Story of Discovery: Digital Doctors and Mobile Medicine

Science Highlights
May 16, 2006
Advances in communications, computer science, informatics, and medical technology have facilitated the practice of "telehealth" which is broadly defined as the use of communications technologies to provide and support health care at a distance. Today, the term “distance” is relative and could be as short as across town or as great as across the world. Telehealth can be as simple as two doctors talking on the phone about a patient’s care or as elegant as the use of robotic technology to perform surgery in another country. In each case the type of data transmitted can take one of many forms—videos, images, patient records, or sounds.
The National Aeronautics and Space Administration (NASA) is generally credited for the first effort in telehealth when it transmitted physiologic signals from astronauts via satellite in the 1960s. However, a case could be made that telecommunications-facilitated healthcare has been used since the early days of the two-way radio and the telephone. As early as 1906, Einthoven, the father of electrocardiography, first investigated electrocardiogram transmission over telephone lines! In the 1920’s, radios were used to link physicians standing watch at shore stations to assist ships at sea that had medical emergencies. By the end of World War II, telecommunications technologies were an integral part of medical care for those wounded in the battlefield. Today, if a soldier is wounded and surgical personnel are not available on the battlefield, the Army can deploy a Trauma Pod, which is a mobile operating room with robotic surgeons hooked up to real surgeons in a real-time, virtual reality link.

Improving the Quality of Care through Teleconsultation

As telehealth technologies have progressed, they have become more targeted toward specific patient needs and less expensive to adopt. As a result, more medical practitioners have engaged in telemedicine activities. For patients with complicated cases or chronic illnesses, especially those in rural or outlying areas, consultation with an appropriate specialist can vastly improve the quality and outcome of their healthcare. In certain cases, imaging technologies like magnetic resonance imaging (MRI), computerized tomography (CT) and ultrasound can be used to diagnose or monitor a disease process. To facilitate the routine use of teleconsultations for these patients, images captured locally by a physician can be incorporated in a medical record and sent to a specialist elsewhere for consultation. To hasten and streamline the process, the remote consultant should only receive relevant, high-quality information. This can be a difficult task as hundreds of images may be generated at one time; forcing the practitioner to spend considerable time reviewing information to determine what is most useful. To help focus the consultation process, one NIBIB researcher is developing and testing a "context sensitive" telehealth infrastructure that is based on automated incorporation of relevant clinical data into a single, condensed file. The method integrates two processes, natural language processing and automatic image selection. Natural language processing allows computers to "understand" statements written in human languages. In this case, the referring physician’s hypothesis about the patient's problem is used as the information source to automatically drive image selection and summarization in a real world environment. Although the study focuses on neurological and musculoskeletal disorders, the approach can be adopted for many different diseases.
Another researcher has developed an expert visual guidance system to direct rural health care providers in acquiring diagnostic medical ultrasound images. This project builds upon the visual guidance system developed for NASA to assist flight personnel in acquiring medical ultrasound images on each other while aboard the International Space Station. The innovation lies in the fact that the new system will not just passively transmit images to an expert at a distant center, but will enable the expert to actively guide the untrained health care provider in acquiring the images. The rationale is that by providing assistance at the time of image acquisition, the expert at the receiving end can prevent difficulties in interpreting the studies due to poor diagnostic quality. The expert provides guidance through a visual and anatomic interface that projects a schematized three-dimensional image of the target organ onto a video display. The group has collected a library of anatomical images by extracting features from actual scans. The selected image is then projected onto the examiner’s screen to serve as a visual tutorial to guide image acquisition.

Remote Monitoring: Reducing Surgical Risk

Intraoperative monitoring (IOM) is a technique that allows a surgeon to perform continuous checking, recording, and testing during a sophisticated surgical procedure. In neurological surgeries IOM is used to detect potentially damaging changes in brain, spinal cord, and peripheral nerve function prior to irreversible damage. The procedure also has been effective in localizing anatomical structures, such as peripheral nerves, which helps guide the surgeon during dissection. IOM is traditionally performed in medical centers where experienced neurophysiologists are available. In regional hospitals this type of monitoring is often difficult to perform because of lack of experts. NIBIB researchers have developed technologies for multimedia remote IOM systems capable of transmitting data, voice, and images over the Internet. However, the transmission of digital video of an acceptable quality is still somewhat of a problem, even when a broadband Internet connection (a high data-transmission rate) is used. The primary reason is lack of a high-performance algorithm (a mathematical function that is used to encrypt and decrypt information) that can adapt the special features of IOM video. The researchers have now formed an interdisciplinary team—electrical engineers, neurophysiologists and neurosurgeons—to tackle this high-tech problem. They are currently developing a special-purpose video compression algorithm that minimizes the bandwidth problem. They are also developing new methods for improved synchronization and integration of multimedia data for remote IOM.
Another NIBIB researcher is developing a high-resolution, holographic, three-dimensional (3D) color display for use in telehealth applications. Such a display would improve remote medical teaching, assist less skilled personnel in medical diagnosis, and further facilitate the sharing of 3D imaging data between networked sites. This 3D display uses "white light" illumination rather than lasers to eliminate potential concerns for eye safety. Success in this endeavor will provide an enormous boost for future medical telehealth applications.

The Electronic House Call

There is no doubt that the Internet has played a significant role in the growth and awareness of telehealth. But today’s telehealth goes beyond remote diagnosis and surgery. Preventative care and disease education and management are all being delivered virtually by medical personnel. For example, an NIBIB scientist is using cable TV technology to deliver an interactive weight loss program in patients with type 2 diabetes. Obesity and type 2 diabetes are emerging epidemics in America. Weight loss has been shown to improve diabetes outcomes, reduce the need for medication, and prevent diabetes from developing in some at-risk patients. However, implementation of behavioral weight-loss programs in a primary care setting has proven to be a challenge. Although Internet-based weight-loss programs are known to be effective, access to computers and the Internet is limited among low-income individuals and the elderly, two populations at risk for type 2 diabetes and its complications. This project demonstrates that a diet and exercise program can be delivered directly to individuals in their home using a TV and a special interactive remote control. The technology allows patients to interact with their TV set so that their blood sugar and body weight can be monitored and they can receive and respond to special notices.

Personalized Medicine: Tune In for Tomorrow's Successes

With the advent of miniaturized devices and wireless communication, the way in which doctors care for patients has changed dramatically. The next decade will bring a new realm of precision and efficiency to the way information is transmitted and interpreted and thus the way medicine is practiced. Empowering clinicians to make decisions at the "point-of-care" has the potential to significantly impact health care delivery and to address the challenges of health disparities by providing diagnostic capabilities to communities with limited access to large healthcare facilities. The success of such a shift relies on the development of portable diagnostic and monitoring devices for near-patient testing that, when combined with suitable telehealth technologies, effectively empower clinicians or other providers to make decisions at the point-of-care. Results are immediate as samples do not have to be shipped off-site to a centralized laboratory. This is further complemented by their ability to carry out multiple assays such as blood gases, electrolytes, chemistries, coagulation, hematology, glucose, and cardiac markers simultaneously. The NIBIB has contributed to advances in this area by funding the development of sensor and microsystem technologies for point-of-care testing. These instruments combine multiple analytical functions into self-contained, portable devices that can be used by non-specialists to detect and diagnose disease, and can enable the selection of optimal therapies through patient screening and monitoring of a patient’s response to a chosen treatment. These technological advances limit the reliance on submission of samples to centralized laboratories, with results available within minutes as opposed to several hours or days, enabling clinicians to make decisions regarding treatment at a time when these decisions can have the greatest impact. In specific cases, sensors and microsystems can enable patient self-testing, and can contribute to the realization of personalized medicine by creating a link between the diagnosis of disease and the ability to tailor therapeutics to the individual.