Telehealth
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SPECIALIZED SOLUTIONS FOR MEDICAL IMAGERY.
Air Force Colonel Les Folio reflected on Moore’s law, observing that data storage and archival capabilities double every 18 months while the price drops by half.
“I have a thing I call Les’s law, where we drive how cameras have been getting exponentially better in megapixel and quality, which increases storage consumption and bandwidth consumption,” Folio told Military Medical Technology. “So even though storage and archival ability grows every year because of improved technology, the improved technology of the image acquisition device, such as CT scanners and MRIs, those types of things are generating demand faster than archival space can keep up.”
Those challenges occupy Folio’s mind because he’s a radiologist, flight surgeon, scientist and associate professor of radiology and radiological sciences at the Uniformed Services University of the Health Sciences (USUHS). He specializes in combat radiology, hence his knowledge of telehealth and how to relay very large medical images around the globe.
As a member of the Air Force Joint Expeditionary Telehealth Solution (JETS) team, Folio visits Iraq regularly to assist with telehealth solutions implemented at U.S. military hospitals. As a leading Air Force expert on the subject of teleradiology, he speaks at a number of conferences around the world on the state of U.S. military capabilities in that area. For example, he lectured at the International Blast and Ballistic Trauma Congress in South Africa at the end of September.
“We have challenges like bandwidth that we are always trying to approach our leaders with,” Folio noted. “Our agenda when we go to these conferences is to make sure we have dedicated bandwidth for medical transmissions and how we will work it when all of the connections are in place when we overcome the security issues.”
Folio has been working on technologies that may not mature for another decade, like transmission holograms, but in the meantime, he helps implement solutions available now for the transfer and storage of very large digital imaging and communications in medicine (DICOM) format files. These files, which usually require a special diagnostic workstation to view, are incredibly sophisticated electronic pictures or X-rays of patient cases.
“The CT scan that we get on every single trauma patient that has massive trauma is about a gigabyte of data. Moving a gigabyte of data can be a challenge, especially when all you have are antennae and things that you set up and transition every few months when you are moving people in and out,” Folio remarked.
As technology improves, so must bandwidth and security, Folio stressed. Technological evolution must occur within the context of proper security, so as to prevent the compromise of patient information.
That being said, Folio has been hard at work on new standards to highly compress and transfer medical imagery. He is part of a team that has filed for a patent on a 1:100 compression ratio for CT data. A gigabyte of CT data can compress down to about 5-10 megabytes, he said, enabling quick transfer to commercial devices like cellphones that would have been impossible previously.
The technology, called DICOM2MP4, would convert DICOM format to MP4 format.
“I have proposed taking DICOM digital data from CT and X-ray and compressing it by changing it into an MP4 file,” Folio explained. “As iPods have become very popular, along with BlackBerrys and all of that, this kind of combines the audio and visual capabilities, more the video capabilities, similar to how DVDs, which are MP2, aregoing to MP4 and all of your movies are going to be on your iPod.”
The patents concern the algorithms that enable the smooth conversion of DICOM to MP4, which provides a means through which medical personnel can view imagery on commercial equipment instead of very expensive diagnostic workstations.
“This patent will allow people to get the images from situations where there are multiple casualties from a bomb or something and there is no radiologist. They can send the entire set of scans to someone’s BlackBerry and they can scroll through. It’s pretty revolutionary,” Folio remarked.
MEDWEB
The expertise of Folio and other members of the JETS team is critical to deploying existing equipment to the field. He visited Iraq last year to help set up the connectivity for Medweb servers. These specialized computer servers handle the DICOM images used by the medical community, while meeting strict security requirements.
Dan Riordan, an application support representative for San Francisco-based Medweb, recently returned from his fourth visit to Iraq to deliver and set up Medweb servers in Baghdad, Mosul and Balad.
“We have limited resources for radiologists in theater,” Riordan told MMT. “So these doctors are able to log on remotely from another site or have the studies forwarded from site to site where a doctor can read the images and give a much better reading than an ER doctor.”
The Medweb servers are extremely portable and connect easily to both the Unclassified but Sensitive Internet Protocol Router Network (NIPRNet) and the Secret IP Router Network (SIPRNet). The servers can communicate directly with satellites and other Medweb products in the field. They connect directly to X-ray machines and MRI scanners from General Electric, Fuji and other manufacturers.
an X-ray system, images are captured on a plate that is read by a computer radiology (CR) system, which saves the images to a workstation. From there, medical personnel can transfer the DICOM images to Medweb, which can act as a relay station to another destination or as an archival system for the storage of the images.
“It’s easy to install and easy to maintain. They are also durable. We provide a very portable, sophisticated system that works well in desert conditions—dry, hot and dusty,” Riordan added.
A deployable Medweb system needs only a satellite connection or some Internet access to start working right out of the box—which is a Hardigg box roughly 3 feet or less on all sides. The basic kit comes with two servers, so that one can take over for the other in the event of a breakdown or failure of some kind, as well as a switch, a UPS power supply, surge protection, a PC, a monitor and a keyboard.
The U.S. military has seven of the units in Iraq at press time, along with three in Kuwait and five in Afghanistan. Many more are deployed around the world, Riordan said, and the U.S. military has been using them for about 10 years.
MEDPIX
Back at USUHS, located in Bethesda, Md., Folio’s boss, Dr. James G. Smirniotopoulos has developed a database for medical images that is being widely used within the military academic community. The database, called Medpix, is patented by Smirniotopoulos and Henry Irvine, a USUHS radiology resident.
Smirniotopoulos, chair of radiology and radiological sciences at the Uniformed Services University, told MMT that Medpix stores medical images, providing clinical information about a patient, enabling doctors to examine patient history and exam findings as well as treatments and outcomes.
“The images can be Xrays, MR, CT or ultrasounds,” Smirniotopoulos said. “They can be gross pictures of the patient. We have some trauma cases, including some cases from our current conflicts. We want to expand its use to a more comprehensive trauma database. It’s a very complex program that does a lot of things.” Doctors or support staff can enter the database and conduct a keyword search on images to compare against current cases, for example. The images are high-resolution JPEG files, so medics can view them over a standard PC or laptop without a diagnostic-quality monitor.
Those with access to Medpix also can upload JPEG images into the database, enabling others around the world to access the files with a standard Web browser. Smirniotopoulos cautioned that files input by remote users are subject to a verification process that limits public access to the files until peer reviews have approved their inclusion. Editors can comment on case files and link case files to related files.
Medpix also acts as a training system, providing continuing medical education for physicians and nurses. Students can take tests and receive scores from Medpix online. Students also can use Medpix as a study tool to examine cases and learn how to identify and distinguish various scenarios and afflictions.
Although Medpix has been around since 1996, Smirniotopoulos only recently received his patent on it. The database also has a great deal of unrealized potential, he noted, as it is presently used largely for research and not for consultation.
“Somebody using an ordinary Web browser and a standard Internet connection could send a case in and ask for a consultation on it,” Smirniotopoulos said. “We don’t actually use those functions, so I want to be careful to make sure that people understand we are not actually using Medpix right now to make diagnosis but that functionality is built into the system.”
The biggest challenge with using Medpix for consultation arises from credentialing.Doctors at one location are often not credentialed to practice at the point of origination for images, thus preventing them from making a diagnosis on patients at that location.
Still, Smirniotopoulos foresees an expanded role for Medpix in the future.
“What we would like to do is to integrate the system into the workflow, so that somebody would be working on a clinical case and it would somehow be linked into Medpix, and Medpix would have already done a search on relevant information to present for a comparison. So it might be a diagnostic adjunct. That is the point-of-care application that we are looking to develop,” he said.
Meanwhile, Medpix continues to serve an atlas and a reference tool through its primary portal at http://rad.usuhs.mil/medpix/ medpix_home.html. ♦