Small Animal/Exotics Compendium January 2000

EMERGING TECHNOLOGY V

Telesonography*
Marc Papageorges, DVM, MS, PhD
Diplomate, ACVR
Veterinary Diagnostic Imaging &
Cytopathology, P.C.
Gresham, Oregon
he primary obstacle to more
in-house services by allowing practi-
tioners to consult with specialists
during the learning phase and when
faced with difficult cases (see Tele-
consultants). Some practitioners
“virtually” incorporate specialists in
their practices and have every sono-
gram reviewed by radiologists or car-
diologists. Such full service can raise
and on-site training with electronic
training but to provide veterinarians
with a personal instructor. Such in-
struction is very helpful because prac-
titioners need months of practice
to develop good skills and years to
perfect them. Veterinarians can obtain
second opinions from specialists on
a regular basis or participate in sched-

T widespread use of ultrasonog-

raphy in veterinary medicine
is not cost but the effort required by
practitioners in developing expertise.
Telesonography, which is telemedi-
cine applied to ultrasonography, can
resolve this dilemma by providing a
quick, affordable vehicle for sending
the ultrasound images to specialists.
Telesonography is affordable because
images can be directly imported
from most ultrasound machines
without having to rely on an expen-
sive image-capture device. Thus tele-
sonography has been more readily
accepted by veterinarians than has tele-
radiology. In the United States, approx-
imately 500 practices are presently
using telesonography to enhance their
practice value.
Diagnosis, Training, and
Continuing Education
Telesonography services offer sev-
eral advantages to both veterinarians
and their clients (see Advantages of
Telesonography). It can facilitate
training in ultrasound techniques
and increase the diagnostic yield of
*Adapted from Papageorges M: Tele-
sonography, in Understanding and Using
Telemedicine: How to Harness the Tele-
communication Revolution. Gresham, OR,
VDIC Publishing, Inc, 1999; with per-
mission.
the level of medicine, increase client
satisfaction, limit professional liabili-
ty, and increase job satisfaction.
uled rounds or training sessions through
interactive consultations (i.e., video-
conferencing). The possibilities de-
Telesonography also eliminates pend on the type of telemedicine sys-
travel time and costs associated with tem installed and how much a
practitioner training and referrals to practitioner wants to rely on the sys-
specialists. Telesonography consulta- tem.
tions cost between $25 and $50 per
case, depending on the frequency of Store-and-Send Systems
use. With telesonography, veterinari- In store-and-send telemedicine sys-
ans can better retain information be- tems, still images are stored in the
cause it is applied as needed. Tele- practitioner’s computer and sent by
sonography training can be tailored to modem to a remote computer for re-
individual needs and performed as of- view by specialists at their conve-
ten as required. The idea is not to re- nience. Store-and-send formats can
place scientific literature, seminars, also use short (8- to 12-second) se-
Advantages of Telesonography
■ To veterinarians and clients
Elimination of travel time and associated training and referral costs
Less stress and wasted time in seeking diagnostic answers
Fewer errors (reduced professional liability)
Learning experience (expert second opinion on every case)
Improved quality of sonograms
More diagnostic information per study
More studies performed
■ To veterinarians
Increased client satisfaction and compliance
More confidence in results
Increased perceived value of ultrasonography
More confidence in ability to handle complicated cases
Greater satisfaction in practicing medicine
Compendium January 2000
Teleconsultants
American College of
Veterinary Radiology
c/o Tom Nyland, DVM
Department of Veterinary
Radiology
School of Veterinary Medicine
University of California, Davis
Davis, CA 95616
503-752-2511
www.acvr.ucdavis.edu
Animal Medical Imaging
16390 87th Street North
Redmond, WA 98052
800-888-0197
Email: charlesR81@aol.com
www.animalmedicalimaging.com
Remote Veterinary
Consultants
100 Chastain Center Road
Suite 100
Kennesaw, GA 30114
800-553-3265
Email:bcampbell@remotevet.com
www.remotevet.com
Veterinary Diagnostic Imaging
& Cytopathology, P.C.
2892 SE Vista Way
Gresham, OR 97080
888-DIC-STAT
Email: marcp@vdic.com
www.vdic.com
VETMED
Larry P. Tilley, DVM,
and associates
22 Descanso Road
Santa Fe, NM 87505-9125
800-214-9760
Email:TILLEY@compuserve.com
www.vetmedfax.com
quences of moving images recorded
during real-time examinations.
Store-and-send systems have sever-
al advantages. They are relatively in-
expensive and require minimal coor-
dination between practitioners and
specialists unless a report is needed at
once (i.e., stat.). These systems in-
clude electronic storage of still im-
ages and videoclips for future refer-
TABLE I
Budgeting Videoconferencing Services
Item
Videoconferencing software and camera
Dedicated telephone line (ISDN)
Consultant fees
ence and can print representative im-
ages along with the specialist’s report
for pet owners to take home. The
stored images can also be sent elec-
tronically to other locations (e.g., to
a surgeon or other referral specialist).
The major disadvantage of store-
and-send systems is the lack of direct
interaction between general practi-
tioners and consultants. Staff at send-
ing sites must carefully input all of
the required data (e.g., representative
images, patient description, history,
clinical signs). If any information is
missing, the specialist’s interpreta-
tion may be incomplete and requests
for more information or additional
images can double or triple the time
and effort needed to complete the
teleconsultation.
Interactive Consultations
Most interactive consultations are
presently performed as regular tele-
phone conversations while the prac-
titioner and specialist examine the
same still images on remote comput-
ers. The ability to ask questions in-
creases diagnostic accuracy because
the consultant has a more complete
clinical picture and better under-
standing of what was observed dur-
ing the real-time ultrasound exami-
nation. In addition, practitioners can
ask questions and learn from the
conversations. A major problem, how-
ever, is the need to coordinate the
schedules of practitioners and con-
sultants without wasting time.
Real-time interactive ultrasonogra-
phy consultations can also be com-
Small Animal/Exotics
Cost ($)
1000
70–100/mo
120–200/hr
pleted through videoconferencing, in
which the specialist “virtually” looks
over the veterinarian’s or technician’s
shoulder during ultrasonography. Such
consultations are most successful us-
ing a dual video-input videoconfer-
encing system that allows the consul-
tant’s computer screen to display
simultaneously the transducer posi-
tion (with a video camera) and real-
time images imported directly from
the ultrasound machine. This system
can be used to schedule training ses-
sions or on an emergency basis to
help practitioners during difficult ex-
aminations.
Cost was initially an obstacle; but
today interactive consultation is with-
in the budget of many practices (Table
I), with prices continuing to decrease.
Interactive consultations are more
time-consuming than are store-and-
send consultations and will probably
remain time prohibitive for routine
consultations. When better-quality
videoconferencing becomes more
readily available and affordable,
however, it may become an excellent
vehicle for ultrasonography training.
Cost
In practices already equipped with
an ultrasound machine, telesono-
graphy is relatively inexpensive (Table
II) to incorporate. In addition to
ultrasonography equipment, a mid-
to high-end computer (400-mHz
Pentium® II with 64 MB of RAM
is recommended), telemedicine or
imaging software, and communica-
tions software are needed. Software
Small Animal/Exotics
TABLE II
Budgeting Telesonography Services
Item
Ultrasound machine
Computer and 20-inch high-resolution monitor
Telemedicine and imaging software
Transmission fee
Consultation fee
Two days of on-site training
Ultrasonography library (books)
Seminars or short courses (3)
Total
Lease
is available from several ultrasonog-
raphy vendors as well as telemedi-
cine software providers (see Teleso-
nography Systems and Software
Vendors). Practitioners can also
purchase an image-capture adapter
(e.g., Sony Digital MaviCap MVC-
FDR1) for approximately $300.
The MaviCap stores data on a stan-
dard floppy disk using the JPEG/
Bitmap format and standard NTSC
video signal from virtually any
video equipment, including the
video output of ultrasound ma-
chines. The stored images are then
attached to an email message that
provides the accompanying clinical
information. All the consultant
needs is viewing software.
Training
Telesonography is a complex pro-
cedure; without proper training, er-
rors are likely to consume profits. At
least 1 full day—preferably 2 days—
of uninterrupted in-house training is
needed for veterinarians and staff to
understand telemedicine equipment
and procedures. Such training may
need to be ongoing because of per-
sonnel turnover. I advise practitio-
ners to have at least three staff mem-
Cost ($)
25,000
2500
0–6000
0–10/case
25–50/case
2500
500
3000
33,000 to 39,000 + 0–60/case
700/mo
bers trained in equipment use and
transmission procedures. Although
many telemedicine companies pro-
vide some training when a new sys-
tem is installed, such training is of-
ten superficial. Thus the practitioner
must assume responsibility for train-
ing personnel. In addition to the ba-
sic training, practitioners should hold
weekly staff meetings to discuss prob-
lems and continue developing proto-
cols and procedures.
Veterinarians also need to learn ul-
trasonography and scanning tech-
niques to provide consultants with
the images needed for accurate diag-
noses. I recommend that practitio-
ners complete at least two or three
short courses or seminars on ultra-
sonography methods and practices
before using telesonography.
After the telesonography service has
been initiated, practitioners must also
become versed in explaining ultra-
sonography results to clients as well as
challenged to accept more complicat-
ed cases. Regular interactions with
consultants and other types of contin-
uing education (e.g., readings, semi-
nars, advanced courses, additional on-
site training) should become part of the
practitioner’s standard routine.
Compendium January 2000
Telesonography Systems
and Software Vendors
DVM Communications
3645 Warrensville Center Road
Suite 212
Cleveland, OH 44122
800-417-9707
Email: DVMcom.com
www.dvmcom.com
Remote Veterinary
Consultants
100 Chastain Center Road
Suite 100
Kennesaw, GA 30114
800-553-3265
Email:bcampbell@remotevet.com
www.remotevet.com
Sound Technologies
5256 South Mission Road
Building 804
Bonsall, CA 91003
800-268-5354
Email: soundvetco@aol.com
Veterinary Specialists
Network
2414 Bayou Drive
League City, TX 77573
281-338-9785
www.veterinary.com
What Information Needs
to be Transmitted?
As part of establishing a relation-
ship with consultants, practitioners
need to understand the images (see
Recommended Ultrasonography Im-
ages) and information (see Informa-
tion Needed for Telesonography) that
consultants will require to assist in
obtaining an accurate diagnosis. This
principle may seem elementary, but
lack of information is one of the
more significant problems encoun-
tered by specialists who provide
telesonography services. In addition
to basic information about the prac-
Compendium January 2000 Small Animal/Exotics

Recommended Ultrasonography Images Information Needed for Telesonography

■ Kidneys—Minimum of six images of each ■ Communication information
kidney plus any additional views that show focal Veterinarian’s name
abnormalities: three sagittal (one of the pelvis with Hospital or practice name and address
measurements, one lateral to the pelvis, and one Telephone and fax numbers
medial to the pelvis) and three transverse (one of Email address (optional)
the pelvis with measurements, one cranial to the
pelvis, and one caudal to the pelvis) ■ Patient and medical information
Degree of urgency (stat.)
■ Liver—Minimum of eight images plus any Owner’s name
additional views that show focal abnormalities: Patient’s name
seven sagittal (one of the caudate lobe plus the Patient’s species, breed, sex, age, and weight
right kidney, one of the vena cava and hepatic Chief owner complaint
veins, one of the gallbladder, one of the cystic/ Patient history
common bile duct, one of the left medial lobe, Pertinent laboratory results and results of other
one of the left lateral lobe, and one of the liver diagnostic studies
and spleen) and one transverse that includes the Reason(s) for ultrasonography
gallbladder Your ultrasound findings
Diagnostic differentials
■ Spleen—Minimum of seven images plus any Working diagnosis
additional views showing focal abnormalities: four Any specific questions
sagittal (one including the splenic vein, one lateral
to the splenic vein, one medial to the splenic vein, ■ Image information
and one with the spleen against the liver) and Images should be labeled if obvious anatomic
three transverse (one including the splenic vein, landmarks are not included (location and
one cranial to the splenic vein, and one caudal to transducer orientation)
the splenic vein)

■ Urinary bladder—Minimum of six images plus
any additional views showing focal abnormalities:
three sagittal (one including the trigone and
urethra, one left lateral to the trigone, and one right
lateral to the trigone) and three transverse (one
cranial aspect, one midportion, and one caudal
aspect); add two or three standing views of calculi if
warranted
tice (e.g., contact name, address, telephone and fax num-
bers, email address), information about the patient and de-
gree of urgency are standard requirements. Practitioners
should initially transmit as many images as possible; after
developing confidence and skills, however, fewer images
showing abnormalities or tissue known to be affected by
disease may be required.
Conclusion
Within 5 to 10 years, a majority of veterinary hospitals
will be offering ultrasonography services. Already the
dilemma is not whether veterinarians should add ultra-
sonography services to their practices but how they should
do it (i.e., in-house, a mobile service, or both). As part of
in-house ultrasonography services, telesonography can help
practitioners become more accurate diagnosticians.