The aim of this project is to setup a transportable telemedicine workstation (PC plus telecommunication capabilities) connected with a light, portable ultrasound station and use it as a telemedical device in isolated areas such as islands, rural areas and crisis situation areas. The system proposed has low price, low weight, is transportable, non radiating, and supports a very large range of applications varying from gynecology to abdominal scans. The technical principle consisting of an integrated workstation containing a portable ultrasound device, computing and telecommunication capabilities. By using advanced techniques the workstation will be able to collect 3-dimensional ultrasound data of the patient, i.e. to perform a "echotomography". The doctor in the field will scan the corresponding part of the patient. By means of the build in flexible telecommunication channel (phone line, ISDN, Internet, Satellite) the acquired 3D-dataset will be transferred to the remote expert, who can be virtually everywhere in the world. After data transmission both experts will be linked online over the telecommunication channel performing "virtual echography" on the 3D-data replicated in each site and viewing the identical images on the screen in realtime and without lag even through narrowband telecommunication channels. The workstation and a portable device will be tested in different socio-economic conditions and will be adjusted accordingly to meet needs of developing countries and countries in transition. The project includes a development phase at the beginning after which a field test will be performed, with clinical relevant situations. A redesign will be processed and evaluated in a second field test phase. At the end of the project a medical teleconference emergency workstation is expected to be available that will be used in Europe as well as in other regions of the world allowing to provide health care service where it is not possible by the usual means (ecological disaster areas, remote rural areas, isolated islands). The user needs in this area are already clearly identified and stated in many ways and forms. This project will use already proven technology in real situations. The objective here is to provide a cost and use effective solution for crisis situations in isolated areas. This isolations are created both by geographical issues (islands and rural areas) and human related issues (war, pollution). The proposed solution lies, in part, in a popular notion circulating in various medical circles, especially where telemedicine is concerned. This is the idea of "scanning the data and not the patient." The idea here is to establish a kind of "information equivalence" between the patient and the representation of that patient in digital form, so that there is little to no loss in examining the patient through the data representation, compared with what would be lost during a direct in-person examination. Given that it is faster and cheaper to ship information around than to ship people (patients and doctors), volumetric representations become compelling as a substitute for the live patient. The point for the radiologist is that the volume representation can be "resliced" from any direction one might desire. This avoids the need to acquire a whole new set of images (requiring the patient to make another trip to the hospital), if for some reason the original set leaves 3D relationships ambiguous. Recent developments in the area of 3D Ultrasound are also quite compelling. Interventional ultrasound, as in the case of biopsies, can benefit significantly from volume visualization. In addition, unlike its radiationbased counterparts such as MRI and CT, ultrasound devices can be reduced to backpack size, making them portable. Augmented with telecommunications capabilities, this makes possible a degree of health care previously unachievable in regions that are difficult-to-serve, expensive-to-serve, or under-served. It is this area in particular, of portable ultrasonography, that has motivated recent developments at the Fraunhofer Center for Research in Computer Graphics in the area of volume visualization. The technological solution has been tested and evaluated in a real crisis situation. The user reactions where highly positive and the proposed solution was approved. Now the intention is to work further on this technology improving it and making it more suitable for a more broad set of crisis situations. For this the consortium has joined a excellent set of entities that represent all the necessary intervenients in this process : technology providers, hardware providers, endusers, world-wide representative institutions.

2.1.1 User needs to be addressed and description of application sites
A long standing problem in the health care industry has been the delivering of first-class care in areas that are difficult-to-serve, expensive-to-serve, or simply under-served. Doctors are, understandably, often adverse to working in areas that are high in conflict and/or remotely situated and, therefore, out of touch with peers and mainstream medicine. By minimising or even eliminating such disadvantages, telemedicine stands to reengineer (that is, revolutionise) the delivery of health services world-wide. First-class expertise can be made available at anytime, anywhere.
This is specially the case in isolated areas (rural, islands) and in crisis situation areas (ecological disaster, military conflict). Developing countries, with different diseases and in different situations, and where the traditional infrastructure does not function for whatever reasons, have a urgent need for telemedicine. The main situations where this need is most clear are:
- n Isolated areas / rural areas / islands
- n areas of calamity or ecological disasters
- n conflict zones
These communities need to have access to health care services that were until now either inaccessible or very difficult to obtain (long travels and staying in medical centers). This access is only achieved through the use of applications that allow remote expert consultation providing a faster response in emergency and crisis situations.

• 2.1.1.1 ISOLATED AREAS / Rural Areas / ISLANDS
  Isolated communities can not be served directly by specialists due the difficulties of transportation (case of some islands), to its distant location or even to low inhabitancy. Therefore it is clear that the only way to provide a reasonable health care service to these populations is through Telemedicine. On the other hand most rural communities do not have imaging capabilities such as MRI and CT. The only economically and practically affordable imaging equipment at this moment is ultrasound (US). The system proposed in this project is a low price, low weight, transportable, non radiating, and with an ENORMOUS range of applications from gynecology over endocrinology, gastro, urology, surgery, orthopedy to cardiology, US scanner connected to a telecooperation off-the-shelf workstation.
  This setup has one possible drawback: at least in most of the European countries, for creating a diagnosis the doctor has to directly interact with the patient: keep the transducer and free-hand "navigate" in the patient’s body. It so out of question to use it as a remote acquisition device in this terms.
  The solution however is available: use 3D ultrasound instead of conventional 2D in order to create a "virtual 3D-digital patient tomographic ultrasound model". The next step is to transmit it to the remote expert using usual channels (ISDN, Satellite, Mobile Communications) and make online real-time telecolaboration. This eliminates all drawbacks from the expert being not inplace with the patient. There are several areas for which this scheme is appropriate and feasible and that the consortium of TeleInViVo has identified:
• 2.1.1.2 Islands of Azores in Portugal
  In the Azores Islands the main Hospital is located at the city of Ponta Delgada. It collaborates on frequent basis with other regional hospitals and has a special agreement with the Univ. Hospital of Coimbra for patient and physicians interchange. Also there is a wide see area that is covered by these islands. Casualties overseas is another crucial aspect that has to be considered in order to improve health service quality in islands. Through the TeleInViVo setup it is possible to give direct emergency support to ships using satellite or mobile communications with the help of both the medical centers in Azores as well as to provide emergency service throughout the several islands that form the Azores archipelago and also from the islands to the University hospital of Coimbra.
• 2.1.1.3 Canary Islands
  The Canary Islands have a population over 1,5 million people and an average population density about 200 inh/Km². Tenerife is the second more populated island with 685,583. The most important cities of Tenerife are Santa Cruz, the capital, and La Laguna with a population of 202,674 and 117,718 inhabitants respectively. TeleInViVO will be here specifically used for prevention and treatment of the prenatal malformations and high risk pregnancies at distance and for the control of infertility and in vitro fertilization. Emergency cases are the other aspect to be taken care of whenever needed (aboard ships, other islands, etc.).

2.1.3 Areas of ecological disasters: Aral sea area in Kazakhstan
The United Nations Environment Programme (UNEP) considers that, in terms of its ecological, economic, and social consequences, the Aral Sea is one of the most staggering ecological disasters of the twentieth century (World Bank, Uzbekistan, country study).
The main issues pertaining to the Aral sea basin area are as follows: the reduction of the sea, the distraction of its aquatic ecosystem, the lowering of soil quality in the Aral Sea basin, the pollution of surface and groundwater, (e.g., the adverse effects of sand and solt storms), the depressed economy (e.g. no employment opportunities), and the adverse health impact on the population (e.g., waterborne diseases), due to the absence of potable water and inadequate sanitation. "Incidence of chronic, noninfectious diseases among the population of the highly polluted Aral region is 1.5-2 times higher than the national average. The health status indices in the Kzyl-Orda highly polluted oblast (where the Aral sea situated) show an increase of cancer among teenagers and a high incidence of invalidism in young people" (UNDP,Kazakhstan Human development report, 1995). The Aral Sea region considered as a rural and remote area (to some "islands" one can get only by airplane). When the Sea was there, fishery was the main occupation of the local population. Now when the Sea is gone, indigenous people (those who stayed) became cattle-breeders in the middle of the desert. Kazakhstan can be also considered as developing country in terms of health care indices:
"The indices of women’s health in the Republic (Kazakhstan) averages 30 % lower than standards for the developed countries. In some regions where the population capacity to adapt to the constantly deteriorating conditions of life is practically exhausted, it is even lower. Every second woman in the Republic suffers from anemia and every six from kidney disease" (UNDP,Kazakhstan Human development report, 1995).

2.1.4 Implications of the application for the user community, its impact and innovation
The proposed system has a wide range of applications in terms of medical diagnosis and therefore it will have a big impact if used in isolated and crisis situation areas. This impact is reflected through the improvement of the Health service provided - specially the case of islands - and through the availability of a fast and effective emergency service in crisis situation areas.
Due to its special characteristics (portable, wide range application, multiple communication option) it is possible to use it in almost all locations and situations. Azores and Tenerife will be test sites within the EU UNESCO will manage sites in Uganda and Aral sea area and through it open the range of application situations. A typical consultation (or emergency) session will take no more then 4 steps:

1. patient scanning
2. setting the system up (making the necessary communication connections)
3. exchange of data
4. telemedicine consultation

The implications that can be foreseen and expected from the use of the described telematics scenario are: cost and time savings, increasing of effectiveness, optimising patient handling, improvement of medical knowledge, better preventive care, especially for isolated communities.

• 2.1.4.1 Cost and Time savings
  On the economic point of view, the perspective of this technology will have two implications. First, the short term consequence is a significant reduction of the number of patients transferred for diagnosis with no real need for "high level" treatments. Second, the results of this project will have some implications in the reorganisation of the Health care services. These aspects will arise due to the fact that:
  - the physicians do not have to travel so much and so long
  - reduce patient transportation, saving costs and time
  - avoid duplication of diagnostic procedures
• 2.1.4.2 Increasing effectiveness, optimising patient handling
  The use of the telematics application will improve the quality of the Healthcare service provided through:
  - better patient handling and logistics management
  - faster help in emergency situations
  - better management of resources (human and equipment)
  - reduce patient transportation, avoid risks and inconvenience
• 2.1.4.3 Better preventive care for isolated communities
  The isolated communities addressed in this project will have access to health care services that where until now either inaccessible or very difficult to obtain (long travels and staying in medical centers), avoiding dangerous transportation.

2.1.5 Application and its aim
The Fraunhofer IGD together with its partners, has already implemented a working prototype of the medical field workstation of the future on a notebook or laptop-sized PC with powerful 3D visualization software, groupware tools, communications capabilities (e.g. ISDN), and inexpensive light-weighted, portable, battery powered, diagnostic sensors, like 3D ultrasound. Manufactured in quantity, these machines should be low-cost and should be attractive products for private, for-profit companies (e.g., those operating emergency response ambulance teams in the United States and other Western Nations), international civilian relief agencies (like the Red Cross and some United Nations agencies), government emergency management agencies (like the US Federal Emergency Management Agency: FEMA), government health agencies (in countries in most of Africa, Asia, and Middle and South America), and military agencies (Army, Air Force, Navy, Marines).
In the summer of 1996, based on IGD’s software technology and telecommunication modules a prototype 3-D ultrasound telemedicine system was developed for use by NATO military peacekeeping forces during the "Bosnia War" under field conditions. This system, called the MUSTPAC-1, was tested using satellite communications between Germany, Bosnia, and several sites in the U.S. This test included a workstation located at the Tuzla hospital and a similar one at Madigan Army Center in the State of Washington where radiological specialists where located and available for real time consult with their medical counterparts on location in Bosnia. It worked very well, exceeding expectations in some areas. Typically this system is used as follows. First, the patient is scanned by placing an ultrasound probe on the patient and mechanically sweeping it across their skin over the area of interest. During the scan, the system records ultrasound data from a sizable 3D volume of the patient’s anatomy, producing a 3D volumetric dataset of ultrasound reflectivity. The scanning process requires no interpretation of the ultrasound images, other than possibly to confirm that the intended anatomy is covered and can therefore be performed also by non-medical trained personal as well.
Scans in the form of 3D volumetric datasets are then transmitted over any standard digital network to a qualified diagnostician. Finally, a diagnostician interprets each 3-D scan using a Virtual Ultrasound Probe that simulates a conventional real-time handson examination procedure. This allows the diagnostician to display arbitrary 2D slices from the 3D dataset simply by moving the probe as if they were interactively examining the patient. The Virtual Ultrasound Probe and corresponding screen displays are very natural to diagnosticians, leading to rapid acceptance and productivity. Our aim is now to improve significantly this workstation with a lighter and robuster US scanner with 3D capabilities. The telecommunications option will be extended from ISDN, to also several telephone lines, mobile communications up to ATM and Satellite. Good response times for transmission of data and cooperation will be crucial as also security aspects. On the user interface and cooperation level ergonomics, intuitiveness will be improved and adapted in order to guaranty a minimum training time and easy use by all.
Field test sites will be setup in Azores and Canary islands with a mobile station and a fixed station for medical diagnosis support in Coimbra at the University Hospital. For the areas of Kazachstan and Uganda a capital of the country where the tests taking place is going to function as the supporting medical site. The proposed workstation will consist of a portable lightweight US device specially modified for the purposes of this project. For the work of modification and creation of this component of the WS we need 10 KECU per device according to the responsible partner for this task. In addition to that the WS will provide telematics capabilities through a modified portable computer. This computer will also be adapted for specific needs prevision of costs are around 8 KECU for this part. Finally for the integration work, packaging, inclusion of special boards, etc. an additional sum of 2 KECU will be needed.

1. the delay for data transmission, but also the time needed to prepare the "examination package", were incompatible with the emergency context
2. the "emitters" had no real control on the quality of the expertise which was often felt as "anonymous".

Until now the research projects addressing this area have been technology driven and have only handled isolated aspects of telemedicine. Commercially available products provide only specific, isolated solutions. Besides this, the lack of cheap, secure and generally available reliable communication interfaces restricted the impact of this technology on the user community, although everybody believes that this aspect will play an important role in the near future.
The improvement of telecommunication speed, the dropping costs, the general availability of these services, and the improved reliability, allows its use by a wide range of users and application areas. To add to these expectations, the appearance of low-cost terminal devices, are going to widespread even more the daily use of telecommunication in all areas of human enterprise.

2.2.2 InViVo- Volume Renderer and 3D Ultrasound Upgrade
The Interactive Visualizer of Volume Data (InViVo) is a robust and fast software tool for viewing almost any kind of scalar three-dimensional data (G. Sakas and S. Walter, Extracting Surfaces from Fuzzy 3D-Ultrasound Data, Siggraph 95 Conference Proceedings, pg. 465-474, 1995). Running on virtually all UNIX platforms, PC’s with Linux or Windows NT, and Macintosh, it is a very affordable volume processing solution. Performance scales almost linearly with additional CPU’s, and it supports the DICOM-3 standard and arbitrary image sizes (i.e., resolution). All major volume visualization techniques are available and can be arbitrarily combined. Volume and surface rendering can be mixed to generate varying degrees of transparency. Arbitrary slices can be taken through the data, and there are tools for filtering, measuring, segmenting and planning trajectories. Perhaps its most outstanding feature is its cutting-edge processing of notoriously noisy ultrasound data, yielding results that are second to none. With all these capabilities, InViVo is poised to be a major tool in the teleradialogical medicine bag.
Nonetheless, to rightfully claim such a position, it must do more than display data. It must facilitate the communication of information among medical personnel involved in collaborative diagnosis and treatment planning. It must allow for ease of communication between the radiologist, the radiology technologist, the primary care physician, and the patient. In short, it must enable computer supported cooperative work (CSCW) among health care professionals. InViVo (Interactive Visualizer for Volume data) is characterized by its high performance, versatility, and friendly, compact interface. The name, InViVo, has actually come to represent a modular family of volume visualization products each of which adds new functionality on top of a common core of capabilities. There are currently six major variations on the theme:

1. InViVo-Vis - the most basic version comes with a powerful set of tools to render surfaces (e.g., gradient shading), peer through volumes (e.g., maximum intensity projection), and slice through data.
2. InViVo-RAD - which includes DICOM3 compatibility and segmentation.
3. InViVo-3DUS - which adds special ultrasound filters.
4. InViVo-Plus - which adds advanced tools for segmentation, measurement, and diagnostic support.
5. InViVo-Scan - using 3DUS or Plus as the base, it enables conventional 2D ultrasound systems to acquire volume data by tracking the sensor’s 3D position and orientation.

1. Collecting User needs, Specification of HW and SW. Only after consulting all user a detailed specification can be generated.
2. Setup of equipment and software. The software has to be adapted to the user specifications. The hardware has to be constructed/integrated accordingly
3. Initial test, alpha acknowledgment. Will be performed mainly with Coimbra Hospital
4. Installation at field test sites. All test sites will be installed within this period
5. Application test, verification list. After a few months of initial tests several modifications wishes will be collected
6. Redesign, back to step 3. Implement requested modifications and re-install
7. Demonstration of the working prototypes to a wide number of potential future users, organizations etc.

The harmonization of the Health Care sector at European level will be supported and incited through the exchange of knowledge and information among Health Care professionals and the technological community. This will allow to exploit the existing differences, in the European Union, in terms of legal, cultural and socioeconomic structural issues, for the definition and identification of existing and new problems in the area.
This includes the harmonization of the telecommunication infrastructure, in order to obtain a global European communication structure. In this aspect the project will contribute to the test and use of communication facilities and technologies at a European. This Task can only be done, if the use of Telematics applications is done at a international level that allows the creation of a set of guides to integrate existing (and used) application technology.
Another very important issue is the cost-effectiveness of the Telematics technology that will be used. If the validation of this issue is done only at National level, it will not be possible to obtain a representative result, taken into account the existing economic structural differences.
For this validation task, the project involves users that represent the main categories of European Countries, and will perform the validation taking into account different kinds of situations and conditions.
Directly linked to this aspect is also, the cultural and legal aspect. It will be necessary to consider always for the validation of applications and system involving the communication of medical data, cultural and legal aspects. These include data security (requirements vary from region to region), user interfaces, communication between users, etc.

• Users involved The consortium involves users representatives of two European states (Portugal, Spain) and UNESCO which will test the system in Uganda and Kazakhstan. Coimbra Hospital will work as the centre of expertise and provide remote consultation to all sites
• Technologies and/or approach used The proposed technological solution has been proven in real cases as prototype. The aim now is to improve it making the station lighter, cheaper, robust, secure, easy to use, adding new desired features to it such has mobile communications facilities, improved user interface, etc.
• Expected benefits for the citizen The possibility to provide medical imaging emergency service in remote areas such as islands, rural areas or in crisis (war, pollution) situation areas is itself an enormous improvement in live quality. Physicians will be able to provide better care, in a faster and easier way.
• Expected benefits for the users of the application Medical care can be provided through this system almost anywhere at anytime. The physicians and Health Care organisations will be able to guaranty high quality care without having to travel and being moved over long distance.
• Expected benefits for the European Industries We expect to have at the end of this project a "killing application product" offering a maximum of functionality and performance within a minimum of time. The consortium involves two industry partners that are directly interested in commercialising the product. If the re-sults are as expected it is probable to be used at a world wide range.
• Contribution to EU-policies Contribution to the improvement of Health Care quality in Europe, namely in remote locations, like islands in less favoured regions. Creation of products according to CE certification norms for medical areas. Co-operation at international level with world wide Health Care organisations.

The Health Care sector suffers from a increasing growth of the costs attached to it, and in order to respond to these needs and demands, it is necessary to create ways and means for a better effective use of already existing facilities, technology and resources (human and equipment). This can only be done, as already demonstrated in previous European activities, using existing and generally available Telematics technologies.
If we compare, the costs attached to a major new investment in equipment, infrastructures and human resources and those attached to investments on Telematics Health care systems and applications, the last ones are much more lower and consequently practicable, than the first ones, which can not be supported by any country or institution. The developments we propose are cost effective if made at European level: the complementary of the knowledge involved and individual experiences, the validation of results and the investments needed to perform the project goals are needed but very difficult at national level.
The social impact of this common strategy could be measured by the increment of the health care services quality and the equality of the health care services in the different European regions.

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