CYBERTHERAPY
REPORT
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Abstract:
Since the development of methods of electronic communication, clinicians
have been using information and communication technologies for the exchange
of health-related information. However, the emergence of new shared
media, such as the Internet and virtual reality are changing the ways
in which people relate, communicate, and live. E-health,
the integration of telehealth technologies with the Internet the next
logical step of this process. To date, some e-health applications have
improved the quality of health care, and later they will lead to substantial
cost savings. However, e-health is not simply a technology but a complex
technological and relational process. In this sense, clinicians and
health care providers that want to successfully exploit e-health need
a significant attention to technology, ergonomics, human factors and
organizational changes in the structure of the relevant health service. The
goal of the report is to analyze the processes by which e-health applications
can contribute to the delivery of state-of-the-art health services.
Particular attention is given to shared hypermedia and distributed virtual
reality worlds.
1.
What is telehealth Telehealth
means “medicine at distance” where “medicine”
includes not only medical activities - involving ill patients - but
also public health activities - involving well people (Wootton, 1999a).
In other words telehealth is process and not a technology, including
many different health care activities carried out at distance. Since
the development of methods of electronic communication clinicians have
been using information and communication technologies for the exchange
of health-related information: Telegrapy signalling by wires
telephony, radio and television has been used for distance medicine
since mid 19th century (Wootton, 1999b). However, rapid and far-reaching
technological advances are changing the ways in which people relate,
communicate, and live. Technologies that were hardly used a few years
ago, such as the Internet, e-mail, video teleconferencing and shared
virtual reality are becoming familiar methods for modern communication. Health
care is one of the areas that could be most dramatically reshaped by
these new technologies. Distributed communication media could become
a significant enabler of consumer health initiatives. In fact they provide
an increasingly accessible communications channel for a growing segment
of the population. Moreover, in comparison to traditional communication
technologies, shared media offer greater interactivity and better tailoring
of information to individual needs. E-health,
the integration of and telehealth technologies with the Internet and
shared virtual reality is the next logical step. Although e-health is
a branch of telehealth, it is differentiated in several important ways.
As noted by Allen (1999b) telehealth to date has been largely non-Internet
based and has been characterized by point-to-point (e.g., T1) and dial-up
(e.g., telephone, ISDN) information exchange. E-health, on the other
hand, is more accessible due to its increasingly affordable ability
to communicate through a common set of standards and across operating
systems. According
to Wootton (1999b), there are basically two reasons why telehealth is
used: “either because there is no alternative, or because it
is in some sense better than traditional medicine" (p. 12). In
this sense telehealth has been used very successfully for optimising
health services delivery to people who are isolated due to social and
physical boundaries and limitations (Fletcher, 1999; O'Sullivan &
Somers, 1999). Nevertheless, the benefits of telehealth, due to the
variety of its applications and their uneven development, are not self-evident
(Lehoux, Battista, & Lance, 2000; Mair, Haycox, May, & Williams,
2000). In a recent study Currel et al. (2000) assessed all the randomised
trials available in scientific literature to verify the effects of telemedicine
as an alternative to face-to-face patient care. Although none of the
studies showed any detrimental effects from the interventions, neither
did they show unequivocal benefits and the findings did not constitute
evidence of the safety of telemedicine. However,
the emergence of e-health is supporting the cost-effectiveness of certain
applications (Charles, 2000) such as radiology, prisoner health care,
psychiatry, and home health care. Its key advantage is the possibility
of share different media and different health care tools in a simple
to use and easily accessible interface. A recent Australian study showed
that the cost-effectiveness of both telehealth and telemedicine improves
considerably when they are part of an integrated use of telecommunications
and information technology (Mitchell, 2000). The conclusion of the author,
is that it is unwise to promote telehealth in isolation from other uses
of technologies in health-care. To
date, some e-health applications have improved the quality of health
care, and later they will probably lead to substantial cost savings
(Coile, 2000). However, e-health is not simply a technology but a complex
technological and relational process (Jerome et al., 2000). In this
sense, clinicians and health care providers that want to successfully
exploit e-health need a significant attention to technology, ergonomics,
human factors and organizational changes in the structure of the relevant
health service (Riva & Gamberini, 2000a). The
goal of the paper is to analyze the processes by which e-health applications
can contribute to the delivery of state-of-the-art health services.
Particular attention is given to shared hypermedia and distributed virtual
reality worlds. 2.
E-health: processes and opportunities Shared
media, such as Internet and distributed Virtual Reality (VR) offer different
paths for augmenting the health care services in clinical and non-clinical
settings. In particular it is possible to identify three areas in which
e-health can offer a competitive advantage over traditional processes:
clinical care, health education and public health activities (Riva &
Gamberini, 2000a). In
the following paragraphs these three areas will be discussed and the
potential of shared media investigated. 2.1
Virtual Environments A
Virtual Environment (VE) is an interactive, virtual image display enhanced
by special processing and by nonvisual display modalities, such as auditory
and haptic, to convince users that they are immersed in a synthetic
space (Ellis, 1994). In a different fashion, virtual reality (VR) is
an application that lets users navigate and interact with a three-dimensional,
computer-generated environment in real time (Pratt, Zyda, & Kelleher,
1995). Virtual
reality, is not only a hardware system (Riva, 1999). But also an emerging
technology that changes the way individuals interact with computers.
It can be described as "...a fully three-dimensional computer-generated
'world' in which a person can move about and interact as if he actually
were in an imaginary place. This is accomplished by totally immersing
the person's senses...using a head-mounted display (HMD)" or some
other immersive display device, and an interaction device such as a
DataGlove or a joystick (Satava, 1993a, p. 111). However, it is the
user immersion in a synthetic environment that characterizes VR as being
different from interactive computer graphics or multimedia. In fact,
the sense of presence in a virtual world elicited by immersive VR technology
shows that VR applications may commonly differ fundamentally from those
associated with graphics and multimedia systems (Rothbaum et al., 1995b). Virtual
environments provide a unified workspace, which allows almost complete
functionality without requiring that all functions to be in the same
physical space. According to Ellis (1994, p. 17), VEs can be defined
"...as interactive, virtual image displays enhanced by special
processing and by nonvisual display modalities, such as auditory and
haptic, to convince users that they are immersed in a synthetic space."
Less technically, a virtual world can be described as an application
that lets users navigate and interact with a computer-generated 3-D
environment in real time. The system has three major elements: interaction,
3-D graphics, and immersion (Pratt et al., 1995). According
to Bricken (1990) the essence of VR is the inclusive relationship between
the participant and the virtual environment, where direct experience
of the immersive environment constitutes communication. In this sense,
VR constitutes the leading edge of a general evolution of present communication
interfaces involving television, computer and telephone (Kay, 1984).
The main characteristic of this evolution is the full immersion of the
human sensorimotor channels into a vivid and global communication experience
(Biocca & Delaney, 1995). In fact, VR provides a new methodology
for interacting with information (Satava & Jones, 1996). Since telemedicine
is principally involved with transmitting medical information (Gamberini
& Riva, 2000), VR has the potential to enhance the telemedicine
experience. The two principal ways in which VR can be applied are interface,
which enables a more intuitive manner of interacting with information
and environment, which enhances the feeling of presence during the interaction
(Satava & Jones, 1996). Many
VR applications have emerged in entertainment, education and military
training (Satava, 1995). Nevertheless, the considerable potential of
VR in medicine has been recognized only recently. These and similar
applications share three common attributes, which offer significant
advantages over current tools (Riva, 1998b): Content:
Until the last decade, computers were used to control numbers and text
by entering numbers and text using a keyboard. Recent direct-manipulation
interfaces have allowed the manipulation of iconic representations of
text files, or two-dimensional graphic representations of objects, through
pointing devices such as the mouse. The objective of direct-manipulation
environments was to provide an interface that mimics object manipulation
in the real world. The latest step in that trend, virtual reality systems,
allows the manipulation of multi-sensory representations of entire environments
by natural actions and gestures. Feedback:
VR systems are capable of displaying feedback in multiple modes. Thus,
feedback and prompts can be translated into alternate senses. The environment
could be reduced to achieve a larger or general perspective (without
the "looking-through-a-straw" effect usually experienced when
using screen readers or tactile displays). Sounds could be translated
into vibrations while environmental noises could be selectively filtered
out. Method
of Control: Current alternate computer access systems accept only
one or at most, two modes of input at a time. A computer can be controlled
by single modes such as pressing keys on a keyboard, pointing to an
on-screen keyboard with a head pointer, or hitting a switch when the
computer presents the desired choice. Present computers do not recognize
facial expressions, idiosyncratic gestures, or monitor actions from
several body parts at a time. VR systems open the input channel mor
widely: VR systems have the potential to monitor movements or actions
from any body part, or from many body parts simultaneously. All properties
of movement, not just contact of a body part with an effector, could
be monitored. Recently,
some research projects have begun to test the feasibility of using VEs
in medicine and e-health (Riva & Gamberini, 2000b). Applications
of this technology are being developed for health care in the following
areas: surgical procedures (remote surgery or telepresence (Satava,
1993b; Satava, 1995), augmented or enhanced surgery (Giorgi, Pluchino,
Luzzara, Ongania, & Casolino, 1994; Ossoff & Reinisch, 1994),
and planning and simulation procedures before surgery (Dunnington &
DaRosa, 1994; Muller, Ziegler, Bauer, & Soldner, 1995)); medical
therapy (Botella et al., 1998; Hoffman, Doctor, Patterson, Carrougher,
& Furness, 2000; Riva et al., 2000a; Riva et al., 2000b; Rothbaum
et al., 1999; Rothbaum & Hodges, 1999; Rothbaum, Hodges, Kooper,
Opdyke, & et al., 1995a; Strickland, Mesibov, & Hogan, 1996;
Vincelli, Choi, Molinari, Wiederhold, & Riva, 2000; Wiederhold et
al., 2001; Wiederhold, Gevirtz, & Spira, 2001; Wiederhold &
Wiederhold, 1998, 2000, 2001); neuro-psychology (Pugnetti et al., 1995;
Riva, 1998a; Riva et al., 1997; Rizzo & Buckwalter, 1997; Rose,
Attree, & Johnson, 1996; Wann & Turnbull, 1993; Wilson, Foreman,
& Stanton, 1997); preventive medicine and patient education [Hoffman,
1995 #264; (Mendozzi et al., 2000)]; medical education and training
(Merril & Barker, 1996; Merril, Notaroberto, Laby, Rabinowitz, &
Piemme, 1992); visualization of massive medical databases (Merril, 1997);
and skill enhancement and rehabilitation (Bertella, Marchi, & Riva,
2000; Greenleaf & Tovar, 1994; Riva, 2000). 2.11
The VR Technology A
three-dimensional computer-generated environment enables the user to
move about and interact as if he actually were in it. This effect is
achieved by totally immersing user senses in the VE via both a head-mounted
display (HMD) or some other immersive display device, and an interactive
device such as a DataGlove or a joystick (Satava, 1993a, p. 111). The
VE may be displayed on a desktop monitor, a wide field-of-view display
such as a projection screen, or a head-mounted display. A virtual environment
displayed on a wide field-of-view display, which is fixed in space,
is called partially immersive virtual reality. A fully immersive virtual
reality environment utilizes a head-mounted display, with a head position
sensor to control the displayed images so that they appear to remain
stable in space when turning the head or moving through the virtual
environment. A see-through head-mounted display and head position sensor
may be used to augment the user’s experience of the real world
by superimposing space-stabilized computer-generated images of virtual
objects on the user’s view of the outside world (Riva, 1997). 2.111
Low cost VR Due,
in large part, to the significant advances in PC hardware that have
been made over the last three years, low cost VR systems are approaching
reality. While the cost of a basic desktop VR system has not changed
much, the functionality has improved dramatically, both in terms of
graphics processing power and VR hardware such as head-mounted displays
(HMDs). The availability of powerful PC engines based on Intel's Pentium
IV and Itanium, Motorola's Power PC G4, and the emergence of reasonably
priced 3D accelerator cards allow high-end PCs to process and display
3D simulations in real time. A
standard Celeron 1200 Mhz with as little as 128 Mb of RAM can offer
sufficient processing power for a bare-bone VR simulation, a 2 Ghz
Pentium IV/Athlon with 256 Mb of RAM, can provide a convincing virtual
environment, while a dual 2.6 Ghz Pentium IV XEON configuration with
OpenGL acceleration, 512 Mb of RAM and 128 Mb of VRAM running on Windows
XP Professionam, can match the horsepower of a graphics workstation. Immersion
is also becoming more affordable. For example, Virtual I-O (USA) now
has a HMD that costs less than $1200 and has built in head tracking.
Olympus distributes its basic DVD headset for about $600 without
headtracking. Two years ago HMDs of the same quality were about 10 times
more costly. A HMD with VGA quality is now about $2,000. However, this
price will probably decrease during the next five years. Presently,
input devices for desktop VR are largely mouse- and joystick-based.
Although these devices are not suitable for all applications, they can
keep costs down and avoid the ergonomic issues of some of the up-to-date
I/O devices such as 3D mouses and gloves. Also, software has been greatly
improved over the last three years. It now allows users to create or
import 3D objects, to apply behavioral attributes such as weight and
gravity to the objects, and to program the objects to respond to the
user via visual and/or audio events. Ranging in price from free (Alice
WTK - http://www.alice.org) to $6,000, the toolkits are the most functional
among the available VR software choices. While some toolkits rely exclusively
on C or C++ programming to build a virtual world, others offer simpler
point-and-click operations for simulation. 2.112
The Virtual Reality Modelling Language A
further attempt to spread the diffusion of low-cost VR comes from the
development and increasing diffusion of the Virtual Reality Modelling
Language (VRML). The VRML is a file format and run-time description
of 3D graphics for use on the World Wide Web. It includes interaction
and animation elements as well as interfaces to scripting languages,
thereby providing more general simulation behaviors and interfaces in
network services (Pesce, 1995). Today VRML worlds can be scripted with
Java and JavaScript, both of which are familiar to most web programmers. The
first version of VRML (1.0) allowed the creation of virtual worlds with
limited interactive behavior. These worlds can contain objects that
have hyper links to other worlds, HTML documents, or other valid Multimedia
Internet Mail Extensions (MIME). The second version of VRML (2.0), available
now, allows the user for richer behaviors, including animations, motion
physics, and real-time multi-user interaction. VRML2.0
was designed and implemented in 1995, and it has been an International
Organization for Standardization standard since 1997 (called VRML97).
VRML97 is the only existing open standard for describing 3D graphics
on the web, though several proprietary packages with similar capabilities
exist. The development and maintenance of VRML97 are overseen by the
Web3D Consortium whose members include Sun, Microsoft, SGI, Apple and
Intervista. The
first step in viewing a VRML document is retrieving the document itself.
The document request comes from a Web browsereither a VRML browser
or a HTML browser. Users send their request to the Web browser, and
the Web browser forwards the request to its intended recipient. The
Web server that receives the request for a VRML document attempts to
fulfil the request with a reply. This reply goes back to the VRML browser.
Once the VRML browser has received the document, it is read and understood
through visible representations of the objects described in the document.
Each VRML scene has a "point of view," which is called a camera:
you see the scene through the eye of the camera. It is also possible
to predefine viewpoints. All browsers feature some interface for navigation,
so that you can move the scene's camera throughout the world. A VRML
world can be distributedthat is; it can be spread across the Web
in many different places. In the same way that an Internet Web page
can be composed of text from one place and images from another, a VRML
world can state that some parts of the scene come from this place, while
other parts come from that place. This
means that VRML files are often loaded in stages. First, the basic scene
description is loaded. Thenif this refers to nested (scene within
a scene) descriptionsthe browser loads these after the basic scene
has been loaded. Typically, computer speeds are not quite as fast as
we would like. Similarly, modems are not as capable as the demands we
like to make upon them. Hence, there is usually some delay in loading
a VRML world. It rarely appears immediately, or all at once. VRML
can show you where objects will appear before they have been downloaded.
Before the object appears, it is shown as an empty box of the correct
dimension (called a bounding box), which is subsequently replaced by
the actual object when it is read. Called lazy loading, this allows
the VRML browser to take its timewhen it has no other choice loading
the scene from several different places, while still giving you a correct
indication of what the scene will look like when it is fully loaded
(Pesce, 1995). Since
a variety of open standard VRML authoring tools are now freely available
on the Web, hardware changes in PCs have accelerated the deployment
of VRML on the desktop. Available PCs meet the requirements for moderately
complex VRML97 worlds. Specifically, almost all desktop PCs sold since
mid 1998 have been shipped with a 3D graphics accelerator. In addition,
VRML97 browsers are now standard in IE5.0 (Intervista WorldView) and
Netscape4.6 (CosmoPlayer). Plugin browsers are available for earlier
versions of these software packages. Much
of the power of VRML over other 3D technologies is that 3D worlds can
be integrated into standard 2D web page descriptions. Given that the
web page is a very familiar "front-end" to the Internet, and
that VRML scripts can access the capabilities of Java scripting, games
developers and on-line shopping providers have been quick to recognize
the potential of hosting thousands of users within a controlled 3D environment. The
general experience of VRML worlds on the Internet will be vastly improved
over the next few years as basic technologies such as 2nd generation
graphics accelerators and network technologies such as Asymmetric Digital
Subscriber Line (ADSL) become available. Up to now, applications of
VRML for telemedicine VR are available in visualization (Marovic, Valentino,
Karplus, & Jovanovic, 1999) and training (Kling-Petersen, Pascher,
& Rydmark, 1999). 2.12
Human factors The
introduction of patients and clinicians to VEs raises particular safety
and ethical issues. In fact, there are well-documented side-effects
of exposures to virtual reality environments which could lead to problems
(Lewis & Griffin, 1997) including: -
symptoms of motion sickness; -
strain on the ocular system; -
degraded limb and postural control; -
reduced sense of presence; -
the development of responses inappropriate for the real world which
might lead to negative training. However,
the improved quality of the VR systems has drastically reduced the occurrence
of simulation sickness. For instance, a recent review of clinical applications
of VR reported instances of simulation sickness are few and nearly all
are transient and minor (Riva, Wiederhold, & Molinari, 1998b). Nonetheless,
patients exposed to virtual reality environments may have disabilities
that increase their susceptibility to side effects. Precautions should
be taken to ensure the safety and well being of patients, including
established protocols for monitoring and controlling exposure to virtual
reality environments. Strategies are needed to detect any adverse effects
of exposure, some of which may be difficult to anticipate, at an early
stage. According
to Lewis & Griffin (1997) exposure management protocols for patients
in virtual environments should include: -
Screening procedures to detect individuals who may present particular
risks. -
Procedures for managing patient exposure to VR applications to ensure
rapid adaptation with minimum symptoms. -
Procedures for monitoring unexpected side effects and for ensuring that
the system meets its design objectives. Unfortunately,
the effect of VEs on cognition is not fully understood. In a recent
report, the US National Advisory Mental Health Council (1995) suggested
that "research is needed to understand both the positive and the
negative effects [of VEs]... on children's and adult's perceptual and
cognitive skills." Such research will require the merging of knowledge
from a variety of disciplines including (but not limited to) neuropsychology,
educational theory and technology, human factors, medicine, and computer
science. 2.13
Ergonomics Ergonomics
plays an important role in the development of effective e-health tools.
In this area, the achievement of certain performance criteria may be
the main objective of VR-based telemedicine applications (Abke &
Mouse-Young, 1997). For instance, virtual environments designed for
surgery must realistically represent the real task that is being simulated.
An important aspect of such simulation can be the measurement of performance
to assess likely competence in the real task. As noted by Lewis and
Griffin (1997), “the introduction of artifacts by the virtual
environment which affect the performance of the task are likely to reduce
the effectiveness of the training or lead to negative transfer of training
to the real environment” (p. 41). This
leads many researchers to explore the characteristics of visual-motor
co-ordination tasks in virtual reality systems and simulators. Most
of these kinds of studies have focused on the effects of lags between
the sensing of head, limb or control position and the movements of images
on the display (Kennedy & Stanney, 1996; Reason & Brand, 1975).
Lags of a similar order to those present in many practical systems have
had a significant effect on the tracking, manipulation and reading tasks
(Lackner, 1992). Studies have also demonstrated the benefits of stereoscopic
displays to provide depth cues to aid the manipulation of virtual objects
in three dimensions, such just as it is called for in surgical simulation.
Moreover, the VR system should minimize the total delay between head
position sensing and the presentation of a suitable image. This may
involve the choice of suitable position sensors and the minimization
of synchronization errors (Adelstein, Johnston, & Ellis, 1996).
Similarly, the system update rates should be maximized. Minimizing the
visual delay and maximizing update rates should reduce both the probability
of simulator sickness symptoms and minimize the interference with the
user’s interactivity with the environment. This is especially
important where the effectiveness of the application depends on the
performance of a visual-motor task as in many VR-based telemedicine
applications. Significant delays and low update rates may lead users
to adopt unnatural movement strategies. This would subsequently interfere
with the transfer of training for a real task (Lewis & Griffin,
1997). Interaction
plays an important role in VR, indeed, the essence of VR is the ability
to interact in a three-dimensional computer-generated environment. Some
clinical applications may simply call for subjects to be present in
an interactive virtual environment. For example, applications are being
developed to desensitize subjects in anxiety-provoking situations. The
effectiveness of such applications is likely to be strongly dependent
on the sense of presence within the virtual environment that is felt
by the subjects. More than the richness of available images (Sheridan,
1992; Sheridan, 1996) the sensation of presence depends on the level
of interaction which actors have in both real and simulated environments
(Mantovani & Riva, 1999). Normally, a certain amount of freedom
of movement is needed in order to adapt to the needs of a changing environment.
That is why a good VR system must grant a certain amount of freedom
of movement to the actors who move in it. As noted by Ellis (1996) the
key questions for a VR designer are: “ Can [the users] accomplish
the tasks they accept? Can they acquire the necessary information? Do
they have the necessary control authority? Can they correctly sequence
their subtasks?” (p.258). In fact, the successful implementation
of a VR-based telemedicine system will depend directly on the answers
to these kinds of questions. In this sense, emphasis shifts from quality
of image to freedom of movement, from the graphic perfection of the
system to the actions of actors in the environment. "Experience
of space will depend more on the mode of locomotion than on the visual
and acoustic images. The reality of a surface will be in its implications
for action (e.g., does it impede locomotion) rather than in its appearance
(e.g., does it look like a wall). In this approach, the reality of experience
is defined relative to functionality, rather than to appearances"
(Flach & Holden, 1998). 2.2
E-health in clinical care The
first area in which e-health can offer a competitive advantage is medical
consultation and diagnosis. Remote video consultation, for example,
could give consumers greater access to skilled health professionals
regardless of geographic proximity. The efficacy of the use of remote
consultation in e-health is confirmed by different research. For instance,
Craig et al. (2000) recently compared the outcome of neurological patients
admitted to two small hospitals. In one hospital all patients with neurological
symptoms were seen by a neurologist at a distance using an interactive
video-link transmitting at 384 kbit/sec; in the other patients with
neurological problems were managed as per usual practices. No appreciable
differences were noted between the two hospitals in the final outcome. Lange
et al. (2000) developed an Internet based e-health system for treatment
of post-traumatic stress disorder. The treatment comprised 10 writing
sessions (45 min each) over five weeks. Reduction in post-traumatic
stress symptoms compared favourably to changes in control and experimental
groups in trials of similar but face-to-face treatment. Elford
and colleagues (2000) used a PC-based videoconferencing system transmitting
at 336 kbit/sec to conduct child psychiatry assessments. An independent
evaluator concluded that in 96% of the assessments the diagnosis and
treatment recommendations made via the videoconferencing system were
the same as those made in face-to-face meetings. No significant difference
was found in the patients' or parents' satisfaction responses after
the two types of assessment even if most parents (91%) indicated that
they would prefer to use the videoconferencing system than to travel
a long distance to see a psychiatrist in person. Also
the cost-effectiveness of remote video consultation is supported by
experimental data. Mielonen et al. (2000) assessed in Finland the costs
of psychiatric inpatient care-planning consultations to remote areas
using videoconferencing, instead of the conventional face-to-face consultations
at a hospital. At a workload of 20 patients per year, the cost of the
videoconferences was FM2510 per patient; the cost of the conventional
alternative was FM4750 per patient. At 50 care consultations per year,
a remote municipality would save about FM117,000. Even
if, for the most part, remote consultation programs rely on dedicated
networks (not the Internet) to provide connectivity between remote clinics
and a centralized consulting facility, e-mail is emerging as low-cost
alternative to facilitate electronic communications between patients
and care providers (Jerome et al., 2000). In particular the use of e-mail
in e-health offers the following advantages: the ability to offer routine
transactions and patient education; increased efficiency; the self-documenting
nature of this medium; cost-effectiveness; and serving as a clinical
extender (Taylor, 2000). Given
the successful results obtained using a less immersive medium, some
researchers are thinking that the use of immersive VR in e-health could
further strengthen the assessment and rehabilitation process (Glantz,
Durlach, Barnett, & Aviles, 1997; Riva, Bacchetta, Baruffi, Rinaldi,
& Molinari, 1998a) resulting from its ability to immerse the patient
in a life-like situation that she/he is forced to face. As noted by
Miller & Rollnick (Miller & Rollnick, 1991) people are "more
persuaded by what they hear themselves say than by what other people
tell them" (p. 58). Future applications of remote VR in e-health
are expected to appear during the next year for the treatment of phobias
and eating disorders (Riva & Gamberini, 2000b; Riva et al., 1998b). A
second important section of e-health for clinical care is medical imaging.
In fact, the use of the Internet to transfer medical images to expert
interpreters could accelerate and improve the diagnostic processes as
well as reduce costs (Shortliffe, 2000). For instance Braun et al. (2000)
recently verified the efficacy of teledermatoscopy under routine conditions
in private practice. In particular they found that diagnostic accuracy
of the teledermatoscopy approach was superior to that of the conventional
approach for malignant melanocytic lesions. Usually,
data visualization is performed slice by slice, or by using volume rendering
on costly graphics workstation (Riva & Gamberini, 2000b). However,
the recent development of Internet technologies, the dramatic improvements
of rendering capabilities on PC's and the diffusion of the Virtual Reality
Modelling Language (VRML) make three-dimensional visualization based
upon client-server architecture possible (Kling-Petersen et al., 1999). Moreover,
state-of-the-art VR and high speed networks have made it possible to
create an environment for clinicians geographically distributed to share
immersively massive medical volumetric databases in real time. One of
the most successful systems in this area is the one developed by the
VRMedLab at the University of Illinois at Chicago. This research group
has developed a tele-immersion program that allows clinicians to interact
with the same volumetric models, point, converse and see each other
through an ATM network (Ai, Rasmussen, & Silverstein, 2000). Participants
are depicted by virtual representations (avatars) which have their head
and hand tracked so that they can convey natural gestures such as nodding
and pointing. Moreover, the system allows the users to fly through space
using a joystick, and to interact with objects in the space using a
tracked wand. Participants can pick, delete or move any of the objects
and speak to each other using a virtual intercom system. A more advanced
research project was developed at NASA in the “Virtual Collaborative
Clinic” project at NASA’s Ames Research Center. It used
the high bandwidth Abilene network (9920 Gbps) for multicasting in real-time
complex images (1200000 polygons) generated on a central graphic server
at NASA (Ross, Twombly, Bruyns, Cheng, & Senger, 2000). To allow
interaction with remote sites, the project used a combination of client-side
(local) low resolution rendering (20000 polygons) during object manipulations
and multicast image distribution for single frame (static) image display.
To achieve these outstanding results, the project used a 39Mbps bandwidth
through satellite communication. Another
typical use of visualization applications is the planning of surgical
and neuro-surgical procedures (Abbasi, Weigel, Sommer, Schmiedek, &
Kiessling, 1999; Bergman et al., 1999). The planning of these procedures
usually relies on the studies of series of two-dimensional MR (Magnetic
Resonance) and/or CT (Computer Tomography) images which have to be mentally
integrated by surgeons into a three-dimensional concept. This mental
transformation is difficult, since complex anatomy is represented in
different scanning modalities, on separate image series, usually found
in different sites/departments. An e-health VR-based system is capable
of incorporating different scanning modalities coming from different
sites providing an interactive three-dimensional view. Within the Virtual
Collaborative Clinic project NASA researchers developed Cyberscalpel,
a VR based telemedicine surgical system for planning and practice (Ross
et al., 2000). To plan the operation of a patient with cancer of the
jaw, the upper and lower jaws were reconstructed using Cyberscalpel
starting from a CT scan. The scan was reduced to 20000 polygons, and
the final model used to prove how fibular bone could be sectioned to
mimic and replace the jaw pieces. The display of the Cyberscalpel was
multicast to the participant Virtual Clinic clients during this procedure. 2.3
E-health in health education Even
if computer-assisted instruction (CAI) programs for medical education
were developed more than 30 years ago their limits lack of portability,
update and local availability have drastically reduced the potential
impact of this approach (Haag, Maylein, Leven, Tönshoff, &
Haux, 1999). However, the appearance of Internet-based information and
communication technologies is changing how training is being conducted
in many medical schools (Cox, White, Brinson, & Ramey, 2000). As
noted by Federico (1999) “we are in the midst of a paradigm shift
in education and training from classroom centric to network centric”
(p. 653). The
key of this shift is the emergence of “hypermedia”, that
can be described as “on-line setting where networks of multimedia
nodes connected by links are used to present information and manage
retrieval” (Federico, 1999, p. 662). The Internet is a well-known
hypermedia environment that users can access by using interactive browsers,
such as Microsoft’s Internet Explorer or Netscape’s Navigator.
If the information is textual in the first place, we talk of a hypertext,
and if there are certain visual, musical, animation elements or the
like included, we talk of a hypermedia (Encarta, 1999). Hypertexts
and hypermedia are structured around the idea of offering a learning
environment that mimics human thinkingthat is, an environment
that allows the user to make associations between “concepts”
rather than move sequentially from one to the next, as in an alphabetical
list. Using hypermedia, students are no longer forced to follow linear
lesson sequences but can choose “… what to view, when
to view, for how long to view and how many times to view” (Large,
1996, p. 104). Consequently, on-line students, can dynamically adapt
the educational experience to their own momentary needs, by directly
interacting with hypermedia (Barab, Bowdish, & Lawless, 1997). However,
some researchers are skeptical about the educational relevance of hypermedia
environments. As noted by Large (1996), “Linking information
may be a necessary condition for learning, but it is not sufficient.
Links can be made in many ways, including totally arbitrary ones with
little semblance to how people associate ideas” (p. 98). Moreover,
enabling learner control assumes that students have sufficient knowledge
to select and make optimal links. Unfortunately this is not always true,
especially for novices who also have to face the cognitive load required
to keep track of their navigational paths, or in bad structured hypermedia. For
instance, Gotwald et al. (2000) recently assessed 30 web sites for radiological
education. Even if many of them contained large numbers of interesting
radiological images of good quality, the structure and organization
of the sites were their weakest features, reducing their educational
potential. To
overcome these problems a new form of hypermedia is now emerging: shared
hypermedia (SH). SHs are new Internet tools attaching computer-mediated-communication
to Web browsing (see Table 1 for a list of available SHs). In
SHs different users, who are simultaneously browsing the same Web site,
can communicate with each other and share files or web addresses. Using
a simple interface, usually resembling a little remote control, SHs
users can get a constantly updated list of all the other online users
who are visiting the same Web site. Usually
a SH let the user conduct group and private chats, exchange information
or files, and share the same web pages. On any Web site SH users can
see a list of other users and talk with them on group and private levels.
SHs further enhances the user experience by consolidating different
form of CMC (e-mail, IRC, etc.) into one fully integrated interface.
Many SHs also have a search engine that can be used to find user with
a specific age and/or similar interests. In this way is really easy
to set up a group with a common interest, like Cardiology or Eating
Disorders; or get online to practice a foreign language with a mother-tongue
users. The
most advanced SHs (i.e. Cahoots and Firetalk) have an option - the web
tour - very interesting for its possible use in teaching. During a web
tour a leader can guide the browsing of a small group of users (usually
up to 20), who are forced to follow him, interacting with them in real
time. By assembling people with similar interests and surfing habits,
this new Internet platform transforms Web browsing into a social activity.
In this sense SHs can be the starting point of community-centered environments
that can improve the experience of learning. A
second emerging area in e-health applications for health education is
remote visualization of massive volumes of information and databases.
Through remote 3-D visualization, students can understand important
physiological principles or basic anatomy. For instance, Internet based
VR can be used to explore the organs by "flying" around, behind,
or even inside them. In this sense, VR-based e-health can be used both
as didactic and experiential tool, allowing a deeper understanding of
the interrelationship of anatomical structure that cannot be achieved
by any other means, including cadaveric dissection. The
number of developed applications in this area is very large. For instance
Westwood and colleagues (Westwood, Hoffman, Robb, & Stredney, 1999)
reported more than 10 different educational and visualization applications.
A typical example is Anatomic VisualizeR, a VR-enhanced multimedia application
used in medical school anatomy and high school biology classes (Hoffman
& Murray, 1999). A more advanced attempt in using a VR-based telemedicine
system for surgical simulations comes from the Manchester Visualization
Center (John & Phillips, 2000). Using VRML and JAVA to render the
3D models, the authors created simulations of ventricular chatheterisation
accessible through Internet. Early in their training, trainees in neurosurgery
need to gain an appreciation of the ventricular system and how to cannulate
it in an emergency. The flow of cerebrospinal fluid can be obstructed
in the ventricles by several pathological processes leading to hydrocephalus.
The pressure within the ventricles can rise leading to loss of consciousness.
The ventricular system can be cannulated in the operating theatre, fluid
drained and a potentially lethal rise in pressure relieved. In
the virtual environment the user can move the virtual cannula to the
entry point on the 3D patient. The cannula is then placed with the correct
orientation. Finally, it is inserted through the virtual patient and
into the ventricular system. The
authors are also exploring the possibility of allowing multi-user collaboration.
Using the Deep Matrix software (Reitmayr, Carroll, & Reitemeyer,
1999) as a base platform, researchers have extended the simulators to
allow a single instance of one simulator to be accessed by several users
over the Internet. Any change in the VRML word produced by one user
is propagated to all the other participant web browsers. This enables
the teacher to explain to a remote audience how a procedure should be
performed. A
similar approach - VRML plus JAVA - is used by the Department of Neurosurgery
in the Leeds General Infirmary, UK, to train surgeons in the treatment
of trigeminal neuralgia. Specifically, the teletraining system simulates
the insertion of a needle in Percutaneous Rhizothomy (Li, Brodlie, &
Phillips, 2000). The collision detection between the instrument and
patient is critical to this simulation. Hence, the virtual environment
provides a pair of linked views: one from the eye of the surgeon and
one from the viewpoint of the needle. The different parts of the procedure
- marking anatomical landmarks, orienting the needle and inserting it
- are all simulated by the application. The simulator is freely available
on a public access Web site: http://synaptic.mvc.mcc.ac.uk/home.html. The
opportunity for international collaboration in medical conferences is
another potential application now being explored (Brennan & Brennan,
1995) in this area. Interaction and participation using shared VR might
alleviate some of the stiltedness of current videoconferencing capabilities.
However, even if many of these applications could be developed, their
actual use in this area is still limited by both technology-related
factors - such as lack of high visual fidelity or price/performance
issues - and design-related factors - such as poor interface and sensory
overload. 2.4
E-health in public health activities Public
health activities are one of the areas that could be most dramatically
reshaped by the Internet. Public health activities include all the health
care activities aimed at giving consumers a more pronounced role in
their own health and health care. More in detail, public health activities
range from home-based monitoring of health status, to the development
of tools for self-assessment of health risks and management of chronic
diseases (Shortliffe, 2000). One
public health area that is exploded over the past few years, is the
one including consumer-oriented Internet sites. In fact, many providers
of health information have identified the Internet as an effective medium
for reaching large numbers of health consumers. These sites are usually
dedicated to the promotion of various healthy lifestyles, the diagnosis
and management of diseases, and interventions to prevent the onset of
disease. The formats range from mailing lists to interactive Web sites,
chat sessions, or compilations of online resources. However,
given the huge volume of health information available on the Internet,
a key issue for the diffusion of e-health is the creation of tools and
guidelines to help consumers find information of interest and evaluate
its quality (Gamberini & Riva, 2000). For example, a simple Web
search for "cannabis" can return more than 130,000 Web pages
(Gamberini & Riva, 2000), and some 61,000 Web sites contain information
on breast cancer (Shortliffe, 2000). To search through this incredible
amount of data, consumers need effective searching and filtering tools
and a way to judge the quality, authoritativeness, and provenance of
the information. In
a recent study Kim et al.(1999) analyzed the published criteria for
specifically evaluating health related information on the Internet.
The most frequently cited criteria were those dealing with content,
design and aesthetics of site, disclosure of authors, sponsors, or developers,
currency of information (includes frequency of update, freshness, maintenance
of site), authority of source, ease of use, and accessibility and availability.
The results suggest that, even if there is a general agreement on some
criteria, is still required the identification and assessment of a clear,
simple set of consensus criteria that the general public can understand
and use. Another
key area of public health activities that is affected by e-health is
the access to health records (Paperny, 2000). Historically, care providers
have maintained voluminous records of patient encounters within their
organizations, documenting dates and times of consultations, diagnoses,
lab results, prescriptions, and more. Electronic
medical records are the e-health evolution of traditional paper-based
health records. These systems have evolved from simple databases to
true medical records systems with variable levels of functionality.
Early systems provided simple anamnestic data. Modern systems now even
provide laboratory results, copies of the radiology images and therapeutic
orders. If
electronic medical records were initially used for allowing medical
specialists to share patient records and to communicate with each other
on the Internet (Sung, Kim, Kim, Yoo, & Sung, 2000), in the last
years a number of new Web sites have begun to allow consumers to store
their own health records online. The potential benefits of these sites
are many. As noted by Shortliffe (2000) “Using them, consumers
can create comprehensive, longitudinal records that capture information
about the care received from different organizations over an extended
period of time. Consumers can use these records to help monitor and
evaluate their health status, and they can grant access, if they wish,
to different providers for purposes of care” (p. 53). Some
sites also provide some sort of emergency feature that enables care
providers to gain access to a patient's records in an emergency situation,
something that is much more difficult to do if the records are not stored
online. 3.
Conclusions The
emergence of e-health could have a strong effect on health care. As
we have seen, the key characteristic of e-health is the use of shared
media. Using the Internet, therapists can present, from a remote site,
a wide variety of stimuli and to measure and monitor a wide variety
of responses made by the user. However, at this stage, there are different
short-comings that the potential of this approach. The
main problem is non-technical and is related to the personal and organizational
changes needed to introduce e-health in healthcare organizations (Cardno,
2000). Although the introduction of shared media has been successful
and become accepted practice in many areas of industry, traditional
methods have tended to prevail in health-care. Telehealth and e-health
have been adopted by enthusiasts who recognize the potential benefits
of a these new media. However, the more widespread introduction of e-health
requires considerable organizational change in the way health-care is
delivered (Birch, Rigby, & Roberts, 2000). This requires an alteration
of established factors such as consultations and referral patterns,
ways of payment, specialist support for primary healthcare, co-operation
between primary and secondary healthcare, defining geographical catchment
areas and the “ownership” of the patients (Olsson &
Calltrop, 1999). A
further problem is the technology of e-health. Actual technology
hardware, software and transmission is expensive and far from
perfect (Lou, Lin, Lin, & Hoogstrate, 2000). Insufficient image
quality, low framing rate, flickering and delays makes working in front
of a video terminal unattractive and in particular very tiring. An important
effect of this is, among other, an increased tendency to produce errors. Fortunately
the quality of technology in this area is increasing while costs are
falling down. Prices
are declining by about 25 per cent per year (Allen, 1999a). Simple telephone-based
videoconferencing system are now available for under $500 while high
quality board-based ISDN systems can cost less than $1000. New transmission
technologies, including Digital Subscriber Line (xDSL) and cable modem,
promise to provide order-of-magnitude increases in dependable bandwith
for a small increment of price. For the success of e-health applications
widespread access to the Internet is also required. Many applications
currently demand only moderate bandwidth and latency, meaning that standard
modem access to the Internet, at 28.8 to 56 kbit/s may suffice. A
recent research evaluated a low-bandwidth e-health system in eight community
hospitals connected to a central hospital via the Internet. PCs were
used with videoconferencing software and modem connections to the telephone
network. Even if the average live video frame rate was 1 frame/sec.
(at the best image quality), with an average latency of 3 seconds, the
results suggested that Internet-based videoconferencing is acceptable
for certain telemedicine applications (Lemaire, Boudrias, & Greene,
2000). Successful results with a limited bandwith have also been obtained
by an e-health teleconsultation application developed in Croatia: a
33 kbit/s link was established between a team of specialists in the
General Hospital 'Sveti Duh' in Zagreb and a general practitioner's
clinic in Selca, on the island of Brac using $700 computer systems (Ostojic
et al., 2000). Another
relevant issue is that of ensuring equitable access to health resources
by different demographic groups. There are already considerable differences
in access to health care in the world. Ensuring that differential access
to the Internet along demographic lines does not exacerbate this imbalance
could become an increasingly important issue, especially if the provision
of health care moves online (Shortliffe, 2000). Security
and legal protection are two more key issues for the diffusion of e-health
(DeVille & Fitzpatrick, 2000; Hirsch, 2000). In fact this approach
involves three fundamental types of relationship (Stanberry, 1999) in
which a duty is owed by one party to another: -
the relationship between the clinician and the patient; -
the relationship between clinicians; and -
the relationship between the provider of the telemedicine system and
the user. The
situation may be complicated by the involvement of multiple clinicians
and/or the providers of the telemedicine systems (call centers, telecommunications
network, etc). As noted by Stanberry (1999), if “a patient is
harmed during a teleconsultation (the healthcare centre) could choose
to name a number of these organisations or individuals as defendants
to a legal action for negligence if it is unclear what went wrong or
where responsibilities are” (p. 24). Moreover
e-health can hide severe privacy and security risks, because patient
data and hospital data stored on a secure Intranet can be manipulated
by connecting it to the Web. This is even truer for e-mail consulting.
Most e-mail exchanges between patient and provider involve discussions
of personal health information, which must be suitably protected from
breaches of confidentiality and, to a lesser extent, alteration (Sogner,
Goidinger, Reiter, Stoeger, & zur Nedden, 2000). However
the establishing of a firewall and the introduction of HPC (Health Professional
Card) can drastically reduce the risk of un-authorized access to the
hospital server. For secure e-mail, PGP (Pretty Good Privacy) can be
easily used as a standard protocol (DeVille & Fitzpatrick, 2000).
In general, planning all activities exactly as well as introducing advanced
form of data protection are important requisites for reduction of security
risks in Internet (Seibel, Kocher, & Landsberg, 2000). To
spread the diffusion of e-health, further research is needed. More evaluation
is required of clinical outcomes, organizational effects, benefits to
health-care providers and users, and quality assurance. It is also very
important that professionals in this field share information about their
experience and examine the results of evaluations so that the suitable
development work can be speeded up. Acknowledgements The
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