine through the Internet during MedNet'99. Seven speakers highlighted the technical and legal issues, and the sometimes surprisingly creative solutions this type of remote application holds in store for the user. Experiences from the field in Germany and Italy but also in developing countries, situated in Africa and South-America, as well as the particular definition and implication of remote for a country like Australia, were presented to the audience by Christian Elsner, Claudio Eccher, Klaus Woerle, Jack Woodall, and Joe Hovel. Giorgios Kontaxakis described the impact of the TeleInViVo project in the Azores, Kazakhstan and Uganda.


Dr. Della Mea briefly introduced the store-and-forward concept by defining it as a discipline where the information is recorded before or after transmission but not simultaneously. As a result, less bandwidth is needed but networks do have to be available. We do not talk here of a new invention since radiographs or glass slides also constitute a type of store-and-forward telemedicine. The technique is only used if the data can be acquired without any intervention from the person receiving it, like in the case of ECG. Store-and-forward should always be considered before real time telemedicine since it is cheaper and easier to perform, although the user deals with a sampling problem, having no complete view on the case.

The technical aspects relate to the analogue or directly digital acquisition of diagnostic information; the aspects of file compression for storage; the direct communication or indirect use of a server architecture for data delivery; and the display at the expert site. Dr. Della Mea indicated the different types of store-and-forward, such as audio transfer, data and text transmission, and still or moving images, by respectively using the examples of heart sounds, tele-ECG, teleradiology, and ultrasound video images. In teledermatology, teleradiolodgy, telepathology, and telecardiology, multimedia e-mail is used through MIME-format, SMTP, POP and IMAP to offer security services such as signature and encryption.

Dr. Della Mea concluded that store-and-forward sometimes forms the only way to offer remote medical services, because of the lack of infrastructure, different time zones, and large data sets. We therefore need to identify when this technique can be applied and when not. The workshop offered a range of test cases in which the store-and-forward concept is proving its usefulness. As such, the German company MedKonsult and the Heart Centre of Leipzig have designed a Web- and fax-based consultancy and information service for clinicians dealing with ECG diagnostics and rhythmologic problems. Speaker Christian Elsner emphasised the complex legal issues that play a major role in offering this EcgConsult service. As such, it is not at all sufficient for the German law to guarantee the safety of person-related submission of data by Secure Socket Layer (SSL) and firewalls.

At the IRST Institution in the Province of Trento in Italy, a store-and-forward collaboration has been set up in order to share clinical records. Dr. Claudio Eccher explained how an inter-hospital network has been created which is accessible from different departments to transmit digital clinical records with multimedia data. Dr. Klaus Wörle from the University of Regensburg highlighted the use of standard Internet technology and wavelet compression to limit the download time for images taken at the hospital which need to be consulted by private ophthalmologists. MedNet'99 co-chair Dr. Jack Woodall illustrated how store-and-forward e-mail through low orbit satellite use can solve communication problems for Third World health workers. The required ground stations cost only $10.000 which turns the every-six-hours-a-day e-mail service into a slow but affordable and very useful tool.

The IT² use in remote Australian rural health, Internet medicine and the infrastructure challenge in this vast country was covered by Joe Hovel. Health professionals in Australia are slowly starting to use electronic mail, the mobile phone and desktop for communication with colleagues, patients and clients. Giorgios Kontaxakis, the last speaker in this store-and-forward telemedicine workshop came from Fraunhofer Institute in Germany where a portable 3D ultrasound telemedicine workstation has been developed for use in isolated regions, areas of calamity as well as developing countries. This TeleInVivo system includes a personal computer, ultrasound equipment, the InViVo software for free-hand scanning in 3D, a modem, ISDN, Ethernet, and collaborative facilities. Please, visit the Web site of the University of Udine for an overview of the Store-and-Forward Telemedicine Through The Internet workshop.

Leslie Versweyveld

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