Traditionally, telemedicine systems have been designed to improve access to care by allowing physicians to consult a specialist about a case without sending ...
Copyright © 2001 Society of Photo-Optical Instrumentation Engineers. This paper was published in Proceedings of the SPIE, Medical Imaging 2001 Display Conference, vol. 4319, pp. 693-698 and is made available as an electronic reprint with permission of SPIE. One print or electronic copy may be made for personal use only. Systematic or multiple reproduction, distribution to multiple locations via electronic or other means, duplication of any material in this paper for a fee or for commercial purposes, or modification of the content of the paper are prohibited.
Web-based Home Telemedicine System for Orthopaedics Christopher Laua, Sean Churchillb, Janice Kima, Frederick A. Matsen IIIb, and Yongmin Kima a
b
Departments of Bioengineering, University of Washington, Seattle, WA 98195 Orthopaedics and Sports Medicine, University of Washington, Seattle, WA 98195 ABSTRACT
Traditionally, telemedicine systems have been designed to improve access to care by allowing physicians to consult a specialist about a case without sending the patient to another location, which may be difficult or time-consuming to reach. The cost of the equipment and network bandwidth needed for this consultation has restricted telemedicine use to contact between physicians instead of between patients and physicians. Recently, however, the wide availability of Internet connectivity and client and server software for e-mail, world wide web, and conferencing has made low-cost telemedicine applications feasible. In this work, we present a web-based system for asynchronous multimedia messaging between shoulder replacement surgery patients at home and their surgeons. A web browser plug-in was developed to simplify the process of capturing video and transferring it to a web site. The video capture plug-in can be used as a template to construct a plug-in that captures and transfers any type of data to a web server. For example, readings from home biosensor instruments (e.g., blood glucose meters and spirometers) that can be connected to a computing platform can be transferred to a home telemedicine web site. Both patients and doctors can access this web site to monitor progress longitudinally. The system has been tested with 3 subjects for the past 7 weeks, and we plan to continue testing in the foreseeable future. Keywords: telemedicine, home monitoring, web, Internet, shoulder replacement arthroplasty, physical therapy, rehabilitation
1. INTRODUCTION Since the earliest documented telemedicine studies, the focus of telemedicine has mainly been on using videoconferencing to replace an in-person visit.1,2 It has been noted in teleradiology, however, that the store-and-forward model is more practical because it eliminates the need for scheduling.3 Store-and-forward in the form of a simple e-mail for physician-patient communication was first documented in 19944,5 and discussions of the technical and social issues followed.6,7,8 As more people are becoming connected to the Internet, e-mail is becoming an attractive option for patients and physicians to contact each other. The primary benefit of e-mail is that each person in the communication does not need to be available at the same time. This is a requirement for the real-time videoconferencing type of telemedicine and is clinically very difficult to meet. Another benefit of e-mail is the recorded nature of the communication. Patients, families, and physicians can go back and read old messages as often as they need. For example, doctors can refer to the details of a patient’s question from several months ago and patients can reread doctor’s instructions as often as needed. E-mail interactions are also easy to document by either adding them directly to a patient’s electronic medical record or printing them out to include in a paper medical record. E-mail is also more convenient for patients and providers than contact by telephone or office visits. They can access each other without waste of energy, time, or money, which is particularly important for individuals who are disabled. Although e-mail has a number of attractive properties, there are also a number of drawbacks. Intermediate networks along the delivery route of an e-mail message can eavesdrop on the communication. This has caused some concern if patients use their employer’s network to send e-mail messages to their physician. Although it is now possible to encrypt messages in many popular e-mail programs, the reports of patient-physician e-mail usage to date have shown that encrypting messages is not widely practiced. In order to use encryption, users must obtain keys identifying the recipients of their messages. Although an infrastructure for key distribution and authentication across the Internet is in place, it is more commonly used by enterprises, such as commercial web sites, rather than by individuals. In addition to the encryption issue, there is also an issue that e-mail contacts are not structured, which can lead to inefficiency. For example, follow-up messages to previous contacts from a patient are mixed in with appointment requests in a physician’s inbox, and messages must be manually added to a patient’s medical record. Even with the sophisticated filtering capabilities in e-mail programs, adding structure to e-mail contacts is difficult and transferring the information from an e-mail into an electronic medical record tedious.
A web-based messaging system offers the same benefits as regular e-mail and addresses many of e-mail’s drawbacks.9 In this type of system, patients and physicians log into a web site to both send and read messages, but messages can only be sent to other users of the same web site. This design addresses the security issue because all web transactions can be easily encrypted. Even if a patient uses his or her employer’s network to access the web site, all information transmitted over the network is encrypted to prevent eavesdropping. Most importantly, use of a centralized web server to implement the system allows the patient-physician communication to be structured to enable efficient management of messages. Although webbased systems to manage patient-physician interaction have been developed both by universities9 and companies (Healinx, Alameda, CA and MedicaLogic, Hillsboro, OR), they have not yet used the web’s capability to exchange information other than text and simple forms. In this work, we present a system based on web standards that allows the bidirectional exchange of richer information than previous systems have allowed.
2. METHODS A web-based messaging system, called E-Medicine, was developed that allows patients to easily send multimedia information, such as video and audio, to their physicians. Patients are also monitored through multiple-choice self-assessment questionnaires, such as the SF-36,10 implemented as web forms. Video and audio, which cannot be entered using HTML forms, is collected using a web browser plug-in. Although browsers can post a binary file to a web server, users must manually select the file to post either from a graphical interface or by typing in the file path on a web form. To streamline the user interface and eliminate the multiple steps involved in acquiring video, saving it to a file, compressing the file, and entering the path to the file in a web form, we have developed a browser plug-in that performs these tasks. The plug-in posts videos using the same message format that web browsers use when posting binary data, so no proprietary server software is required to accept the posted files. All connections are made using the secure sockets layer (SSL) so that all data are encrypted when traveling over the Internet. This is an advantage over systems that use a separate FTP server to accept files.11 Although the files transferred using FTP can be encrypted, login information is always transmitted in clear text. The networking component of the current browser plug-in can be reused in the future to implement plug-ins that acquire and transmit data from various biosensors, such as blood glucose, blood chemistry, heart rate, motion and acceleration sensors, etc. Information Flow The target application of our initial E-Medicine system is monitoring the recovery of shoulder replacement surgery patients. Surgeons would like to monitor their patients’ progress through video status updates of how they are progressing in their assigned physical therapy exercises. Videos are necessary to help identify problems that may be developing, and the system saves patients a trip to the doctor’s office if they are progressing well. Through the system, physicians can change assigned exercises and link patients to digital video on the web site demonstrating how to properly perform the exercises. The system also reminds patients about the medications they should be taking. Patients are asked to periodically fill out SF-36 and simple shoulder test (SST)12 self-assessments. Doctors can view the scores from these surveys graphically over time. The information flow for the system is shown in Figure 1 and proceeds as follows. Patients are authenticated during log-in by entering a user ID and password. If they have not completed an SF-36 health status survey recently, they will be given this choice before proceeding further (Figure 2). The SF-36 is a general health questionnaire used commonly in the medical field, which gives a general indication of physical and mental health and can be used to track patients’ progress through the recovery process. After the survey, patients can review their current treatment, which includes medication and physical therapy exercises (Figure 3). They can also review previous status reports and service requests filed. At this point, they can file a status report, or if they are having a specific problem, they can send a message to their physician about the problem. If they choose to file a status report, they will be asked to complete a Simple Shoulder Test form, which contains questions used to gauge their shoulder function. They are then asked to record videos of themselves performing their physical therapy exercises (Figure 4). In the case of a question or problem, they can record a single video demonstrating the problem. They then log out of the system while waiting for a response to the question or status report. When orthopaedists log in, they see a list of service requests from their patients (Figure 5). After choosing a request to view, they are presented with a summary of the patient’s previous SF-36 and SST scores as well as information entered about the current status report or question (Figure 6). The physicians can also view the videos patients have recorded for the service request and view previous requests along with the physician responses for those requests. Physicians then type in a response to the service request being viewed and optionally change the medication or exercises assigned to the patient (Figure 7). At
the patients’ next log-in, they will see physicians’ responses to their requests (top of Figure 3) along with updated exercises and medications. Patient Log-in
Patient Log-in
SF-36 Survey
Review Current Treatment
Patient Service Request
Service Request Response
View Service Request List
Physician Log-in
Review Physician Response
Figure 1. E-Medicine application information flow.
Figure 2. SF-36 function self-assessment.
Figure 3. Patients’ home page.
Figure 4. Patients’ video recording interface.
Figure 5. Physicians’ home page.
Figure 6. Physicians’ status report review page.
Figure 7. Physicians’ treatment adjustment page.
System Implementation The system is a typical three-tier web application (Figure 8) using Internet Information Server (IIS) and Microsoft SQL Server 7.0 running on Windows 2000 Advanced Server and Windows 98 with Internet Explorer 5.5 on the client side. The text of the web pages is generated using VBScript code running from the Active Server Pages (ASP) filter included with IIS. The graphs of the SF-36 and SST results are generated using an IIS extension written in C++ that produces JPEG streams using the Intel JPEG Library. Although the GIF or PNG format would be ideal, a free library for encoding these formats was not readily available when we were implementing the system. A Java application runs on the server once a day to send e-mail reminders to doctors if they have unanswered messages on the E-Medicine system. The Active Desktop feature of Internet Explorer was used on patients’ machines so that a simple login screen is displayed after the computer is booted. By clicking a login button on the Active Desktop, patients can establish a dial-up connection to the Internet and connect to the E-Medicine web site in one step after powering up the machine. Patients’ web browsers have a plug-in installed that can capture video directly from the browser window, compress it, and transfer it to the server. The plug-in was implemented using the Microsoft DirectShow API to control a video camera. It compresses the video to 128 kbps using the H.263 codec included with QuickTime. QuickTime was chosen as the video format because the most common computers used by our clinicians are Macintoshes, and the QuickTime software has both Macintosh and Windows implementations. The H.263 codec works well with the type of video we are acquiring because the camera is stationary, and there is no fast motion in the videos. The encoded videos are sent to the web server using the HTTP POST request format specified in Internet RFC 186713 for file posting from an HTML form. The secure HTTP connection is established using the WinInet library included with all current versions of Microsoft Windows. Web Browser DHTML User Interface
HTTP Web Server
Data Collection Plug-in
Application Server
HTTP RFC 1867
Figure 8. E-Medicine system architecture.
Database
Preclinical Trial The E-Medicine system is currently being tested with patients recovering from shoulder operations at the University of Washington Medical Center. Patients are trained to use the system in their hospital rooms on the second day after their operation. When they are discharged, they are loaned a video camera and laptop computer with all the necessary software installed. Patients are asked to try to file one status report including video images each week and are encouraged to report any problems regarding their recovery immediately. Usage of the various features of the application and users’ navigation patterns are being tracked to help improve the design of the application. Users’ comments and suggestions are also being collected for the next revision of the system.
3. RESULTS AND DISCUSSION The preclinical trial has been operating for 7 weeks with one subject who has already returned the unit and 2 ongoing cases. Our index case consisted of a patient undergoing a complex humeral reconstruction for a chronic humeral infection. Initially, the E-Medicine system was used to monitor the incision for signs of recurrent infection. Later as the patient progressed with recovery, the unit was utilized for prescribing and monitoring physical therapy. The patient was instructed during his initial hospitalization on how to use the system, including a brief demonstration on how to image the incision. However, the first video from the patient did not have an ideal camera angle for the physician to adequately evaluate the status of the incision— the camera was held too close to the incision, making it difficult to tell the orientation of the camera. Following this, the patient was instructed via the E-Medicine web site, on the proper distance and orientation of the camera to obtain optimal quality images. As the patient progressed to shoulder range of motion exercises, he was instructed to place the camera on a stationary object to further improve image quality. For the standard shoulder replacement patients the system was designed for, we addressed this problem by posting example videos on our web site of all the physical therapy exercises we expect to be assigned. The examples both remind patients how to do the exercises and show the recommended camera orientation. We will be able to evaluate the benefits of this solution after we have results from the more standard shoulder replacement patients. While our initial application of monitoring patients after shoulder replacement surgery is necessarily specific, the system has the potential to be generalized for other application areas. For example, an E-Medicine system could be used to document the home progress of an individual with spinal cord injury or follow an individual with a chronic disease, such as AIDS, arthritis, asthma, or diabetes. In these applications, the data from patient self-assessments and video utilized in the current implementation could be augmented by data from electrodynamometers to measure strength, goniometers for joint motion, spirometers for lung volume, and microfluidic devices still under development for blood chemistries. Each of these measures could be collected without leaving home and each measure could be made part of an individual’s E-Medicine record for comparison with prior and subsequent data.
4. CONCLUSION A distributed electronic medical records system was developed using off-the-shelf Internet, video, and database technologies. A web browser plug-in was developed to simplify the process of capturing video and transferring it to a web site. The technique used to construct the video capture plug-in can be extended to capture and transfer any type of data to a web server. For example, readings from home biosensor instruments (e.g., blood glucose meters and spirometers) and medical imaging systems (e.g., home ultrasound machine) that can be connected to a computing platform with a plug-in extensible web browser can be transferred to a home telemedicine web site. Both patients and doctors can access this web site to monitor progress longitudinally. According to a recent report from the Institute of Medicine,14 even medicine’s best people are struggling to keep up with medical advances and communicate with each other and patients. It faults the system with lagging behind in adopting computer technology. The report states that care should be available when patients need it, 24 hours a day, by Internet, phone or face to face, and patients should have more control of their treatments and medical records. The home telemedicine system we have developed recognizes the opportunity to enhance the ability for patients to get the information they need just in time and for them to control and make entries in their own medical record.
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