In recent years, communication of not only sound but also of video in real time has been attained by third generation cellular phones with TV phone functions. This type of cellular phone has a high possibility that it will be applicable to telemedicine in the near future. It is reported that teleradiology, telemental health, teledermatology, and home telecare are effective forms of telemedicine (Hailey et al, 2002). We expect that telemedicine using third generation cellular phones with TV phone functions will become effective for home health care needs, such as meeting with patients and home rehabilitation (Palsbo and Bauer, 2000). The purpose of this study is to develop and evaluate a movie transmission system for visiting nursing and rehabilitation using a movie cellular phone. Two systems, including a real-time interactive system using a movie cellular phone and a file-storage one-way system using a movie PDA, PHS, and ISDN were constructed for comparison. A clinical evaluation was performed on both systems (Hori et al, 2003a, Hori et al, 2003b, Ogasawara et al, 2003).
Figure 1 shows the construction of a real-time interactive movie transmission system See Figure 1. The movie cellular phone named FOMA SH2101V (NTT DoCoMo Hokkaido) was used as a mobile terminal at the patient's home, whereas the TV telephone named Moppet (NTT Eastern Japan) was used as a fixed terminal at Hokkaido University hospital. Movie pictures from the patients' homes were received through the TV telephone and sent via ISDN to the hospital where a digital video recorder and a TV monitor were used for recording and conferencing. Movie pictures from the hospital were taken with the TV telephone camera at 15 frames per second and 640 x 480 pixel resolution. All movie pictures were compressed by MPEG-4 standard and the transmission speed was 64 kbps.
Figure 2 shows the construction of a file-storage one-way movie transmission system Figure 2. A PDA with a camera function named Eggy (NTT DoCoMo) was used as a mobile terminal at the patient's home. Movie images, recorded by the PDA and stored in a file, were sent as email attachment files using PHS and ISDN lines, and finally received and stored as files in a picture server at the hospital. After verifying the received movie picture using the monitor at the picture server, the experts in the hospital communicated with counterparts at the patient's home using common telephone lines. The resolution of the movie pictures produced by the PDA was 160 x 120 pixels (normal mode) or 320 x 240 pixels (fine mode), and the transmission speed was 64 kbps.
In order to investigate whether it is possible to use the system in practical visiting nursing settings, experiments were performed for evaluation. The evaluators included two nurses who were engaged in visiting nursing, three rehabilitation therapists, and four system developers. Eight patients with cerebral vascular disease, Parkinson's disease, muscular weakness due to muscle atrophy, and motility disease such as rheumatoid arthritis were selected for evaluation. In the process of nursing visits, each patient was asked to perform some simple movement, and movie images were taken using both the real-time system and file-storage system. These pictures were transmitted to Hokkaido University hospital by visiting nurses. In the hospital, physical therapists (rehabilitation staff) received and analyzed the patient movements in these pictures and gave instructions regarding training, ADL, and home care. An evaluation was performed by the visiting nurses and the physical therapists who conducted the movement analysis, including comparisons between the two systems, the usefulness of the systems, and the technical problems in clinical settings at the time of picture-taking and picture-transmission.
The image quality of movies transmitted was better with the file storage system than with the real-time system. The file-storage system was especially well suited for distinguishing changes of facial expression, quality of skin, and grade of joint modification. When there was a lot of motion in the background, or when the motion of the photographic subject was quick, block noise appeared. Block noise in the real-time systems makes the motion and the facial expressions of the patient difficult to make out. Although it was possible to grasp general motion with both systems, we sometimes could not distinguish joint movements in detail.
But there were also some advantages with the real-time system. This system can simultaneously transmit both movies and voice. When the physical therapist and the patient conduct their first meeting, much useful information can be acquired through cooperation with a nurse. Therefore a physical therapist could perform the evaluation and instruction for the patient smoothly, answer the patient's questions immediately, and provide additional explanations. Since there was no restriction of video-recording time, correction of the environment was possible, as was motion while taking the movie. Even if at first we did not fully perform a prior-arranged shoot, we were later able to get the required footage. On the other hand, in order to transmit video to the file-storage system, several minutes were necessary. Since the movie contents could not be checked until transmission was completed, a significant standby time was required. Moreover, because we had to check the movie using a cellular phone and communicate by telephone with another circuit, the working efficiency of the file-storage system was not as good as that of the real-time system, and much time was needed to perform patient instruction. Since there is a restriction of video-recording time, detailed arrangements between the visiting nurse and physical therapist were required before taking the movie.
With regard to motor dysfunction, the physical therapist who conducted the clinical evaluation concluded that the real-time system was more effective when evaluating harmonic motions, rough motion of Parkinson's disease, etc. When we observed deformity of the joint by rheumatism, the file-storage system was better due to its better picture detail. The file-storage system, with its high image quality, was also found to be more suitable for evaluating skin condition than patient's motion, if patient information was acquired beforehand.
The nurses who operated the systems in practical settings expressed the opinion regarding the real-time system that "a person who has used a cellular phone in the past could master the system immediately." About the file-storage system, they expressed the opinion that "a person who could send and receive email could use the system without much effort." In fact, they were able to use the systems after only a two-minute explanation.
Visiting nurses indicated three problems encountered during clinical use: 1) Slight motion caused a decrease in picture quality and also made it hard to make out facial expressions and small movements when the camera was operated by hand. This tendency was more noticeable in the real-time system. 2) Picture quality deteriorated remarkably due to halation caused by backlight behind the patient (or an object) in both of the systems (Figure 3). In most cases of patients needing home care, it was necessary to account for brightness during picture-taking and to adjust the lighting situation because the beds of many patients were arranged near windows. 3) There was also the problem that a whole-body picture of a patient that was necessary for a rehabilitation diagnosis could not be taken because of the limitation of space and way of holding a cellular phone. The movie pictures taken by the visiting nurses under these limitations might not be good enough for diagnosis. A distance of more than three meters between the camera and the patient (or the object) was necessary for taking a whole-body picture. However, it was impossible to make out facial expressions when the distance between the camera and the patient was more than three meters.
In order to investigate the cost-effectiveness of telemedicine using cellular phones, considering the solutions to the problems mentioned above from a social-economic viewpoint, the cost related with the introduction and management of these kinds of systems, and the current situation of regional medicine, the impact of communication range limitation of cellular phones on telemedicine should be analyzed further in the future.
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