Teleradiology and Teleteaching
James G. Smirniotopoulos, M.D.Chair, Dept Radiology
Professor of Radiology and NeurologyUniformed Services University
Bethesda, MD
Telemedicine and Teleteaching:
Educational Objectives
• Describe the Advantages and Disadvantages of Live Didactic Lectures
• Contrast the advantages of electronic and print media
• Summarize the Opportunities for Enhancing Learning with Electronic Teaching
PACS and Teleradiology: PACS and Teleradiology: Technology and ImplementationTechnology and Implementation
Evan Fram, MD
NeuroradiologyBarrow Neurological Institute, Phoenix, AZ
Roles of Film
• Display for study interpretation• Viewed by referring physician• Transportable• Archive• Part of Imaging Process for
Radiography
Problems with Film
• Expensive to produce• Expensive to store• Expensive and slow to retrieve• Can be lost• Only in one place at a time
Telemedicine Goals:Better Patient Care
• Improve timeliness of reports• Immediate access to cases
– images available everywhere electronically and no lost exams
– exams read immediately– exams available without
searching
• Improve clarity of reports• Improve access to experts
Telemedicine Functional Requirements
• Extremely fast• User-friendly, simple• Cost-effective long term
archive• Hard-copy alternative to film• Tele-transmission to doctors
offices and homes
Enabling Technologies• Powerful, inexpensive, widely
available, industry standard computers - Wintel (Intel Chip & Windows OS)
• Archive - Inexpensive permanent• Extremely Fast Network / Servers• Extremely Fast Image Display• Client-Server Architecture• Telecommunication
Softcopy Reading is Better
• Improves Patient Care• Improves Timeliness of
Reporting and Efficiency of Radiologists and staff
• Improves Access for Clinicians• Promotes Subspecialization• Readings More Accurate• Saves Money
Image Acquisition
• Digital Modalities
– Frame Grab - Laser Camera– Digital - DICOM vs
Proprietary• Analog Modalities - Film Scanner• Implement Digital Modalities First
– Medically sound - full fidelity– Best return on investment– Least Physician Resistance
HIS - Hospital InformationRIS – Radiology Information
• Ordering information (order entry system) and demographics flow from HIS / RIS to PACS
• Reduces work of technologists• Increases accuracy• HL7 standard for information
exchange• Reporting Results
Image Archive• Requirements:
– Permanent and Non-modifiable– Standard Format– Inexpensive compared to film
• CD-ROM Works – DICOM– ISO 9660– $2 for 680 MB
• Tape Fails
Server Hardware
• High speed on-line storage for immediate access to several weeks of cases
• Mission Critical Fault tolerant architecture
• Allows simultaneous display on multiple viewstations
• Maintains databases of cases, referring doctors, radiologist’s preferences...
Hardcopy- “Film on Demand”
• Interface to existing laser camera
• Print as needed, even from PACS archive
• Automatic formatting of entire case or montage
• Free spooler functionality
Hardcopy Alternative
s
• Automated formatting and printing of entire case or montage
• Copies sent with report to referring clinician for chart
• Grayscale printer vs high resolution paper laser printer
• No chemicals, darkroom or processor
Clinical Viewstation
• Key to Telemedicine success• LAN and Teleradiology• Must be widely accessible to result in
goal of improved access and efficiency
• Inexpensive PC or laptop• Wards, OR, ER, clinics, homes• Simple to operate - 1 minute training• Dedicated Software or WWW browser
Key Features of Clinical Workstation
• Simple exam search and display tools
• Monitor exams in progress across the LAN / WAN.
• Compare to old studies• Instant access to all on-line exams
from any PC• Display montage, play voice clip,
and display report
Key Features of Radiology Workstation
• Fast / Simple to Use and Learn• Multiple Modes of Image Display and
Navigation - Stored Preferences• Image Display Tools: W/L, Mag, …• Control of Archive and Hardcopy• Ability to Compare to Old Exams• Ability to Create Report / Montage• Monitor Exams in Progress
Teleradiology• Primary vs Secondary Reading• Push vs Dial-in Access• Queue of cases to be sent can be
assembled and managed, e.g. stat sending
• Automated transmission with automatic redial
• Compression used for low speed• Voice grade lines, switched 56, ISDN, T1
Subspecialization via Teleradioogy
“… it may be preferable to have a superb neuroradiological opinion by such remote methods rather than the opinion of the on-site gastrointestinal radiologist or general radiologist, doing their half-day a month reporting the stack of neuro-CT cases.”
Hynes et al. Toward filmless and distance radiology. Lancet 350:657-60,1997
From Blackboard to WEB:
Changing Strategies in Education
James G. Smirniotopoulos, M.D.Chair, Radiology and Nuclear
MedicineProfessor of Radiology and
NeurologyUniformed Services University
Bethesda, MD
Begin with the END in Mind
Broadest Goals of the SOM:
–Competent Caring Physicians
–Practice Evidence Based Medicine
–Life Long Learners
(BTW - Must Pass the USMLE Step 1 and 2)
Traditional Teaching Methods
Medical ApprenticeshipClassroom x 2 years
didactic lectureslaboratory, small grouptextbook, syllabus, handouts
Clinical x 2 yearssmall groupbedside and practice
Basic Assumptions
• People learn differently– reading, writing, listening, seeing
• Learning is not linearly ~ teaching• People learn better when
“engaged”– fear of tests– excitement of learning– challenge of self assessment
Traditional Teaching Methods
Didactic lecturefixed time and placeminimal interactivitypace controlled by instructordirection (path) controlled by
instructor
Enduring Materials
Textbook, syllabus, handoutsuser chooses timeminimal interactivitypace controlled by userdirection (path) controlled by
author
Traditional Teaching Methods
Advantages“Proven” technologyTeacher comfort
Limitationslinear learning processsingle learning pathwaydiscourages independent thinkingsubjectively less satisfying
Traditional Teaching Methods:
with a Slight TwistAudio cassette (of lecture)Videotape (of lecture)Laserdisc (slide collection +)CDROM (slide collection +)Usually a linear and instructor
directed single pathway or a Reference Work or Atlas
Electronic Teaching Methods:
Minimal application• Electronic “page turning”
– Books on tape (w/pictures)
• Index and searching– Find answers faster
• Additional content– Not available in lecture or text
Electronic Teaching Methods:
Moderate application• Audio track
– Static image w/narration
• Video clips– Motion sequence (pt. Video)
• Self-assessment mode– How well am I doing? (user
feedback)
Electronic Teaching Methods:
Opportunities• Interactivity
– stimulates user
• Branching content– Natural Learning through Exploration– stimulates user– individual user pathways
• Self evaluation– feedback and remediation of problems
Electronic Teaching Methods
• Sensible Animations• Meaningful Interactivity• Bandwidth Concerns• Expense vs. Savings
– Color (no extra cost)– Sound (free)– Additional Content
• Education vs. Entertainment
Traditional Large Group Teaching Methods
(like this Didactic lecture …)• Comfortable consistency • Often Have a Rigid Structure• Can Be Relatively Dull• Foster memorization rather
than integration• But: “I know I can pass the
Exam.”
Risks of New Teaching Methods: Perception
• New techniques are UNPROVEN
• New techniques are Expensive
• More work for Faculty
• New techniques are not Accessible
Risks: Reality• New techniques are UNPROVEN
– no validation of existing methods
• New techniques are Expensive– short term investment, long term
reward
• More work for Faculty– you were revising your handout anyway
• New techniques are not accessible– > 85% of USU students are computer
literate in college
Advantages
• Reduction in Textbook Costs– CDROM ~$1.00 regardless of content– color and sound w/o added expense
• More Current– Easier to update (link to website)
• Self directed Learning– SOM becomes a “Voyage of
Discovery”
Internet - Advantages
• Minimal service and delivery costs
• Always current• Link to other content• “It’s Everyone’s”
Disadvantages
• IP Service Access Costs– USU provides free access at 56k
• Not portable– new wireless technologies
• Bandwidth Concerns (at 56k)– OK for static images– streaming audio/video?
CDROM - Disadvantages
• Duplication & Distribution– equipment & personnel costs– human resources
• Fixed Content• Not Linked
Electronic Teaching Methods:
Faculty Issues• Faculty competence with technology
– Time to Learn New Techniques– Expense for Software/Hardware
• Tradition (inertia) to continue past methods
• Incentive to Change– Course Director (wants to)– Chair (recommends)– Dean (requires it)
Examples
• Cranial Nerve Anatomy– Simple diagram– Annotated diagram– Highlighted diagram– Animated diagram– Shockwave Animation of Eye
Motion
Conclusions
• Teleradiology offers opportunities to improve quality and timeliness of care
• Teleteaching and Computer Aided Instruction offer opportunities to make Medical School a “Voyage of Discovery”
Telemedicine and Teleteaching:
Educational Objectives
• Describe the Advantages and Disadvantages of Live Didactic Lectures
• Contrast the advantages of electronic and print media
• Summarize the Opportunities for Enhancing Learning with Electronic Teaching