RESUMO
OBJECTIVE: To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. SUMMARY BACKGROUND DATA: Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. METHODS: Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. RESULTS: The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.
Assuntos
Colecistectomia Laparoscópica , Tomada de Decisões Assistida por Computador , Internet , Sistemas de Informação em Salas Cirúrgicas , Consulta Remota/instrumentação , Sistemas Computacionais , República Dominicana , Equador , Humanos , VirginiaRESUMO
The objective of this paper is to determine the effect of varying transmission bandwidth on image quality in laparoscopic surgery. Surgeons located in remote operating rooms connected through a telemedicine link must be able to transmit medical images for interaction. Image clarity and color fidelity are of critical importance in telementoring laparoscopic procedures. The clarity of laparoscopic images was measured by assessing visual acuity using a video image of a Snellen eye chart obtained with standard diameter laparoscopes (2, 5, and 10 mm). The clarity of the local image was then compared to that of remote images transmitted using various bandwidths and connection protocols [33.6 Kbps POTS (IP), 128 Kbps ISDN, 384 Kbps ISDN, 10 Mbps LAN (IP)]. The laparoscopes were subsequently used to view standard color placards. These color images were sent via similar transmission bandwidths and connection protocols. The local and remote images of the color placards were compared to determine the effect of the transmission protocols on color fidelity. Use of laparoscopes of different diameter does not significantly affect image clarity or color fidelity as long as the laparoscopes are positioned at their optimal working distance. Decreasing transmission bandwidth does not significantly affect image clarity or color fidelity when sufficient time is allowed for the algorithms to redraw the remote image. Remote telementoring of laparoscopic procedures is feasible. However, low bandwidth connections require slow and/or temporarily stopped camera movements for the quality of the remote video image to approximate that of the local video image.
Assuntos
Aumento da Imagem , Laparoscopia/métodos , Telemedicina/métodos , Cor , Terminais de Computador , Apresentação de Dados , República Dominicana , Equador , Telemedicina/instrumentação , Telemedicina/normas , VirginiaRESUMO
BACKGROUND: Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world. STUDY DESIGN: Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine. RESULTS: Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps. CONCLUSIONS: Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.
Assuntos
Unidades Móveis de Saúde , Procedimentos Cirúrgicos Operatórios , Telemedicina/instrumentação , Equador , Humanos , Mentores , Relações Médico-Paciente , Consulta RemotaRESUMO
Surgical procedures can be performed and monitored in operating rooms physically isolated, but electronically linked to a parent medical center, and certainly from distant consultation. Quality of surgical care has been measured in retrospect rather than in real time, and outcomes have generally not had the benefit of immediate consultation and group analysis. However, telemedicine can connect consultants, surgeons, patients, and databases. The Yale Telemedicine Center has developed network schemes, which connect the OR of trainees with the laboratory of the teacher, and has opened a continuum between pedagogy and product. The program has connected regional hospitals, connected components of hospital systems, and has been used in international testbeds. The particular operative procedures studied have been laparoscopic procedures. The consultant is based at Yale and is connected with the distant OR to share the laparoscopic surgical field. Connection includes real time video, audio and the ability to draw instruction on the OR screen. Bandwidths as low as 12kbs(POTS) have been employed with modification with effective intervention. The potential for quality improvement is substantial, and inclusion in quality programs is strongly recommended.
Assuntos
Laparoscopia , Garantia da Qualidade dos Cuidados de Saúde , Consulta Remota/métodos , Connecticut , Equador , Cirurgia Geral/educação , Humanos , Avaliação de Programas e Projetos de Saúde , Programas Médicos Regionais , Serviços de Saúde Rural , Comunicações Via Satélite , ZimbábueRESUMO
Adherence to the treatment regimen for patients with diabetes is of major concern to healthcare practitioners, particularly when dealing with the high-risk, low-income, Mexican-American population. Assessing the attitudes and beliefs of this group is vital for planning effective and realistic intervention strategies. Therefore, we designed a culturally sensitive instrument to measure health beliefs and attitudes of low-income Mexican Americans with diabetes. The Health Belief Model (HBM) was used as a basis for this study because it is well accepted as a predictor of health-related behaviors. However, we found that the HBM was not an effective tool for assessing the health beliefs or attitudes of this patient population even after rigorous efforts to operationalize the HBM and after conducting extensive statistical analyses. Only two of the five subscales of the traditional HBM, barriers and benefits, were reliable. Scales to measure acculturation and fatalism were added to increase the cultural sensitivity of the tool. These added components were found to be an important variable in interpreting the results for low-income Mexican-American patients.