Closing the gap between paramedics and medical experts – Development of a teleassistence device for precise ultrasound diagnostic in remote areas

Introduction and Objectives Ultrasound has become indispensable as an imagining tool that allows quick differential diagnosis, identification of the most important medical emergencies and immediate introduction of targeted treatment. It enables the sonographer to decide about further proceedings and their urgency, like transport to a specialized clinic or immediate surgical intervention. Several studies illustrate significant differences in the diagnostic accuracy between experienced sonographers and less-experienced examiners. Therefore international organizations, like the German Society for Ultrasound in Medicine (DEGUM) or the World Federation for Ultrasound in Medicine and Biology (WFUMB) demand better education programs and quality assurance in diagnostic sonography . Specialized diagnostic investigation is not available in every part of the world. Especially large countries and remote areas are having only few specialized clinics and the consultation of medical experts is associated with life-threatening delays and high transport costs. In those regions paramedics or nurses are practicing as the only medical professionals on site. They are of course no alternative to the physicians located in hospitals. To ensure rapid medical care for patients, even in poorly served regions with low resources, a guided tele-ultrasonographic-system, named ASYSTED II - Advanced System for Teleguided Diagnosis II, has been developed and implemented. ASYSTED-II allows a doctor located in a hospital to conduct an ultrasound examination in a remote area by precisely instructing a non-expert on site to operate the ultrasonic probe (teleassistance) while receiving the live imagery from this ultrasonic device. Methodology With expertise from many years of telemedicine in military applications a new teleassistance device for ultrasound diagnostics is currently in development. ASYSTED II (Advanced System for Tele-guided Diagnosis) provides intuitive visual and acoustic guidance to improve ultrasound probe placement and image acquisition. Using military proven videoconference systems for video, audio and file transfer ASYSTED II is available to operate using every IP-connection including satellite communications thus being operational ubiquitously (water, land, air). ASYSTED II can be used in connection with almost every ultrasound system commercially available. Thus examiners can use their own and well known (portable) ultrasound device while being instructed by a medical expert. ASYSTED II consists of software and hardware components and bases on a system for video, audio and data transmission. In detail the ASYSTED II Software connects the remote sonographer with the expert located in a central hospital by using the IP-connection available on-site. Satcom is supported so ASYSTED II can also be used on off shore installations or vessels. The expert is able to give acoustic and visual advice while observing the live imagery of the ultrasound device on a screen. Additional cameras on site can be selected by the remote expert to get an overview of the examination situation and the movements/positioning of the ultrasound probe performed by the examiner. The medical expert uses a commercial of the shelf three-dimensional joystick to transmit instructions visualized as directional indicators combined with information on the desired pressure or distance to move the probe. On the sonographer’s side the display of the ultrasound device shows the ultrasound picture, the screen of the mobile videoconference system presents the experts instructions. During the examination the expert can request still images created by the ultrasound device as DICOM-files. This allows focusing on interesting structures. As DICOM still images do not underly a lossy compression medical diagnostics is possible on this basis. The capabiity of a direct bidirectional communication between examiner on site and remote expert and remote support of allow prompt sonographic diagnostics even if a physician is not available on site. Medical treatment can be initiated earlier and quality of care in emergencies can thus be improved. Furthermore costs for innecessary transports can be avoided. In addition ASYSTED II offers the opportunity for distance education of inexperienced sonographers. Results The system is currently in development and will be available on the market in 2016. First demonstrations with a test model showed good results in optimizing communication between medical expert and examiner. All volunteers who tested the prototype system reported an intuitive usability of the guidance system and appreciated the faster workflow by using the automated DICOM transfer to the expert side. Conclusion By using intuitive audio and visual indicators quality and process improvements in teleguided ultrasound diagnostics are possible without the application of expensive robot systems for ultrasound probe placement. ASYSTED II helps the untrained examiner to easily follow the guidance of an experienced sonographer even in remote areas with rough environment and poor data connection. After the release of a first pre-series model of ASYSTED II a usability study together with a telehealth provider in the US will be conducted at the end of 2015