T
he primary obstacle to more widespread use of ultrasonog-raphy in veterinary medicineis not cost but the effort required by practitioners in developing expertise.Telesonography, which is telemedi-cine applied to ultrasonography, canresolve this dilemma by providing aquick, affordable vehicle for sendingthe ultrasound images to specialists.Telesonography is affordable becauseimages can be directly importedfrom 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 theirpractice value.
Diagnosis, Training, and Continuing Education
Telesonography services offer sev-eral advantages to both veterinariansand their clients (see Advantages of Telesonography). It can facilitatetraining in ultrasound techniquesand increase the diagnostic yield of in-house services by allowing practi-tioners to consult with specialistsduring the learning phase and whenfaced with difficult cases (see Tele-consultants). Some practitioners“virtually” incorporate specialists intheir practices and have every sono-gram reviewed by radiologists or car-diologists. Such full service can raisethe level of medicine, increase clientsatisfaction, limit professional liabili-ty, and increase job satisfaction.Telesonography also eliminatestravel time and costs associated withpractitioner training and referrals tospecialists. Telesonography consulta-tions cost between $25 and $50 percase, depending on the frequency of use.With telesonography, veterinari-ans can better retain information be-cause it is applied as needed. Tele-sonography training can be tailored toindividual needs and performed as of-ten as required. The idea is not to re-place scientific literature, seminars,and on-site training with electronictraining but to provide veterinarians with a personal instructor. Such in-struction is very helpful because prac-titioners need months of practiceto develop good skills and years toperfect them. Veterinarians can obtainsecond opinions from specialists ona regular basis or participate in sched-uled rounds or training sessions throughinteractive consultations (i.e., video-conferencing). The possibilities de-pend on the type of telemedicine sys-tem installed and how much apractitioner wants to rely on the sys-tem.
Store-and-Send Systems
In store-and-send telemedicine sys-tems, still images are stored in thepractitioner’s computer and sent by modem to a remote computer for re-view by specialists at their conve-nience. Store-and-send formats canalso use short (8- to 12-second) se-
Telesonography *
Marc Papageorges, DVM, MS, PhDDiplomate, ACVRVeterinary Diagnostic Imaging &Cytopathology, P.C.Gresham, Oregon
EMERGING TECHNOLOGY
V
*Adapted from Papageorges M: Tele-sonography, in
Understanding and Using Telemedicine: How to Harness the Tele- communicationRevolution
. Gresham, OR,VDIC Publishing, Inc, 1999; with per-mission.
Advantages of Telesonography
I
To veterinarians and clients
Elimination of travel time and associated training and referral costsLess stress and wasted time in seeking diagnostic answersFewer errors (reduced professional liability)Learning experience (expert second opinion on every case)Improved quality of sonogramsMore diagnostic information per study More studies performed
I
To veterinarians
Increased client satisfaction and complianceMore confidence in resultsIncreased perceived value of ultrasonography More confidence in ability to handle complicated casesGreater satisfaction in practicing medicine
Small Animal/Exotics
Compendium
January 2000
quences of moving images recordedduring real-time examinations.Store-and-send systems have sever-al advantages. They are relatively in-expensive and require minimal coor-dination between practitioners andspecialists unless a report is needed atonce (i.e., stat.). These systems in-clude electronic storage of still im-ages and videoclips for future refer-ence and can print representative im-ages along with the specialist’s reportfor pet owners to take home. Thestored images can also be sent elec-tronically to other locations (e.g., toa surgeon or other referral specialist).The major disadvantage of store-and-send systems is the lack of directinteraction between general practi-tionersand consultants. Staff at send-ing sites must carefully input all of the required data (e.g., representativeimages, patient description, history,clinical signs). If any information ismissing, the specialist’s interpreta-tion may be incomplete and requestsfor more information or additionalimages can double or triple the timeand effort needed to complete theteleconsultation.
Interactive Consultations
Most interactive consultations arepresently performed as regular tele-phone conversations while the prac-titioner and specialist examine thesame still images on remote comput-ers. The ability to ask questions in-creases diagnostic accuracy becausethe consultant has a more completeclinical picture and better under-standing of what was observed dur-ing the real-time ultrasound exami-nation. In addition, practitioners canask questions and learn from theconversations. A major problem, how-ever,is the need to coordinate theschedules of practitioners and con-sultants without wasting time.Real-time interactive ultrasonogra-phy consultations can also be com-pleted through videoconferencing, in which the specialist “virtually” looksover the veterinarian’s or technician’sshoulder during ultrasonography. Suchconsultations 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 fromthe ultrasound machine. This systemcan be used to schedule training ses-sions or on an emergency basis tohelp practitioners during difficult ex-aminations.Cost was initially an obstacle; buttoday interactive consultation is with-inthe budget of many practices (TableI),with prices continuing to decrease.Interactive consultations are moretime-consuming than are store-and-send consultations and will probably remain time prohibitive for routineconsultations. When better-quality videoconferencing becomes morereadily available and affordable,however, it may become an excellentvehicle for ultrasonography training.
Cost
In practices already equipped withan ultrasound machine, telesono-graphyis relatively inexpensive (TableII) to incorporate. In addition toultrasonography equipment, a mid-to high-end computer (400-mHzPentium
®
II with 64 MB of RAMis recommended), telemedicine orimaging software, and communica-tions software are needed. Software
Teleconsultants
American College of Veterinary Radiology
c/o Tom Nyland, DVMDepartment of Veterinary Radiology School of Veterinary MedicineUniversity of California, DavisDavis, CA 95616503-752-2511 www.acvr.ucdavis.edu
Animal Medical Imaging
16390 87
th
Street NorthRedmond, WA 98052800-888-0197Email: charlesR81@aol.com www.animalmedicalimaging.com
Remote Veterinary Consultants
100 Chastain Center RoadSuite 100Kennesaw, GA 30114800-553-3265Email:bcampbell@remotevet.com www.remotevet.com
Veterinary Diagnostic Imaging & Cytopathology, P.C.
2892 SE Vista Way Gresham, OR 97080888-DIC-STATEmail: marcp@vdic.com www.vdic.com
VETMED
Larry P. Tilley, DVM,and associates22 Descanso RoadSanta Fe, NM 87505-9125800-214-9760Email:TILLEY@compuserve.com www.vetmedfax.com
TABLE I
Budgeting Videoconferencing Services
ItemCost ($)
Videoconferencing software and camera1000Dedicated telephone line (ISDN)70–100/moConsultant fees120–200/hr
Compendium
January 2000Small Animal/Exotics
is available from several ultrasonog-raphy vendors as well as telemedi-cine software providers (see Teleso-nography Systems and SoftwareVendors). Practitioners can alsopurchase 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 NTSCvideo signal from virtually any video equipment, including thevideo output of ultrasound ma-chines. The stored images are thenattached to an email message thatprovides the accompanying clinicalinformation. All the consultantneeds is viewing software.
Training
Telesonography is a complex pro-cedure; without proper training, er-rors are likely to consume profits. Atleast 1 full day—preferably 2 days—of uninterrupted in-house training isneeded for veterinarians and staff tounderstand telemedicine equipmentand procedures. Such training may need to be ongoing because of per-sonnel turnover. I advise practitio-ners to have at least three staff mem-bers trained in equipment use andtransmission procedures. Althoughmany telemedicine companies pro-vide some training when a new sys-tem is installed, such training is of-ten superficial. Thus the practitionermust 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 withthe images needed for accurate diag-noses. I recommend that practitio-ners complete at least two or threeshort courses or seminars on ultra-sonography methods and practicesbefore using telesonography. After the telesonography service hasbeen initiated, practitioners must alsobecome versed in explaining ultra-sonography results to clients as well aschallenged to accept more complicat-ed cases. Regular interactions withconsultants and other types of contin-uing education (e.g., readings, semi-nars, advanced courses, additional on-site training) should become part of thepractitioner’s standardroutine.
What Information Needsto be Transmitted?
As part of establishing a relation-ship with consultants, practitionersneed to understand the images (seeRecommended Ultrasonography Im-ages) and information (see Informa-tion Needed for Telesonography) thatconsultants will require to assist inobtaining an accurate diagnosis. Thisprinciple may seem elementary, butlack of information is one of themore significant problems encoun-tered by specialists who providetelesonography services. In additionto basic information about the prac-
Telesonography Systemsand Software Vendors
DVM Communications
3645 Warrensville Center RoadSuite 212Cleveland, OH 44122800-417-9707Email: DVMcom.com www.dvmcom.com
Remote Veterinary Consultants
100 Chastain Center RoadSuite 100Kennesaw, GA 30114800-553-3265Email:bcampbell@remotevet.com www.remotevet.com
Sound Technologies
5256 South Mission RoadBuilding 804Bonsall, CA 91003800-268-5354Email: soundvetco@aol.com
Veterinary SpecialistsNetwork
2414 Bayou DriveLeague City, TX 77573281-338-9785 www.veterinary.com
TABLE II
Budgeting Telesonography Services
ItemCost ($)
Ultrasound machine25,000Computer and 20-inch high-resolution monitor2500Telemedicine and imaging software 0–6000Transmission fee0–10/caseConsultation fee25–50/caseTwo days of on-site training2500Ultrasonography library (books)500Seminars or short courses (3)3000Total33,000 to 39,000 + 0–60/caseLease700/mo
Small Animal/Exotics
Compendium
January 2000
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