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The Telepathology and Teleradiology Network in Croatia

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The Telepathology and Teleradiology Network in Croatia 223 The telepathology and teleradiology network in Croatia ∗ S. Seiwerth and Z. Danilovic partments of pathology equipped with relatively few, Institute of Pathology, Medical Faculty, University of sometimes little experienced staff members and some Zagreb, Croatia of them working in isolated or hardly accessible hospi- tals (like Dubrovnik), felt this need very strongly. After Telepathology as a demanding branch of telemedicine poses some experimental work during 1993, the concept of a real challenge to experts. The introduction of telepathol- telepathology in Croatia was launched [2,4]. Contem- ogy in underprivileged countries with poor infrastructure porary to this work, a project (supported by the Min- and low health-care budget is a difficult task. On the other istry of Science) with the scope of telepathology as a hand these countries would mostly benefit by introducing basis for Telemedicine started. The technical prereq- telemedicine/telepathology. In our experience it is possible to uisites, inherited from disintegrated Yugoslavia, were build an efficient telepathology/teleradiology network using poor: no other infrastructure except the plain old tele- analogue telephone links and still image transmission, and phone system (POTS) was available. Most of the hos- a store and forward mode of operation. This experience is pitals, university hospitals and university buildings had based on the application of telepathology in Croatia for seven analogue, operator driven switchboards. The develop- years leading to a national teleradiology network. In this pa- ment of adequate software seemed to be the next im- per the ideas, development and software solutions in the pro- cess of establishing a national telepathology and teleradiol- portant steps. A system should be developed which ogy network are highlighted. would be able to function under the given, rather prim- itive circumstances. In addition, it should be the adapt- Keywords: Telepathology, Croatia, teleradiology, still image transmission able to future technical developments [2,8,9]. It be- came obvious that this task could only be performed in a close cooperation between medical and computer 1. Introduction experts working on the spot. To keep scientific enthu- siasm in realistic borders, the cooperation of an univer- sity staff and a small, profit-based company (VAMS, The technological level of communication infras- Zagreb) seemed to be a good solution. These efforts tructure (analogue telephone links versus ISDN versus led at the beginning to a telepathology network, and broadband) needed to introduce telemedicine in gen- few years later to a national teleradiology network. The eral and telepathology in particular is a matter of dis- aim of this paper is to highlight the concepts and tools cussion. The some holds true for the feasibility and ad- of the enterprise. equacy of different operation modes (dynamic versus static; interactive versus store and forward) [1,3,6,13– 17,22]. 2. Concept of telepathology in Croatia Croatia with its specific geographical shape and fo- cal distribution of medical facilities seems to be a Being confronted with the unpleasant situation of country that could greatly benefit from the introduc- war, enemy control areas, isolated hospitals, poor in- tion of telemedicine. This idea was greatly fostered by frastructure and critical finances, the idea of introduc- the war 1991–1995. During this time large parts of na- ing a high-technological tool like telemedicine seemed tional territory were under Serb control and numer- quite ambitious. The first system in use was a deriva- ous vital communication routes were closed. The De- tion of a custom-made image analyzer. The PC-based *Corresponding author: Ass. Prof. Sven Seiwerth M.D., Ph.D., In- system had all equipment and tools required for im- stitute of Pathology Medical Faculty University of Zagreb, Salata 10, age acquisition and the possibility to store image Croatia. Tel.: +385 1 45 66 977/980; Fax: +385 1 46 83 829. files. A simple image transmission program, using a Analytical Cellular Pathology 21 (2000) 223–228 ISSN 0921-8912 / $8.00 2000, IOS Press. All rights reserved 224 S. Seiwerth and Z. Danilovic / The telepathology and teleradiology network in Croatia whiteboard and enabling interactive “chat mode” was authors, is the inability of the receiving side to scan the added. Voice communication was possible using a sep- whole specimen. Thus, the consultant has to relay upon arate telephone line. Based on the experiences work- the judgement and choice of the referring pathologist. ing with this system a concept to develop a national To solve this drawback, different solutions have been telepathology network was elaborated. The geograph- proposed [12,27]. In 1998 we introduced a new tool, ical and socio-political situation was accounted for. called “patchwork” which seems to be very useful in The future network was planed hierarchically with re- overcoming this problems. It enables semi-automatic gional centers (Osijek, Rijeka and Split) and a na- image sampling operated interactively or with a motor- tional center in Zagreb. A close cooperation with the ized stage. To our opinion and experience a continuous newly formed Croatian tumor bank was planed. All control of the focus has to be maintained even when communication was planed on POTS, using interac- using the motorized stage. The result of the patchwork tive mode with still image transmission. Quite soon a is an overview image of the whole specimen, com- telepathology network including 6 workstations, com- posed of full-size, high quality images. These images prising four teaching and two peripheral hospitals was can be expanded to a full screen size. In this man- established [4]. ner the consulting pathologist has the opportunity to Meanwhile, the government started to build an opti- select the field of his interest by himself. The patch- cal cable network throughout the country, as a basis for work can consist of as many as needed elements. The introducing ISDN and ATM. It became obvious that image generated in this way can be stored as a sin- the technical basis for telepathology/telemedicine had gle file or as a part of the ISSA patient file. The size to be improved and the development of new software of a patchwork file composed of 12 images acquired solutions had to be considered. The introduction of the with 6.3 objective and JPEG compressed is about 1.6 Internet as a powerful tool in information exchange MB (Fig. 2). This file size allows easy manipulation created completely new possibilities and opened new and transmission within few minutes [3]. Recently a fields of investigation [1]. Trough the gathered expe- tool enabling dynamic store and forward telepathol- rience and the new emerging technologies the “store ogy was added to ISSA. The histological slide can be and forward” mode of operation came into focus of our scanned in a standard fashion and the scanning se- interest, instead of the interactive mode implemented quence can be recorded (“cine loop”). The images are in the beginning of our studies. The need for further of high quality and high resolution. From the recorded development of the whole telepathology software by sequence every single image can be separately ana- adding new programs, such as an multifunctional im- lyzed and manipulated (enlarged, stored, transmitted). age database, was also obvious. However, storage of these sequences requires space (5–8 times the space of the corresponding patchwork), and a longer transmission time has to be taken into ac- 3. Software solutions count [25]. All the pictorial data described above and stored in To meet our established needs a bi-module tele- ISSA can be compressed and sent via ordinary tele- pathology system was created. It consists of a pa- phone line or Internet, or can be attached to an e-mail. tient database with multimedia functions (ISSA) and Using this mode the images can be assessed by any po- a telepathology module (PHAROS) working on a PC tential communication partner. An other possibility is under Windows environment [7,9,10]. to send the whole ISSA patient file, including textual ISSA is a patient database allowing simultaneous part, alphanumeric data and images. This type of file storage of textual (history, status), alphanumerical can only be opened by a corresponding program on the (laboratory) or images patients’ data as well as sound/ receiving side. By this point-to-point communication voice (Fig. 1). The images can be captured either di- patient data protection is ensured. rectly from source (DICOM standard) or by a camera. The database has also the most often used morpho- CT, MR, US, as well as plain radiographs, images of metric operations (distance, counting, perimeter, area) macroscopic specimens and histological slides can be needed in daily routine. acquired. An additional tool enables the acquisition of PHAROS is a teletransmission module. It works on live image sequences (“cine loop”) [25]. the multipage whiteboard principle, with additional One of the major drawbacks of the classical store chat fields. Single images or patchworks can be placed and forward telepathology, as established by different on the whiteboard. Interactive and store and forward S. Seiwerth and Z. Danilovic / The telepathology and teleradiology network in Croatia 225 Fig. 1. ISSA patient data file (images from different source). mode of operation can be used. When using POTS, 4. From telepathology to teleradiology frozen image transmission is the only possibility. In the interactive mode of operation two cursors and different Soon after the first telepathology network has been marking and measuring tools are simultaneously dis- established and the program solutions described above played on both communication ends. In the mean time have been verified in practice, a national teleradiology voice communication (trough voice modem) and chat network has been established in Croatia. In 1998 the screen are enabled. The program continuously records network, countrywide linking 33 CT machines in 27 a communication chart, a feature important due to le- hospitals, has become fully operational.
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