Dr. David Hareva Medical Informatics ITT Telkom, 24 September
2011 Slide 2 What is Telemedicine & Teleradiology? Medicine
Genomics Informatics Communications Clinical Genomics Telematics
Telemedicine Bioinformatics Biomedical Informatics Medical
Informatics Telemedicine informatics Teleradiology Slide 3
Definition of Telemedicine Telemedicine may be defined as the use
of electronic information and telecommunications technologies to
support long-distance clinical healthcare, patient and professional
health-related education, public health and health administration.
Nihal FG and Elif DU. Theory and Applications of Telemedicine.
Journal of Medical Systems, Vol. 26, No. 3, June 2002 Slide 4
Specialties in telemedicine Specialties that use telemedicine often
use a 'tele-' prefix; Tele-radiology Tele-cardiology
Tele-psychiatry Tele-pharmacy etc Modalities of Medical Imaging
(X-Ray, Ultrasound, CT, MRI, etc) and Data acquisition. DICOM and
PACS Image Processing/Analysis Image compressing Fix line,
wireless, microwave, satellite, mobile network. Security Radiology
Informatics Tele- Communication + + Slide 5 What is Teleradiology?
Teleradiology is the transmission of radiologic images from a site
of image acquisition to a remote location for interpretation.
Today, image transmission depends primarily on high- speed
electronic communication networks, such as an ATM or the internet,
which enable the rapid transmission of digital images without loss
of content or resolution. Slide 6 Why is teleradioogy necessary?
Teleradiology provides a means to provide rapid diagnosis and
report turnaround for radiological examinations acquired locally or
transmitted to a radiologist from anywhere in the world. At
Hospital for Special Surgery (HSS), teleradiology has been employed
to provide improved and timely care to patients imaged at a
hospital, as well as to provide our radiology subspecialty
expertise in orthopaedic and rheumatologic conditions. Through
teleradiology services the musculoskeletal imaging and diagnosis
can be network with orthopaedic centers or expanded worldwide with
other hospitals in the world to maximize the diagnostic information
needed to treat their patients. With the constant improvement of
digital imaging modalities, the role of teleradiology will continue
to expand in the future, enabling expert diagnostic interpretation
by HSS radiologists around the globe or around the corner. Slide 7
How is teleradiology performed? The interpretation of digital
images, whether MRI, CT, ultrasound or conventional x-ray images,
acquired digitally e.g. computed radiography (CR) or direct
radiography (DR), is accomplished utilizing workstations with high-
resolution monitors. Each workstation is part of an image
management network, which also has access to image archives and
patient databases. Current computer software innovations provide
the capacity to transmit and receive images from outside a medical
facility while maintaining image security and patient
confidentiality. Slide 8 Modalities of image acquisition Computed
Tomography (CT) Radiographic (X-ray) Ultrasound Magnetic Resonance
Imaging (MRI) Nuclear Medicine Imaging (NMI) etc Slide 9
Radiographic (X-ray) Function: It is a painless test used by
medical professionals to help diagnose and treat a wide range of
medical problems. Feature: An X-ray uses electromagnetic radiation
(shorter wavelength) to take photo like images of different areas
of the human body. X-rays, demonstrate body structures
proportionally with their density, bone (high body tissue density)
which is white and fat(low density) which is gray or air (no
density) which is black. Benefits: X-ray is the fastest and easiest
way to assess sprains, torn muscles and broken bones. Slide 10
Computer Tomographic (CT) Function: It good for bone spine and
joints abnormalities (abdomen, pelvis or head), bony structures,
joints, soft tissue structures, and soft tissue calcifications.
Feature: A type of x-ray examination using a thin x-ray beam with a
series of detectors that are contained in a doughnut shaped
machine. Benefits: still digital x-rays with multiple shots without
movement or noise disturbances. Cons: cost involved with digital
x-ray is twice x-ray film. Some CT examinations will require an
injection of an iodinated contrast agent into your vein. Slide 11
Function: MRI scans can be used to diagnose tumors, strokes and
torn ligaments. Many MRIs are done on the head to determine the
cause of headaches, nervous system problems or developmental
disorders of the brain. Feature: MRI is a diagnostic test that
depicts both soft tissue and bone. MRI depicts soft tissue injury
and abnormalities with greater sensitivity and specificity than
x-ray even CT. Benefits: MRI scans are better than X- rays at
showing soft tissue, showing inflammation, detailing blood vessels
and creating cross-sectional pictures. In addition, the patient is
not subjected to any radiation. Magnetic Resonance Imaging (MRI)
Slide 12 Ultrasound (sonography) Function: The ultrasound waves
enable things inside the body to be measured, such as fetuses,
gallstones, kidney stones, cysts or other growths. Features: The
probe sends out sound waves, and receives their echos. The
sonographic scanner, which interprets the echos to determine the
size, shape, depth and what the internal object is made of (fluid,
solid). Benefits: non-invasive and non-radiation tool for
diagnostics. An ultrasound is able to capture more information
about soft tissue than an x-ray scan, though it has trouble with
harder tissue such as bone. Ultrasounds are also readily available,
and less expensive than other diagnostic or treatment options.
3D/4D ultrasound Slide 13 Nuclear Medicine Imaging (NMI) Function:
a bone scan, lung scan, cancer scan, gallium scan or Indium III WBC
scan Features: A nuclear medicine examination relies on specific
radioactive isotopes to detect specific suspected pathology.
Nuclear materials called radiopharmaceuticals are either injected,
ingested or inhaled. They travel through the body and cause the
organs to release gamma rays. These rays illuminate the organs or
bones, and make them easily observable by a special gamma camera.
Benefits: This exam is used mainly to allow evaluation of organs
and regions within organs that cannot be seen or tested on
conventional X-Ray images. Slide 14 Digital mammography Function:
the early detection of breast cancer, typically through detection
of characteristic masses and / or microcalcifications. Feature: is
the process of using low-energy-X-rays (usually around 30 kVp) to
examine the human breast and is used as a diagnostic and a
screening tool. Benefits: low radiation. Most doctors believe that
mammography reduces deaths from breast cancer, although a minority
do not. Slide 15 X-Ray/CTUltrasoundNuclearMR Chest (+) widely
used(+) excellent () no, (+) except for heart (+) extensive use in
heart (+) growing cardiac applications Abdomen (+) widely used(+)
excellent (+) excellent, () problems with gas Merge w/ CT(+) minor
role Head (+) widely used () bleeding, trauma () poor(+) PET(+)
standard Cardiovascu- lar (+) X-ray (+) Excellent, with (-)
catheter- injected contrast (+) real-time, non-invasive, cheap, ()
but, poorer images (+) functional information on perfusion (+)
getting better High resolution Myocardium viability Skeletal /
Muscular (+) strong for skeletal system () not used (+) Research in
elastography (+) functional (-) bone marrow (+) excellent Slide 16
How are plain film (standard radiograph) images captured? Standard
radiographs can be digitized by either a video camera or a film
scanner. Video cameras (commonly referred to as a "camera on a
stick") were in fact the method of digitizing any image for
transmission as recently as about 15 years ago. Typical camera
systems utilize a light box designed to illuminate radiographs, an
extension arm for holding the camera above the film, and a
high-sensitivity video camera with a zoom lens. This is an
inexpensive but poor-quality method of image acquisition. Film
scanners and digitizers arrived on the teleradiology scene about 10
years ago. There are two basic types of film scanners: CCD (charge
coupled device) digitizers and laser digitizers. Over the past few
years, and today high quality CCD digitizers produce images as good
as (or nearly as good as) top-of-the-line laser digitizers. The
major difference between images produced with laser digitizers and
CCD digitizers is in the optical density captured from the film.
Slide 17 DICOM and PACS DICOM (Digital Imaging and Communications
in Medicine) is a standard for handling, storing, printing, and
transmitting (TCP/IP) information in medical imaging. It consists
of a number of attributes, including items such as name, ID, etc.,
and also one special attribute containing the image pixel data.
Pixel data can be compressed using a variety of standards,
including JPEG, JPEG Lossless, JPEG 2000, and Run- length encoding
(RLE). DICOM enables the integration of scanners, servers,
workstations, printers, and network hardware from multiple
manufacturers into a picture archiving and communication system
(PACS). PACS typically comprised of an image acquisition device,
data management system, image storage devices, local or wide area
network, display stations, and devices to produce hard-copy images.
Slide 18 DICOM format: size and transmission Slide 19 Medical Image
Processing Medical image processing that produces from modalities
allows physicians to view the inside of the human body for clinical
purposes or medical sciences. Medical image processing techniques
can yield more detailed and easily manipulated images. This allows
for a more in-depth review of the internal organs and structures of
the human body. Slide 20 Medical Image processing Cancer in the
posterior right breast on digital mammography. All images courtesy
of Maxine Jochelson, MD. Same view on MRI.Enhancement after
contrast. Slide 21 Medical Image Processing Structure of digital
images Improvement of image quality Enhancement of abnormal lesions
Determination of image features of abnormal lesions Slide 22 Image
Analysis Image analysis involves manipulating the image data to
determine exactly the information necessary to help solve a
computer imaging problem. It can be divided into three primary
stages: Preprocessing: It is used to remove noise and eliminate
irrelevant, visually unnecessary information. Data Reduction: It
involves either reducing the data in the spatial domain or
transforming it into another domain called the frequency domain and
then extracting features for the analysis process. Feature
Analysis: In this the features extracted by the data reduction
process are examined and evaluated for their use in the
application. After the analysis we have a feedback loop that
provides for an application-specific review of the analysis
results. Input Image Preprocessing TransformSegmentation Filtering
Feature extraction Feature Analysis Slide 23 Image Compression
Image compression involves reducing the size of image data files,
while retaining necessary information. The resulting file is called
the compressed file and is used to reconstruct the image, resulting
in the decompressed image. It consists of two parts: Compressor: It
consists of a preprocessing stage and encoding stage. The first
stage in preprocessing is data reduction. For example, the image
data can be reduced by gray level and/or spatial quantization. The
second step in preprocessing is the mapping process, which maps the
original image data in to another mathematical space, where it is
easier to compress the data. Next, as part of the encoding process,
is the quantization stage, which takes the potentially continuous
data from the mapping stage and puts it in discrete form. The final
stage of encoding involves the coding the resulting data, which
maps the discrete data from the quantizer onto a code in an optimal
manner. Decompressor: In this the decoding process is divided into
two stages. First, it takes the compressed file and reverses the
original coding by mapping the codes to the original, quantized
values.Next, these values are processed by a stage that performs an
inverse mapping to reverse the original mapping process. Finally,
the image may be postprocessed to enhance the look of the final
image. Slide 24 Compressor- System Model Decompressor- System Model
Slide 25 Open source software for medical image analysis ImageJ 3D
Slicer ITK OsiriX GemIdent MicroDicom FreeSurfer ClearCanvas Seg3D
[2] NumPy + SciPy + MayaVi/Visvis InVesalius Slide 26 ImageJ ImageJ
can display, edit, analyze, process, save, and print 8-bit, 16-bit
and 32- bit images. It can read many image formats including TIFF,
PNG, GIF, JPEG, BMP, DICOM, FITS, as well as raw formats. ImageJ
supports image stacks, a series of images that share a single
window, and it is multithreaded, so time-consuming operations can
be performed in parallel on multi-CPU hardware. ImageJ can
calculate area and pixel value statistics of user-defined
selections and intensity thresholded objects. It can measure
distances and angles. It can create density histograms and line
profile plots. It supports standard image processing functions such
as logical and arithmetical operations between images, contrast
manipulation, convolution, Fourier analysis, sharpening, smoothing,
edge detection and median filtering. It does geometric
transformations such as scaling, rotation and flips. The program
supports any number of images simultaneously, limited only by
available memory. Slide 27 CVIPTools Image Analysis Segmentation
& Morphological Filtering Fourier Transform Histogram Features
Image Restoration Image Enhancement Image Compression Slide 28 Fix
line and satellite technologies PSTN (public switched telephone
network): Telkom, Indosat ISDN (integrated service digital network)
Satellite Connection Wireless Technology Microwave Connection
Leased line ATM (asynchronous transfer mode) Cellular Technology:
CDMA, GSM Slide 29 Barrier to Telemedicine Physician/Patient
Acceptance Funding/ Reimbursement Issues Convenience Legal
Availability of Technology at a Reasonable Cost Privacy and
Security Concerns Slide 30 The World Health Organization (WHO) has
reported that about 75% of the world's population is without access
to ultrasounds, X-rays, magnetic resonance images, and other
medical imaging technology that can detect tumors, diagnose
tuberculosis infections, and monitor pregnant women. Around 95% of
medical technology in developing countries is imported. More than
50% of the medical equipment in developing countries is left unused
or broken because it is too complicated or expensive to operate and
repair, . The combined components of medical imaging devices (data
acquisition hardware, image processing software, and a display
device) into a solitary unit, causes the cost is substantially
increased. Boris Rubinsky. A New Concept for Medical Imaging
Centered on Cellular Phone Technology. Hebrew University of
Jerusalem, April 30, 2008. Application 1: Medical Imaging centered
on Mobile phone Slide 31 Application 1, Cont... Conventional
stand-alone medical imaging device, image reconstruction, control
and transmit processed images from the patient site. A new medical
imaging system made of two independent components connected through
cellular phone technology. The independent units are: a data
acquisition device (DAD) at a remote patient site that is simple,
with limited controls and no image display capability and an
advanced image reconstruction and hardware control multi-server
unit at a central site. the breast cancer tumors patient self-test
screening Frequency-Division Multiplexing EIT, Seven AC currents
(at different frequencies) are injected simultaneously. Signals
from voltage electrodes (V1 to V8) are connected to an analogue
multiplexer Slide 32 Application 2: Ultrasound imaging with a
smartphone William D. Richard, Ph.D at Washington University
coupling USB-based ultrasound probe technology with a Windows
mobile- based smartphones, $100,000 grant by Microsoft awarded in
2008. It is possible to ultrasound probes for imaging the kidney,
liver, bladder and eyes, endocavity probes for prostate and uterine
screenings and biopsies, and vascular probes for imaging veins and
arteries for starting IVs and central lines.
http://news.wustl.edu/news/Pages/13928.aspx, April 20, 2009 Slide
33 Application 3: A Viewing and manipulated Medical Image on
Smartphone J Ross Mitchel. A Smartphone Client-Server Teleradiology
System for Primary Diagnosis of Acute Stroke. J Med Internet Res
2011;13(2):e31. http://www.jmir.org/2011/2/e31/ A: A remote
physician is equiped with iOAS. ResolutionMD is visualization
server and picture archiving and communication system (PACS) is
connected. B.1: secure http connection, B.2: user select an image
for interpretation. C.1: load patient exam into memory, C.2:
reformat 2D into 3D JPEG compression, C.3: This frame is sent to
iOAS appl, C.4: display it on iOS device. D.1: This produce a touch
event, D.2: which is sesnt into visualization server, D.3:
interaction event causes a new rendered frame, D.4: that display on
iOS device. E: User exits the iOS application. (+) no patient data
is located outside the firewall; the large data can be viewed and
manipulated on iOS without using its memory. Slide 34 Satellite
Teleradiology In a poster presentation at the 2003 Symposium for
Computer Applications in Radiology (SCAR), Dr. Lance Williams of
Womack Army Medical Center (WAMC) at Fort Bragg, NC, detailed a
telemedicine solution the Army used to provide radiology coverage
both in Bosnia and at WAMC. Slide 35 Running Researches Analisis
metode perbaikan citra untuk mengidentifikasi kanker pada hasil
mamografi menggunakan adaptive contrast enhancement II.
Optimalisasi sistem pemantauan gizi menggunakan perangkat mobile
dengan algoritma genetika dalam kasus diabetes. Kemungkinan
smartphone untuk pengolahan gambar medis Pengolahan citra irisan
mata menggunakan mobile phone. Etc. Slide 36 Thank you
