Telemedicine (Information Technology) - Mathankumar.S - VMKVEC

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TELEMEDICINE At present, the major constraint is in terms of the financial

viability of e-healthcare initiatives. However there have been several isolated initiatives from various organizations and hospitals for implementation of projects.

For example The Indian Space and Research Organization has today 32 telemedicine location in India and is investing heavily to help Indian healthcare to graduate in this technology and then use it for its own purpose in the future to monitor Indian astronauts who undertake journeys in space.

Most of the developments in this field are likely to focus around the needs of ISRO.

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The answer to make projects financially viable also probably lies in pooling together resources by various facilities within a geographic locality and sharing the benefits and revenues thus created.

To elaborate on this point, several hospitals within a city like e.g. Salem can share a common Tele-pathology service or Teleradiology service.

The benefits of such a pooled service are obvious. Investigations can be viewed by a group of expert consultants.

Such a model will reduce the initial project costs and with the patient traffic from several affiliated hospitals can achieve economy of scale and thus reduce costs of trained manpower and material costs and also provide a very efficient and optimal service to the community. 3

Information Technology

India is well placed and potentially the ideal location for experimenting with e-healthcare solutions for the

following reasons: India has best computer Technocrats India has a very skilled medical

fraternity private healthcare emerging as a key-player in the country Indian Healthcare spending likely to increase to 200,000 crores by 2012 from present86,0000 crores. Potentially India a very suitable location and resources pumped in this sector now are likely to be of great benefit.

The government has the responsibility for the framing the basic standards guidelines to make use of IT in Healthcare possible. The ICT Ministry has come out with its recommendations by recommending some basic standards.

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Tamil Nadu particularly is well positioned to benefit for the following reasons:

1. Lowest cost of skilled manpower.2. Highly developed healthcare System.3. Highest numbers of Hi-tech surgeries like. By-pass

surgeries & Transplants.4. Large Tamil NRI population.

A pool of patients from Northeast who regularly frequent Chennai and Vellore for their treatment requirements. These regulars and loyal patients can use Telemedicine facilities effectively.

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Continue .. .5. Three leading institutions for Telemedicine solutions -

Apollo, Sri Ramachandra Hospital and Sankar Nethralaya .

6. Govt. encourages a Public - Private enterprise7. Three large Corporate leading in overseas healthcare

contracts - TCS, Cognizant, KJ Medical Transcription unit.

8. Large number of smaller companies undertaking overseas medical contracts.

9. Broadband connectivity are being offered and available at a reasonable cost.

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Telemedicine in principle is well suited for countries like India, Africa and South America where there is a large rural based population separated by large distances and needing access to regular medical care of quality.

The telephony revolution of nineties of India has linked most of our smaller towns and villages with rest of the world.

The railway also has a vast network of fibre-optics cables already laid out on many of its routes.

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The Space scientist of our country have placed strategic satellites of communication making a broadband network not too difficult to achieve with expenditure of minimum resources, These gateways of communications should be all used to help with the project of telemedicine and hence reduce applications costs.

Even subsidies could be incorporated to facilitate telemedicine projects in our country.

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Information Technology Revolution It is the question of bringing together these different

agencies and forums to make the revolution of telemedicine happen and to provide our humanity with the best possible medical care.

If these experiments work in India over the next decade, the vast population living in developing countries will be the winners and bear the fruit of our success.

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Continue ...

Internet and Telemedicine should be a used as style of practice of modern medicine rather than be exhibited vulgarly as a technological showcase. Perhaps the slogan "Health for all by 2000" which was forgotten by our politicians towards the end of last century can still be achieved by the year 2020 by making "the Information Technology Revolution happen in healthcare in India ".

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Medical Computer Society of India

The "Medical Computer Society of India" promotes the use of IT in healthcare including Telemedicine. The goal of the society is to get both computer technocrats and medical professionals on one platform and speak the same language of developments for the healthcare applications.

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02/02/15 12

Solving problems in biology and medicine using engineering methods and technology (e.g., research, design and development of biomedical instrumentation.)

Image is an Artifact that reproduce the likeness of some subjects usually a physical object.

Images are pictures! A picture that represents visual information.

Used to save visual experiences. A picture is worth a 1000 words…I think

more!!!

How are non-digital images stored?Photographic filmCanvas/paintDigitally

Imaging is the process of acquiring images. Shorthand for image acquisition. Process of sensing our surroundings and then

representing the measurements that are made in the form of an image.

Passive imaging – employs energy sources that are already present in the scene.

Active imaging – involves use of artificial energy sources to probe our surroundings.

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Passive imaging is subject to the limitations of existing energy sources.

Passive Imaging Passive Imaging

Active imaging is not restrictive in this way but is invariably a more complicated & expensive procedure.

Active imaging predominates in medical field, where precise control over radiations sources is essential.

Active imaging is also an important tool in remote sensing.

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Active Imaging Active Imaging

DICOM - Digital Imaging and Communications in Medicine

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User Consortia (e.g., HL7)

Organizations (e.g., NEMA, IEEE)

US Government Agencies (e.g., ANSI, NIST)

Foreign Government Agencies (e.g., CEN)

United Nations (e.g., ISO, CCITT)

The name was changed to separate the standard from the originating body

1991 - Release of Parts 1 and 8 of DICOM 1992 - RSNA demonstration, Part 8 1993 - DICOM Parts 1-9 approved,

RSNA demonstration of ALL parts 1994 - Part 10: Media Storage and File Format 1995 - Parts 11,12, and 13 plus Supplements

MAGN

ETOM

Information Management System

Storage, Query/RetrieveStorage, Query/Retrieve, , Study ComponentStudy Component

Query/Retrieve, Patient & Study ManagementQuery/Retrieve, Patient & Study Management

Query/RetrieveQuery/RetrieveResults ManagementResults Management

Print ManagementPrint Management

Media ExchangeMedia Exchange

LiteBox

SOPSOP

Data DictionaryData Dictionary

Real-World ObjectReal-World Object

Information ObjectInformation Object DIMSE Service GroupDIMSE Service Group

Composite Verification Storage Query/Retrieve Study Content Notification

Normalized Patient Management

Study Management Results ManagementBasic Print Management

Joint CEN-DICOM development Medicom = DICOM MIPS 95 work is underway with JIRA IS&C Harmonization is also in progress HL7 Harmonization continuing interest New DICOM organization

Companies: NEMA and non-NEMA ACR, ACC, CAP, ... individuals

Networking is a critical component of all

medical imaging systems

Support for Open Communication Standards is a

MUST

DICOM is here, NOW

DICOM products exist on the market

DICOM is emerging as THE common protocol for

medical image communication - WORLD WIDE!

Primary purpose is to identify pathologic conditions.

Requires recognition of normal anatomy and physiology.

Create image of body part

Disease Monitoring

Medical imaging is the technique and process used to create images of the human body or it’s parts for clinical purposes .

Non-invasive visualization of internal organs, tissue, etc.

Medical imaging has come a long way since 1895

when Röntgen first described a ‘new kind of ray’.

That X-rays could be used to display anatomical

features on a photographic plate was of immediate

interest to the medical community at the time.

Today a scan can refer to any one of a number of

medical-imaging techniques used for diagnosis and

treatment.

Medical Imaging using Ionising RadiationsMedical Imaging using Ionising Radiations

The transmission and detection of X-rays still lies at the heart of radiography, angiography, fluoroscopy and conventional mammography examinations.

However, traditional film-based scanners are gradually being replaced by digital systems

The end result is the data can be viewed, moved and stored without a single piece of film ever being exposed.

Digital SystemsDigital Systems

Projection X-ray (Radiography)

Ultrasound

X-ray Computed Tomography (CT)

Magnetic Resonance Imaging(MRI)

1. X-Rays

2. Computer Tomography (CT or CAT)

3. MRI (or NMR)

4. PET / SPECT ((Positron Emission Tomography, Positron Emission Tomography, Single Photon Emission Computerized TomographySingle Photon Emission Computerized Tomography

5. Ultrasound

6. Computational

7. Mammography

8. Angiography

9. Fluoroscopy

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X-rays: A form of Electromagnetic Energy travelling at the speed of light.

Properties*No mass *No charge *Energy

Wavelength – Range of 0.01 to 10 nanometer

X-rays: a form of electromagnetic energy Travel at the speed of light Electromagnetic spectrum

Gamma Rays X-raysX-raysVisible light Infrared lightMicrowaves RadarRadio waves

X-Rays - Visibility Bones contain heavy atoms -> with many electrons,

which act as an absorber of x-rays Commonly used to image gross bone structure and

lungs Excellent for detecting foreign metal objects Main disadvantage -> Lack of anatomical structure All other tissue has very similar absorption

coefficient for x-rays

Computerized (Axial) Tomography

Introduced in 1972 by Hounsfield and Cormack

Natural progression from X-rays

Based on the principle that a three-dimensional object can be reconstructed from its two dimensional projections

based on the Radon transform (a map from an n-dimensional space to an (n-1)-dimensional space)

From 2D to 3D !From 2D to 3D !

Radon again!Radon again!

CT (or) CATCT (or) CAT

• Johan Radon (1917) - Showed how a reconstruction from projections was possible.

• Cormack (1963,1964) - Introduced Fourier transforms into the reconstruction algorithms.

• Hounsfield (1972) - Invented the X-ray Computer scanner for medical work, (which Cormack and Hounsfield shared a Nobel prize).

• EMI Ltd (1971) - Announced development of the EMI scanner which combined X-ray measurements and sophisticated algorithms solved by digital computers.

measures the attenuation of X-rays from many different angles

a computer reconstructs the organ under study in a series of cross sections or planes

combine X-ray pictures from various angles to reconstruct 3D structures

One 256-Slice CT Scan

256 x 0.5 MB = 178 MB

Medical Applications Type of Tomography

Full body scan X-ray

Respiratory, digestive systems, brain scanning

PET Positron Emission Tomography

Respiratory, digestive systems. Radio-isotopes

Mammography Ultrasound

Whole Body Magnetic Resonance (MRI, NMR)

PET scan on the brain showing Parkinson’s Parkinson’s DiseaseDisease

MRI and PET showing lesions in the brainlesions in the brain.

Non Medical Applications Type of Tomography

Oil Pipe FlowTurbine Plumes

Resistive/Capacitance Tomography

Flame Analysis Optical Tomography

ECT on industrial pipe flows

Significantly more data is collected

Superior to single X-ray scans

Far easier to separate soft tissues other than bone from one another (e.g. liver, kidney)

Data exist in digital form -> can be analyzed quantitatively

Adds enormously to the diagnostic information

Used in many large hospitals and medical centers throughout the world

significantly more data is collected

soft tissue X-ray absorption still relatively similar

still a health risk

MRI is used for a detailed imaging of anatomy – no X rays involved.

1979 “For the Development of computer assisted tomography (CAT)” – Hounsfield & Cormack

2003 “For the Discoveries concerning magnetic resonance imaging (MRI)” - Paul Lauterbur & Peter Mansfield

Nuclear Magnetic Resonance (NMR) (or Magnetic Resonance Imaging - MRI)

Most detailed anatomical information High-energy radiation is not used, i.e. this is “safe

method” Based on the principle of nuclear resonance (medicine) Uses resonance properties of protons

MRI (or) NMRMRI (or) NMR

Magnetic resonance imaging (MRI),

Magnetic resonance imaging (MRI), is a non-invasive method used to render images of the inside of an object. It is primarily used in medical imaging to demonstrate pathological or other physiological alterations of living tissues.

Hydrogen nuclei(protons) under a strong magnetic field in phase with one another and align with the field.

Relaxed protons induce a measurable radio signal.

1952Main modality for image guided surgery.Ability to discriminate between subtle surfaces.Very safe.

--Not effective for bone scanning.

Positron Emission Positron Emission TomographyTomography

Single Photon Emission Single Photon Emission Computerized Computerized TomographyTomography

•Positron Emission Tomography (PET) is a nuclear medicine medical imaging technique which produces a three-dimensional image or map of functional processes or Metabolic Activities in the body.

the use of high-frequency sound (ultrasonic) waves to produce images of structures within the human body

above the range of sound audible to humans (typically above 1MHz)

piezoelectric crystal creates sound waves

aimed at a specific area of the body

change in tissue density reflects waves

echoes are recorded

Delay of reflected signal and amplitude determines the position of the tissue

still images or a moving picture of the inside of the body

there are no known examples of tissue damage from conventional ultrasound imaging

commonly used to examine fetuses in utero in order to ascertain size, position, or abnormalities

also for heart, liver, kidneys, gallbladder, breast, eye, and major blood vessels

by far least expensive very safe very noisy 1D, 2D, 3D scanners irregular sampling -

reconstruction problems

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Mammography is a radiographic examination that is specially designed for detecting early breast cancer, yielding a significant improvement in breast cancer survival.

Mammography has been used in clinical practice since 1927 in the diagnosis of breast abnormalities.

In the late 1950s, the pioneering work of Gershon – Cohen and Egan demonstrated that even clinically occult cancers of early detection of breast cancer by screening asymptotic women. 57

Since the first mammography units (xeromammography and screen-film mammography in the 1970’s) became available, both the equipment and the examination procedure have changed and progressed.

A high degree of accuracy was developed with this technique to differentiate between Benign and Malignant disease.

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PastPast PresentPresentANALOGICAL ANALOGICAL TECHNOLOGYTECHNOLOGY

DIGITAL DIGITAL TECHNOLOGYTECHNOLOGY

ScreeningScreening Clinical mammographyClinical mammography

Computed radiography (CR)Computed radiography (CR) Digital directDigital direct Computed Aided Diagnosis Computed Aided Diagnosis

(CAD)(CAD) TTomosynthesis - 3D 3D CESMCESM

MammographyMammography

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Improved detection efficiency

A linear dynamic range

Increased signal-to-noise ratio (SNR)

Excellent Image Handling

Data in Digital form

Computer Aided Detection

Compatibility with PACS and Telemammography

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Early Detection Is Your BEST PROTECTION

If breast cancer is found and treated early, the five-year survival rate is 98 percent.

The social prejudices and stigma associated in screening of breast is to be sensitized.

The success of the scheme depends upon the involvement of radiologists and lab attendants who have to handle with delicate and humane.

Another success of the scheme rests upon instead of bringing the people to lab, the lab itself has to go in search of the patient. For which a handy and portable mammogram has to developed for instant and hassle free Service. 62

Portable MammographyPortable Mammography

GE unveiled an impressive portable mammography concept as part of a portfolio of integrated technologies aimed at combating cancer.

The SenoCase is mobile mammography system which can be folded and easily stored in a car boot.

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According to GE, such portability could remove geographical barriers to regular breast screening for many women on a global scale.

The system could also be more cost effective than conventional mammography systems, making it more accessible to smaller practices and clinics.

A standard field of view Cesium Iodide detector

Similar image quality to a full-field digital mammography system

A user-friendly interface, operable by a single clinician

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Digital Portable Mammography model was preferred in employee surveys.

Employee feedback confirmed that Women Diagnostic Center mammograms are more convenient, private and familiar because employees feel more comfortable.

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Digital mammography has proven to be an essential tool in the diagnosis, treatment and fight against breast cancer. And studies have shown that routine mammograms can help reduce breast cancer mortality.

The important thing is that you make annual mammography screening a top priority for yourself and the women you care about.

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As defined at the beginning of this chapter, angiography refers to radiologic imaging of blood vessels after injection of a contrast medium.

To visualize these low-contrast structures, contrast media is injected by a catheter that is placed in the vessel of interest.

Positive contrast media are more commonly used, but there are instances when use of negative contrast media is indicated. Highly specialized imaging equipment is required for these procedures.

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Fluoroscopy is a technique in which a continuous beam of x-rays is used to produce moving images.

It is used to show movement in the digestive system (which may require ingestion of a high-contrast liquid such as barium) and the circulatory system (angiograms).

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(Still in use in some countries)

Staff in DIRECT beam

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• AVOID USE OF DIRECT FLUOROSCOPY• Directive 97/43Euratom Art 8.4.

In the case of fluoroscopy, examinations without an image intensification or equivalent techniques are not justified and shall therefore be prohibited.

• Direct fluoroscopy will not comply with BSS Performance of diagnostic radiography and

fluoroscopy equipment and of nuclear medicine equipment should be assessed on the basis of comparison with the diagnostic reference levels

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Remote control systemsNot requiring the presence of

medical specialists inside the X Ray room

Mobile C-armsMostly used in surgical theatres.

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Interventional radiology systems Requires specific safety considerations.

In interventional radiology the physician can be near the patient during the procedure.

Multipurpose fluoroscopy systems Can be used as a remote control system

or as a system to perform simple interventional procedures

MEG (Magneto encephalography) imaging and application to MEG (Magneto encephalography) imaging and application to chronic pain patientschronic pain patients

MEG is the only technology suitable for functional imaging for DBS patients as they have metal implanted in the skull so fMRI cannot be used. MEG uses a set of very sensitive magnetic sensors placed around the head to detect the magnetic fields associated with the neuronal activity.

Once the signal have been acquired, an image is formed using a technique known as beam forming which uses them to reconstruct the sources within the brain, a technique known as beam forming.

The signals acquired are typically with low signal to noise ratio, non-Gaussian distribution and correlated. Beam forming is therefore challenging. It is particularly difficult for DBS patients because artefacts arise from the coil of wire left beneath the burr hole (through which wires are taken to the battery.

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Microwave imaging to diagnose breast cancer

Microwaves are an attractive imaging method for finding breast tumours as the contrast between healthy tissue and tumour is very high. However the resolution is low.

We are working to improve the interpretation of the data gathered from both phantoms and clinical images using microwave clinical imaging system developed in Bristol University.

A spin out company from Bristol University has one of the few clinical systems in use worldwide, which has been used in trials in Frenchay Hospital. This work is funded by EPSRC.

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Imaging Modalit ies Imaging Modalit ies Imaging for medical purposes involves the services of

radiologists, radiographers, medical physicists and biomedical engineers working together as a team for maximum output. This ensures the production of high quality of radiological service with consequent improvement of health care service delivery.

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Technological advances have made human imaging possible at scales from a single molecule to the whole body.

By linking the anatomical data collected with emerging imaging technologies to computer simulations, researchers now can form truly functional images of individual patients.

These images will allow physicians not only to see what a patient’s organs look like but also how they are functioning even at the smallest dimensions.

A major challenge is how to store, analyze, distribute, understand and use the enormous amount of data associated with thousands of images.

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Biomedical engineering stands at the forefront of this effort because its researchers are able to integrate the engineering tools needed to solve the technological problems of image analysis with the deeper knowledge of the underlying biological mechanisms.

Already, members of the Department of Biomedical Engineering, in close collaboration with the Departments of Applied Mathematics and Statistics, Computer Science, Electrical and Computer Engineering, and Radiology, have pioneered the use of imaging technology in computational anatomy, neuropsychiatry, computer-integrated surgery and cardiac procedures.

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Now, researchers are expanding their imaging efforts into other modalities and organ systems.

Ultimately, their work will contribute to advancing image-guided therapy and to the early diagnosis and treatment of a host of disorders, including heart disease and brain dysfunction.

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Included in Medical Imaging Research Creating new systems and methods for measuring and analyzing

imaging data in humans, developing mathematical and computational approaches to compare data across individuals, and applying these techniques to understand, diagnose and treat disease.

Using novel imaging techniques to provide information on three-dimensional structure and function at the molecular, cellular, tissue, organ and organism level.

Improving ways to image blood flow and cardiac motion with magnetic resonance imaging, computed tomography, ultrasound and fluoroscopy.

Finding and modeling the cerebral cortex to understand both normal and abnormal shape and the relation to genetic and environmental disease.

Developing bio-inspired algorithms for recognizing objects and actions in video. 80

Research - Biomedical Research - Biomedical ImagingImaging

New developments in biomedical imaging provide a window into complex biological phenomena.

Imaging enables researchers to track the movements of molecules, cells, fluids, gases, or sometimes even whole organisms.

Imaging techniques such as x-ray crystallography and magnetic resonance imaging can also yield information about important biological structures from single proteins to the human brain.

The frontiers of biomedical imaging promise to make diagnosis of disease more accurate and less invasive, and to improve our understanding of disease.

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Imaging research encompassesImaging research encompasses Imaging of protein complexes involved in synaptic communication in the

brain Fluorescence tagging of molecules involved in intracellular signalling

networks Non-invasive imaging of cancer Imaging of human movement using dynamic MR, motion capture systems,

and ultrasonic imaging Molecular and biochemical imaging with PET, SPECT, and optical imaging Three-dimensional medical imaging of blood flow, blood vessels, and

cardiovascular lesions Functional human brain mapping Strategies for fusing images across modalities (e.g., CT and MR) Ultrasonic diagnostic technology in medicine Computational analysis and reconstruction of complex imaging data

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