Review Article

Teleultrasound: Historical Perspective and Clinical Application

Table 1

Main findings about the published articles about teleultrasound.

Reference
number
AuthorTitle and journalYearMain findings

[1]World Health Organization–WHO Telemedicine: opportunities and developments in Member States.
Reports on the Second Global Survey on eHealth 2009. HYPERLINK “http://www.who.int/goe/publications/goe_telemedicine_2010.pdf
2009(1) Teleradiology currently has a 33% rate of established service provision globally.
(2) While developing countries are more likely to consider resource issues such as high costs, underdeveloped infrastructure, and lack of technical expertise to be barriers to telemedicine, developed countries are more likely to consider legal issues surrounding patient privacy and confidentiality, competing health system priorities, and a perceived lack of demand to be barriers to telemedicine implementation.
(3) Following the analysis of the survey results, WHO recommends steps member states can take to capitalize on the potential of ICTs. One such step is creation of national agencies to coordinate telemedicine and eHealth initiatives, ensuring they are appropriate to local contexts, cost-effective, consistently evaluated, and adequately funded as part of integrated health service delivery. Ultimately telemedicine initiatives should strengthen rather than compete with other health services.

[2]Law and MacbethUltrasound: From Earth to Space. MJM 2011; 13(2): 59–65.2011Ultrasound is a well-proven diagnostic modality on Earth and is becoming increasingly useful in space.
Ultrasound shows much promise in benefitting both astronauts and patients on Earth.

[3]Sutherland et al.A comparison of telesonography with standard ultrasound care in a rural Dominican clinic. J Telemed Telecare. 2009; 15(4); 191–5.2009The pilot study demonstrated that store-and-forward telesonography reduced time of diagnosis and increased the continuity of care compared to the usual ultrasound referral system in the region of the Dominican Republic which was studied.

[4]Sutherland et al.Telesonography: foundations and future directions. J Ultrasound Med. 2011; 30(4): 517–22.2011Future projects may use telesonography to supplement the training of health care providers in remote locations in an effort to establish permanent sonography services for their respective communities.

[5]Popov et al.The feasibility of realtime transmission of sonographic images from a remote location over lowbandwidth Internet links: a pilot study. AJR Am J Roentgenol. 2007; 188(3): 219–22.2007Real-time transmission of sonographic images over low bandwidth Internet links offers the potential for sonography to be performed at a remote underdeveloped region and interpreted in real time at a distant site by trained radiologists, thereby extending the presence of physicians in virtual space.

[6]Hersh et al.The evidence base of telemedicine. J Telemed Telecare. 2006; 12(Suppl 2): S1-2.2006

[7]Ferrer-Roca et al.Tele-virtual sonography. J Perinat Med. 2006; 34(2): 123–9.2006(1) 3D reconstruction could reduce multiple explorations due to image constrains such as suboptimal fetal positioning among others.
(2) Virtual sonography was important to reach confidence on distant diagnosis.
(3) It was also considered a tool for offline local review of nontrained sonographer acquisitions.

[8]KasmaiRealtime Telesonography: Vision or Reality? Ultrasound. 2006; 14(3): 152–4.2006It is now possible to configure and set up a streaming telesonography service with minimum cost and effort.

[9]Afset and Lunde Tele-echocardiography. Education in echocardiography via video conferences. Tidsskr Nor Laegeforen. 1994; 114(10): 1175–8.1994Teleechocardiography is a method that is suitable for basic training in echocardiography and the diagnostic precision is sufficient for the method to be applied clinically.

[43]Afset et al.Accuracy of routine echocardiographic measurements made by an inexperienced examiner through tele-instruction. J Telemed Telecare. 1996; 2(3): 148–54.1996The reproducibility and accuracy of routine echocardiographic measurements made by an inexperienced doctor using teleinstruction were comparable to those observed in reproducibility studies made under normal examination conditions. There were no systematic measurement errors. Teleinstructed echocardiography is also an excellent educational tool, allowing an inexperienced examiner gradually to take responsibility for the local echocardiographic service.

[44]Trippi et al.Emergency echocardiography telemedicine: an efficient method to provide 24-hour consultative echocardiography. J Am Coll Cardiol. 1996; 27(7): 1748–52.1996

[45]Mulholland et al.Application of a low cost telemedicine link to the diagnosis of neonatal congenital heart defects by remote consultation. Heart. 1999; 82(2): 217–21.1999Transmitted images were of sufficient quality to allow confirmation or exclusion of major congenital heart disease. The telemedicine link facilitated early diagnosis and initiation of appropriate management in patients with complex congenital heart disease and avoided the need for transfer in those where significant congenital heart disease was excluded.

[21]Wootton et al.The effect of transmission bandwidth on diagnostic accuracy in remote fetal ultrasound scanning. J Telemed Telecare. 1997; 3(4): 209–14.1997A study which found that, although there were no perceived differences in technical quality between recordings transmitted at 384 or 1920 kbit/s, diagnostic accuracy was marginally worse at the lower bandwidth. This suggests that the higher bandwidth conveys more detail and information to the observer, which in turn enables more accurate diagnosis. However, further work is required before a definitive choice can be made about the optimum transmission bandwidth for remote fetal ultrasound studies.

[22]Hussain et al.Evaluation of a training and diagnostic ultrasound service for general practitioners using narrowband ISDN. J Telemed Telecare. 1999; 5(Suppl1): S95–9.1999A pilot study which demonstrated that store-and-forward images are far superior to hard-copy images for technical quality.

[23]Brebner et al.The diagnostic acceptability of low-bandwidth transmission for tele-ultrasound. J Telemed Telecare. 2000; 6(6): 335–8.2000The quality of dynamic ultrasound images transmitted at 384 kbit/s was diagnostically acceptable but was unsatisfactory at 128 kbit/s.

[10]Hussain et al.The feasibility of telemedicine for the training and supervision of general practitioners performing ultrasound examinations of patients with urinary tract symptoms. J Telemed Telecare. 2004; 10(3): 180–2.2004Forwarded images were superior to hard-copy images.

[11]Adambounou et al.System of telesonography with synchronous teleconsultations and nchronous telediagnoses. Med Sante Trop. 2012; 22(1): 54–60.2012A successful pilot trial of a low cost synchronous teleultrasound system in a developing country.

[12]MeuwlyTelesonography-Modern Solutions for an old Question. Ultraschall in Med 2010; 31(4): 421–3.2010As volume US acquisition seems to be rather independent of the skill of the local operator, asynchronous remote interpretation of reconstructed images from volume data sets appears to be a well-appropriate technical solution for telesonography, provided that suitable workstations for postprocessing will be available.

[13]Chan et al.Randomized comparison of the quality of realtime fetal ultrasound images transmitted by ISDN and by IP video conference. J Telemed Telecare. 2002; 8(2): 91–6.2002We compared the quality of real-time fetal ultrasound images transmitted using ISDN and IP networks. There were no significant interobserver variations. The most significant variable affecting the mean score was the bandwidth used. IP transmission in a private (nonshared) network is an acceptable alternative to ISDN for fetal teleultrasound and one deserving further study.

[14]Lewis A tele-ultrasound needs analysis in Queensland. J Telemed Telecare. 2006; 11(Suppl 2): S61–4.2006A teleultrasound needs analysis in Queensland which found that approximately 10% of cases would have benefited from telesonography and that there was a strong preference for store and forward transmission.

[15]Sheehan et al.Expert visual guidance of ultrasound for Telemedicine. J Telemed Telecare. 2010; 16(2): 77–82.2010An inexperienced ultrasonographer can be significantly assisted by EVG compared to verbal instruction alone. This could be useful for telementoring in rural hospitals as well as for teaching, both in person and at a remote site.

[16]Yoo et al. Performance of a web-based, realtime, tele-ultrasound consultations system over highspeed commercial telecommunications lines. J Telemed Telecare.2004; 10: 175–9.2004A Web-based, real-time teleultrasound consultation system was designed and tested by radiologists. A bit rate of more than 0.6 Mbit/s, at 30 frames/s, is suggested as the threshold for the maintenance of diagnostic image quality.

[17]Pian et al.Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings. Emergency Medicine International. 2013. Article ID 986160, 9 pages. HYPERLINK “http://dx.doi.org/10.1155/2013/9861602013This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

[18]Ferlin et al.Tele-obstetric ultrasound: analysis of first-trimester ultrasound images transmitted in realtime. J Telemed Telecare. 2012; 18(1): 54–8.2012Teleobstetric ultrasound: analysis of first-trimester ultrasound images transmitted in real-time; the quality of images transmitted via the Internet through the use of low-cost software appeared suitable for screening for chromosomal abnormalities in the first trimester of pregnancy.

[19]Paulus and Thompson Inexpensive, realtime teleultrasound using a commercial, web-based video streaming device. J Telemed Telecare. 2012; 18: 185–8.2012System was feasible; response times increased with increasing distance.

[20]Bassignani et al.Review of technology: planning for the development of telesonography. J Digital Imaging. 2004; 17(1); 18–27.2004With less compression, the bit rate rises, and the only way the encoder can contain bit rate within the set bandwidth is by lowering frame rate or reducing image quality. Review the relevant technologies and industry standard components that will enable low-cost telesonography.

[24]Chan et al.Realtime fetal ultrasound by telemedicine in Queensland. A successful venture? J Telemed Telecare. 2001; 7(Suppl 2): 7–11.2001A real-time fetal teleultrasound consultation service in Queensland, which uses ISDN transmission at 384 kbit/s, 1500 km away. All significant anomalies and diagnoses have been confirmed. A crude cost-benefit calculation suggests that the teleultrasound service resulted in a net saving which enabled almost four times the number of consultations to be carried out.

[25]O’Neill et al.The design and implementation of an off-the-shelf, standards-based tele-ultrasound system. J Telemed Telecare. 2000; 6(Suppl 2): S52-3.2000A feasible DICOM system, synchronous.

[26]Arbeille et al.Use of a robotic arm to perform remote abdominal telesonography. AJR Am J Roentgenol. 2007; 188(4): 317–22.2007Robotic telesonography can be used for reliable diagnosis without moving the patient. No false diagnoses were made in this study. A bandwidth of 250 Kbps via integrated services digital network or satellite is required for reliable diagnosis.

[27]Courreges et al.Clinical trials and evaluation of a mobile, robotic tele-ultrasound system. J Telemed Telecare. 2005; 11 Suppl 1: 46–9.2005Feasibility of a robotic teleultrasound system.

[28]Martini et al.A Cross-Layer Approach for Wireless Medical Video Streaming in Robotic Teleultrasonography. IEEE Eng Med Bio Conference.2007 (EMBC 2007), Lyon, France, August 2007.2007Successful performance of video streaming in a robotic teleultrasonography system through a cross-layer approach based on tailor made controller structures is presented.

[29]Fuentes Remote interpretation of ultrasound images. Clin Obstet Gynecol. 2003; 46(4): 878–81.2003In the near future, the ability to transmit volume rendered images over standard phone lines will enhance the application of telesonography.

[30]Cavina et al.Telesonography: technical problems, solutions and results in the routine utilization from remote areas. Studies Health Technol Informatics. 2001; 81: 81–9.2001

[31]Demiris et al.To telemedically err is human. Joint Commission. J Quality Safe. 2004; 30(9): 521–7.2004To address patient safety and provide high-quality care, a framework for addressing and examining telemedical errors needs to be established.

[32]Lagalla Telecommunications, health and radiology: potential synergies for the new millennium. Radiol Med. 2001; 102(1-2): 14–9.2001Italian paper to highlight the potentialities and limitations in the use of teleradiology and to provide a set of recommendations/guidelines.

[33]Soong et al.The fetal tele-ultrasound project in Queensland. Aust Health Rev. 2002; 25(3): 57–73.2002We report on some of our practical experiences and difficulties in establishing such a service.

[34]Arbeille et al.Fetal-tele-ecography using a robotic arm and a satellite link. Ultrasound Obstet Gynecol. 2005; 26(3): 221–6.2005Teleechography using a robotic arm provides the main information needed to assess fetal growth and the intrauterine environment within a limited period of time.

[36]Awadallah et al.Tele-echocardiography in neonates: utility and benefits in South Dakota primary care hospitals. S D Med. 2006; 59(3): 97–100.2006A study of teleechocardiography to assess neonates with suspected congenital heart disease. Teleechocardiography accurately distinguished neonates who required tertiary cardiac care from those with less critical cardiac disease fostering prompt diagnosis and appropriate care while subjecting a minimal number of patients to costly emergency transport.

[37]Crawford et al.How to set up a low-cost teleultrasound capable videoconference system with wide applicability. Critical Ultrasound J. 2012; 4: 13.2012A functional remote telementored ultrasound (RTUS) system was constructed with a laptop computer wireless Internet and/or was tethered through a smartphone. The RTUS system allowed real-time mentored teleultrasound to be conducted from a variety of settings via VOIP transmissions. Numerous types of ultrasound examinations were conducted such as abdominal and thoracic examinations with a variety of users mentored who had previous skills ranging from none to expert. Internet connectivity was rarely a limiting factor, with competing logistical and scheduling demands of the participants predominating.

[38]Su et al.Application of Tele-Ultrasound in Emergency Medical Services. Telemed e-Health. 2008; 14(8): 816–24. 2008This study describes the development of teleultrasound for prediagnosis in a medical emergency setting which will enhance prediagnosis options for on-duty emergency physicians; emergency medical technicians can also obtain instructions from on-duty physicians to enhance damage and disaster control ability in critical moments.

[39]Wootton Telemedicine in the National Health Service. J Roy Soc Med 1998; 91: 614–21.1998Having become technically and economically feasible, telemedicine deserves investigation by well-conducted research, which is adequately funded.

[40]World Health OrganizationTelemedicine: opportunities and developments in member states report. In Second Global Survey on eHealth Global Observatory for eHealth Series. 2011, vol 2. WHO Press, Switzerland.2011