PO@HEALTH
A Medical Training Telemedicine Case Study based on Ultrasound Images over an
Hybrid Power Line Network
Alécio Pedro Delazari Binotto, Flávio Ávila, Carlos Eduardo Pereira
CETA - Center of Excellence in Advanced Technologies SENAI, Av. Assis Brasil 8450, Porto Alegre, Brazil
UFRGS - Federal University of Rio Grande do Sul (Informatics and Electrical Engineering Departments), Av. Bento
Gonçalves 9500, Porto Alegre, Brazil
Cirano Iochpe
PROCEMPA - Information and Communication Technology Company of Porto Alegre, Av.Ipiranga 1200
Porto Alegre, Brazil
UFRGS - Federal University of Rio Grande do Sul, Av. Bento Gonçalves 9500, Porto Alegre, Brazil
Ilias Sachpazidis, Georgios Sakas
IGD - Fraunhofer Institute for Computer Graphics, Fraunhoferstrasse 5, Darmstadt, Germany
Keywords: Telemedicine, Power Line Communication, Medical Training, Medical Images, Collaborative Interactivity.
Abstract: The growth of fast internet, including the recent advance on using PLC (Power Line Communication) for
reaching rural and remote areas in Brazil, and the state-of-the-art of image compression methods allowed
rapid teleconsultations and medical training based on medical images. At the present time, one of the
challenging problems in telemedicine is the real-time teleconsultation in case of emergency and for the
medical training at remote regions where the internet access is precarious. In this paper, we present the kick-
off of the applied project PO@Health, which merges the European-Latin American T@lemed Project
(telemedicine based on ultrasound images) and the Brazilian PLC Restinga Project (communication via
Power Line in a remote district). The platform used for medical teleconsultations and residents training is
able to perform both on-line (in real-time) and off-line image-based teleconsultations over the Internet
connection. For the ultrasound cases, the platform is being adapted to work with the DICOM medical
images synchronized with the physician hand position images of the examination in order to increase the
diagnosis precision. In addition, we describe the hybrid network over PLC that is being used by the
telemedical platform.
1 INTRODUCTION
Actually, telemedicine is currently growing as a
research topic for the improvement of health
services, increment of the population life quality,
and also for remote medical training, including the
residents. Based on this advance, the qualified health
care of excellence medical centres is extended to
remote and undeserved areas with difficult access
and precarious communication.
Most telemedicine applications are massive
image-based (examinations obtained from
ultrasound, CT, ray-X, resonance, etc), being used
not just for teleconsultation, but also for a simple
second opinion, repository research or remote
training through the Internet. However, this strategy
depends completely on the Internet bandwidth and
its reliability and security.
The communication through the electric net
grows very quickly all over the world (Motorola,
2007). Designated PLC (Power Line
Communication) in Europe and BPL (Broadband
Power Line) in the United States, the data
communication through electric power nets is
already an alternative that competes and/or
28
Pedro Delazari Binotto A.,
´
Avila F., Eduardo Pereira C., Iochpe C., Sachpazidis I. and Sakas G. (2008).
PO@HEALTH - A Medical Training Telemedicine Case Study based on Ultrasound Images over an Hybrid Power Line Network.
In Proceedings of the First International Conference on Health Informatics, pages 28-33
Copyright
c
SciTePress
complements the wireless communication systems,
satellite and wired applications, like cable TVs
(Opera, 2007).
Based on the telemedicine and using PLC as part
of the communication channel, this paper will
present the ongoing work and its preliminary results
performed at the PO@Health Project, located in the
capital city of Porto Alegre (Rio Grande do Sul
State, Brazil) and it is organized as follows. It starts
with a brief motivation and description of the
medical scenario. We follow with previous work on
projects in the telemedicine and PLC areas and a
detailed explanation of the proposed platform
(emphasizing ultrasound examinations) and the
network communication. Then, we present the
medical, technical, and social results achieved
during the first pilot. Finally, we discuss the
estimated benefits and directions of the on-going and
for future work.
2 MOTIVATION
At Porto Alegre, capital city of Rio Grande Do Sul
State in Brazil, the Maternal-Infantile Hospital
Presidente Vargas (HPV) is a medical referral center
involving pregnancy. The public hospital assists a
vast part of the population in the city who lacks of
specialized maternal/medical infrastructure. Most of
these patients come from remote districts just for the
accomplishment of routinely ultrasound
examinations and for accompaniment of pregnancy
evaluation.
Restinga is the poorest and the most remote
district of Porto Alegre, having more than 80.000
inhabitants, with a population density of 23
inhabitants/ha, and occupying more than 20.000
homes. The growth tax between 1991 and 2004 was
from 5,6% per year and the medium monthly
income of the answerable for the domiciles is 3,03
minimum wages.
The district counts just with a small health center
and lacking of specialist physicians and basic
medical devices, including ultrasound equipment.
The health center sums up an average of 300 patient
transfers to HPV per month for basic ultrasound
examinations, being more than the half in the field
of obstetric/gynaecologic. This represents a risk for
the patient since this kind of transfer involves
transportation risks in bad conditions streets,
traumas and other financial costs for simple exams.
In addition, it overflows the HPV capacity with
patients that, in the majority of the cases, could be
assisted in their own district by available General
Practitioners, the residents, for example, helped by
an expert doctor, using a basic structure with
ultrasound and internet connection. In fact, most of
the cities have a basic structure of general doctors
who, very often, cannot give a final and correct
diagnosis without a second medical opinion or
assistance/discussion, even remotely over the
internet.
Nevertheless, there was no fast internet
connection structure at Restinga since the year of
2006, when a power line communication pilot
project started to be implemented, offering fast
internet communication in the plug-ins of four
public buildings.
The next section will go in detail over two
previous projects, one based in telemedicine and the
other based on PLC, which are the basis for the just-
started applied project PO@Health (telemedicine
over PLC).
3 PREVIOUS AND PARALLEL
EXPERIENCES
3.1 T@lemed
Following the telemedicine concepts, the T@lemed
Project (T@lemed, 2007) was developed by the
authors and was based on a teleconsultation
platform, named TeleConsult, which allows a
medical store-and-forward image-based
telediagnosis in real-time on-line mode or either off-
line.
Figure 1: TeleConsult main interface.
The TeleConsult software platform is based on
TeleInViVo (Kontaxakis et al., 2000), which is a
telemedicine workstation used in isolated areas such
as islands, rural areas and crisis situation areas. The
TeleInVivo system integrates in one custom-made
PO@HEALTH - A Medical Training Telemedicine Case Study based on Ultrasound Images over an Hybrid Power Line
Network
29
device a portable PC with telecommunication
capabilities and a light and portable 3D ultrasound
station, combining low price, low weight, mobility
and a wide range of non-radiating examinations. The
integrated workstation used advanced techniques
able to collect 3-dimentional ultrasound data of
patients, which were presented on (Sakas and Hartig,
1992), (Sakas, 1993) and (Sakas et al., 2000).
For T@lemed and for this case study project, the
reason to work with ultrasound data is based on its
support to a very large range of applications (Ferrer-
Roca et al., 2001), varying from gynaecology and
abdominal scans to cardiological examinations and it
is currently the only economically and practically
affordable imaging modality. However, the platform
can deal with any other DICOM images acquired
either through the DICOM network. Figure 1 shows
an overview of the TeleConsult interface.
As an example of its functionalities, digital
annotations can be made by the generalist in the
medical images and sent to the specialist physician,
aiming to delineate some region of interest to be
argued. The data sending can be carried through an
off-line connection, where messages (images +
annotations + first opinion + other crucial data to the
diagnosis) are sent in determined moment (at night,
for example) and later on, in another moment, the
medical specialist performs the diagnosis or opinion;
or through an on-line connection. In this last way,
depending on the bandwidth, the data are transmitted
in few seconds and collaborative discussion
(annotations + chat + voice + measurements +
interaction), is carried out in real-time. Figure 2
depicts the annotation interaction.
Figure 2: TeleConsult collaborative annotations.
In the scope of T@lemed, the doctors from four
remote cities of the Rio Grande do Sul State were
connected over wired internet (512Kbps) with the
specialist center (Santa Casa Hospital) in the capital
city of Porto Alegre. Figure 3 explore the simple
network configuration.
Figure 3: T@lemed network configuration.
3.2 PLC Restinga
The PLC Restinga Pilot Project, PLC network in the
Restinga district, arises to supply an economical gap
promoted by wire telecommunication companies, to
attend deprived communities. Concerning the work
of (Borges, 2005), the digital inclusion goal in Brazil
is to look for the population (or at least its great
majority), independently of age, sex, income, race,
ethnic origin, exceptionality level or geographical
location, to be able to receive access to tools,
services, and necessary technological abilities in the
new economy. The PLC technology implementation
cost and installation, using the medium tension net
for data transmission, could be cheaper than the
costs of available technologies, being the
sustainability and cost effectively one point of study
in this on-going work performed by part of the
authors from this article.
Figure 4: The PLC network at a whole.
Basically, we can classify the segments of
communication networks via PLC in 3 areas (see
Figure 4):
HEALTHINF 2008 - International Conference on Health Informatics
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Medium tension: interval between the electric
power company substation and the
transformer of low tension that serves the final
consumers;
Last mile: interval of electric net in between
the transformer of low tension and the
consumer's residence;
Last inch: interval of electric low tension net
located in the consumer's dependences.
Taking advantage of the fiber optic network from
the Information and Communication Technology
Company of Porto Alegre, which is interlinked to
the optic ring from the State Company of Electric
Energy, a PLC network was formed, beginning from
the CEEE substation, located in one of the
extremities of the Restinga neighborhood. Illustrated
on Figure 5, four different points are connected,
chosen from its geographical position and lack of
digital services: (1) public primary school; (2)
district administrative center; (3) professional
primary school; (4) health center.
Figure 5: PLC medium tension map at Restinga.
The pilot reaches a linear extension of
approximately 3.5 kilometers, transmitting data in
high-speed (45Mbps, since we use the first
generation of equipments) on the electric network of
energized medium tension of 13.8 kV. The project
foresees the implantation of several services, taking
maximum advantage of the communication speed
made available by the system. Thus, its
complementally with the telemedicine application.
The implementation of this net was only
possible due to an optic fiber channel located at the
CEEE substation (point 0 in the Figure 5). Starting
from this point, the sign from the optic fiber is
injected in the medium tension net throughout
capacitive couplers (Figure 6a). The PLC sign goes
direct trough the electrical line, with acceptable
losses, in distances of up to 1200 meters, where
regenerators modems (Figure 6b) are installed
aiming the system sign losses reconstitution.
Repeating modems (Figure 6b) are also installed in
these points to overlap the maneuver keys and the
derivations in the medium tension net. In the
extremities special modems (Figure 6c) are used,
called HE (Head End), that receives the PLC signal
from the medium tension line and re-inject this
signal in the electric net of low tension
(127V/220V). The signal that arrives in the assisted
points through the low tension is extracted from the
power plug using a modem for low tension (Figure
6d), designated as CPE. Finally, the communication
system among the modems HE and CPE are point-
to-point, i.e., for each modem HE just exists one
CPE modem connected.
Figure 6: PLC equipments: (a) capacitive coupler; (b)
regenerator and repeating modem; (c) HE modem; (d) low
tension modem.
4 PO@HEALTH PROPOSED
PLATFORM
The “Health at Porto Alegre” (PO@Health) Pilot
Project is on its user requirements phase and has the
goal to merge the experiences described on Section
3 (telemedicine over hybrid PLC network) with the
foreseen significant differences bellow:
Ultrasound training for residents: the focus
on this pilot is on the resident physicians
distance training. This means that the platform
should offer an interface with fast connectivity
where the expert physician is able to guide
interactively the resident physician on image
(a)
(d)
(b)
(c)
PO@HEALTH - A Medical Training Telemedicine Case Study based on Ultrasound Images over an Hybrid Power Line
Network
31
acquisition and thereafter on the diagnosis.
The study case increases on its importance
since the Brazilian law authorizes just medical
physicians to operate ultrasound;
Interactive tele-acquisition: as the focus is on
residents, the expert doctor has to visualize the
ongoing-acquirement of images in real-time or
at least with acceptable interactivity and not
allow just a store-and-forward collaborative
opinion or telediagnosis;
Transducer location image: ultrasound is the
only medical device which produces medical
images that are completely human-dependent
on its acquirement. Due to that situation, the
ultrasound transducer position on the patients
body is a crucial information for the exam
interpretation. Hence, the platform must also
afford the medical images synchronized with
the transducer position;
PLC and telemedicine economical model
improvement: the pilot will deploy an
feasibility study for PLC based on
telemedicine direct costs (for example, costs
of exams, communication, transportation, etc)
and non-direct costs (for example,
psychological traumas, savings due
prevention, etc);
Prevention control: on the medical point of
view, the pilot should also contribute on
development of prevention control methods
for remote regions, since they do not need to
wait for the symptoms because telemedicine is
a way to improve the capillarity of expert
knowledge.
5 PRELIMINARY RESULTS
To illustrate PO@Health, only for demonstrating the
project conceptual meaning, the Figure 7 depict the
first prototype using a low-cost portable ultrasound
and a screen sharing application running on the
background of the developed ultrasound viewer.
Different from T@lemed, here we used common
sharing software to perform the initial tests
regarding the real-time acquisition and a web-
camera window for the transducer position. As
expected, the screen sharing consumed a high
bandwidth of dedicated 4 Mbps for screen
transmitting and VOIP. However, the images update
was not performed in real-time allowing basic
training, but not capable for exams aiming the
pulsation detection, like, for example, the fetus
hearts pulse, which is very important to recognize if
the fetus is sleeping or dead in the case of
motionless.
(a)
(b)
Figure 7: PO@Health using a portable ultrasound (a) and a
screen sharing application for the ultrasound images and
transducer position (b).
This test will be useful for a future image-quality
and bandwidth consume benchmark, comparing the
final stream-based solution with other possibilities.
6 CONCLUSIONS AND FUTURE
WORKS
This short paper presented the applied research for
the general conception of a telemedicine system
which is being developed/adapted based on
ultrasound images and on PLC data communication
for resident physicians practical distance training.
The study case scenario is on the Restinga remote
district of Porto Alegre city, where there is a PLC-
based network implementation going on. We believe
that the use of PLC as the channel for data
transferring will be feasible and bring great
capillarity for telemedicine services, which deal with
large data.
As current work, we are performing the
benchmark tests using a stream-based application
sharing (RRD Streaming, 2007) which is a general
solution to stream desktop contents to remote
HEALTHINF 2008 - International Conference on Health Informatics
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locations in real-time, focusing on live video,
presentations, simulations, 3D visualizations, and
dynamically changing scenes applications.
Depending on the results, RRD Streaming will be
the basis for the TeleConsult adaptation to attend the
main user requirements (synchronized interactive
tele-acquisition module and transducer position in
real-time).
Performance measurements on the PLC network
at Restinga are also a current work, verifying in loco
that the first generation of equipments will allow us
to reach up to 45Mbps in an optimistic situation.
We also intend to update some PLC equipments to
the second generation, allowing theoretically up to
200Mbps and look over the performance of a mixed
network composed by first and second generation
equipments.
Further studies on PLC and telemedicine
feasibility will also be performed, trying to expose
it’s complementarily and thus the PLC capillarity.
ACKNOWLEDGEMENTS
We would like to thanks the following institutional
partners for partial financial support and fruitful
discussions: Porto Alegre City Hall, Science and
Technology Ministry of Rio Grande do Sul State,
Getúlio Vargas Hospital physicians, and CEEE
(State Company of Electric Energy).
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