Prospects of remote diagnostics and telemedicine

Designed to transmit physical examination records and medical reports concurrently to a specialist sitting at a different geographical location, telemedicine and telediagnosis are unraveling a world of exciting medical innovations and utility. Teleconferencing has now stepped into telediagnostics, which ensures that records of images and videos transmitted to a distant location, reflects and stores the diagnostic quality even after being subjected to compression procedures required for transmission. It is streaming of visual information, followed by medical management of the diagnosed cases. 

Innovations in information and communication technology (ICT) are strengthening the advent of telemedicine following telediagnostics, to improve health care of remote populations who remain otherwise inaccessible to specialist physicians. These technologies are avenues to improving equitable distribution of health through expanding the availability of health care to the geographically and topographically remotest population. A major concern, however, is the integration and interoperability of the system and flawless clinical finding and medical record retrieval, which should not be precluded by their regional distribution or ownership. 

Although the terms telehealth and telemedicine are used interchangeably by some, the use of these terms should be differentiated. The former refers to public health and non-clinical services. Another term, i.e. e-Health, on the other hand, refers to electronically generated and stored medical records in general that come within the purview of health information technology.

The inventors and the invention

Wellnitz et al. in 2000 AD first informed the world that x-rays, ultrasound observations, and microscopic examinations of blood films and stool smears could be read remotely. The telediagnostic technique they used was to transform images immediately on a digital platform and transmit with the help of a central computer server (and telecommunication satellite) and a strong, reliable broadband connection, capable of image analysis and instant feedback to both the attending physician in a different geographical area and to the patient or patient's caregivers, including the onsite non-expert medical care providers. 

The telediagnostic technology

Magnetic resonance imaging (MRI), computerized tomography (CT), molecular imaging, computer-aided diagnosis, 4D ultrasound, flat-plate detectors, liquid metal bearings, picture archiving and communication systems (PACS), radiology information systems (RIS), and redundant server technology are all examples of the technology used for telemedical care. These avenues are exhibiting tremendous growth based on new diagnostic technologies and faster computers. Molecular imaging promises a new age of diagnosing and treating disease. Images and reports can be stored digitally and can be accessed quickly to deliver better patient care. All these are based on miniscule millimeter wave technology, used in a hybrid filter architecture which enhances clinical images. But first an adaptive filter is used for background or structural noise suppression and image enhancement prior to the use of millimeter wave technology filter. A good enhancement method may compensate for the limitations in the monitor to some extent and allow direct diagnosis from a monitor as a filmless radiologic or remote diagnosis, by decomposing and recomposing the images more efficiently.

Haptic sensors or an advanced sensorized head, connectivity and efficient telecommunications are supporting telemedicine oriented teleroboticsnow to go beyond and replace the hitherto used teleconferencing. Telehaptics is computer generated tactile (touch) sensations (haptics) over internet, between physically distant service providers and service recipients, using sensors and effectors. Input information from sensors get transmitted to control effectors at a distance to create human linked sensations as outputs.

Sensors range from pressure, temperature and kinesthetic sensing devices, to biofeedback equipment. Haptic sensory effectors evoke a precise perceivable sensation. The effectors vary by type from small motors, fans, heating elements, or vibrators to micro-voltage electrodes which gently stimulate areas of the skin (creating subtle, localized, "tingling" ectrotactile sensations). An assistive telehaptic interactivity technology may also involve synesthesia; e.g. sensed inputs such as breathing, brain activity, or heartbeats etc. which might be presented as gentle, precisely variable bodily sensations in any combination, including warmth, chill, vibration, pressure, etc.; opening possibilities for levels of awareness, and interpersonal communication through distant communication.

One of the challenges in telehaptic applications, however, involves the requirement for stability and the synchronized functioning of multiple tasks in order to effectively operate in a real-time environment which may otherwise be vitiated by background noise.

Platforms and devices for telediagnostics

Several platforms are coming into use in the realm of telediagnoses. The use of an algorithm based Digital Imaging and Communications in Medicine (DICOM) standard is one of those, which ensures heavy file transmission without impairing its original image quality. 

Picker's remote diagnostic tool, an artificial intelligence device, used for CT scanners is an expert-based system called 'Expert'. It is a portable computer system that the relevant operatives may use in the field by inserting a modem into the computer at the 'Picker service center'. The interactive link enables step-by-step diagnostic procedures. 'Expert' is primarily used by Picker field engineers and support staff. The system is licensed for a fee or sold under exclusive contract to end-users. 'Picker' trains hospital in-house service staff in the use of 'Expert' (Donald F. Blumberg, Clinical Engineering Handbook, 2004).

Remote Medical Diagnostician (REMEDI), a project devised by the European Union, uses a prototype robot  controlled from hundreds of kilometers away to conduct a physical examination, (by using an appropriate degree of humidity, temperature and force sensors), and pass data to healthcare professionals. Specifically, the robot is designed to palpate a patient's abdomen for its stiffness of the internal organs and receive the patient's feedback, as well as performing an ultrasonographic examination. The robot used may possess an optional ultrasonic probe at one end and a remote interface (placed at the doctor's location). A sophisticated force-feedback, active vision and locomotion capabilities are fitted at the distal end. The force-feedback stiffness data allow the doctor at the control site to 'feel' the patient's abdomen through a specially designed surface mounted on a robotic arm. The remotely attending doctor sits in front of three screens: one, which shows where the doctor's hand is on the patient, the second allows for direct communication with the patient, and the third is for ultrasound imagery. The combination allows the doctor to decide if the patient should be hospitalized or if an alternate treatment pathway should be adopted. The project authority has been approached by physicians from Australia and Canada where transferring a rural patient to a doctor's office or hospital may take several hours.

The European Space Agency (ESA) supported by an advanced version of therobotics technology is helping the physicians to examine the heart, abdominal and urinary tract diseases in rural and remote hospitals, nursing homes, and prisons in Europe and Canada, for more than 20 years. It was also instrumental in developing a tele-echography technique that can be used in a real-life environment. Radiologists can examine now their patient's chest x-rays to help diagnose pneumonia in corona patients stationed in remote areas. Staffs working in remote health centers without any skill, for example, in reading an ultrasound report, need to position only a robotic arm now on a patient needing an ultrasound based testing.  A trained radiologist, cardiologist, or midwife would then move the robotic arm remotely for quality images, which may also be displayed simultaneously on a larger screen for more focused scrutiny. Ultrasound machines have come into use even for diagnosing pneumonia when an x-ray machine is not available in a remote location. 

As simple a device as a hand-held global positioning system, a laptop, an internet connectivity, and high resolution computer can be used to follow documented prevalence of an infection or an infestation through a 'real-time' surveillance system. The systems that include all these components have been given a name- 'telematics', which is the technique of combining the telemedicine components for the end user. 

Application of telediagnosis technology

Diagnostic procedures were conducted in Paraguay from 54 hospitals for 182,406 people residing in remote mountainous regions. The diagnostics included tomography, electrocardiography, electroencephalography and ultrasound studies. Tomography was done for the skull, cerebrovascular diseases, the chest, the backbone, the abdomen and other anatomical regions. The ECG was useful in diagnosing unspecified arrhythmias, sinus bradycardia, left ventricular hypertrophy, sinus tachycardia, right and left bundle branch block, ischemia, atrial fibrillation. On the other hand, EEG was useful in diagnosing antecedents of seizure, evolutionary control, headache, cognitive impairment, attention deficit in children, brain death, abnormal muscular movements and sleep disturbance. Ultrasound studies were done for prenatal services (Pedro Galván et al. Innovative telediagnosis technology for universal coverage in remote locations without access to specialists).

Application of telemedicine technology

The first successful remote surgery was conducted on 7 September 2001 by Dr. Jacques Marescaux- a French surgeon, from New York City, conducting a cholecystectomy on an old woman, 6,230 km away in Strasbourg, France. It was named Operation Lindbergh. France Telecom provided the fiber-optic ATM lines to minimize latency and optimize connectivity. The Computer Motion was provided by a modified Zeus robotic system. The success and exposure of the procedure led the robotic team to use the same technology (but this time, Bell Canada's public internet) between Hamilton, Ontario and North Bay, Ontario, at a distance of about 400 kilometers. While Operation Lindbergh used the most expensive ATM fiber optics to ensure reliability and success, the procedures in Canada used standard public internet, provisioned with QOS-MPLS. The surgery in Ontario performed twenty complex laparoscopic procedures. An expert clinician from one spot supported the surgeon who was less experienced, operating on his patient in the second spot with the patients. This resulted in patients receiving the best care possible while remaining in their hometown, the less experienced surgeon gaining valuable experience, and the expert surgeon providing their service without travel. 

Remote surgery or telesurgery uses a robotic teleoperator system controlled by the surgeon. The remote operator may give tactile feedback to the user. Remote surgery combines elements of robotics and high-speed data connections. Critical factors are the speed, latency and reliability of the communication system between the surgeon and the patient for a critical surgery. A robotic surgical system consists of one or more surgeon-controlled arms, an onsite master or console controller and a sensory system, which sends feedback to the surgeon.  In Europe, a network of European web servers has been developed in recent times to ensure stable high-speed and high fidelity data transfer. This e-Health allows clinicians to discuss a case through video conferencing, including diagnostic tests checked and interpreted by a body of experts or individual experts, followed by conduction of a robotic surgery or provision of physical therapy through digital instruments from a remote area; and home monitoring through transmission of patient health data, etc. 

In contrast to remotely operated technology, the 'da Vinci Surgical System' is a commercially available onsite robotic surgical system made by the American company Intuitive Surgical. It was approved by the Food and Drug Administration (FDA) of the USA in 2000. The system is used for prostatectomies, and increasingly for cardiac valve repair and gynecologic surgical procedures. It was used for about 200,000 surgeries in 2012, mostly for hysterectomies and prostate removals. By 2019-2020, about 4,986 units were installed worldwide. The "Si" version of the system costs on average slightly under US$2 million, in addition to a hefty amount of US$ 180,000 dollars of annual maintenance fees. The robots in the system assist the surgeon visually, with better precision and less invasiveness to patients. The da Vinci Surgical System has been transformed into a 'Dual Da Vinci System', allowing two surgeons to work together on a patient at the same time, enabling them to control different arms of the robot, switch command of arms at any point and communicate between themselves through headsets during the operation. But these are, as stated, on-site maneuvers.

Medical consultations and diagnoses over telephone and televideosis have been expanding gradually and so also more complex robotic procedures, as mentioned above. The advent of SARS-CoV-2 and the consequent Covid-19 is turning more and more people away from visiting a doctor in person. Physicians themselves are also restricting personal contact with their patients as much as possible to prevent getting themselves infected with SARS-CoV-2. The onsite telemedicine, mentioned above, may also be a useful approach toward ensuring the safety of medical service providers and other care seekers in Covid-19 like situation.

The scope for Bangladesh

Considered from various angles, these technologies and the processes will also be helpful to hinge the universal health coverage on, which the Government of Bangladesh is pledge bound to implement in the country. It is expected that expansion of the availability of health care in its various types and forms along with the fall in the cost of the care (mostly due to saving of the price that other-wise would be needed for travelling, time wasted in waiting, referrals, use of scarcely and costly human resources and saving the opportunity cost) will essentially ensure implementation of the strategy of universal health coverage more efficiently through the pathways of ICT and robotics dependent service provision. In this repulsive period of Covid-19, telediagnoses and telemedicine is an attractive proposition as well, as it reduces the possibility of transmitting infectious diseases between the patients and the healthcare professionals during providing medical care.

Conclusion

The technique of diagnosing a clinical case from a remote site, which does not match with the present day practice of using diagnostic approaches of imaging and recording the findings that are ultimately used for treatment of medical cases, may be questioned on ethical and legal grounds, although no legal measures are in practice anywhere to antagonize this. Although this is a theoretical possibility, stalling these antagonistic approaches needs some legal support. 

Robots might one day be able to perform surgeries with little or no human input, based on their studies of the techniques of expert surgeons stored in computer systems. Carlo Pappone, an Italian surgeon, has developed software that uses data collected from several surgeons and thousands of operations to perform surgery without human intervention. This could one day make costly surgeries available to patients in remote villages at reasonable price.

Abu Muhammad Zakir Hussain is an epidemiologist.