Telepathology Software and User Interface Design

Researchers and developers agree that one of the weakest link in modern network services remains the interface between the human and the technology [Wyman, 1994]. Therefore the interface design has to be done carefully.

Dynamic software can be briefly described as a specialized video conference system⁶⁰, with a video data communication interface, video/audio sources, loudspeakers, monitors, and a

60 For example, one standard videoconference system which is employed for telepathology is ‘Intel ProShare 200’, which allows a communication by a European standardized ISDN connection, or the ‘Intel Business Video Conferencing System’. The main components are the conference manager, which coordinates data-input and data-output, the video window that displays the images, the data and image transfer features, the memo pad and the ‘application sharing’ tool, which enables all partners to work on the same pad and to use the same applications [Klutke, 1997, p. 68]. Further video conference systems used for telepathology are ‘In Person’ (Silicon Graphics, Mountain View, CA, USA), ‘CUSeeMe’ (Cornell University and White Pine, Nashua, NH, USA) together with the Macintosh based telepathology system ‘Path Maker’ or ‘NetMeeting’ (Microsoft, Redmond, WA, USA).

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video switch [Hartviksen, 1994]. Two-way audio and video is part of all dynamic

telepathology communications. The dynamic robotic telepathology software further has to establish a data connection for controlling the remote video switch, for coordinating all microscope control tools, the light for the macro camera and for displaying the remote cur-sors at both locations. Thus one can say that the basic requirement of dynamic telepathol-ogy software is, to handle the system integration between the robotic microscope, the mul-timedia workstation, and the telecommunications procedures.

Static imaging systems are often realized by simply employing e-mail systems and Internet data exchange, expanded by image capturing and image management features [Kuakpae-toon, 2000; Rosenthal, 2000; Beltrami, 2000; Della Mea, 2000/(1); Della Mea, 2000/(2);

Mihailovic, 2000].

User-Friendliness

Systems should be user friendly from the practitioner’s perspective, and as simple to handle as the telephone. Procedures for conducting telepathology services have to be as plausible and as effortless as possible [Puskin, 1995/(2), pp. 126-127; Klutke, 1997, p. 77;

Coen, 1997, p. 207]. That is also that physicians like to be able to operate a system without a huge training effort. Most pathologists have limited knowledge of computers. Therefore systems have to be so user friendly that no technological problems preclude its daily use.

”Operating a telepathology system is analogous to walking; knowing exactly the origins, insertions, and actions of the leg muscles is not necessary for the ability to walk. Hence, one does not need to be a computer expert to operate remotely a computer controlled robotic microscope.” [Almagro, 1998, p. 1162].

It is obvious that there is a need for adequate user interfaces to create pathological working environments where even non-computer minded people, as physicians often are, can feel at home. Whereas complex program commands, and complicated screen layouts may result in refusal of usage. It is important

”... maintaining compatibility with people not using the software by means of the Internet standard protocols” [Della Mea, 1995, p. 242].

That is why designing telepathology interfaces has to take the general research findings of interface developments in consideration. Mouse, pull down menus, buttons, or touch screen interfaces are more accepted than keyboard commands. Moore even claims that physicians need an extremely simple system.

”You just push one button. Anything harder than that, and the docs won’t use it.”

[Moore, 1995, p. 3].

Unfortunately system designers often fail this demand and create frustrating tools for the physician. For example, if there is a window-like icon screen on the system’s front-end, which does fail to lead to the expected screen, or if physicians have to know exactly how the system recognizes commands, or even have to type commands correctly, physicians will not accept the system as practical [Mariner, 1995]. Regarding telepathology, such systems have to be multi-medial to manage all textual, visual and acoustic data. The retrieval of case data or image capturing has to be simple and fast. For example, at the system used in Sweden, the telepathologist is able to return the microscope to a specific image position with the original magnification just by clicking on that image in the gallery [Cajander, 1996, p. 483].

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A new requested feature by physicians is the data input by spoken commands as well as the capability to recognize speech for computer commands or for generating text from speech. With such tools physicians would be able to directly dictate comments to a case, which are automatically converted to text for insertion into medical records. As an exam-ple, the supplier ‘GSF-Medis⁶¹’ is using the voice processing system ‘IBM-Voicetype’ for developing tools especially for pathologists. This system directly picks up voice dictation by a microphone fixed at the microscope and sends them to a PC for macroscopical and microscopical documentation. The system is a combination of dictation and command input, where a controlled, well structured vocabulary is guiding the user through a workflow structure. When practicing across boundaries, such features could even be combined with translation services [Williams, 1995; Kolb, 1998, p. 114].

Support of the Telepathology Processes - Workflow Management

An important demand of users is that systems should support their workflow instead of the physician has to follow technological restrictions.

”Designs of current systems are driven more by technology than by the needs of practitioners.”

[Puskin, 1995/(2), pp. 126-127]

”First keep the focus on program objectives and secondly on technology.” [Wyman, 1995]

When considering for example the workflow process of a pathological consultation, case selection or the creation of a new file has to be simple and clear. Two users of this study argued that ‘multistep working’ does not satisfy users. That is if the user has to control several tasks within a telepathology session (image transfer, storage, remote microscope control) instead of all these functions are logically integrated. System functions have to be reliable, adequate, and flexible enough for the specific needs of the users and to support all tasks efficiently. In this way telepathology systems could become an important part of everyday pathology practice.

First of all telepathology applications must have a patient data management module.

This module should present patient data input features for the identification of data and clinical comments. It should offer automatic internal index files for the linkage to external patient ID, patient file retrieving functions, as well as patient file archiving and deleting features. Already available patient data should be easily retrievable and linked with the actual data [Bria, 1994]. It would also be from value, if the user is offered a list of actual communication partners to select from. After a partner is selected, a command should be sent through a serial port of the PC to the data terminal equipment to set up the connection [Hartviksen, 1994].

Other very important features of the telepathology software are image capturing and manipulation tools. First of all macroscopic video images have to be captured and docu-mented automatically. Then microscopic image acquisition and digitalization tools have to be available. Image visualization and presentation should be kept flexible and clear (size, icons). The ergonomy should be intuitive and user-friendly. Interfaces have to offer simple to use image treatment tools such as zoom functions, or image cutting and positioning fea-tures. Field width and luminosity, image contrast rendering are further criteria for satisfy-ing interfaces. The pathologist has to be able to select the camera connected on the

61 GSF-Medis, Institut für Medizinische Informatik und Systemforschung, Neuherberg, Germany

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scope to capture images which will be included in the patient’s file. In addition, the telepathologist has to get the possibility to easily add comments of a case to the file and to safe the file with his signature [Allaert, 1999]. The telepathologist further has to have the option to create diagnostic reports for the client or other involved physicians without a lot of additional effort.

Compatibility With Other Telepathology Systems

Dynamic telepathology systems are mostly based on video conference systems. Since the ITU set up the standards H.320 and T.120, most of the standard videoconference systems are able to communicate with each other. The point of weakness is the coordination of the remote control features, which are not standardized and therefore make dynamic system integration difficult and the selection of telepathology partners restricted. Static telepathol-ogy systems are mostly compatible with each other that is that a telepathologist in New York can exchange images with a colleague in Paris without difficulties. Many static sys-tems use open interfaces and documents are translated into the HTML format of the World Wide Web, since such documents can easily be read with every standard browser and no special software is necessary [Schwarzmann, 1999]. In summary, system compatibility has to be taken seriously, since clients may wish to contact different experts, dependent on the kind of service and examination they wish to execute. If a system is only compatible with one partner, which is the case at the moment with many dynamic systems, but also with several static ones, users may be disappointed (the problem of standardization is discussed in chapter 14).