13 Medical applications

Medicine is a source of interesting applications that require high-quality infrastructure and a high throughput capacity. CESNET has been interested in this area for some time. In the second half of the 1990s, many medical videoconferences were held and the CESNET infrastructure was used for transmitting medical image data. As interest in medical projects has been growing, a new independent activity, Medical Applications, was started in the second half of 2004.

The intention of this new activity is to search for and develop further projects in the field of medicine. Many activities (such as Virtual Collaborative Environments, MetaCenter, and Distance Education) were related to medical applications and were undertaken using their general techniques and procedures. Our approach is searching for new projects and extend current programs with specific features required for medical data processing, rather than repeating these general procedures.

The following projects were implemented in the second half of 2004:

Standard environment of medical applications
Formalizing and transmitting data on oncology patients
Videoconference for remote consultations in genetics - telegenetics
MEDIMED project development
Searching for new telemedical applications

The staff of the 2nd Medical Faculty at Charles University in Prague and of the Masaryk University in Brno were directly involved in the said activity. In addition, staff from EUROMise (a joint facility of the Academy of Sciences of the Czech Republic and Charles University in Prague), Constitutional Court in Brno, Thomayer Teaching Hospital, Central Military Hospital in Prague, Masaryk Memorial Cancer Institute, the 1st Medical Faculty of Charles University and the IMA Ltd. company joined the working groups in implementing individual projects and preparing joint grant applications for the next grant period. Specialized programming equipment was developed in association with the TATRAMED Ltd. company from Bratislava.

13.1 Standard environment of medical applications

Standardization and transparency of the legal environment which defines the communication between healthcare entities are among the key problems in communication between medical facilities. In addition, harmonizing our legal environment with the EU legislation is crucial in order to avoid working on something that already exists in Europe. Making these issues transparent is essential for acquiring new partners among healthcare facilities because some managers of these institutions are afraid to transmit data outside the hospital walls.

Concerning the area of harmonizing the legislative environment and standards, we have established successful cooperation with the staff of EUROMise and with a lawyer from the Constitutional Court involved in analysing information on legal aspects of maintaining medical records and telemedicine in the EU countries.

A general introduction has been prepared which discusses the concept of the existence and mutual interactions of legal systems, "the national law of the EU member country" vs. "the EU law" vs. "international law". This general section is important for understanding the principles that serve as a basis for specific legal regulations.

Concentration on more specific problems will follow. In the first place, Czech legal regulations for the maintenance of medical records will be studied. This will involve analysis of the options for the maintenance of medical records in electronic form, including the issues of Act No. 20/1966 Coll. on Public Healthcare (especially Section 67a et seq.), the Electronic Signature Act (227/2000 Coll.) and the Personal Data Protection Act (101/2000 Coll.). The work will also deal with penalties that might be considered in the event of a breach of the duties set forth in respect thereof in the legislation (administrative infractions or, as the case may be, criminal acts).

The next step will deal with the European legal regulation including directives or other legislation of the EU governing the said issues. At the European level, this will include the possibility of transmitting personal data (or information from medical records) between member countries.

We expect that the first complete publication of these materials in the form of a study or article in a scientific journal will be ready by the end of 2005.

13.2 Formalizing and transmitting data on oncology patients

Formalizing the oncology patient data is a brand-new activity. A method has been completed and tested for exporting current and archived data from whole-body gammagraphy of thyroid gland carcinomas. In addition, procedures have been prepared for the conversion of images into a standard graphic format. The objective is further processing of the individual images and their sequences, quantitative evaluation of thyroid gland activity and searching for potential secondary carcinoma foci.

XML presentations of data from history records of the unique database of thyroid gland carcinoma have been created. XML presentations were used to create database structures for SQL database and web forms for effective data input.

This method is used to process two basic data sentences of the carcinoma database: input data of individual cases (a card to be completed during the first meeting with the patient), and longitudinal data to be completed during each checkup.

Establishing this database is required for taking part in future national and international cooperation. One example is the involvement planned in the project of the informational society program titled Intelligent support for decision-making during diagnostics and therapy in nuclear medicine using Bayes processing of uncertain data and probability mixtures which is being undertaken by the Institute of Information Theory and Automation of the Academy of Sciences of the Czech Republic.

In addition, a proposal has been submitted for a project for the 6th Framework Programme in the area of Life Sciences, with participation in the Network of Excellence for research in cystic fibrosis.

In terms of further data processing, it is important to establish contacts with the authors of the MEDAL (Medical Algorithms Project) system which includes algorithms of freely distributable programs for medical data processing.

Given the short term of implementation, we do not expect to produce any publications in this area until the second half of the year.

13.3 Videoconference for remote consultations in genetics - telegenetics

We are continuing work on the successful project of videoconferences for remote consulting in medicine focused on genetics, also known as telegenetics. A proposal has been made and testing has been prepared for specialized functions of a communication mirror suitable for teleconference modes and round-table presentations. In addition, the required functions of the client programs have been specified.

In cooperation with EGF, a storage space for digitized video recordings of lectures held in the European School of Genetic Medicine, including accompanying documentation, has been created and made accessible. Statistics and a model example for content-driven pre- and postgraduate medical education are also available.

Together with the University of Bologna, a pilot project for the EU program Leonardo (support of professional education) has been prepared. A project is now available for interconnecting communities of geneticists and hematologists studying thalassemia (genetic hematopoietic disorder) for the 6th Framework Program. The University of Bologna is a partner in education, while CESNET is a partner in infrastructure.

13.4 MEDIMED project development

The MEDIMED project has been extended successfully into a Prague workplace by connecting the Thomayer Teaching Hospital (FTN) in Prague in July 2004. Based on the experiences of production operation, FTN invested approximately CZK 30 million (approx. 1 million Euro) to equip the PACS center and is now interested in establishing the PACS center for the Prague locality. Interconnecting the General Teaching Hospital (VFN) and Teaching Hospital Na Bulovce is under negotiation.

Figure 13.1: A PACS Review Workstation

Anonymizing software for PACS has been created in cooperation with the CESNET Association, MU Brno, Masaryk Memorial Cancer Institute and the TATRAMED Ltd. company. The system is designed for students of medical sciences and for new hospital radiologists. Currently, functionality of the anonymization module, a general version of the description editor, and a module for administrating case studies are being tested in production operation.

After being filled with data, the database of anonymous image studies intended for teaching will be made accessible to students of the Masaryk University Medical Faculty in the classroom belonging to the Masaryk University, Medical Faculty (Biostatistics and Analysis Centre) and Faculty of Natural Sciences. This Centre is equipped with 30 powerful PCs and high-quality LCD monitors and TomoScan licenses. The system may be operated at selected sites of cooperating teaching hospitals, subject to an agreement.

The results of these partial activities were presented at the prestigious IASTED conference in the USA in November 2004.

13.4.1 Developing technical resources of the system

The training system is being developed in cooperation with the TATRAMED Ltd. company. This involves modifying the current commercial concept which is extended to include special components for teaching purposes. The system is designed to meet all the compatibility requirements needed for systems working in production operation.

The key components of the implementation are in particular:

anonymizing module (all information allowing the patient's identification is removed from an image study)
editor enabling the addition of an image description in the DICOM Structured Report format
support of keywords usage (for easy retrieval, etc.)
extension for creating teaching programs (specialized editor enabling the creation of problem-oriented, specialized case studies with references to image information).

Workstations connected to the teaching system enabling the anonymizing and sending the image studies to the PACS database, have been installed in the Masaryk Memorial Cancer Institute, the Clinic of Pediatric Oncology of the Teaching Hospital of Brno, St. Anne Teaching Hospital of Brno, and the Center for Cardiovascular and Transplantation Surgery in Brno.

13.4.2 Including an image study in the teaching system

Each image study included in the teaching system can be provided with a structured signature (its format follows the international DICOM standard) and with a set of attributes (keywords). The structured signature can be logically divided into several parts, according to the character of the project, as follows:

description of the image study
description of the diagnostic procedure used

Basic (technical) attributes of the image study are automatically saved upon inclusion of the image study into the teaching system. The values of these attributes are based on the original image study obtained during the routine operation.

modality (CT, US, PET/MR, PET/CT, ...)
name of the healthcare facility where the examination was performed
date of examination
patient's year of birth (actual date of birth is to be transformed, e.g., into 1/1/1964)
all technical parameters of the examination (distance between sections, number of images, number of series, ...)

13.4.3 Case study

A case study shall mean a document comprising independent text pages with optional references to image studies such as DAPET. The teaching system will contain tools (specialized, purpose-adjusted editors) enabling radiologists to create their own case studies.

13.4.4 Further development

Coordination in defining new keywords
Training users
The Thomayer Teaching Hospital is taking part in preparing draft contents and development
Many district hospitals, teaching hospitals and specialized healthcare facilities throughout the Czech Republic are interested in joining the system
Particular attention is being paid to the fields of oncology, pneumology and cardiology
Solving security issues (access authentication, hierarchy of certification authorities)
The system is designed to be open to foreign cooperation.

13.5 Searching for new telemedical applications

As part of activities for the second half of 2004, two new grants of the Informational Society program, announced by the Academy of Sciences of the Czech Republic for a period of up to 5 years starting from 2004, were successfully prepared and defended. The first project is the MediGRID, with the 2nd Medical Faculty of the Charles University being the main researcher, and the Masaryk Hospital in Ústí nad Labem and CESNET being fellow researchers. The second project is the Effective processing of medical image information with the CESNET being the main researcher and Masaryk University and Masaryk Memorial Cancer Institute in Brno being fellow researchers.

Prospective applications include an international research project in the area of neuroscience, BIRN (Biomedical Informatics Research Network), which enables access to high-performance models and brain examination techniques. The Department of Neurology of the Central Military Hospital Prague has already shown interest in becoming involved in the BIRN project via the CzechLight network. Negotiations on involvement in this project are underway with the Thomayer Teaching Hospital and Teaching Hospital Motol.

A system for supporting highly demanding exchange of image data (microscopy, MR, PET) should be another interesting application of the MEDIMED system for the newly-built Cell Therapy Centre. Once established, this system will connect the Charles University - 2nd Medical Faculty, Academy of Sciences of the Czech Republic (AV ÈR), IKEM, and MZLU Brno. Given the research character of this facility, we are considering the use of the CzechLight infrastructure tentatively in the second half of 2005.

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