V. Kazinov, A. Danilov, C.
Pokrovsky, V. Fedorov
DiViSy Video Networks in Clinical Practice
Telemedicine will be one
of the basic stages in upgrading of medical services in all
public or private hospitals in Russia in the third millennium. This
fact calls for no proof and is not seriously argued against, as
However no progress has
been observed in bringing telemedicine into clinical practice. There
are several reasons for that.
First, the medical staff
is not prepared to implement modern telecommunication and
computer technology. The complexity of the technology, its only
partial adaptation for the direct implementation in medicine,
and the lack of time leading medical experts have to master it
are posing quite explainable problems for using telemedicine in
Second, there is no system
(or it is in the very initial stage) of teaching and training
personnel in telemedicine.
Third, for the lack of
special-purpose hardware and software for telemedicine sessions
in real time many experts use standard business video
conferencing many parameters of which do not meet the
requirements set forth for telemedicine consultations.
And fourth, the financing
of telemedicine implementation has not been sufficiently
developed yet that gives a misleading impression of the
necessity immediate investing of rather large funds that the
majority of hospitals cannot afford.
In the authors' opinion,
the best plan to be followed is to create inhospital medical
video networks that do not require large financing in the
initial stage and open fresh opportunities for clinical
medical video networks.
The design and realization
of medical video networks in any hospital should take into
account its management and personnel organization systems. It
is known that medicine, especially the Russian medicine,
accepts innovations with great difficulty. Because of this each
operator's station should be adopted for a concrete leading
medical expert in one or other field of diagnosis or treatment.
properly created medical video network will provide the
following opportunities for a hospital:
- For the professional development of the hospital
medical staff. A video network within a hospital provides an
opportunity to follow the course of diagnosis and
treatment and to be trained in the same in interactive
mode without getting in the way of the process. Being a
viewer of the work of hospital leading experts in the
interactive mode with an opportunity of voice
communication gives much more for any doctor than any
multi-hour lectures. In the course of observation any
medical student may take a note of the most interesting
points and create his own video, audio, graphic and text
data base. Merely theoretical workshops and lots of time
and funds are no longer required This makes education much
more efficient financially. In a similar way high-skilled
doctors may follow the course of diagnosis and treatment
of their young colleagues and intervene if required. Apart
from training, they have a chance to prevent the young
experts getting into an undesirable situation that may
- Video consultations become possible during which different experts
may investigate scheduled or urgent cases directly
including diagnosis and treatment. For instance, the
Moscow Oncologic Research Institute named after P.A.Herzen
in the first stage of the creation of their video network
organized an interaction between the endoscopic department
(headed by Professor V.V.Sokolov) and pathomorphologic
department (headed by Professor G.A.Frank). As a result a
pathomorphologist may observe biopsy in the course of
bronchoscopic or gasteroscopic diagnosis, record the
picture of the tumor and the point where the biopsy was made
that contributes greatly to further hystologic diagnosis.
- Leading experts of the hospital have an opportunity
of more frequent consulting in the course of diagnosis and
instance, the head of the endoscopic department has an
opportunity of remote consulting and participation in
diagnosis that is being made by his employees. In this
case he saves both time and efforts and at the same time
his direct participation makes the medical procedure more
efficient. In a similar way leading surgeons of the
hospital have an opportunity of remote control over their
subordinates and correction of their actions. Insurance
medicine and patients may take this process as diagnosis
or treatment with personal participation of leading
- A new type of the interaction among medical staff
is created. In the framework of the current system when an
attending doctor is responsible for making a decision he
may have additional opportunities of taking advice that
makes his work more open for his colleagues. In the course
of such consulting all hospital experts have practice in
remote working together and become experts trained for
commercial telemedical consultations in which other
hospitals may take part as well.
- Possibilities of inter-operation
consulting become wider. This is
especially urgent for the hospitals that have several
operating rooms located apart from each other. In this
case no urgent search, call and waiting for a medical
consultant are required to take advice on one or other
complicated matter that may arise in the course of the
operation. For instance, currently the Central Hospital at
the Ministry of Realway Communications is realizing a
project of creation of a video network to connect several
operating rooms and the cytologic department (headed by
Professor N.A.Shapiro). As a result the participation of
leading cytologists in urgent diagnosis will reduce the
time required to make diagnosis and improve chances to
make a correct decision.
- Workable possibilities of
telemedical consulting with participation of experts of
different hospitals are created. With the
availability of medical video networks in several
hospitals it is really possible to conduct telemedical
consulting among hospitals. This process becomes natural
because experts of different hospitals who have gained
experience in remote consulting in the framework of their
local video networks may easily begin remote interaction.
- A base is created for
rendering radically new medical services - a remote observation
and consulting of home patients. Software and
hardware of medical video networks will allow hospital
experts to offer their patients a new type of medical
services - an observation and consulting at home by means
of telephone and other communication channels (depending
on the financial situation of a patient). This is
especially pressing for patients after operations or
The realization of a pathomorphologic fragment of
the medical video network.
A realization of pathomorphologic fragments of
medical video networks is one of the initial steps in creating
of a video network in a hospital in general. Within the
framework of this fragment training sessions of both
pathomorphologic research and scheduled or inter-operation
consulting may be conducted.
There are several problems on the way they may be
solved the efficiency of telemedical consulting in the course
of pathomorphologic research depends mainly.
The first problem is how pathomorphologic
preparations are made. This is a very important process, which
is responsible for the quality of initial information and thus
the efficiency of all further processes of pathomorphologic
diagnosis. Let us use hystologic test to consider this aspect.
For this process the quality of a glass plate (how thick it is,
how uniform the both glass surfaces are, how transparent they
are, etc.) the quality of methods used to prepare the tissue to
be investigated, and the quality of its applying to the surface
of glass are extremely important. Once the above processes have
been done properly, one can be assured that all further stages
of the hystologic test will have the greatest possible
efficiency. Similar methods are available for cytologic tests.
The second problem is the problem of developing of
a uniform procedure of telemedical pathomorphologic consulting
for all parties involved. Thus it is extremely important to
arrange for advance training of doctors, the subscribers of the
fragment of the video network, in the diagnosis methods used by
their high-skilled director in his every day practice.
Operational methods of a pathomorphologic fragment
of the video network.
The most complete description of the operation
methods of a pathomorphologic fragment of the medical video
network may be obtained in the course of training usage of this
Several methods of traditional training of
Face-to-face training. A teacher studies a
preparation under the microscope and a student or students in
turn view those fragments of the preparation which the teacher
offers them to view. Each fragment of the preparation is
commented and discussed. The chief disadvantage of this method
is that it does not make available to follow all actions of the
teacher in the course of the review of the preparation and at
the moments of changing from one fragment to another. In
addition it is not possible to keep records of the preparation
pictures with the required comments for their repeated
Training with the usage of catalogues and other special
literature. This method offers no interactive process
and gives no opportunity to learn how to study a concrete
preparation. A low quality of the illustrations is rather
common for catalogues.
Computer training. This is the most
progressive method that allows not only to follow diagnosis in
real time but to discuss all actions of the teacher in the
interactive mode as well.
None of the existing methods teaches telemedical,
or remote consulting. While developing the DiViSy PM2000
software and hardware complex for pathomorphologic fragments of
the video network all advantages of the existing methods of
training were taken into account and added by some fresh
possibilities offered by new digital and telecommunication
The greatest possible efficiency of teaching
methods of pathomorphologic diagnosis may be gained providing
- an uninterrupted visual control of
teachers over all the diagnoses being made in real time,
- a duplex sound exchange among all
parties of the training process,
- an availability for students to do
immediate records of the most significant points of the
- an availability for students to do
further individual digital editing of the records done
(video, audio, text) for keeping records and refreshing
- an availability for a teacher and
students to communicate only in a remote audio/visual mode
(an unavailability of direct contacts teaches remote
- an availability of the remote control
over a microscope.
All the above availabilities are provided by the
DiViSy PM2000 software and hardware complex.
The composition of the DiViSy PM2000 software
& hardware complex for a pathomorphologic fragment of the
medical video network.
The DiViSy PM2000 software and hardware complex is
comprised of two types of telemedical units: DiViSy PM1 for a
teacher (or a high-skilled doctor) and DiViSy PM2 for doctors
involved in training (or doctors who would like to take part in
telemedical consulting). An information exchange within the
framework of this software and hardware complex is carried out
through a local network which combines all telemedical units.
If it is required to connect remote users, practically any
communication channels may be used. In this case it should be taken
into account that the speed of frame exchange of the pictures
of the preparations to be studied depends on the speed of the
The DiViSy PM1 telemedical unit for a teacher
consists of a motor-powered Leica DMRXA microscope, an analogue
3CCD video camera, a BOVA-DiViSyPM1 unit for processing of
video and audio information based on the Pentium III processor,
a 17'' monitor, and required peripheral equipment (a video
camera for video conferencing, a microphone, amplified speaker
systems (a headset), a scanner, a printer, etc.).
The DiViSy PM2 telemedical unit for students
consists of a Leica DMLB (DMLS) microscope, an analogue 3CCD
video camera, a BOVA-DiViSyPM2 unit for processing of video and
audio information based on the Pentium III processor, a 17''
monitor, and required peripheral equipment (a video camera for
video conferencing, a microphone, amplified speaker systems (a
headset), a printer, etc.).
The telemedical units include DiViSy PM2000
software, which allows:
- to provide in real time an entry and
a conversion into the digital form of the video pictures
received from both the microscope video camera and the
video cameras for video conferencing,
- to provide in real time an entry and
a conversion into the digital form of the sound signals
from the users' microphones and to mix the sound,
- to transmit audio and video
information among the parties involved in training. The
DiViSy PM1 telemedical unit allows to manage the procedure
of giving the floor to the parties involved in training,
- to record the training process either
on the hard disk or on any other data carrier,
- to provide availability of
simultaneous working with pictures of a pathomorphologic
preparation for all the parties involved in training,
- to provide an output of the video
information in the analogue form for viewing it on a TV
monitor or recording it on a video recorder,
- to carry out a local and a remote
control over the motor-powered microscope,
- to carry out other required functions
in the course of training.
In addition, the telemedical units include
standard peripheral equipment for a digital nonlinear montage
that allows to edit educational films on the subjects of the
workshops and lectures.
It is extremely important for the training process
to place the telemedical units for experts to be trained in
separate rooms isolated from each other. This allows to create
an environment of the remote telemedical consulting and teaches
the users to act at request of the teacher or their colleagues
and to listen attentively to a user who has been given the
floor without interrupting him, to wait for one's turn to be
given the floor, and to manage the remote microscope
independently. All this teaches the students to act together,
that is required for telemedical pathomorphologic consulting in
real time, and to participate in a more complicated process, in
a video consultation. Developing rules of behavior during
remote consulting is especially important for inter-operation
telemedical pathomorphologic consultations when in the course
of an operation the consulting doctor who may be far from the
operating room makes an urgent diagnosis of the preparations
with the doctor who is near the operating room and the
diagnosis may be made within several minutes after the preparation
has been made.
major results which may be achieved in the course of working in
the framework of pathomorphologic fragments of medical video
- Doctors are taught methods of
pathomorphologic diagnosis through a detailed study of the
methods of testing of various preparations perfectly known
by a expert who teaches these methods.
- Doctors are taught methods of
individual work on the telemedical units and methods of
remote interaction with their colleagues and consulting
- Doctors keep personal records of the
main and the most informative fragments of the lectures.
The records contain video pictures of the preparations
with the required sound and text comments.
- Doctors are taught methods of urgent
inter-operation telemedical consulting for a further
creation of such systems in their hospitals.
A regular work within the framework of
pathomorphologic fragments of the medical video network will
result in skilled experts who will be able not only to make
top-quality pathomorphologic diagnosis but to take active part
in bringing the new principles of working in remote telemedical
consulting into every day practice.
Other fragments of the medical video network,
endoscopic, ultrasound, X-ray, surgical, etc. will be operating
in a similar way.
A distinctive characteristic of such
fragments is their complete interfacing irrespective of the
type of diagnosis or treatment. It is essential that all
doctors, whose working in a definite fragment of the network is
characterized by individual peculiarities, should have an
opportunity of cooperating with doctors from other fragments.
Such unification of the software and hardware potentialities of
the operator's stations of doctors, the users of the video
network, results in realization of video consultations.
Different medical experts may be parties of a video
consultation on the problems of concrete patients. For
instance, when considering the diagnosis of an oncologic
patient, who has undergone through several diagnostic
processes, the attending doctor at the same time may discuss
the problem of making diagnosis with a pathomorphologist, who
explains his view and demonstrates a picture of the hystologic
preparation, with a roentgenologist who may show an x-ray
picture, with an expert in ultra sound diagnosis who
demonstrates ultra sound pictures. Such discussion increases
the likelihood of making correct diagnosis in complicated
From December 14 through 17, 1999 in the
conference hall of the Presidium of the Russian Academy of
Science a subregional telemedicine workshop of the CIS and
Baltic countries which was organized by International Electric
Communication Union (ITU), Geneva, Switzerland, and
Telemedicine Foundation, Moscow, Russia, was held. It was also
attended by representatives of Belgium, Bulgaria, Malaysia,
Norway, USA, Sweden, Japan and other countries.
At the same time with the workshop an exhibition
of scientific and engineering achievements in telemedicine was
organized. The DiViSy Research Center demonstrated on its
exposition stand DiViSy telemedical units for pathomorphology,
endoscopy, ultra sound, etc. Together with "Comcor"
Company, the owner of the Moscow fibre-optical network for data
transmission, a communication channel was organized with the
Moscow Oncologic Research Institute named after P.A.Herzen and
City Hospital no.33.
On December 15, 1999 a telemedical session on
histology was conducted between the exhibition stand and the
pathomorphologic department of the Moscow Oncologic Research
Institute named after P.A.Herzen. Professor G.A.Frank conducted
a training session on histology which was translated in real
time to the exhibition through the fibre-optical communication
channel and was on view simultaneously at three DiViSy
telemedical units. The participants of the workshop attentively
followed all stages of the diagnosis, viewed Professor
G.A.Frank, heard his comments and asked questions. In this case
within the framework of one channel two video flows of high
quality and one sound flow were translated.
In a similar way other fragments of medical video
networks will operate for endoscopy, ultra sound, x-ray
diagnosis, control over laparoscopic and cavitary operations,
etc. In this case all these fragments will be compatible with
each other and make possible creating fully functional medical
video network both for inhospital communication and
communication among several hospital.
At present all required software and hardware
means for creating medical video networks are available.
The most efficient way to bring video networks
into hospital practice is to do it by stages because it does
not require large investments.
Bringing medical video networks into hospital
practice is a real way of increasing the quality of the medical
aid to be rendered and enhancing its efficiency.
A practice in medical video networks allows to
develop methods of telemedical consulting, which will be used
in working with remote hospitals.