CORENET TOHOKU Group

IT and Telemedicine The history of telemedicine dates back to the 1970's. At that time, the Medical Law was an enormous barrier to the practice of telemedicine. It was only in 1997 when the amendment to Article 20 of the Law pronounced telemedicine as not running counter to the legal provisions for direct physician-to-patient practice. In 1999, electronic media were accepted as a form of medical records like paper and photographic film. Intraoperative pathological diagnosis was covered by the health insurance system in 2000. Encouraged by these institutional improvements, telemedicine is now attracting much attention as an important reinforcement on community medicine. This issue of Nature Interface focuses on the approaches to telemedicine taken by CORENET TOHOKU Group and affiliated medical institutions, including Tohoku University School of Medicine, Iwate Medical University, and Onagawa Hospital. In the next issue, we turn our eyes to the future and discuss what services will be made possible by the expanded use of information technology in community medicine.

Telemedicine, the Backbone of Community Medicine

First, we briefly look at the situation of medical care in the Tohoku region, the northern part of Japan's main island.

According to the 1992 statistics of the Ministry of Health and Welfare, there were 40 pathologists per 100 hospitals in the metropolitan Tokyo area, while the number was only 14 in the Tohoku region. Considering the wide area of Tohoku, this difference is astonishing.

In the case of Miyagi prefecture at the center of the Tohoku region, pathologists are only available in Sendai City and the suburban cities of Shiogama and Natori. There are no pathologists in other municipalities.

This fact illustrates the typical medical care environment of the Tohoku region, and it gives a clue to understanding the problems of community medicine in general.

With the advancement of medicine, physicians are now extensively specialized and diversified. They are able to provide high-grade medical care, only when they are allowed to concentrate on their specialties. Any medical institution providing all-round medical services, thus, need to employ many specialist physicians.

Needless to mention pathologists, specialists tend to work in highly populated urban areas. Many hospitals, clinics, and other medical institutions in rural areas are chronically suffering from the shortage of specialists.

This situation aggravates the problems with the increasing number of aged citizens. While many aged patients in rural areas require treatment by home health care, they are offered no choices other than traveling to university hospitals and major hospitals in large cities. Very aged patients and patients with disabling conditions should ideally be supported by a system of home health care, in which physicians visit the patients' homes.

The Tohoku region, with its aging population structure, is an area where telemedicine can work miracles both in providing advanced medical care and in reducing the burden on the patients.

Onagawa Telemedicine Study Group

The role of the IT revolution in telemedicine is immeasurable.

The spread of personal computers, penetration of advanced Internet technologies, sophisticated image processing and high-speed data transmission are all accelerating the emergence of telemedicine from experimental and conceptual stages to reality.

As an example of such development, we look into a telemedicine project promoted with the central involvement of Tohoku University and the infrastructure support from CORENET TOHOKU Group.

During the last decade, we have seen rapid advancement of medical technology. CT, MRI, and other medical equipment have become digital, and large hospitals, in particular university hospitals, are now equipped with LAN or other forms of networking.

On the other hand, hospitals in rural areas are not sufficiently staffed with radiologists, neurosurgeons, and other specialists who are capable of advanced medical functions. In the Tohoku region, highly specialized medical care is available only at central hospitals, such as Tohoku University Hospital.

The regional disparity between urban and local areas has been expanding, in fact, in parallel to the specialization of medicine and the advancement of medical technology, including the spread of digital equipment.

Wide-area telemedicine systems based on the use of multimedia and information technology are emerging as an effective means to correct this regional disparity. One of such projects first started as the telecommunication link between Tohoku University Hospital and Onagawa Hospital, and it now envisions to cover the entire Tohoku region. The launch of Onagawa Telemedicine Study Group in 1996 was the seed of this project.

This study group was formed shortly before the establishment of Onagawa Hospital with a view to promote telemedical practice connecting this town-owned hospital and Tohoku University Hospital. The group consisted of not only the staff of these hospitals, but also CORENET TOHOKU Group and other companies providing necessary infrastructure development. Mr. Kazuo Shoji, General Manager in Management and Planning, CORENET TOHOKU Co., Inc., remembers as follows:

"Onagawa Telemedicine Study Group has been one of the forerunners in the practical use of telemedicine. It evolved from an organization called Sendai Telepathology Study Group, which was established in 1992. In cooperation with NHK, the telepathology group pursued the possibility of pathological diagnosis using the Hi-Vision technology. Later it was expanded to include the fields of radiology, neurosurgery, and dermatology, and was reorganized as Onagawa Telemedicine Study Group. The goal was a practical system for fiber-optic transmission of diagnostic images. We have been pursuing the possibility of telemedicine through cooperation with these two organizations. From the beginning, we have been working with Tohoku University School of Medicine and the town of Onagawa, in the role of providing system supports for communities, or assisting in community promotion measures."

Onagawa Town is located northeast of Ishinomaki City. The town is about 65 km away from Sendai and about 15 km from Ishinomaki. The town area includes several islands and two peninsulas embracing Onagawa Bay. It is a town of the fishing industry, having a long history of prosperity in deep-sea fishing. At present, fishing and a nuclear power plant are the main sources of the town's revenue. The population is about 12,000. Onagawa Hospital was opened in 1997 as the only general hospital in the town. It has 100 beds and is practicing in internal medicine, surgery, orthopedics, pediatrics, ophthalmology, ENT, and dermatology. The hospital is staffed with five full-time physicians. Except for internal medicine and surgery, practice in other specialties are supported by physicians from Tohoku University Hospital, who visit the town hospital on fixed days of the week. There are, however, no specialists in pathology, radiology, and neurosurgery. Although the hospital is designated as an emergency medical institution, patients requiring high-level emergency care and specialized diagnosis are usually referred to other hospitals, such as the one in Ishinomaki.

As a newly established public hospital, Onagawa Hospital was relatively well-equipped in terms of machinery and instruments even before the introduction of telemedicine. But, like all other local hospitals, the problem was the shortage of specialist physicians.

One of the hospital's weak point was the inability to perform rapid intraoperative pathological diagnosis during cancer surgery because of the lack of pathologists. Another weak point was diagnostic radiology. While radiological instruments such as CT and MRI are used for the diagnosis of lesions in the digestive tract and those in the head, even experienced specialists often experience difficulties in diagnosing lesions in these areas. Although the hospital had CT and MRI equipment, some patients had to be referred to a central hospital without receiving examinations using these equipment. The third weak point was the lack of neurosurgeons. Patients requiring prompt treatment, such as the cases of stroke and head injury, sometimes lost the chance of recovery because of the length of time for transportation to other hospitals.

In addition, there was a problem that the medical staff, including physicians, were deprived of the opportunities to receive further training. It was almost impossible for the staff to attend seminars and study meetings, usually held in large cities, while doing their duty in daily practice.

Practice of Telemedicine Using IT

Mr. Shoji continues:

"For that reason, we connected the two hospitals via a dedicated 384k fiber-optic line, and actually performed rapid intraoperative pathological diagnosis and teleradiology. We also used teleradiology in the telediagnosis of neurosurgical cases, as well as we studied the possibility of telediagnosis in dermatology (Figure 1.2).

"Speaking of intraoperative pathology, we used to perform operations at Onagawa Hospital, and histopathological preparations were sent to Tohoku University by mail or a courier service, because there were no pathologists in Onagawa. If the lesion was proved malignant, we used to plan reoperation, considering the recovery of the patient from the first operation. This was the usual flow of surgery performed here.

"Since telemedical intraoperative diagnosis has become possible, histopathological preparations are now made during the first operation and their images are transmitted to Tohoku University via the network. A team of physicians, on standby at the Pathology Division of Tohoku University, diagnoses the transmitted images. If the lesion is benign, the operation is over. If it is found malignant, the pathologist instructs that extirpation of affected organs is necessary. In this case, the operation can be resumed quickly while the lesions are still exposed. As the result, this reduces the mental and physical stress on the patient, eliminating the need for a second operation.

In the case of neurosurgical diagnosis, a patient is found to have an abnormality in the brain and sent to Onagawa Hospital. Here, the patient is run through a series of tests using CT and MRI. In the old way, a diagnosis was given and then various arrangements were made. In many cases, the patient was moved to a hospital equipped for neurosurgery, and sometimes CT examination had to be repeated there. Thus, it could take a very long time before treatment decisions were made, including the judgment of the necessity of operations. Now, we can transmit radiological images to Tohoku University for immediate diagnosis by specialists. We can receive prompt answers as to whether an emergency operation is necessary or a conservative treatment will do. If an operation is necessary, the patient can be transferred to an appropriate facility in time.

"During patient transportation, images are also sent to the hospital where the operation will be done. Because the hospital staff can decide on operation strategies and set up the operation room beforehand, the operation can start as soon as the patient arrives at the hospital. In neurosurgery, a delay of minutes or seconds can determine the survival of the patient. In our experience, this system shortened the time by one or two hours in some emergency cases."

The records of telemedical practice by Onagawa Telemedicine Study Group are listed in Figure 3. These include activities in the following categories:

(i) Telepathology (rapid intraoperative pathological diagnosis): Microscopic images of histopathological preparations are transmitted to pathologists at a central hospital, who perform rapid intraoperative pathology to support operations at local hospitals. In the case of a cancer operation, we can avoid the need for a second operation, because pathologists at the central hospital are able to check the spread of cancer and the presence of residual cancer in excised specimens during the first operation. In the case of a lung lesion, they can tell whether it is tuberculosis or cancer, supporting the surgeon's decision between limited and extended methods of surgery. In the case of organ transplants, diagnosis can be made whether the findings after a dose of immunosuppressant have been caused by side effects or rejection.

(ii) Teleradiology: CT and MRI images are sent over the Internet to specialists for interpretation. With this system, the specialist radiologists need not travel to local hospitals, while the patient can receive examinations at a hospital in the community. This reduces the mental and physical burdens on patients, in particular aged patients. For the benefit of local hospitals, teleradiology also improves the effective use of CT and MRI equipment. The combined use of a teleconference system and teleradiology is an effective way for providing up-to-date medical information, as well as continuing education and graduate education for physicians.

(iii) Application of teleradiology to neurosurgery: The largest merit of the use of teleradiology in emergency neurosurgery is the shortening of the time required for diagnosis. Brain diseases requiring urgent treatment can be telediagnosed by specialists in neurosurgery. Telediagnosis also helps reducing the number of unnecessary transportation of patients that are not actually indicated for neurosurgical treatment (Figures 4 and 5).

(iv) Teledermatology: At Onagawa Hospital, dermatology is practiced by a physician sent from Tohoku University Hospital once in a week. This has been causing considerable inconvenience on the side of patients. The Study Group has just launched a practice in teledermatology, so that telemedicine can be utilized for treatment in addition to diagnosis. They plan to use digital cameras and other digital equipment for the evaluation of skin lesions, but this requires the solution to technical hurdles, such as the transmission of still images, moving pictures, and audio information. This endeavor is currently in the experimental stage.

Although not included in the Study Group's current project, this fourth category has a wide applicability in the fields of internal medicine, ophthalmology, psychiatrics, rehabilitation, etc.

As overviewed above, the activities of Onagawa Telemedicine Study Group herald the promising future of telemedical practice. Rapidly catching up with the developments in Western countries, telemedicine in Japan is now entering the era of practical use against the backdrop of the aging society, the regional disparity in medical care, and the increasing autonomy of local governments.

CORENET TOHOKU's Vision of a Medical Information Center

Building on this success, CORENET TOHOKU and several neurosurgery groups launched a project called Aoba Brain Imaging Research Center.

This project connected many brain research organizations -- universities, research institutes, and companies -- in a high-speed fiber-optic network, for the purpose of constructing a brain image database, sharing image analysis software, and providing facilities for teleconference on the study of brain functions. The system was operated from 1997 to March 2001.

Another project is the expansion from the diagnostic use of teleradiology. The telemedical radiotherapy support system has been operated through Internet connections between the Department of Radiology, Tohoku University School of Medicine and 16 medical institutions, including Furukawa City Hospital and Sendai City Hospital.

We asked Mr. Shoji about the future activities of CORENET TOHOKU Group in telemedicine.

"We're going to develop business plans as a medical ASP (application service provider) based on our past achievements," he replied. "In other words, we want to promote information technology as a support to community medicine. We plan to promote advanced medical information systems, and to establish a medical information center covering the Tohoku region as a whole. This center will start test operation in December."

Compared with other industries, medical institutions seem to be lagging behind in the use of information technology, although the need is acknowledged widely.

They are at the stage of introducing hospital-wide IT applications. While integration of medical information in each hospital is on the move, they are still a long way from the construction of a global network, which companies in other industries are achieving at the moment.

In the next issue of Nature Interface, we look into CORENET TOHOKU Group's vision of the wide-area medical information system, and report the present state of IT revolution taking place in cities, communities, companies, and medical institutions.