Telepathology in Tromsoe, Norway

[Source: Nordrum, 1991, pp. 514-518; Nordrum, 1994, pp. 881-890; Nordrum, 1995, pp.

253-256; Nordrum, 1997, Nordrum, 2000; Eide, 1992/(1), pp. 405-407; Eide, 1992/(2), pp.

409-412; Eide, 1994, pp. 881-890; Elford, 1997, pp. 1-22; http://www.fm.uit.no/;

www.patologi.net; contact: ivar.nordrum@medisin.ntnu.no⁴⁶].

Participants

Expert: University Hospital of Tromsoe, 400 km distance from the remote site in Kirkenes; University of Trondheim; Norwegian Radium Hospital of Oslo Client: Kirkenes Hospital, Hospital of Hardstad, Hospital of Namson, Hospital of

Levanger, Hospital of Arendal;

Additional planned participants: 3 installations in Northern Norway, 8 in Middle Norway, 2 in South Norway.

Background

The use of telecommunications for medical purposes in Norway has a long tradition.

Already in the 1920s ships got medical advises and assistance via Bergen Radio. In

Norway over 85% of the general Norwegian practitioners use an electronic patient medical record system and most patients laboratory results are processed electronically. The stan-dard of health care facilities is very high. Therefore it is no surprise that the Norwegian Ministry of Health and Social Affairs was one of the first that has acknowledged tele-medicine as a legitimate way for health care delivery of medical services, especially since one of the governmental political health care objectives is that Norwegians should have equal access to medical services irrespective of their geographical location. That is why the government recognized telemedicine as a possibility to transfer the medical know-how of the 22 medical centers of Norway to the less populated regions. Together with the Nor-wegian Telecom the government started to financial support telemedicine activities. In February 1993 the first telemedicine department of Norway was officially opened at the University Hospital of Tromsoe by the Minister of Health. In August 1996, one of the first official telemedicine fee schedules world-wide was implemented in Norway, making all telemedicine services reimbursable by national health insurers [Elford, 1997, pp. 1-2].

The ‘Telemed A200’ telepathology system in Norway was introduced in 1990 between the University Hospital of Tromsoe and the Kirkenes Hospital. Since the late 1980s these two hospitals already were involved in various telemedicine approaches, for example teleradi-ology, teledermatteleradi-ology, remote endoscopy, remote gastroscopy, tele-echocardiography, transmission of electrodiagrams, telepsychiatry, electronic delivery of laboratory results or distance learning for health professionals, etc.. In February 1993 the first telemedicine de-partment of Norway was officially opened at the University Hospital of Tromsoe by the Minister of Health. This department helps to maintain, monitor and evaluate telemedicine activities. Today it is staffed by approximately 20 employees and has a guiding position in telemedicine in Norway [Elford, 1997, pp. 1,3].

The introduction of telepathology in Norway was part of the national telematic project [Nordrum, 1991, p. 517]. The pioneer who strongly promoted all activities is Ivar

46 Ivar Nordrum, Associate Professor, Department of Laboratory Medicine, University Hospital of Trondheim. Address: Morphology Building, University Hospital of Trondheim, 7006 Trondheim, Norway; Phone: +4773867396; FAX: +4773867130

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Nordrum. From 1990 to July 1994 tissues from 100 patients have already been examined [Allaert, 1999]. In June 1992 another telepathology system was installed at the Hospital of Hardstad, 200 km from Tromsoe. Further telepathology applications will be installed between the University Hospital of Trondheim and the Hospital of Namsos and the Hos-pital of Levanger, and between the Norwegian Radium HosHos-pital of Oslo and the HosHos-pital of Arendal [Nordrum, 1995, p. 254]. At the end of 2000 ‘PATNET’ will be installed, the Version II of the actual system.

Pathological Services

The telepathology system in Norway is used for frozen section examination, for tele-consultations to review microscopic findings, for the discussion of major diagnostic issues, and for educational purposes. Breast and thyroid tissue examination account to 74% of all teleconsultations. With the installation of PATNET, Version II, the use of the system for second opinion diagnoses, group discussions, quality assurance, and the access to various Internet resources will be expanded.

Equipment

The Norwegian telepathology workstation was developed by the company AM ELEKTRO-NIKK AS (Applied Multimedia Electronic AS, Fetsund) in collaboration with the

University Hospital of Tromsoe and the Norwegian Telecom (now called Telenor), Department of Research. Video images of both, macroscopic and microscopic specimens are processed by a single chip video camera (Sony DXC-107P and DXC 3000) mounted on the microscope. They are transferred to a video codec (Philips VCD-2M-G and Philips VCD ZM-G, later changed to Philips Titan Videoreceiver, programmable for different transmission rates on demand from 128 Kbit/s up to 2 Mbit/s) [Eide, 1994, p. 884; Eide 1992/(2), p. 410]. A videoconference unit with a macro-table and a single chip video cam-era are available for macro-examinations.

The remote hospital in Kirkenes had a Zeiss Axiotron microscope with five objectives (2.5 x 0.075; 10 x 0.30; 20 x 0.5; 40 x 0.75; 100 x 1.3). Later this microscope was replaced by a Leica Medilux microscope (objectives: 1.6 x 0.05; 2.5 x 0,08; 6.3 x 0.20; 16 x 0.48 and 40 x 0.7) and a Mikon A200 remotely controlled motorized microscope, also offered by Applied Multimedia Electronic AS, Fetsund, Norway [Nordrum, 1997, p. 172]. The microscope offers motorization of the stage (Maerckhaeuser, 50 x 75 mm 0.25 µm step) and focusing (Zeiss), an objective revolver and a zoom lens [Nordrum, 1991, p. 514]. The microscope is directed from a workstation at Tromsoe by a computer (IBM PC-AT) pro-grammed for activating the motorized function of the microscope. A computer (PLS, Spider Industries) is connected to the motors to trigger the stage and focus maneuvers from a remote workstation via the tele-network [Nordrum, 1995, p. 255].

Video images can be viewed simultaneously on high resolution 20 inch monitors (Philips 4CM-2789) in Kirkenes and Tromsoe, which enhances the communication between the client and consultant. Frozen sections are prepared by biotechnicians at Kirkenes, who were introduced in doing standard frozen section procedures [Nordrum, 1991, p. 514].

Communication Connection

The system in Norway was designed to use a bandwidth corresponding to approximately 32 telephone channels. The images were transmitted via a two-way video and telephone

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work of the Norwegian Telecom with a maximum capacity of 2 Mbit/s. With availability of ISDN 6 B-channels (384 Kbit/s) are available.

Image reduction filtering was executed by a Philips VCD 2M-G videocodec, later Philips Titan, which is able to handle rates from 128 Kbit/s to 2 Mbit/s. In 1995 the 2 Mbit/s link was switched to a standard rate of 384 Kbit/s [Elford, 1997, p. 7]. The difference between 384Kbit/s and 2 Mbit/s can be ignored, but 128 Kbit/s had proved to be not sufficient [Nordrum, 1995, pp. 254, 256]. For this the video images are compressed in a video-codec and then transmitted via the telenetwork to the receiver’s video-codec for encoding.

Description of the System

The system used in Norway is a hybrid system that incorporates both, dynamic and static imaging. Samples at the client’s site are handled by the surgeon and a medical technician.

Since the bandwidth at the beginning of the project was poor, the dynamic feature was used for the critical steps of specimen orientation on the slide, for overview interpretation, and for general interpretation of normal and uncomplicated structures of a specimen [Nordrum, 1991, p. 516, Eide, 1992/(2), p. 411]. To improve the transmission speed, the volume of live image information was reduced to a minimum before transmission.

The static imaging tool was used for grabbing video images of fields of interest, storing them without compression, and then separately transmitting them as high-resolution static images for tele-examination [Krupinski, 1993, p. 68]. Since transmission time is long, still image retrieving is mostly used for confirming live image interpretation and is only per-formed a few times during an examination. To facilitate the capture and transmission of still images, an application called VIDA was added to the workstation’s PC [Elford, 1997, p. 7]. Still images are of superb quality and are retrieved on a separate monitor.

Video images have a resolution of 288 x 256 pixels in 24-bit color at 25 frames/s, trans-mitted over a 2 Mbit/s network. Still images have a resolution of 576 x 720 pixels x 24-bit color [Elford, 1997, p. 6]. The system is based on the PAL video standard [Nordrum, 1995, p. 255]. In 1994 the videoconferencing equipment was upgraded to H.320 standards

[Elford, 1997, p. 7].

Video images from macroscopic and microscopic examinations are displayed on monitors at both sides. The pathologist at Tromsoe guides the surgeon in Kirkenes by using an arrow. He controls the remote robotic microscope with a supermouse (Mikon A200, devel-oped by NOVAKOM, Norway), which has special buttons for intensity of illumination, for control of magnification and for the optional remote macro camera zoom. Focusing is car-ried out by rotating the supermouse about the vertical axis, and the specimen stage is con-trolled by moving the mouse backwards or forwards and left or right [Nordrum, 1997, p.

172; Eide, 1994, p. 882].

Problems with the System

In August 1993 the telepathology system could not be used because the videoconference network was repaired without notification. In May and June 1994 problems with the soft-ware in the new videocodec lead to difficulties with the transmission of video images.

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