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

Manoli and Jim’s #4

Manoli and Jim’s #5

Let’s Get Started!

Radiologic

Pathologic Correlation

Teleradiology

PACS and Teleradiology: PACS and Teleradiology: Technology and ImplementationTechnology and Implementation

Evan Fram, MD

NeuroradiologyBarrow Neurological Institute, Phoenix, AZ

Telly and George Radiology

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

Yeah, and you can get MP3’s from the Internet, too!

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

Who Will Police Teleradiology

Halfway Done

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

Electronic Teaching Methods

• Docudrama

• Edutainment

• Thrill of Learning

• “Voyage of Discovery”

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 - Advantages

• No IP service required• Portable• No bandwidth problems• “It’s MINE”

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

Cranial Nerves

Olfactory Nerve

Optic Nerve

Oculomotor Nerve

Trochlear Nerve

Trigeminal Nerve

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Hyperlink to the Internet

• Cranial Nerve Diagram

• Eye Motion Simulator

• Calvarium Dissector

Clinical Examination of EOM’s

Look to your Left

Left 3rd Paralysis

Right 6th Paralysis

Patient looking Right

Patient looking Left

Hyperlink to the Internet

• Cranial Nerve Diagram

• Eye Motion Simulator

• Calvarium Dissector

Calvarium Dissector

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

Telly and Crocker Radiology

THE END

Any Questions?

Cranial Nerve Anatomy

• Olfactory I• Optic II• Oculomotor III• Trochlear IV• Trigeminal V

Risks of New Teaching Methods: Reality

• New techniques are UNPROVEN– Code for “I don’t want to!”

• New techniques are Expensive– Code for “I don’t want to!”

• New techniques are not accessible– Code for “I don’t want to!”