Cancer care improves with videoconferencing

The urgent need to share the delivery of clinical services among local hospitals and specialist centers has shaped the role of videoconferencing and teleradiology in cancer care. To increase effectiveness of care and improve outcomes for patients, efficient, easy communication between units is essential, and this is where regular videoconferencing sessions can be useful. The technology provides a sort of proxy patient access to specialist healthcare, and it must be secure and confidential.

Videoconferencing is a straightforward technology, available from many companies. We use it mostly to manage rare cancers, because there may be only one or two specialists in the region. In local hospitals, all clinical diagnoses and staging are performed to agreed-upon criteria, and patients travel only for definitive treatments. This approach leads to a structured clinical environment, which helps to ensure high-quality, evidence-based uniformity of care.

Special videoconferencing software on a networked PC acts as a data source by logging in to other systems, such as a PACS Web browser. Other requirements are ISDN lines or a wide area network with sufficient bandwidth to avoid lag phenomena. We use image projection on two large-screen TVs, two zoomable video cameras, twin direction-sensitive microphones, an interactive white board, a digital film and document viewer, a digital microscope, x-ray viewers/PACS workstations, and a separate networked PC for communication.

A dedicated room should be set up for multidisciplinary team meetings and videoconferencing. Multiple presentation facilities must be available, including video, PowerPoint, CD-ROM, intranet, and Internet.

In the U.K., cancer care services are being centralized. One objective is to deliver care for specified cancers only in a unit that is serving a population of at least one million people. For rare tumors, such as pancreatic cancer, this increases to two to four million. This trend pushes development of clinical networks.

An important benefit of teleradiology is that images acquired in one unit are viewable at another. Sharing of image archives, working as a group, faster diagnoses, more subspecialization, and sharing of specialist imaging devices all become feasible.

Four types of teleradiology systems are available. The first is Web-based simple technology, in which images are converted to a standard JPEG format and demographic data are stripped out and placed in associated text files. A standard Web browser is used, and a list of viewable images in a Web page is formatted in HTML. The server creates a Web page of images plus data, and the Web page is transferred to a remote (non-DICOM) user. The main drawback is that image control is limited.

The second option is Web-based DICOM teleradiology. Remote users connect via a standard Web browser, and specialist software allows access to a list of viewable images. There is an archive Web server, and DICOM attributes are required to view images. DICOM images/data and viewer applet are transferred to a remote user's PC.

The third type is DICOM-based "pull" technology. This can be combined with Web-based teleradiology or used with direct ISDN/DSL telecommunications and dedicated virtual private networks or WANs. DICOM files are stored in a special teleradiology server. Remote users have a dedicated DICOM viewer, and they use a DICOM query/retrieve system to select and transfer (or pull) images.

The fourth option is a DICOM-based "push" system. Again, DICOM files are stored in a special teleradiology server, and a router (software) selects images and recipients. When a remote user connects to the specific IP address, the teleradiology server forwards (pushes) images. Remote users have a dedicated DICOM viewer.

The optimal approach is to store images of all patients in one vast centralized PACS archive, ready to be pulled over an ultrahigh-bandwidth connection, as required, by any hospital PACS linked to the archive. This is the aim of the National Health Service PACS IT strategy, which will begin implementation in early 2005 and has a proposed end date of mid-2007.

Whichever type of equipment is used, videoconferencing and teleradiology should be clinically led and patient-oriented. It is incorrect to regard these clinical encounters in the same way as business transactions. It is important to use the right set of technologies appropriately. To ensure confidentiality, a patient's identification and data must be protected.

DR. FOORD is a consultant radiologist at the East Sussex Hospitals NHS Trust, U.K., and chair of the Upper Gastrointestinal Tumour Group of the Sussex Cancer Network.