AN OPEN SOURCE TELE-REPORTING SYSTEM BASED ON RAILS

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Aziende Sanitarie Virtualiper i Popoli Migranti
Aldo Franco Dragoni  
Lorenzo FalsettiNicola Tarquinio  
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TCP/IP-BASED TELECARDIOLOGYRESULTS PITFALLS -
PERSPECTIVES
U.O. DI MEDICINA INTERNAOSPEDALE DI
OSIMO Director Dott. Prof. Francesco
Pellegrini UNIVERSITA POLITECNICA DELLE
MARCHE FACOLTA DI INGEGNERIA Prof. Aldo Franco
Dragoni Pellegrini F, Falsetti L, Del Prete S,
Filippi G, Tarquinio N, Rossini S, Di Stefano S,
Ciotti G, Vaccarini I, Clavelli A and Aldo
Franco Dragoni
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A 5-years experience

• A TCP/IP-based telemedicine system has been
  implemented all over our territory
• Since then, it has been used to carry several
  kind of informations 1. Cardiological
  Consultation2. ECGs (first opinion/second
  opinion)3. Echocardiograms (second opinion)

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Standard Protocols
Standard Protocols

• In order to reduce errors, we Standardized
• EquipmentThe whole operations were based upon
  the same system
• OperatorsA formation period of 2 months was
  required for the initial training of a standard
  equipe of 2 nurses.
• ProceduresAll the procedures, from acquisition
  to report were made upon the same protocol

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Man power
Man Power

• This system allowed to manage the work in our
  Hospital with a minimal equipe 1. Physicians
  3 trained physicians Report,
  Quality control
  Case management
  
  Second-level examinations
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  (when needed) 2. Nurses
• 2 trained nurses/point Data collection
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  Data transfer
• Small damages repair

Every acquisition point was entirely managed by
2 Nurses. Resident physicians were excluded
from protocols but could have access to the
system and could ask for a second opinion on
their exhamination
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Standardization

• We applied the same protocols for- Inpatients
  - Admitted in our Unit - Admitted in the
  other Units- Outpatients - Territorial
  cardiology - Other Units Outpatients (Day
  Hospital) - Drug survelliance for psychiatric
  patients- Other Nations Services

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Nonstandard Procedures

• Non-standard procedures were allowed only
• in a service based upon our servers but using
• another technology for a mission in the
• Philippines.
• The whole operation has been managed by
• University of Siena.

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Endpoints
Endpoints

• Reduce reporting times
• Increase number of reports
• Standardize reporting
• Increase productivity
• Create a large repository of anamnestic data
• Create a common database for instrumental
  findings

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Outside Italy
Emerging Countries

• Despite the massive workload in our Zone we were
  asked to try to export our experience in foreign
  Countries
• We were asked to install the same system in
  Kerkennah Island, near Sfax (Tunisia)
• The place have been selected by locals who asked
  for a cardiology reporting system

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Outside Italy
Outside Italy

• Another mission, managed by University of Siena
  but hosted in our systems, was installed in the
  Philippines

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Outside Italy
Outside Italy

• Kerkennah system is a mirror of our actual
  territorial installations - 2 tunisian nurses
  teached in our hospital- A client and a
  digitizer for cardiological informations
• In our vision, this installation should have been
  a pilot project in order to extend our model of
  telecardiology outside Italy

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Pitfalls
Pitfalls

• In Italy we are working with large volumes of
  data (about 11000 ECGs reported, with a mean of
  500 ECG/digitizer/year).
• Tunisian equipe didnt send more than 150
  tracings over a two-year period an useless
  volume, counting the high cost sustained by our
  Hospital (Formation, Gear, Installation)

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Pitfalls
Pitfalls

• Technology issuesa. Network incompatibility
  fixedb. Software bugs
  fixed
• c. Client Hardware errors
  fixed
• Manpower issuesa. On-site training and
  re-training doneb. On-site quality
  control missions done

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Pitfalls
Pitfalls

• Still, this project, despite the hard work, is
  not growing as expected
• The main reason is that local physicians have
  (mis)interpreted the presence centralized system
  as an exclusion from the diagnostic process
• Thus, despite continous interventions, this
  project is not growing as expected

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The Future
Perspectives

• Despite pitfalls, we are enlarging the networkby
  creating more acquisition points
• In 2008 we will install two more stations, one in
  our territory and one in a foreign country
• This project will evolve, in the next future,
  with another project called Miro which
  should solve many issues

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The Future
Perspectives

• The actual system is, as already stated, a
  centralized system
• Its main limit is that it depends on one or few
  centers
• On the other side, a centralized telemedicine is
  easier to administer. Quality is easier to be
  controlled.

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Actual Situation
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doctors
requesters
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both the doctors and the requesters have to be
authenticated
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DIGITAL SIGNATURE Smart Card
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ASINCHRONOUS BROKER-BASED ARCHITECTURE
VIRTUAL COMMUNITY
SOCIAL NETWORK

• no complex dedicated hardware (PC-based clients)?
• data-transfer throught Internet (ADSL or Dial-Up
  modems)?
• costs independent on the number of installations.
• independent on the particular field of medicine.

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Differences
Osimo Telecardiology(Actual Situation) Miro(Future Convergence)
Centralized Diffuse
One Lab, One Standard Many Physicians
Same quality for pts Heterogeneus
Mainly Cardiological Virtually covers all
Excludes local physician Includes local physician
Propietary Code Open Source
Links DICOM Peripheral Links DICOM Peripheral
Propietary Format Most Common Formats
EBM-based Lab EBM-based System
Costly Free
Requires High-End Systems Runs also on Low-Ends
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Problems Of Other Systems

• Not easy-to-use
• Specific applications and architectures
• Dedicated hardware
• Dedicated connections
• Costs proportional to number of connected hosts
• Lack of sustainable and stable services

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Three Steps
Convergence
Step One Complete Coding Enhance Compatibility

• Step One
• Create Competent Professionals
• Create Trusted Centers

Step Two Enlarge the Network Continuous Teaching
Step Two Create Migration Tools Beta Testing
Step Three Migrate DataInvolve local
InstitutionsInvolve international institutions
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HOSTING in the west world health records of
migrating people
we only needInternet connections
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is for stable and reliable organizations
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is for stable and reliable organizations
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is for stable and reliable organizations
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Conclusions

• being data stored in a central server, a virtual
  health-care agency takes place that maintain
  clinical folders of patients wherever theyll go
  all around the world
• telereporting is an advantage especially for
  regions where there are few sanitary resources
• flexible software architecture for telereporting
  activities based on TCP/IP.
• data-transfer through Internet using digital
  certificates and timestamp.
• creating communities for searching/offering
  medical opinions

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• THANKS FOR THE ATTENTION

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workflow

1. an operator, through MIROs interface,
inserts the patient's data and the information
about the the diagnostic tuipe of the datum (for
instance the ECG) the software will store all
the data on the database of the central server.
2. any specialist is able, through the
appropriate dotation HW/SW, to remotely consult
their appropriate requests he can choose the
case he wants to report and eventually accesses
the patient's clinical folder
3. eventually the specialist might be able to
draw up the report in electronic format.
4. the report is made directly through the
application interface.
5. eventually the operator close the event
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Why Open Source?

• bringing good quality medical services to rural
  and remote areas mainly in developing regions
  with scarce resources
• software development requires little or no
  initial investment
• potential for evolution are generally easier with
  open source software
• interoperability and standards compliance

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clinical folder
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SCHEMA E-R
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timestamping
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REQUESTERs opening mask
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DOCTORs operating mask
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DOCTORs examination viewer
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DOCTORs operating mask
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DOCTORs report mask
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DOCTORs operating mask
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REQUESTERs viewing mask