An Interactive Medical Support System for ...

An Interactive Medical Support System for Dermatology in Rural Areas E. Hanada1, K. Ikebuchi2, M. Miyamoto2, M. Kitani3, S. Yamaguchi3, I. Dekio4 and E. Morita4 1

Division of Medical Informatics, Shimane University Hospital, Izumo, Japan San-in Denko Inc. Izumo, Japan 3 Masuda Red Cross Hospital, Masuda, Japan 4 Dermatology, Shimane University Faculty of Medicine, Izumo, Japan 2

Abstract—$Vhortage of doctors in rural areas of Japan, especially specialists, has been a serious problem for several years. This has created a need for alternative forms of care in these areas, and telemedicine is a potential solution for this problem. However, Ln spite of a governmental policy to provide nationwide coverage with a fiber optic cable network, there are some areas where it cannot be accessed in Japan. Several types of telemedicine have been developed. Although there is always a doctor at the main terminal, at the remote terminal there may only be a patient, only a doctor, doctor and patient, and sometimes family. Of these possibilities, interactive telemedicine systems focusing on support for the remote doctor have received little attention. We developed a 1Mbps, multimedia, two-way communication system that can be used between rural medical institutions that are short of medical specialists and the nearest university hospital, where medical specialists are always present. We are currently using this online, telemedicine auxiliary system in our dermatology department. This equipment not only does two-way communication using MPEG4, but can rotate the display of the remote terminal from the university side, as well as adjust the zoom and direction of the camera. Moreover, the system has software capable of writing and drawing pictures and characters accessible on the personal computer screen at the opposite location. This system is in use in the mountainous areas and islands of Shimane Prefecture. It is also used for the instruction of interns undergoing training at rural hospitals. Keywords— Telemedicine, Interactive system, Medical telesupport

I. INTRODUCTION A shortage of doctors has been a most serious problem throughout Japan for many years. This is an especially important problem in Shimane Prefecture, which has a population of 740,000 in a rural area of western Japan. For many years, the core hospitals of an area, such as a university hospital, have traditionally dispatched doctors to areas in which medical specialists are insufficient. Such dispatches can be permanent, for one to two days a week or month, or for specific needs such as a surgery. However, there is a severe shortage of doctors in Japan, especially in rural areas. The following are some of the reasons:

࣭ Concentration of the population to urban areas, such as the Tokyo metropolitan area ࣭ Reduction in the number of medical institutions due to a reduction in the population of rural areas ࣭ An insufficient number of doctors in certain specialties because of a poor working environment and an increase in medical lawsuits ࣭ New doctors can train at hospitals of their choosing, with fewer now choosing university hospitals The current shortage of medical doctors can be divided into the following three factors. ࣭ The existence of areas without medical service; "The “doctorless” area problem" ࣭ A shortage of medical specialists in certain areas; "Medical specialist misdistribution" ࣭ A shortage of doctors in established specialty units; "Shortage of the number of doctors needed in specific areas" There are several types of telemedicine. Although there is always a doctor at the main terminal, at the remote terminal there may only be a patient, only a doctor, doctor and patient, and sometimes family. Of these possibilities, interactive telemedicine systems focusing on support for the remote doctor have received little attention. When telemedicine is discussed, the data transfer rate of the communication line is the most important factor. However, there is another problem with the communication infrastructure of Japan. For some years the Japanese government has been promoting the installation of FTTH (Fiber to the Home) to serve the needs of the modern broad-band (high-speed) Internet environment. At present, approximately 2.5 million homes are unable to connect to this fiber optic service [1]. In some rural areas even ADSL service is still unavailable. In Shimane Prefecture, data communication by optical fiber cannot be used in islands and mountainous areas. The “digital divide” problem has not been solved here. Areas in which high-speed communication is not available that also have insufficient, or no, medical specialists are especially problematic. We constructed the system herein described in an effort to ameliorate this problem. We developed a multimedia, two-way communication system with remote control, “Multi-purpose Telecommunication

O. Dössel and W.C. Schlegel (Eds.): WC 2009, IFMBE Proceedings 25/V, pp. 9–12, 2009. www.springerlink.com

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Agent System” (hereafter, "MuTA"). Herein, we report our telemedicine trial of this system, and discuss the style of medical tele-support. II. SYSTEM OUTLINE [2] MuTA is a system in which two terminals are connected using Internet technology (Fig. 1). NTSC video and voice can be communicated two-way using MPEG4 data encoding and compression with a transmission-speed (bandwidth) of at least 768 kbps for both directions. MuTA also has the following functions and features.

Because the display rotates, it becomes possible to show more than one person in the remote location, which is why it is considered an “agent”. Also, because MuTA does not include a personal computer, it can be started with only one switch. No setting up or logging-in operation is needed. MuTA uses a camera made by Canon and a high quality 14-inch CRT by Victor Company of Japan. With this combination, a character printed 2.5 m from the camera of a remote terminal can be expanded and displayed clearly on the display of the main terminal at 3.5 times the original size. III. OUTLINE OF TELEMEDICAL CONSULTATION [3]

Fig. 1: "MuTA" terminals (Left: the main terminal, Right: the remote terminal) x The main terminal user can control the swivel base of the remote terminal so that the display rotates up to 100 degrees in either direction. x Also, the main terminal user can adjust the direction and zoom of the camera on the remote terminal. The camera can be panned 100 degrees right and left or 30 degrees up and down, independently of the display rotation. The camera has auto-focus and automatic white balancing functions. x The above mentioned direction and zoom operations can be done using either of two controllers (Fig. 2) that we developed for the system. One looks like a controller for TV-games and the other has two joy-sticks. No keyboard is necessary.

Following is an outline of our dermatological telesupport between two hospitals. Teledermatology is a welldeveloped field and has been used for years [2,4]. There are two main classifications in telemedicine. One is systems with real-time, interactive communication and the other is a store-and-forward system. In the Shimane area, the lack of dermatologists is a serious problem. In western Shimane, although a few dermatologists do consultations, there are many elderly patients in remote areas with dermatological problems who cannot obtain the necessary medical care in their local area. Masuda Red Cross Hospital, a core hospital in western Shimane, has 327 beds and is 160 km west of Shimane University Hospital, which is in Izumo. Masuda Red Cross Hospital (hereafter, “Masuda”) has no dermatologist on the staff. Because Shimane University Hospital (hereafter, “Izumo”) has a strong dermatology department, a dermatologist is dispatched for part-time service one day a week; however, it is impossible to deal completely with the medical needs of this area in this small amount of time. These two hospitals have established a program for online, remote consultation in dermatology. In this study, the remote terminal was installed in the consultation room for dermatology outpatients in Masuda. A conceptual installation diagram of Masuda is shown in Fig. 3. The main terminal was installed in Izumo, and the terminals were

Fig. 2: "MuTA" controllers (Left: Type 1, Right: Type 2) The main point in which MuTA differs from other existing teleconference systems is that the display of the remote terminal can be horizontally rotated from a remote location.

Figure 3: Consultation room for dermatology outpatients in Masuda Red Cross hospital (Conceptual diagram)

IFMBE Proceedings Vol. 25

An Interactive Medical Support System for Dermatology in Rural Areas

connected with a network as shown in Fig. 4. "MuTA" was used on days when no doctor was dispatched. An example of the operation is shown in Fig. 5. This is a case of a medical consultation using “MuTA” by the vice-director (a neurological physician) in a consultation room on the Masuda side.

Figure 4: Network diagram between two terminals

Figure 5: Example of consultation (Left: Masuda Red Cross hospital Right: Shimane University Hospital) Tele-consultation is done every Monday afternoon, except for holidays. In principle, patients reporting for their first medical consultation must be seen in the clinic of the part-time doctor. “MuTA” is only done for outpatient follow-up or to observe the progress of inpatients. Consultation with “MuTA” was done over 120 times in 30 months. Usually, start-up and use of the system are done only by the doctors of these two hospitals. To date there have been only four connection failures. The causes were a large shift in the timing of the connection and a connection failure caused by a network failure. IV. DISCUSSION Patients at Masuda Red Cross hospital are situated in a position from which they can easily see and communicate with both their doctor and the "MuTA" monitor, as shown in Fig. 3. Also, the patient and medical staff on both sides can confirm how they are displayed to the other party with the picture-in-picture function. These functions help create a level of user familiarity not possible in previous systems [5]. Because the zoom of the camera can be operated by the

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medical specialist in the university hospital, the patient is freed from the movements that would be necessary for precise positioning in front of the camera. Whether the patient is sitting on a chair or lying in bed, "MuTA" can be used without the patient having to move. The reproducibility of colors is very important in the examination of dermatology patients. Thus, we have adopted a display on the university (main) terminal that is commonly used in commercial broadcasting. In addition, we have adjusted the colors using the same color sample for both sides, insuring the high quality picture necessary for the dermatology specialist to make a proper determination of the patient’s treatment needs. In their evaluation of the system, the university hospital doctors said that the resolution of the picture is of a level that allows an accurate diagnosis. An example of the view is shown in Fig. 6. When the zoom is wide (A in Fig. 6), both the patient and the nurse can be seen. In this status, the specialist at the main terminal can identify possible problem areas and zoom in on them, operating the camera by remote control. In the enlarged image (B in Fig. 6), there is sufficient image quality to make medical decisions.

Figure 6: View of a severe zoster patient in Masuda, Recorded by Izumo terminal (Left: A general view of the affected body part, Right: Expanded view of the affected body part) Dermatologists in Japan often receive telephone consultations from the doctors of other departments. A rash, for example, cannot be expressed precisely in a telephone consultation except by a highly trained dermatologist, reducing the effectiveness of diagnosis in telephone consultations with non-specialists. The ability to make a correct diagnose could be improved in telephone type medical consultations if pictures taken by digital camera are used, but taking a still picture at the necessary magnification poses a problem. In dermatological diagnosis, locations at which there is no rash can also pose a problem, and the dermatological specialist performs such observations almost unconsciously. For example, if a rash is seen on the right and there is nothing on the left, a belt-like Blaschko line may occur, indicating a diagnosis of herpes etc. When using "MuTA", a correct diagnosis can be made because such points can be observed. A university doctor who was in charge of telemedical consultation reported that he was happy that each consulta-


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tion could be begun with a greeting when using "MuTA", as in usual consultations. It is also helpful in that it enables the patient and monitor to always be face to face; thus promoting smooth communication and a good doctor patient relationship. The following comments and opinions were received from the Masuda Red Cross Hospital doctor. “It is very valuable because a medical specialist from the university can check the patient. In the case of an infant’s strawberry-like hemangioma, it was very useful to have face-to-face communication. The parents and grandparents can receive a convincing explanation, which promotes confidence in the medical specialist.” “The resolution was sufficient that a malignant skin lymphoma could be seen clearly, and a precise diagnosis was able to be made because of the Masuda side doctor's palpation.” Most Japanese doctors have narrowly defined specialties because there are no training courses for "family doctors" in Japan. Especially in rural areas, the patients are not given sufficient medical support. This is a factor of "Medical specialist misdistribution." Currently in Japan, even in a "general hospital" or the "core hospital" of a rural area, the number of doctors in some clinical specialties has greatly decreased and some clinical departments have closed. As a result, patients living in mountainous areas or on islands in Shimane Prefecture must go to a hospital over 100 km from their homes by themselves to get high quality medical examinations and treatment. Our system is used in situations in which both a doctor and patient are at the remote terminal. It provides good support for the doctors who work in these areas and reduces the burden on the patient. To make medical tele-support effective, a medical payment system needs to be developed. Our teledermatology trial was successful in making high level rural care possible [6]. We selected an interactive type system because there are few dermatologists in western Shimane and because our specialists feared not having the necessary pictures available if we were to adopt a store-andforward system. If specialists cannot obtain the correct pictures, proper diagnosis is difficult. Also, since most patients in Masuda are aged, specialists want to promote good communication to insure a reliable diagnosis for their patients. In our case, the first consultation was done with a specialist dispatched to Masuda. "MuTA" has also been installed in a mountainous area and on an island (Oki) in Shimane. "MuTA" is used not only for telemedicine assistance, but to offer and share technical and medical knowledge, such as sessions on medical safety, and for instruction and joint conferences of

interns and doctors at Shimane University Hospital. Also, taking advantage of the ease of operation of "MuTA", good results have been obtained in trials of communication between hospitalized children [7] , the elderly [8]and their family and friends. V. CONCLUSION Our system offers specialized medical consultation for patients in remote areas in which there are problems with both a shortage of doctors and the digital divide. "MuTA" was shown to be quite effective in supporting both remote doctors and patients. It is possible to attach signal transmission equipment to "MuTA" that can transmit vital signs, and we are currently examining the addition of other add-on features. ACKNOWLEDGEMENT This research was supported in part by the Japan Society for the Promotion of Science (No.20390151). "MuTA" is a registered trademark of San-in Denko, Inc. REFERENCES 1. Ministry of Internal Affairs and Communications (2007) Broadband use situation classified by all prefectures. Whitepaper on telecommunications. 2. Burg G, Hasse U, Cipolat C, Kropf R, et al. (2005) Teledermatology: just cool or a real tool? Dermatology .210 (2):169-173 3. Hanada E., Kaneko S., Ikebuchi K., Morita E., Kitani M., Yamaguchi S. (2007) A Trial of an Agent Type System for Real-time Teledermatology. ISMICT2007 (The 2nd International Symposium on Medical Information and Communication Technology), TS8-3 4. Kanthraj G, Srinivas C (2007) Store and forward teledermatology. Indian Journal of Dermatology, Venereology and Leprology 73 (1):5-11 5. Ferguson J. (2006) How to do a telemedical consultation. Journal of Telemedicine and Telecare 12(5):220-227 6. Jesitus J. (2006) Teledermatology revolutionizes rural care. Dermatology Times 27(8): 22-26 7. Hanada E., Miyamoto M., Moriyama K (2005) Virtual Schooling System for Hospitalized Children. CME2005: pp 371-376, 8. Hanada E, Ikebuchi K, and Miyamoto M. (2006) A system for improving the quality of life for aged people living in special care facilities. Journal of Multimedia Aided Educational Research 3(1):7378 Author: Eisuke Hanada Institute: Division of Medical Informatics, Shimane University Hospital Street: Enya-cho 89-1 City: Izumo, 693-8501 Country: Japan Email: [email protected]
