TURKISH TELEMEDICINE SYSTEM (TUMEDSIS) Birgül EGELİ 1, Alp KUT 2, Fazıl APAYDIN 3 1 Asst. Prof., Boğaziçi University, Turkey 2 Assoc. Prof., Dokuz Eylül University, Turkey 3 Assoc. Prof., Ege University, Turkey Abstract Latest technological changes made cost effective and quality healthcare possible throughout the world. Internet can be used now for communication of patient records and doctor expertise. The aim of the Turkish Telemedicine System (TUMEDSIS) is to establish a remote medical information management system using Internet and World Wide Web (WWW) for interactive medical information change to help remote diagnosis and remote learning. Keywords: Telemedicine, Internet, Medical Information Management System INTRODUCTION The idea of telemedicine was proposed in 1975s. Telemedicine is generally defined as the provision of medical services through the use of a communications system. At its broadest, this definition includes the establishment of electronic medical records and community information networks (HIS2000). Currently, however, the more common telemedicine services which are in existence include: Teleradiology: It is the electronic transmission of radiological images from one location to another for the purposes of interpretation and/or consultation Telepathology: The term 'telepathology' relates to the establishment of fully digitised online pathology imaging which is used to support specialist services in remote areas. Teleconsultation: The term 'teleconsultation' is used to cover a wide range of services which use video conferencing technology to allow consultations between persons at different locations. This may be between two medical practitioners, one of whom would bring specialist or expert skills to the consultation. The patient would often be included in these consultations. In some cases the consultation may be directly and only between a specialist and patient, although this service seems less preferred by practitioners. Telemonitoring: Telemedicine is suited to provide offsite monitoring of cardiac patients and pacemakers. In these cases, 24-hour monitoring is often not useful because of the irregularity of symptoms. Instead, patient-activated event telemonitoring is more costeffective. In addition, the telecommunications approach is being used to provide medical education and clinical support through the use of online medical information databases, interactive medical education systems and clinical data management systems which assist with routine diagnosis and patient management. Telemedicine is a wide ranging subject which encompasses teleconsultation, electronic patient records, continuing medical education and public health information systems. Telemedicine has an impact upon every aspect of health care delivery from remote clinical analysis and consultation between experts based in specialist hospitals, to teleconsultation as a substitute for physical referral between the GP and a hospital, and ultimately the remote
delivery of medical monitoring and care into the home (Garner et al., 1997). Great achievements have been made in the fields of remote diagnosis, remote consultation, remote transmission of x-ray or CT film, remote registration, remote learning or information sharing. Telemedicine applications use audio, text, image and video through computer, facsimile, scanners, camera light box, cameras, multimedia, electronic mail, remote monitoring systems, video conferencing, and other associated technologies to enable the delivery of medical care as an attempt to lessen the gap between the availability of expertise and services at remote locations (Mukaida et al., 1996). BENEFITS OF TELEMEDICINE Benefits of implementation of the telemedicine are (Huilong, D., 2000): To improve quality of care in rural and outlying area. Telemedicine can provide fast and convenient health care without transfer. It also can attract physicians to work in remote area by providing chances of consultation with specialist and continuing education. To lower costs of delivering health care. Telemedicine can eliminate time and wages lost at work and traveling expenses incurred when specialists and/or patients have to travel for consultations; Keeping patients in their own communities can increase local hospital revenues and decrease the cost to patients; Costs might also be reduced by staffing hospitals and clinics with allied health professionals, such as nurse practitioners and physician assistants, who would deliver services where there is no resident physician. These providers could be assisted and monitored remotely by physicians using a telecommunication link; In some case, overall costs might also be lowered using telemedicine if patients are treated sooner when their illnesses are less severe. To give remote physicians continuing education. Convenient access to the most up-todate information, continuing medical education programs, decision support systems, and consultations with specialists in large medical centers should increase the provider s options and improve his or her ability to accurately diagnose and effectively treat patients. Specialists in medical centers learn about the problems physicians face in different area, which will give them more opportunities to get medical practice. TELEMEDICINE IN THE WORLD The NIVEMES Project, started in January 1996 in Belgium. The goal of NIVEMES is to develop an international network of Telemedicine Healthcare providers and telemedicine services. These services will be offered in a consistent and integrated manner to individuals or groups in remote locations or emergency situations. The project will develop: A core of integrated healthcare services, support functions and applications used by a network of Telemedicine healthcare providers - medical institutions (Ehto). Memorial University of Newfoundland has been continuously involved in telemedicine activities since 1975. In 1997, the Telemedicine Centre delivered approximately 7000 hours of programming and administered a network of 247 dedicated audioconference sites in 161 communities (168 of the sites had telewriter workstations and 75 had multimedia workstations) and eight videoconferencing sites. Approximately 70% of all programming was distant high school and university education, 20% health education, 5% clinical activities, and 5% other uses. Current clinical activities include tele-electroencephalograms, tele-
ultrasonography, tele-nuclear medicine, child telepsychiatry, general teleconsultation from a remote nursing station, and general teleconsultation from an offshore oil platform (Telemed). The teleradiological connection between the University Hospital in Innsbruck, Tyrol, and the Regional Hospital in Zwettl, Lower Austria, is presented as an example of a routine online connection of two helical CT systems. The purpose of the project is to establish a practicable and cost-efficient emergency CT service in a remote hospital during night time and on weekends. Teleradiology enables remote hospitals to provide an emergency CT service even if there is no radiological specialist available outside office hours. Thus time-consuming and cost-intensive patient transfers and delay of therapy can be reduced (Stoger et al., 1996). Recent technical advances in Internet-based client/server applications and new multimedia communications protocols are enabling the development of cost-effective, platformindependent solutions to the problem of remote access to continuously acquired physiological data. The UCLA Neurosurgery Intensive Care Unit (ICU) has developed a distributed computer system that provides access over the World Wide Web (WWW) to current and previously acquired physiological data, such as intracranial pressure, cerebral perfusion pressure, and heart rate from critical care patients. Physicians and clinical researchers can access these data through personal computers from their offices, from their homes, or even while on the road. The system creates and continuously updates a database of all monitored parameters in data formats that can readily be used for further clinical studies. (Nenov & Klopp, 1996). CHILI is a general purpose radiology workstation with additional functions for teleradiology (Engelmann et al., 1999). The task of the system is the transmission of radiological images to different locations for interpretation and consultation. The transmitted images can be simultaneously viewed at different locations and examined cooperatively. The CHILI project is a cooperation between the German Cancer Research Center and a technology transfer company Steinbeis-Transferzentrum Medizinische Informatik (STZ-MI), both located in Heidelberg, Germany. More than 40 systems are running in daily routine in private practices, small hospitals, university clinics, and research institutes. The system is in use in research projects, in medical image analysis, and even surgery planning systems. TELEMEDICINE IN TURKEY Turkey is a country that has areas with no hospitals and having trouble of finding medical expertise. Internet can be a solution to this kind of problems. The aim of the Turkish Telemedicine System (TUMEDSIS) is to establish a remote medical information management system using Internet and World Wide Web (WWW) for interactive medical information change to help remote diagnosis and remote learning. This system will be able to link people, homes, hospitals and universities for information sharing purposes. The objectives of the system are: Development of a remote medical consultation center around a university campus connecting several hospitals. Supply remote consultation to the remote areas of Turkey for patients and doctors who have trouble of traveling for the cost and the time.
Establishment of an educational center and a forum for doctors and practitioners who would like to have expertise and discuss issues related to the practice of medicine in rural areas. Use of Internet for fast information exchange Development of a discussion environment for information sharing between doctors TURKISH TELEMEDICINE SYSTEM (TUMEDSIS) System is developed using Java which will create an open environment for each user connecting through different hardware platforms using Internet and WWW browsers. System is planned for the use of doctors in the first step. Patients and drug firms can be added later on. TUMEDSIS has features as: Patient record based discussion list On-line chat: Doctors in a hospital can consult with colleagues or subspecialists located in other hospitals. Interactive image analysis: Diagnostic imaging examinations carried out by primary care or rural physicians monitored by specialists in a major referral medical center, who can also provide consultation on the diagnostic interpretation of acquired images. Access to previous discussions A user of TUMEDSIS will be able to: Leave a message for a subscriber and check messages for himself/herself Discuss in a shared platform Add his/her own patient information See all the detailed information about recorded patients Comment on a patient and save this comment Analyze images related to a patient See all the detailed information about recorded doctors The user will be able to perform following functions using a session screen: View a list of users attending to the current session View patient information (text and image) View previous discussions and comments Chat with other users to send comments View active picture selected by active user Use a button to become an active user and make changes on the image Exit the session A form has to be filled out to enter the site (Figure-1). For enrollment all the information has to be given fully and correct. This information will be checked by an administrator and after acceptance an e-mail message will be sent to the user. There will be an administrator for each of the sections.
Figure-1. User Entry Screen After the entry process is done, the system will send some Java codes to the user to open up a session to her/him. Communication with others (doctors or the patient) is performed after the connection. A user attending a session will see a screen as given in Figure-2. Discussion Area Picture Area Picture List User List Patient Information Command Buttons Figure-2. Session Screen Information needed for a subscriber includes general information as: name, surname, expertise, company, title, telephone/fax information, gender and date of birth; and user information as e-mail address, password to enter the site. The username will be given as name_surname.
Information needed for patient records is: Doctor name, department dealing with patient's illness, age, gender, complaints, patient history, resume, family history, medical examination findings, treatment, question, and at most 10 images per patient. Figure-3 shows the screen for patient record. Figure-3. Patient Record Screen Users can leave messages to others by selecting the name of the person that the message will be left and the message itself (Figure-4). A user entering the site will see the list of messages than they can reply or delete those messages.
Figure-4. Message Screen Discussion environment will include rooms (Figure-5). The main aim of this environment is the information exchange about a patient. Users will use their usernames to subscribe to the rooms. Figure-5. Discussion Environment Turkish telecommunications structure is not suitable for fast teleconferencing and video conferencing. For that reason sound and video is not included in the current system. But the structure is prepared for any additions to be made.
CONCLUSION The benefits of TUMEDSIS can be summarized as follows: It is the first Turkish Health Management Information System that doctors and patients with no second language can interact with each other easily. Provides easy access to specialized consultants from rural and urban areas, increasing responsiveness to patient needs. Lowers overall healthcare costs by eliminating time and wages lost at work and traveling expenses incurred when specialists and/or patients have to travel. Gives physicians continuing education and provides consistency of care The next step of the project is to evaluate the system performance (usability of the system by doctors and/or patients, acceptability of image download rates, etc.) and perform necessary changes to achieve a better system. ACKNOWLEDGEMENTS Authors would like to thank to Pınar Çağlar and Yavuz Şahin for their involvement in the programming of the website. REFERENCES Ehto. http://www.ehto.be/ehto/journal/issue5/telemedicine.html Engelmann, U., Schroeter, A., Schwab, M., Eisenmann, U., Vetter, M., Lorenz, K., Quiles, J., Wolf, I., Evers, H., Meinzer, HP. (1999). "Borderless Teleradiology with CHILI", Journal of Medical Internet Research, 1(2):e8. Garner, P., Collins, M., Webster, S.M., Rose, D.A.D. (1997). "The Application of Telepresence in Medicine", BT Technology Journal, vol.15, no.4, Oct. http://btlabs1.labs.bt.com/library/papers/5792343.htm HIS2000. http://www.health.govt.nz/his2000/background/telemed1.html Huilong, D. (2000). "Application of Telemedicine and It s Issue", http://www.ecotec.com/sharedtetriss/projects/publics/china/health/chinhigh.html Mukaida, L., Bice, S., Dever, G., Norton, S., and Samisone, J. (1996). "Telemedicine and Telehealth in the Pacific Islands Region: A Survey of Applications, Experiments, and Issues", Proceedings of the Pacific Telecommunications Conference '96, pp 574-581. http://128.171.103.16/info/papers/telemed4.htm Nenov V. Klopp J. (1996). "Remote analysis of physiological data from neurosurgical ICU patients", Journal of the American Medical Informatics Association. 3(5):318-27, Sep- Oct. Stoger, A., Giacomuzzi, S.M., Strohmayr, W., Dessl, A., Springer, P., Buchberger, W., Jaschke, W. (1996). "Establishment of an Emergency CT Service by means of Teleradiology", Fortschritte auf dem Gebiete der Rontgenstrahlen und der Neuen Bildgebenden Verfahren. 165(6):520-3, Dec. Telemed. http://www.med.mun.ca/telemed/telehist/telemulti.htm