Compendium of Health Telematics Projects 94-98 (Draft)
Home Documents Compendium HT Projects 94-98 Updated: Aug 26, 1998 

This is the most recent structured information on this project. Complementary data can be found on previous documents

OPHTEL

Telematics in Ophthalmology

Project code: HC 1036
Project value: 2547.4 KECU
EC contribution: 1000.0 KECU
Number of partners: 11
Number of countries: 5
Duration:36 months
Starting date: Jan 1, 96
               
Contact: Gerd Mann
GSF-MEDIS
Ingolstaedter
85764 Oberschleissheim
Germany

Tel: 49 89 31 87 40 80
Fax: 49 89 31 87 33 70
E-mail: mann@gsf.de
Web Site:

Overview

Within the project Telematics in Ophthalmology (OPHTEL) telemedical services for ophthalmology are under development, which will contribute to an improvement of the quality of patient care. One specific aim is the reduction of the incidence of blindness due to diabetic retinopathy and glaucoma as well as the achievement of cost-savings for health care systems.
Synchronous and asynchronous teleconsultation support the exchange of multimedia patient-data among medical partners. One application is telescreening for diabetic retinopathy that provides new screening tools to improve the interdisciplinary co-operation between diabetologists and ophthalmologists. Knowledge-based information systems will allow rapid access to specific information. Computer-assisted processing of fundus images is expected to support screening for diabetic retinopathy in the near future. Computer-based monitoring systems integrated with electronic patient data management systems will improve the quality of care for patients with diabetic retinopathy and glaucoma. By means of an on-line register for diabetic retinopathy quality assurance in screening for diabetic retinopathy will be achieved.

Purpose and objectives

Similar to other medical domains ophthalmology is under an increasing pressure caused by declining reimbursements on the one hand and the demand for high quality of patient care on the other hand. One answer to this problem is the introduction of new technologies into the health care system. OPHTEL addresses the need for new telemedical services in the field of ophthalmology and diabetology.
The service under development in the project that probably will have the highest impact on the health care process is teleconsultation. Using ISDN-based video-conference equipment or internet-based communication systems, teleconsultation enables physicians and patients who are located in different places to exchange data. In contrast to traditional technologies as telephone, fax, and mail, teleconsultation can provide direct or almost instantaneous access to full colour images, video and other multimedia patient data. For example pre-operative clearance or diagnostic problems can be discussed without the need for a time consuming transfer of patients. Using asynchronous teleconsultation a direct communication is not possible but there are no limitations regarding the quality and size of images, videos and other multimedia data. To ensure secure transmission of patient-related data via the Internet, all data have to be encrypted. Telescreening for diabetic retinopathy based on digital fundus images and specific patient data will provide medical expertise for non-ophthalmologists in primary care and hospitals without ophthalmologic department. Another application of telemedicine is the access to medical information. As shown in various examples the time necessary to transfer results from research into medical practice has to be measured in years. On-line information systems will help to speed up the knowledge transfer. Within OPHTEL a knowledge-based information system is being developed containing up-to-date medical guidelines, reference-images, and other relevant information for diabetic retinopathy and glaucoma. The system is based on a formal domain model. It supports different ways of presenting information, depending on user-types as physicians or patients. An important functionality of the system is the patient-oriented session using patient data (e.g. age, gender, current findings), which will be directly imported by an interface from a patient data management system. This allows for example a ruling out of therapies, which are contraindicated for a given patient. Using the WWW as a medium the costs for providers and users are low and there are almost no limitations regarding contents and accessibility. Telemedicine is also an enabling technology to support monitoring of patients with chronic diseases or at high risk of getting blind. Image processing tools extract automatically information about the image contents, for example occurrence, number and localisation of typical findings (e.g. haemorrhages, hard exudates, vessel abnormalities). Within OPHTEL knowledge-based monitoring systems are built for glaucoma and diabetic retinopathy (DR). At the working place of a physician a ‘watch-dog’ function will be realised, getting active in case suspect changes within the patient’s database are found. The reaction of the monitoring systems is the presentation of an alarm together with a visualisation of related parameters and an on-line query directed to the ophthalmic knowledge-based information system. The latter delivers additional information as therapy variants, risk factors etc. A register for diabetic retinopathy based upon the SEE-Base structure is being developed within OPHTEL, which stores data collected by the SEE software, or other suitably interfaced systems, while examining patients for diabetic retinopathy in individual practices. Data collected at different times for the same patient will allow to monitor the progression of diabetic retinopathy and to record the outcome of interventions in terms of prevention of blindness. SEE and SEE-Base are the official tools for monitoring the Saint-Vincent Declaration objective to "reduce diabetes-related blindness by one-third or more in the next five years". The SEE-Base Register will aggregate the data collected by the single ophthalmologists and send back a report every 6-12 months in which the relative frequencies of diabetic retinopathy in their diabetic patient populations will be calculated and set in comparison with those detected in the general diabetic population of the region and country of the operator and that of overall Europe. Being able to compare his/her own work will enable the individual ophthalmologist to perceive any major differences between his/her practice and the general trend, to consider possible causes for such discrepancies and to take action, where necessary, to correct them. To achieve quality assurance a randomised procedure will extract some patients whose retinal images will be forwarded to the Register, and from this to a centralised Grading Centre, in order to detect the operators' sensitivity and specificity (i.e., their diagnostic performance in terms of true and false positives and negatives), by comparing the diagnoses made against a standardised procedure to grade colour retinal images.

Results

In the project two kinds of teleconsultation services are provided: synchronous and asynchronous teleconsultation. Part of OPHTEL is a pilot network (funded by the Bavarian government within the project By-OPHTEL) among seven private ophthalmologists, ophthalmologic and diabetes centres (Department of Ophthalmology of the Technical University of Munich and the Diabetes Centre Munich-Bogenhausen) and the Institute of Medical Informatics and Health Services Research at the GSF. The user group started synchronous teleconsultation in autumn 1996. Synchronous teleconsultation allows on-line discussions and even the direct involvement of the patient. For economical reasons the base level ISDN (transmission rate of 2x64 kbit/s) has been chosen. A preliminary evaluation showed that in 90 % of the synchronous teleconsultations during the test phase the physicians were satisfied. A formal evaluation study will start in 1998. Meanwhile a tool for platform-independent teleconsultation allowing the use of pre-structured documents has been developed. The interface to patient data management systems has been defined, which allows an automatic in- and export of patient data into these electronic patient record systems. This tool was implemented in September 1997 for a study on the quality of telescreening for diabetic retinopathy, which is sponsored by TOPCON. Results of the evaluation will be the basis for a refinement and exploitation of the software. Negotiations with potential customers already have started. One example that exemplifies the transferability of the approaches is a screening program for mamma carcinoma using mammography, which will include about 1.100 women. With respect to teleconsultation services the OPHTEL partner ifa-company has already contracts or ongoing negotiations with several medical customers.

The Ophthalmic Knowledge-based Information System (O-KIS) is available as a demonstrator for diabetic retinopathy. The medical content is based on the field guide-book 'Screening for Diabetic Retinopathy in Europe' (KOHNER and PORTA, 1992). A reference image database includes more than 80 fundus images of diabetic retinopathy. The present version of the knowledge-base is realised by HTML pages and the use of JAVA scripts. This version is also available on CD-ROM. Commercial interest in this system has already been expressed by several companies. There is also an agreement on the use of the Knowledge-based Information System within the commercially oriented project Ten Telemed. In co-operation with Biermann publishing company an O-KIS demonstrator on glaucoma is under development.

At the beginning of 1997 the first step of image processing, the assessment of the image quality, was realised. This will be marketable in the near future, and there have already been contacts with manufacturers of fundus cameras. Subsequently the next two steps, extraction of the vessel tree and the papilla as well as the extraction of pathologic changes from fundus images have been implemented in a preliminary version.

The glaucoma monitor has already been verified by means of more than 3000 perimetric data sets and the complete data sets of 68 patients. In this system perimetric data are classified by hierarchically organised artificial neural networks. The results are combined with other parameters and information in a multi-layered fuzzy rule set. The final classification (‘normal-pathological-glaucomatous-suspect’) its time dependency combined with the time relations of all relevant parameters are presented to the user. The evaluation of the Glaucoma-Monitor is planned to start in autumn 1997. Diabetic retinopathy requires an ophthalmic and a diabetes related view. Therefore, two different data sets have been defined. In the DR-monitor the description of the ophthalmic status is given by results of automatic image processing and additional patient data. For classification fuzzy rule sets are used. In addition to the classification of the ophthalmic status a description of the patient’s risk is given by an assessment of diabetes related parameters. The DR-monitor is under construction. A prototype will be ready in autumn 1997. It is planned to integrate the Monitoring System into the ifa patient data management system.

In the SEE register for diabetic retinopathy the specifications for databases, software architecture, data entering, data control, analysis, queries on screening have been defined and implemented. Subsequently network functions and interfaces were under development. The implementation of the so far off-line SEE Register in Italy was continued, in June it contained about 6000 data sets. Recently efforts focused on the integration into the OPHTEL infrastructure, especially on the development of an appropriate interface to the ifa system.

In the last six months integration aspects were focused. In several project meetings the interfaces between the different subsystems have been discussed. The partners responsible for the different OPHTEL subsystems set up lists of necessary attributes and their corresponding attributes in the ifa documentation databases. Based on these work soon the first tests of exporting data from the ifa system into the other systems will be performed.

List of deliverables

Year 1

Year 2

Year 3

List of participants

Name: Dr. Gerd Mann
Organisation: GSF-Forschungszentrum für Umwelt und Gesundheit GmbH, medis Institut
Address: PO box 1129
D-85758 Oberschleißheim
Country: Germany
Tel: +49-89-31 87-40 80
Fax: +49-89-31 87-33 70
E-mail: mann@gsf.de
Website: www-ophtel.gsf.de
Name: Prof. Dr. Christian Ohmann
Organisation: Department of Theoretical Surgery
Address: Heinrich-Heine University
Moorenstr. 5
D-40225 Duesseldorf
Country: Germany
Tel: +49-211-311-61 42
Fax: +49-211-311 73 59
E-mail: ohmannch@uni-duesseldorf.de
Name: Prof. Dr. Manfred Mertz ; Dr. Marko Obermaier
Organisation: Department of Ophthalmology
Address: Technical University Munich, Germany
Ismaninger Straße 22
81675 München
Country: Germany
Tel: +49-89-41 40-23 21 (-40 93)
Fax: +49-89-41 40-49 36
E-mail: mertz@sun1.lrz-muenchen.de
Name: Prof. Dr. Massimo Porta
Organisation: Dipartimento di Medica Interna
Address: Universita` degli Studi di Torino
Corso AM Dogliotti 14
I-10126 Torino
Country: Italy
Tel: +39-11-663 23 54
Fax: +39-11-663 47 51
E-mail: maxporta@mbox.vol.it
Name: Prof. Eva M. Kohner OBE MD FRCP FRCophth
Organisation: Emeritus Professor of Medical Ophthalmology
Address: Department of Medicine
St. Thomas` Hospital Medical School
Lambeth Palace Road
London SW1 7EH
Country: United Kingdom
Tel: +44-171-922 80 95
Fax: +44-171-922 80 95
E-mail: e.kohner@umds.ac.uk
Name: Mr. Steven Aldington DMS FBIPP RMIP
Organisation: Retinopathy Grading Centre
Address: Royal Postgraduate Medical School
Du Cane Road
London W12 0NN
Country: United Kingdom
Tel: +44-181-383 32 71
Fax: +44-181-383 21 82
E-mail: saldingt@rpms.ac.uk
Name: Prof. Dr. K.-D. Hepp ; Dr. Bernd Liesenfeld
Organisation: Diabetes Center Bogenhausen
Address: Hospital Munich-Bogenhausen
Englschalkinger Straße 77
89125 München
Country: Germany
Tel: +49-89-502 34 21
Fax: +49-89-92 70-21 16
E-mail: ug142cq@sunmail.lrz-muenchen.de
Name: Rainer Waedlich
Organisation: ifa systems
Address: Ostlandstraße 38a-44a
D-50858 Köln
Country: Germany
Tel: +49-22 34-409 00
Fax: +49-22 34-40 90 69
E-mail: info@ifasystems.de
Name: Dr. Hans Biermann
Organisation: Biermann publishing company
Address: Nideggenerstr. 18
D-53909 Zülpich
Country: Germany
Tel: +49-2252-94 10-0
Fax: +49-2252-94 10-15
E-mail: BIERMANN@BIERMANNOPHTHALMOLOGY.DE
Name: Dr. Toke Bek
Organisation: Department of Ophthalmology
Address: Aarhus University Hospital
DK-8000 Aarhus C
Country: Denmark
Tel: +45-89-49 32 53
Fax: +45-86-12 16 53
E-mail: ueyetb@au.dk

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