CYBERTHERAPY REPORT
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 browser - either 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 distributed - that 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. Then - if this refers to nested (scene within a scene) descriptions - the 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 time - when 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 thinking - that 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 present report was supported by the Commission of the European Communities (CEC), specifically by the IST programme through the VEPSY UPDATED (IST-2000-25323) research projects.


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