THE HERMES PROJECT: INTEGRATING MEDICAL SERVICES, TRAINING AND EDUCATION ON AN INNOVATIVE SATELLITE WEB-PLATFORM

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1 THE HERMES PROJECT: INTEGRATING MEDICAL SERVICES, TRAINING AND EDUCATION ON AN INNOVATIVE SATELLITE WEB-PLATFORM Nunzio Casalino CeRSI - Centro di Ricerca sui Sistemi Informativi Luiss Guido Carli University Rome - Italy ncasalino@luiss.it Abstract The technical advances being made in telecommunications are opening up more and more exciting possibilities. Wireless and satellite transmission capabilities have increased while costs per unit time have decreased. All of this makes telemedicine more feasible. The paper describes the preliminary results of European HERMES research project to develop and evaluate an on-line integrated web-based platform with the implementation of satellite communication technologies, related to multimedia services in telemedicine and teleeducation fields. Telemedicine can play an important role in improving health services. The advantages that satellite communications can bring to telemedicine include instant access to broadband services, particularly in remote areas where telecommunications are poor or non existent and swift response in disaster situations where speed is essential. Key Words Satellite communications, DVB, consulting, medical training, web-based platform, e-learning, clinical trial. 1. Introduction ARTES Element 3 Theme is an European Space Agency (ESA) Programme aimed to promoting the development of European market of broadband satellite and role of satellite systems and services in the teleeducation and telemedicine domains. It encourages the implementation of pilot Projects, operations in real scenarios, innovative services and educational and medical applications. Telemedicine has great potentials, but it is unfortunately very little know potential users. The benefits of expanding the use of telemedicine are threefold: it can improve the quality of healthcare services; permit the best use of often limited hospital resources and expensive medical equipment; and also help to resolve the problem of unequal access to good health care. Throughout Europe the number of people requiring special care is increasing as the proportion of elderly Fabio Di Persio TELESPAZIO Rome - Italy fabio_dipersio@telespazio.it people rises. At the same time, in a high-tech age the expectations of society for better healthcare are also rising. Telecommunications offer the possibility of improving health services within Europe and making the best use of limited and valuable resources. 2. Aims of the Project The HERMES (High transfer Rate Medical and Educational Services by Satellite) Project aims at the implementation of services and satellite telecommunication techniques as multicasting IP and IP/DVB, related to multimedia services in telemedicine and tele-education fields, using: asymmetrical and symmetrical Internet satellite communication services; ISDN terrestrial lines; dedicated hardware and software platforms; HERMES Services Centre; peripheral user stations; access and providing databases. The HERMES Project, in which are partecipating TELESPAZIO, some medical centres and CeRSI-Luiss, aims at demonstrate the effectiveness of the overall system (application and communications platforms) in order to promote the use of telemedicine via satellite in several environments by the compliance to the DVB standard. This final objective is to prove both flexibility and cost effectiveness of this kind of services [1]. Applications implemented for telemedicine are: reference data and medical support services, multimedia patient record and tele-consulting (one to one and/or multipoint). Applications implemented for tele-education are: video lessons (live and/or on-demand), media library and laboratory collaborative learning. The HERMES Project main goal is to develop a community service useful and profitable for the medical patient in three fields: clinical data management, cooperative clinical data management, broadcast of multimedia content by several medical centres for tele-consulting. 3. Health care process In a properly handled situation the patient enters a random point in the health care system (most likely the nearby

2 hospital or the general practitioner) and begins a series of iterations in exams, specialists, hospitals converging to the proper treatment of the patient disease [2]. The probability of incorrect handling of the situation, in a relevant pathology, is dangerously high, mainly due to: Environmental factors. Many Institutes are not prepared to face every disease. In a peripheral hospital only frequent pathologies for that geographical area are treated. Instinctive factors. The decision of the physician is usually based on the limited number of cases in his experience and on static databases object of the published studies. This factor is very variable between different specialists and general practitioners. Emotional factors. Decisions are often influenced by the decisions taken by the preceding physicians that examined the patient. As a consequence the probability of error occurrence is high and the probability of error recognition and correction is very low. This causes the repetition of exams in the same or in different structures and slow down the diagnosis process (resources waste) and the proper treatment [3]. So, proper actions for improving the system must be taken. Correct information management and transmission is a key point and satellite technologies can be relevant. Furthermore the bandwidth requirements of medical data TLC is high and rather asymmetric. There are more often accesses for retrieval than for entry or update. This makes the multimedia clinical record data transmission a very suitable topic for satellite DVB networks. Each actor in the business is connected to the network and actions are driven towards the most proper resource available on the network. 4. Clinical data management and protocols The main objective of clinical data management is the availability of common and precise data relative to the patient treated in a medical centre connected to the network. A telecommunications network and a proper software can make the patient data available in remote sites [4]. The main goals are: Patient assistance. The information collected during the patient contacts with health-care structure is of paramount importance for decisions concerning the future treatment of the patient diseases. Each datum must be accessible by authorized medical personnel only. The basis for collaboration is sharing a common "language". In the clinical and surgery field this "language" is the patient record structure, that can be stated by leading scientific research groups. Medical and paramedical personnel store and retrieve all the relevant data coming from exams, anamnesis, therapy, radiography and any other event relevant to patient contacts with any medical Institution joining the system. Decision support based on large statistical samples. The availability for queries of a wide set of medical cases can be very useful in determining decision about a new patient. A query can be on a single piece of data stored for any patient. For example a physician can find all the patients with a given pathology or some medical data in a given range. Once the statistical sample is extracted, data from any event in the patient record can be exported in a standard format for further statistical analysis. Research activities. The dissemination of large number of medical data collection systems integrated in a single network implies that a huge amount of data is accumulated. This information can be a common base for scientific statistical analysis for medicine and pharmacology. Patient privacy. It is a primary issue enforced through strict security checks. A clinical trial requires data collection relative to the patients involved and this is where HERMES enters. Several categories exist [5]. Satellite technology can help in building a network of medical and research centres participating to these kind of trials, that can have a huge economical impact on medical market business. 5. The MMR software The Multimedia Medical Record (MMR) application is the heart of the HERMES Project. It has been supplied by TELESPAZIO in collaboration with a software house specialized in telemedicine and e-learning software (Kell S.p.a. - Rome). This application, already used in some hospitals and validated by several years of everyday work, it has been adapted to improve satellite effectiveness and speed. The key point is that medical data is stored on a central database, hosted on a server. Data can be stored immediately before collaborative work or off-line for successive independent work by participants involved in the study of that patient [6]. Compared to several telemedicine procedures this brings several advantages: The collaborative work is more than a videoconference with data transfer, being the medical data already validated and stored centrally. This information is permanently available and is major asset for patients and institutions. The data is stored following well-defined guidelines, reducing the probability of asking for supplemental diagnostic procedures on the patients. Off-line consultation is also possible (and is actually one of main the scopes of HERMES). The data recorded centrally can be used for statistical analysis of similar cases and search for multimedia data of previous patients suffering for pathologies similar to the one of the actual patient. Stored data together with the log of the operations on the data are a legal protection for medical practice. Cryptography and the possibility to retrieve anonymous data enforce patient privacy according to 311

3 European Union privacy regulations and laws. The application is "object-oriented" and use relational databases to store all data. It is based on a client-server model and runs besides within a standard web browser, thanks to the Java Virtual Machine. It gives the possibility to reduce the time and problems connected to the configuration of the client stations. This is a fundamental requirement, especially in remote sites where the communications and the journeys of the personnel from a location to another are not easy [7]. Any software update is simply stored in the server where also the patient's data lie. The client connects to the web server by a web browser and the needfull software components are automatically downloaded together with the HTML pages. 6. Data model and decision support functions The patient-record program used in the HERMES Project, is based on the concept of event. An event represents any episode that occurs during the patient s contacts with the Institut. For example, a blood test, an objective test, an anamnesis are events which make up a patient s case history, in this way the clinical record is dynamically built up aggregating the information from the different divisions of the Institut in the form of events. The physician always keeps the entire situation under control without having to move from his workstation. The most innovative aspect of the multimedia medical record (MMR) used, is that each of these different types of events is dealt with utilizing the same sequence of operations, thanks to the objects technology. Data are arranged in forms, representing the logical views of the information. They can be displayed and modified through a standard web browser running on the client stations [8]. A patient s record is the aggregation of all the events belonging to him. Medical data are heterogeneous, ranging from numerical values to radiography images to full motion video. The system stores all these data types on a single relational database. All these are described by a simple formal language, which enables a very easy reconfiguration of the program for other medical fields and multi-language aids without programming activities. The data are shown to the user by a synthetic view of all events, arranged as entries in a table through which the user is able to view details of a single event, or collection of data extracted from multiple events. Query functions act on the whole database of patient data. Physicians and technicians are able to store and retrieve all the relevant data coming from exams, anamnesis, therapy, radiography and any other event relevant to patient. Data from all the patient records can be searched based on any parameter stored on any event. For example a physician can find out all the patients with a given pathology or their systolic blood pressure lying in a given range. Once the statistical sample is extracted, data from any event in the patient records can be exported in a standard format (for example for a spreadsheet application) for further statistical analysis. Any query can be specified by graphical windows, so that even software inexperienced medical personnel is able to use it [9]. The system allows complicated queries including "and - or - not" combination of events. The availability for queries of a wide set of medical cases can be very useful in determining decisions about a new patient. The dissemination of large number of medical data collection systems integrated in a single network implies that a huge amount of data is accumulated. This information can be a common base for scientific statistical analysis in medicine and pharmacology. The relevant step forward is that information is gathered during routine patient treatment, not during activities explicitly dedicated to scientific research within universities or research Institutes. 7. Collaborative work The video-conference system used is the ivisit software that integrates audio, video, chat and messaging into a simple but powerful package that works on dial-up and broadband connections, PC and Mac computers. The system, combined with ivisit software, enable collaborative working, virtual meetings, video-education and on-line video transmissions [10]. The collaborativeworking module is integrated in the patient record system. Most telemedicine systems are built up simply of a videoconference tool and a whiteboard area where users can exchange data on-line. This platform is focused on the medical needs. The structured medical database is the pivot of the system and has a telecommunication layer around it. The system allows multi-point consultations on the centralized database. For example one of the participating Institutions could have a patient whose data they want to discuss about with other centers. Patient data are already collected in the local database. When the discussion session is started all the participants log on the server of the Institution requesting the consultation. 312

4 8. Platform features and the FullSAT system The program is then switched in cooperative mode allowing user commands to be automatically sent to all the participants who see the same window sequence and can also give commands that will be broadcasted to the others. At the same time a whiteboard (called virtual board ) is automatically opened and a chat area enables message sending if there are bandwidth troubles [11]. When a graphic window, as a smear image, is opened from one of the participants it is automatically transferred on the virtual board where operations like zoom, pan and basic drawing can be performed and will be replicated on the PCs of the others. A collaborative work virtual board is extended to include a contrast/brightness adjustment control for smear analysis. The application interacts with the multimedia distribution client to start the client when new content has been received. The structure of the access authorizations of the database is modified to introduce the data-structure of the owner of the patient. In this way operations on data of a patient belonging to a different Institution must be explicitly authorized. A sophisticated encryption system is introduced for data in transit on the network. The satellite network is provided by TELESPAZIO. It is based on IP/DVB transmission to allow Internet connection with asymmetric bandwidth. The terminal incoming bandwidth is limited by network allocation and can be up to 2 Mbps. Outgoing data use a 128K ISDN connection to a local provider or a static Internet connection. Thus IPerSAT network is economically convenient when the data are sent in multicast to several users at the same time and downstream bandwidth needed is more than upstream (as in database access or Internet navigation). This platform allow the using of many multimedial services as programs with audio and video, video-conferences, documents and materials sharing. The traffic of the multimedial applications is essentially asymmetrical. It meanings that proportionally more satellite Internet bandwidth is allocated to downstream traffic than to upstream traffic. The applications that use a lot of video and audio need of a big data transfer in downstream from the server to the end user. The multimedia applications for the telemedicine and teleeducation need so of high speed connections because they use video-lessons, high resolution diagnostic images, operational demonstrations, animations, specialistic texts and graphics. The system is based on these principal macrocomponents: a Service Centre, located in Rome, to manage the network, to host the system software and the database and to link this platform to others mirror sites; an Up-Link station, located at the Fucino Space Centre (Avezzano), to transmit to satellite, all the data coming from the client stations connected to the Service Centre. It send IP packets with a DVB (Digital Video Broadcast) streaming; 18 Client stations that process satellite data. They are connected to the Service Centre with a 128Kbps ISDN line and receive downloaded data through the satellite connection. They are based on a PC with a DVB only data card, linked to an antenna with a size between 60 and 80 cm and equiped with universal LNB; TCP/IP network infrastructure; dedicated lines, to allow secure and permanent connections to the Internet - 24 hours a day, 7 days a week; Eutelsat s Hot Bird satellite situated at the 13 degree East slot, to transmit interactive and multimedia services, on the European and Mediterranean bacine coverage area, with a download speed up to 4 Mbps. The new FullSAT system which is being developed by TELESPAZIO offers point-to-point and multipoint options via the EUTELSAT constellation. The new system allows broadband Intranet communication for identified groups, as well as giving access to selected websites via a proxy server. FullSAT system provides the return channels via satellite link in order to give a 313

5 complete two way satellite connectivity service with a star configuration. The center of the star is constituted by Evolv-e Platform that transmit a DVB carrier of 38 Mbps reaching a population of small sized terminals. These terminals communicate with the Evolv-e platform transmitting TDMA carriers up to 2 Mbps. The satellite employed is Eutelsat W3 at 7 E. The main features of this service are: FullSAT satellite network have a star configuration and is linked with the TELESPAZIO Master Station in Rome. For the return channel, it is provided with the use of a small antenna with a diameter of 97 cm. and a 2w of power consumption. So installations will possible with wall installation or with light modular basements. Max DVB throughput is 10 Mbps. Max return channel speed is 1,6 Mbps. The FullSAT terminal is composed by two units connected each other. 9. Medical education and training In Europe, Japan and the US healthcare operators are required to demonstrate participation in continuing medical education (CME) programs following qualification. Traditionally these courses are conducted face-to-face or via reading materials. With the development of technology, the capability for such courses to be completed on-line has become apparent. This enables healthcare operators to access information at any time and from any location and allows the potential scope of available information to be greatly increased. Traditional web systems are too simple to be really effective [12]. Complex commercial e-learning systems require a complex configuration and are too technical for customers. Furthermore the focus of these system is often on the on-line interactivity, while a structured arrangement of educational content must be the first goal. The new system called J-Study will have the following features: Structured Courses. They are stored in a relational database maintained by an administration tool. Every course is multi-language and contains evaluation forms. Courses structure (lessons, concepts) is readily editable and the result available. Innovation in content. The system will be based on the multimedia object called concept, an innovative way to build a lesson. A concept encloses an image, video and text that are needed to communicate an educational concept.. On-line interactivity. Learners will have access to teachers using multicast audio/video/whiteboard interaction in multi-user sessions (virtual classrooms). The quality of audio/video depends on the network but multicast allows exploitation of asymmetrical ADSL and satellite networks. Minimum configuration of the clients. The system is developed in Java, runs on most operating systems and needs no configuration of the user workstation, apart from downloading the Sun Java run time. Also on the server all open software products are used to reduce system cost and increase performances. The system is based on a central server containing all content and structure of content. The software facilitates access to structured information stored on a server representing education content. A module represents a course and is built of lessons. The lesson is built by concepts and self evaluation forms. The concept is the key feature. It is a software entity representing an extension of a slide. Usually a slide is what in a conventional lesson the teacher draws on the blackboard to present an argument. The concept is a multimedia extension of this class. The concept can be a slide (HTML or raster image), a fragment of audio, a fragment of video or a mix of all these at the same time, presented together on the screen. 10. Objectives and advantages The main objective is the availability of a common base of multimedia data relevant to any patient in any Institution connected to the network. A telecommunications network and a proper software can make the patient data available in remote sites enhancing the co-operation between physicians of different Institutions. This system guarantees besides: Patient Assistance. The underlying idea is that the information collected during the patient contacts with health-care structure is of paramount importance for decisions concerning the future treatment of the patient diseases. Data must be accessible by authorized medical personnel only. The patient must not be bound, as far as possible, to limit working and travelling activities. So the patient is likely to have contacts with other Institutes, possibly abroad and the data must be accessible easily, provided the security permissions are given. Medical and paramedical personnel store and retrieve all the relevant data coming from exams, anamnesis, therapy, radiography and any other event relevant to patient contacts with any Institut joining the system. Decision Support Based on Large Statistical Samples. The availability for queries of a wide set of medical cases can be very useful in determining decision about a new patient. A query can be on a single piece of data stored for any patient. For example a physician can find all the patients with a given pathology and their systolic blood pressure lying in a given range. Once the statistical sample is extracted, data from any event in the patient record can be exported in a standard format (for example to be used in a spreadsheet application) for further statistical analysis. Research Activities. The dissemination of large 314

6 number of medical data collection systems integrated in a single network implies that a huge amount of data is accumulated. This information can be a common base for scientific statistical analysis for medicine and pharmacology. Multi-language support. The application can be used at the same time by users of different nationality thanks to the multi-languages support. It is easy to configure the preferred language for each user. Patient Privacy. Patient privacy is a primary issue, that is enforced through strict security checks. Economic Objectives. The proposed system implies many economic advantages. It allows several classes of patients to be treated in remote sites, sharing with physician in Centers of Excellence all the data relevant for medical decisions and diagnosis. The medical protocols and guidelines for disease treatment can be shared. Remote sites medical personnel can join Centers of Excellence programs and associations. It enhances the autonomy of the remote sites hospital system, increasing efficiency and allowing quality assessment. 11. Conclusions The strategic plan of the HERMES Project foresees an expanding medical community after the end of the project. This assumption is based on strong support several new working proposal and new project done by the personal medical of hospitals participating to the project. Our analysis focus on the issue that the telemedicine systems are not yet subject to any form of reimbursement, either public or private and this is the central problem. The reimbursement models vary from country to country. In more private countries, like the U.S., the insurance companies are the main payers of the medical expense, while in Europe the health care system is mostly centralised and public. In any case the reimbursement is relative to well-defined clinical procedures. The hospitals and physicians, public or private, choose when they can the category of procedures they will perform and build an infrastructure that sticks to this model. Every deviation leads to an economic loss. No reimbursement is foreseen for remote clinical procedure. All clinical procedures are relative to patients going to the reimbursed structure. On the other hand all the experts agree that tele-consultation or home assistance can lead to dramatic economic savings and increase quality of life for patients. In our opinion they are central to the sustainability of the exploding medical expense, but the social and political issues connected to changes in the reimbursement scheme are complex. Our conclusion is that the role of the companies promoting this kind of facilities is to build small and medium size very focussed projects that shows feasibility in particular fields. For example clinical trials, that are not clinical procedures, and can hence be considered side activities, are a good candidate. On the other hand this approach has the risk not to reach a politically significant share of the actors, and of promoting many incompatible systems. An other conclusion is that the trade-off between the big and ubiquitous and small but functional approach to telemedicine projects is that projects must not be big but scalable. They must increase awareness of the professionals and work in limited environments. However everything must work in much bigger environments. The partners remain strongly committed to the initiative, in particular considering that all participants accomplish the potential of the system. Hence the actions that will be taken after the end of the project starting November - December 2003 are: give public communications of the project potential and generally increase user awareness of the system; follow ARTES Programme project guidelines to harmonize this kind of projects; commercially follow the layout of Ministry of Health and the advices of our actual observing partner, to support the future of the initiative. There are numerous advantages associated with e-learning, such as flexibility, accessibility, convenience, worldwide distribution and ease of update. It can be used as an efficient and effective means of promoting productivity and the provision of training for increasing productivity and knowledge. References [1] Warr P.B., Evaluation of medical training, Gower Press, London, [2] Haux R., Swinkels W., Lun K.C., Health and Medical Informatics education: transformation of health care through innovative use of information technology for 21 century. Int J. Med Informatics, [3] D Atri A., Casalino N., Pauselli E., Zini G., Foà R., Web-based European education, training and accreditation in hematology, WBE 2002, Cancun, Mexico, [4] ESA Telecom web site: [5] Hasman A., Albert A., Wainwright P., Klar R., Sosa M., Education and Training in Health Informatics in Europe. State of art - Guidelines Applications. Amsterdam, IOS Press, [6] Health Information Technology Institute, Criteria for assessing the quality of health information on the Internet, [7] Telespazio web site: [8] Hooper S., Cooperative learning and computer-based instruction, [9] Mason R., Globalising Education. Trends and Applications. Routledge, London, [10] Moura A., Lhano M.G, Del Giglio A., Education via Internet, Rev Assoc Med Bras, [11] Rose H. C., A plan for training evaluation, Training and Development Journal, [12] Wong S.T., Huang H.K., Design Methods and Architectural Issues of Integrated Medical Image Data Base Systems, Computerized Medical Imaging and graphics,