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

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

 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

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

 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

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

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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PO@HEALTH - A Medical Training Telemedicine Case Study based on Ultrasound Images over an Hybrid Power Line

Network