Review of technology: planning for the development of telesonography

Telesonography in emergency medicine: A systematic review

Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.

Recent Developments in Tele-Ultrasonography

A long-standing trend that will continue to grow in healthcare is providing high quality services for all the patient, no matter the distance and no matter the place. One approach currently being used to increase population access to healthcare services is telemedicine. This narrative review presents one branch of e-health, in particular the use of teleultrasonography (TUS) in clinical practice, the challenges and barriers encountered. Current advances in ultrasound technology, including the growth of portable and small ultrasound devices have increased the range of applications of TUS, from traumatic patients in emergency medicine, maternal ultrasound and even for monitoring and screening for chronic illnesses. Even though some barriers are still looking for a solution, like standardized training and protocols, errors in data acquisition, the lack of trained professionals to operate in remote areas, TUS has the potential to redesign future health care systems.

Teleultrasound: historical perspective and clinical application

The health care of patients in rural or isolated areas is challenged by the scarcity of local resources, limited patient access to doctors and hospitals, and the lack of specialized professionals. This has led to a new concept in telemedicine: teleultrasonography (or teleultrasound), which permits ultrasonographic diagnoses to be performed remotely. Telemedicine and teleultrasonography are effective in providing diagnostic imaging services to these populations and reduce health care costs by decreasing the number and duration of hospitalizations and reducing unnecessary surgical procedures. This is a narrative review to present the potential clinical applications of teleultrasonography in clinical practice. The results indicate that although barriers persist for implementing teleultrasonography in a more universal and routine way, advances in telecommunications, Internet bandwidth, and the high resolution currently available for portable ultrasonography suggest teleultrasonography applications will continue to expand. Teleultrasound appears to be a valuable addition to remote medical care for isolated populations with limited access to tertiary healthcare facilities and also a useful tool for education and training.

Evaluation of tele-ultrasound as a tool in remote diagnosis and clinical management at the Amundsen-Scott South Pole Station and the McMurdo Research Station

Abstract Background: A large number of Antarctic stations do not utilize ultrasound for medical care. Regular use of ultrasound imaging at South Pole and McMurdo Stations first began in October 2002. To date, there has been no evaluation of medical events requiring ultrasound examination from this remote environment. Additionally, the importance of tele-ultrasound for clinical management in Antarctica has not yet been assessed. We therefore conducted a retrospective analysis of all ultrasound exams performed at South Pole and McMurdo Stations between October 2002 and October 2003.

SUBJECTS AND METHODS

Radiology reports and patient charts were reviewed for pre- and post-ultrasound diagnosis and treatment.

RESULTS

Sixty-six ultrasound exams were conducted on 49 patients. Of the exams, 94.0% were interpreted by the store-and-forward method, whereas 6.0% were interpreted in "real-time" format. Abdominal, genitourinary, and gynecology ultrasound exams accounted for 63.6% of exams. Ultrasound examination prevented an intercontinental aeromedical evacuation in 25.8% of cases, and had a significant effect on the diagnosis and management of illness in patients at South Pole and McMurdo research stations.

CONCLUSIONS

These findings indicate that diagnostic ultrasound has significant benefits for medical care at Antarctic stations and that tele-ultrasound is a valuable addition to remote medical care for isolated populations with limited access to tertiary-healthcare facilities.

Remote sonographic interpretation: comparison of standardized video clips to still images

OBJECTIVE

The aim of our study was to evaluate the role of standardized video clips compared with still images in the diagnostic accuracy of remote sonographic interpretation.

METHODS

We compared the remote interpretation of sonographic examinations acquired with a standardized video clip approach to examinations performed with still images alone in 60 patients with various hepatic and extrahepatic pathologies.

RESULTS

The use of video clips improved the diagnostic accuracy of sonographic studies interpreted remotely compared with the use of still images (p < 0.0001). The sensitivity, specificity, and positive and negative predictive values increased from 47.3% to 68.3%, 81.8% to 87.8%, 71.5% to 81%, and 63.8% to 74.5%, respectively.

CONCLUSIONS

Standardized video clips are easy to obtain, less operator-dependent than still images, and can be transferred to remote sites without loss of important data. We recommend this method in remote interpretation (teleradiology and distant consultation) of sonographic examinations.

Battlefield applications for handheld ultrasound

Combat medical care provides unique challenges and opportunities for military medical teams. The austerity of the environment severely limits access to many diagnostic and therapeutic tools. Because of their compact size, handheld ultrasound (US) machines are increasingly being used in these constrained environments. A growing body of literature documents the diagnostic utility of handheld US for trauma encountered in the battlefield. Furthermore, US guidance may assist in the performance of some procedures performed in battlefield medical care. This review will provide an overview of the history, current status, limitations and potential future of US utility for the battlefield.

Tele-obstetric ultrasound: analysis of first-trimester ultrasound images transmitted in realtime

We evaluated the diagnostic quality of first-trimester ultrasound images transmitted in realtime using low-cost telecommunications. A prospective sample of fetal ultrasound images from 11 weeks to 13 weeks and six days of pregnancy was obtained from pregnant women over 18 years old. The examinations were transmitted in realtime to three independent examiners who carried out a qualitative assessment based on parameters established by the Fetal Medicine Foundation. All fetal structures could be viewed and the quality of images received by the examiners was considered normal. There were significant differences for crown-rump length and nuchal translucency in the transmitted images but the loss in definition was acceptable. Thus the quality of images transmitted via the Internet through the use of low-cost software appeared suitable for screening for chromosomal abnormalities in the first trimester of pregnancy.

Telesonography: foundations and future directions

The practice of telesonography has yielded promising results in several domestic and international projects aimed at providing basic sonography services. Common themes that recur within telesonography-based research include the quality of transmitted images, clinical applications, and technical and nontechnical barriers to implementation. The research base continues to grow in concert with expanding telecommunications capabilities and refinement of small portable sonographic devices. Persistent barriers to the deployment of telesonography systems include a lack of telecommunications access, a lack of standard training and operational protocols, and a paucity of research regarding the long-term health impact of telesonography within target communities. Telesonography may be used directly to improve the standard of care within a given community; however, limited resources and interest may prevent sustained operations. Future projects may use telesonography to supplement the training of health care providers in remote locations in an effort to establish permanent sonography services for their respective communities.

Real-time video transmission of ultrasound images to an iPhone

Background

As point-of-care ultrasound spreads across the globe, there is an increased need for training and supervision of ultrasound studies. Real-time oversight is important, especially in critically ill patients, but often an expert ultrasound over-read is not available on location. Technological advances have improved data transmission so that images and videos can be sent great distances very rapidly. In this study, we examine the feasibility of real-time wireless transmission of ultrasound video to an iPhone.

Methods

An ultrasound machine was connected via a video converter to a laptop. iCam (SKJM, LLC) software was used to transmit the video across the Atlantic Ocean to an iPhone. Images typical for those performed in an emergency department were sent, in random order by a ‘scanning physician.’ An ‘interpreting physician’ overseas was asked to identify the anatomy, presence or absence of pathology, and comment on the quality, speed, and delay of transmission.

Results

Rapid image transmission was feasible and the ‘interpreting physician’ was always able to correctly identify the anatomy and orientation. The average delay was minimal (2.7 s), allowing for real-time feedback. The frame rate was markedly slower in the received images as compared to the transmitted images, and was faster when the iPhone was connected via WiFi (1.1 fps) versus a 3G connection (0.4 fps).

Conclusion

Transmission of real-time ultrasound video to a remote iPhone using inexpensive technology is feasible, with the preservation of image quality and minimal delay. Transmission speed was superior with a WiFi connection than with a 3G connection.

A comparison of telesonography with standard ultrasound care in a rural Dominican clinic

We compared telesonography to usual patient care in a rural clinic in the Dominican Republic. A total of 108 low-income Dominican and Haitian patients volunteered to participate. The patients were randomly assigned to either telesonography or control groups. Patients in the telesonography group were scanned and sonographic images and Request for Interpretation (RFI) forms were sent by email to six volunteer radiologists in the USA. Completed RFI forms were transmitted back to the clinic at the radiologists' earliest convenience. Patients in the control group received an ordinary ultrasound referral, which required travel to a tertiary medical centre where their scans were completed by a local sonographer. Sonographic reports from the control group were hand delivered to the referring physician at patient follow-up. The telesonography system provided a four-fold increase in the proportion of patient follow-ups and a six-fold increase in the proportion of returned radiological reports. In the telemedicine group, the median total elapsed time from referral to report return was 17.8 h (interquartile range, IQR 12.2-27.1) and the median time to patient follow-up was 67.1 h (IQR 45.9-113.7). The latter was similar in the control group, where the median total elapsed time was 76.7 h (IQR 65.8-144.7). The pilot study demonstrated that store-and-forward telesonography reduced time to diagnosis and increased the continuity of care compared to the usual ultrasound referral system in the region of the Dominican Republic which was studied.

Value of head and neck cancer incidence data on UK cancer registry websites: a comparison

We evaluated the relative usefulness of data on head and neck cancer available on the websites of cancer registries in the United Kingdom. Data were analysed to determine the accuracy and completeness of essential information related to the incidence of head and neck cancer.

We found that 16 per cent (2/11) of the registries had some cancer data but none relating to head and neck cancer patients. Seventy-five per cent (9/12) of the registries had selected data on head and neck cancer, but 33 per cent (3/9) of these pooled the various head and neck cancers into a single group. The remainder of registries offering data [66 per cent (6/9)] had a variety of ways of grouping and presenting the various types of head and neck cancer. The overall value and usefulness of head and neck cancer information on these websites were limited, especially when all the sites were considered together.

The cancer registries collectively possess an extremely important asset of immense value to both the medical profession and, possibly, patients with cancer. The accessibility of this data and the overall experience of those seeking information on this subject could be improved. However, this would require significant thought, collaboration and agreement between each registry, which would involve significant extra investment.