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Telemedicine and Ultrasound
The main obstacle to a more widespread use of ultrasound by veterinarians is not cost, but the effort required to develop the expertise. About ten years ago, someone realized that electronic transmission of images could provide a quick and affordable way to send ultrasound images to specialists for interpretation because it did not require an expensive image capture device: images could be directly imported from the ultrasound machine to a computer. Veterinary telemedicine was born. Diagnostic ToolBuying an ultrasound machine does not make one ultrasonographer. Many veterinarians have become skilled at interpreting ultrasound images but only after investing considerable time and effort. Telesonography is very useful to get expert opinions during the early learning phase and to consult on more difficult cases later on. By allowing you to pick the brain of expert sonographers, telesonography increases the diagnostic yield of your ultrasound service. Many veterinarians even elect to have all their sonograms reviewed by a radiologist. Ultrasound TrainingIf applied correctly telesonography is a powerful diagnostic tool, but ultrasound training and continuing education may be its most important. Seminars and short courses are excellent sources of information about ultrasound physics and the principles of image interpretation, but it takes months of practice to develop good skills, and years to perfect them. Telemedicine offers several advantages over traditional teaching: First, the information is better retained because it is learned when it is needed. Second, it allows you to replace long hours of travel and seminar time with 2 to 3 hours of enjoyable one-on-one interactive training sessions for a fraction of the costs. Finally, you can do it when and as often as you want. Telemedicine will not completely replace other forms of learning: reading assignments, seminars and on-site training will always be necessary. But it will provide you with your own personal instructor. Types of SystemsPresently there are ultrasound machines linked to telemedicine systems in over 400 veterinary practices. All these systems use a store-and-send format, which means that still images are stored in the practitioner's computer and sent via modem to a specialist's computer to be reviewed at his/her convenience. The same format can also use ultrasound videoclips (8-12 second sequences of moving images). There are several advantages to using store-and-send systems: they are relatively inexpensive and require minimal coordination between practitioners and specialists (unless a stat report is needed). The turnaround time is simply determined by the availability of the consultant. Such systems allow you to store still images and videoclips in computerized medical records for future reference, and to print representative images with the specialist's report for your clients to take home. You can also send images to other locations for additional opinions, or to a surgeon or other specialist when you refer a patient. The major disadvantage of store-and-send systems is the lack of direct interaction between sending and reading sites. Sending sites must put all the data together, and if information is missing, the interpretation may be incomplete or inaccurate. Requests for additional information or images can double or triple the time necessary to perform a teleconsult. Interactive ConsultationsYou have probably heard about real-time interactive ultrasound consultations during which specialists walk you through the examination as you perform it. Cost is still an obstacle to this attractive technology and at this time most interactive consultations are performed as regular phone conversations while practitioner and specialist examine the same images on distant computers. The ability to ask questions increases diagnostic accuracy because the consultant gets a more complete clinical picture and a better understanding of what was seen during the real time examination. It also provide better continuing education for the practitioner. During real time interactive consultations via videoconferencing, the specialist can virtually look over the practitioner's shoulder to walk him/her through the ultrasound examination. This method can be applied to scheduled ultrasound training sessions using actual patients or normal animals, or on an emergency basis to help practitioners during difficult examinations. A problem with interactive consultations is that coordinating the schedules of practitioners and consultants is difficult to achieve without wasting precious time. Because such consultations are more time consuming than store and forward consults, they are more expensive. I suspect interactive consultations will remain cost and time prohibitive for regular consults, but as soon as good quality videoconferencing becomes available and affordable, it may become the best vehicle for ultrasound training. You Have To Make It WorkTelesonography is an excellent telemedicine application, but there is more to it than simply buying the equipment. You still need training. You have to develop technical and clinical protocols and establish a relationship with your consultants because success with telesonography depends on collaboration and trust: You need to know what information and what images the consultant needs to provide accurate diagnoses and the consultant needs to assume that what he/she has available for review is complete and representative. The radiologist is expected to answer your questions but don't forget that you have to answer his/her questions first. Questions and answers are bound together: clear and focused questions make clear and focused answers. This principle seems obvious but lack of information is one of the most significant telemedicine problems encountered by radiologists providing telemedicine services. The information that should be included with each ultrasound teleconsults is summarized in Table I. Table II is provided as a guide to submit ultrasound images via telesonography. At first, you should include as many images as possible, but as your confidence and skills increase you can submit fewer images and concentrate on sonographic abnormalities and tissues known to be affected by a disease (e.g. elevation of liver enzymes). It is important to label the images when obvious anatomic landmarks are not included. Telesonography should not be used as a screening procedure because many diseases are not associated with easily detected focal lesions. If you do so, be aware that a second consult may be necessary after laboratory results or other clinical data become available. Finally, always remember the important role of survey radiographs: in addition to provide useful information about bones, mineralizations and gas-filled viscera, they allow a global view of the abdomen including size, shape and location of organs or masses. This information can be difficult to obtain from ultrasound images and may be crucial for a final interpretation. Both imaging modalities complement each other and should be submitted together whenever possible.
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Table II. Checklist Of Ultrasound Images To Submit In A Teleconsult
