Biotelemetry provides a means for monitoring and studying human and animal physiologic functions from a remote site with the goals of minimally encumbering or disturbing normal activity allowing ambulatory freedom and often to place the investigator out of harm''s way. Since the early 1950''s biotelemetry has been applied to a wide variety of subjects ranging in size from bees to whales over distances from several feet to thousands of miles. The evolution in sophistication miniaturization and reliability has paralleled the improvements of electronic components and assembly capabilities available to investigators. Modern biotelemetry began as a single transistor Endoradiosonde but now is found in sophisticated miniaturized microcontroller implementations. Signals derived from physiologic transducers have been encoded and formatted in many different ways in an effort to improve transmission reliability and carrier signals have included radio sound and light in air space and water. Power sources have been developed using both primary and secondary cells. Power can now be transferred at radio frequency across the tissues to implanted biotelemeters and their rechargeable batteries to provide for long operational lifetimes. The field of biotelemetry is truly exciting challenging and diverse in new circuit realizations and applications to living subjects.

The ACR-NEMA Standard was developed initially as an interface standard for the interconnection of two pieces of imaging equipment Essentially the Standard defmes a point-to-point hardware connection with the necessary protocol and data structure so that two differing devices which meet the specification will be able to communicate with each other. The Standard does not defme a particular PACS architecture nor does it specify a database structure. In part these are the reasons why implementers have had difficulty in using the Standard in a full PACS. Recent activity of the Working Groups formed by the Committee overseeing work on the ACR-NEMA Standard has changed some of the " flavor" of the Standard. It was realized that connection of PACS with hospital and radiology information systems (HIS and RIS) is necessary if a PACS is ever to be succesful. The idea of interconnecting heterogeneous computer systems has pushed Standards development beyond the scope of the original work. Teleradiology which inherenfly involves wide-area networking may be a direct beneficiary of the new directions taken by the Standards Working Groups. This paper will give a brief history of the ACR-NEMA effort describe the " parent" Standard and its " offspring" and describe the activity of the current Working Groups with particular emphasis on the potential impacts on teleradiology.

Difficulties in delivering health and education services to isolated remote and underserviced areas have stimulated the application of telecommunications including satellite and ground-based systems to meet health care and education needs. Over a 12-year period Memorial University Telemedicine Centre has developed a number of telemedicine and distance education projects in the Province of Newfoundland in other Canadian provinces and internationally. Early experiences included a one-way television two-way voice system linking remote provincial sites to St. John''s by satellite. Following this emphasis was placed on the development of a major Province-wide terrestrially based dedicated 4-wire audio teleconference system which now has five separate divisions and an associated 30-port 2-wire teleconference bridge. The Teleconference System (TCS) is used by about 50 user groups in the fields of health education and community programming in 1989. Medical and educational data are transmitted using telewriters slow scan television and electroencephalograph and electrocardiograph transmission equipment. Research and development activities have included an offshore satellite telemedicine project several teleradiology experiments using slow scan and intercontinental X-ray transmission trials. International projects have included (1) satellite links to East Africa (Kenya and Canada/- European satellite trial using the European Space Agency (ESA) satellite Olympus (hybrid 14/12 and 20/30 Geighz) which was launched in July 1989 (2) the use of a low orbit packet radio satellite in cooperation with SatelLife (an international telemedicine organization) to link Memorial University in Newfoundland with and Uganda in order to support remote health care endeavours (3) a provincial teleradiology experiment using digital slow scan equipment. This presentation will also discuss guidelines followed in the development of a successful telemedicine project. 1.

Teleradiology has been discussed for many years yet its use to thte has been limited. An important factor is the need for adequate image quality so that a diagnosis can be made with confidence. We have developed several generations of digital fluoroscopic units. We now operate four digital fluoroscopic x-ray rooms using large field-ofview intensifiers (40 cm) pulsed progressive readout TV technology and matrix sizes of 1024 X 1024 pixels. This paper will describe how the problems have been addressed. Fluoroscopy is a key component of the imaging armamentarium and digitization of the fluoroscopic image was a major image acquisition problem which has been overcome. The necessary technology with some examples of clinical reluctance will be presented to demonstrate that the digital fluorographic image (videofluorograph) is now ready for teleradiology and picture archiving and communication systems (PACS). We believe that this technology is appropriate for the front-end of a practical teleradiology system. We also briefly discuss the problems in telefluoroscopy. 1.

The increasing use of diagnostic medical imaging at the primary level of medical care has increased the need for radiologists services at this level. The availability of these services in Alberta is the subject of this study.

Though teleradiology and PACS use similar hardware they are often thought of as very different systems. A closer examination however shows that a teleradiology system is usually a small specialized PAC system. In teleradiology the archival medium may be film but there is at least some temporary electronic storage. The communications may employ anything from video channels to satellite links and the scale of distance is usually greater than for a PACS but PACS also use a variety of media. The PACS communications environment is more like a local area network (LAN) in scale as compared to the wide-area network (WAN) nature of teleradiolgy. The advantage in thinking of the related nature of these systems is that proper planning will facilitate the growth of teleracliology into a PACS or the smooth addition of teleradiology capability to an existing PAC system. This paper will focus on the Georgetown experience which included one teleradiology application in its initial plan and added uses in a later phase of the project. These projects proved highly successful both in terms of clinical use and technical performance.

The technology for teleradiology and Picture Archiving and Communications Systems (PACS) is advancing at a rapid rate. Third generation PACS networks which transfer digital images at over 100 Mega-bits per second are to be available in the near future. Imaging equipment and viewing workstations technology currently provide excellent quality images for diagnosis and analysis at several modalities. In the meantime the technology for network and telecommunications systems which transfer the images is also advancing rapidly. The opportunity to merge these technologies into a Global FAGS environment currently exists. This paper investigates the concepts of a Global PACS and presents the requirements for such systems. The concepts are described using user scenarios for the usage of a Global PACS. The Global PACS requirements are presented in operational functional and performance formats. The Global PACS scenarios describe image transfer cross-country or from isolated geographical areas. Other scenarios describe remote diagnosis and consultation by a group of radiologists and physicians. 1. 0

The sheer amount of data involved in the fields of Picture Archival and Communication systems (PACS) and Teleradiology has created a growing interest in efficient compression of medical images. Diagnostic quality digitization of typical medical images such as chest x-rays and mammograms requires about 4Kx4K pixels digitized to 10 or 12 bits. In most medical applications any loss of quality in compression and decompression of images cannot be tolerated. We are investigating coding techniques for reversible compression of medical images in the above context. In this paper we present the results of application of adaptive linear predictive coding techniques to a few typical medical images digitized to about 4Kx4Kxl2-bits using an Eikonix 1412 camera. It was seen that about 75 reduction in transmission times is possible without any loss of image quality for the images considered. It was observed that the optimal predictor order and the optimal block size for adaptive linear predictive coding are higher compared to those for the same images digitized to lower spatial resolution. 1.

The " crisis" in rural health care i. e. the decreasing number of practitioners is partially caused by the increasing use of technology in health care. Health care practitioners in rural Canada are progressively finding their practice more difficult because of their isolation from the population centers housing many of the services and supplies needed in the modern practice of medicine. The centralization of these supplies and services results from the increasing use of technology in medicine. It is uneconomical to place expensive equipment highly trained technicians and consultants and well-stocked and current information sources in rural locations where they are underutilized. Thus over the years the increasing use of technology makes rural practice more difficult and less attractive in comparison to an urban practice that can easily and cheaply employ the benefits of technology and expert consultation. The Saskatchewan situation is examined using data collected by the authors and compared to other rural areas reported in the literature. The ways that computer communications can help alleviate this situation are explained and illustrated through a review of North American telematics activities. Telematic services for physicians are developing in North America. This is in synergy with the increasing ownership of computers by physicians. We contrast the Canadian scene with the American. Telematics is a technological approach that can be employed to reduce the isolation of rural health care practitioners. It can provide

While x-ray computed tomography (CT) is falling in price it is still beyond the means of most primary and secondary health care centres in the world. I would like to show how if a teleradiology system is installed there is a good prospect for also being able to install a simple but diagnostically effective CT system. This can be based on film used either as a one or two dimensional detector. 1. CT SYSTEMS The major components of a CT system are: 1) health care worker(s) who can decide which part of a patient needs to be imaged 2) an x-ray transparent bed on which a patient can be made comfortable positioned and restrained as necessary 3) an x-ray source mounted on a gantry 4) an x-ray detector mounted on the gantry 5) a digitizer for the x-ray signal 6) a computer to receive the signal 7) an algorithm that calculates the reconstructed CT image 8) a halftone or color display monitor 9) a radiologist who can interpret the images 10) communication from the radiologist to the health care worker(s). 2. BENEFITS OF CT VIA TELERADIOLOGY I would like to proceed on the premise that a teleradiology system could be placed between steps 6 and 7. This has the following benefits: a) Radiologists who are relatively scarce and generally located in urban tertiary care centres could serve people in remote areas

With the introduction of a summary of both U. S. and Canadian regulations for unlicensed biotelemetry design criterion for an inexpensive FSK telemetry system are discussed. The results of the evaluation of a commercially available system are illustrated and considerations in receiver antenna configuration are summarized. 1.

Heart rate (HR) telemetry was used in studies of bighorn sheep (Ovis canadensis canadensis) to determine HR associated with normal daily activities and detect changes in HR signalling arousal. HR was measured in wapiti (Cervus elaphus) to clarify the effects of normal activities, arousal and imposed work on FIR and metabolic rate (MR). The instrumentation used was analogue. The electrocardiogram (ECG), obtained from two electrodes on the sternum of the subject, was used to frequency modulate the 148.8 MHz carrier. The signal was transmitted with a power of about one milliwatt and was received by a very sensitive single side band receiver up to distances of about 6 km. The output signal could be checked aurally for adequate quality and was stored on cassette tape for later processing. The original ECG was recovered and either displayed on a strip chart recorder or analyzed with a computer acquisition system. HR was found to be a better indicator of arousal due to external stimuli than was the behavior of the animal. In free-ranging bighorn sheep many factors external to the animal (natural or experimentally-induced) elicited HR responses. In captive wapiti HR was found to be a good predictor of energy utilization in both calm and aroused animals.

The use of home monitors for the detection and prevention of Sudden Infant Death Syndrome (SIDS) in infants has experienced limited success and substantial controversy. The usefulness of home apnea monitors has been plagued with false positive alarms and lack of alarm during apneic episodes. The cause of the alarm is generally not known which increases the anxiety of the parent while lowering confidenca in the monitor. An 87 5 1H microcontroller based respiration and heart rates monitor has been developed to combine the benefits of inexpensive home monitoring with professional data analysis and alarm parameter adjustment. The microcontroller retains heart and respiration rate data (including mean and standard deviation) preceding to and during an apparent Jfe-threatening event (ALTE). The data are stored in a circular buffer as to keep the latest data. The buffer size can be adjisted by the physician depending upon the ALTEs required for further analysis. The home monitor is equipped with telecommunications capability. The stored data and alarm parameters can be transferred at the request of the physidan or parent through an IntErnal telephone modem to a personal computer at the physician''s office or hospital. The monitor retains the cost-effectiveness of home monitoring while providing data collection and analysis by a trained speciaJist.

The designer of a health care and conimunication facility (HCCF) for an isolated resourcepoor community has limited choices open to him and faces the challenge to adapt old and new technologies to suit the conditions. Contributions made by the evolving technologies i. e. renewable energy systems microelectronics and computer assistance to the operation of HCCF''s are recognized with illustrations of operating systems. Solarphotovoltaic systems used in space and on earth are described. Guidelines for choosing hybrid systems are given. 1.

This paper investigates the service demands of telemedical communications on a metropolitan area network (MAN) connecting several local area networks located at different hospitals. The flexible grade of service (GOS) is proposed for better network utilization and lower blocking rate as opposed to conventional fixed GOS. The GOS is supported by network resource allocation schemes. A new scheme to support the flexible GOS is also outlined in this paper. The new scheme can be used for both planning and management of a telemedical communication network. 1

Diagnostic nuclear medicine patient images have been transniitted for 8 years from a regional conununity hospital to a university teaching hospital 700 kiloinetres away employing slow scan TV and telephone. Transruission and interpretation were done at the end of each working day or as circumstances required in cases of emergencies. Referring physicians received the nuclear medicine procedure report at the end of the completion day or within few minutes of completion in case of emergency procedures. To date more than 25 patient studies have been transmitted for interpretation. Blinded reinterpretation of the original hard copy data of 350 patient studies resulted in 100 agreement with the interpretation of transmitted data. This technique provides high quality diagnostic and therapeutic nuclear medicine services in remote hospitals where the services of an on-site nuclear physician is not available. 2. HISTORY Eight years ago when the nuclear medicine physician at Trail Regional Hospital left the Trail area and an other could not be recruited we examined the feasibility of image transmission by phone for interpretation since closing the department would have imposed unacceptable physical and financial hardship and medical constraints on the patient population the nearest nuclear medicine facility was at some 8 hours drive away. In hospital patients would have to be treated either based purely on physical findings or flown to Vancouver at considerable cost to the health care system (estimated cost $1500.

The design of a custom CMOS analog integrated circuit to process telemetry signals will be presented. The telemetry system seeks to filter and extract information from 64 channels of signals transmitted from either chronically implanted sensors or Doppler devices. Each channel is buffered and filtered before further signal transformations. The transforming circuits include individually adjustable scaling circuit for each channel and a phase shifter and summing amplifier for each pair of channels. The scaling circuit is designed to be user-programmable thus increasing the flexibility in the signal processing algorithms implemented based on this processor. The circuit is designed using 2 im CMOS technology and fabricated by MOSIS. The design approaches of the amplifier and scaler circuits will be presented. The results will be compared to the original specifications to discuss circuit performance. 1.

Although medical applications are important designers of electronic systems for medicine are compelled by economic considerations to use components and devices developed for other applications. Nowhere is this more obvious than in teleradiology where the most widely used systems are those that make use of standard components. Teleradiology involves all the functions of Picture Archiving and Communication Systems (PACS) -- image capture compression transmission storage manipulations display and printing -- and in that sense is an economically viable prototype of a FAG system. Looking to the future there are many developments that can enhance the capabilities of teleradiology and PAC systems for reasonable cost. A review of recently developed products and products still in development including those intended for applications outside of medicine indicates the directions in which teleradiology and other image management systems will grow. 1.

One of the most common problems in the response to telephone calls for emergency services (ambulance, police, fire, etc.) is to insure that the responding agency has the appropriate location information and, in the case of individuals with a history of heart disease or other possibly life threatening affliction, pertinent information on their particular medical situation. Typically a 911 Public Safety Answering Point (PSAP) or other response agency must depend upon the information solicited from the caller. In some modern emergency response systems, such as Enhanced 911 (E91 1), Automatic Location Information (ALT) is available from the operating telephone company. Typically, however, E9 1 1 may be cost effective only for relatively large jurisdictions. This is particularly true for those systems in which the information is obtained from the telephone company central data base by means of (redundant) dedicated, high speed data lines. In a previous paper [1], the authors investigated a device, located at the subscriber's residence, which would transmit, via a modem, location and other information to the PSAP upon activation by a request-to-send (RTS). Although the device was technically successful, it had a high projected cost. In the present paper an alternate system approach is taken in which a device located at the subscriber's residence transmits only a seven digit "touch tone" code (typically the subscriber's telephone number) to a personal computer in the PSAP. The computer performs a "reverse directory" data- base lookup for address and/or other pertinent information (eg. emergency medical information) and displays the information which enables the dispatcher to send the appropriate response. The system will also be useful in the case of telephone offices which automatically provide Automatic Number Identification (ANI) but not ALl. This paper describes the system and its device and software components, system costs and discusses several applications in the area of emergency response to telephone requests for service, including a low cost automated medical service request system which can be activated by a simple handheld device.

Departement of Electrical Engineering Escola Federal de Engenharia de Itajuba Itajuba Minas Gerais Brazil This paper describes a " medical satellite network" for long distance diagnosis. The network proposed will be composed by mobile medical laboratories two transmission stations and a satellite system. This network will allow to link two hospitals for emergency expert medical consultations. INMARSAT satellite system is investigated and a tradeoff is made between a land based I ink and a satellitecommunication link. 1.

Transmission via diffused radiation is a technique which implements a mobile wireless link exploiting the ambient diffusion of light or infrared radiation it operates over short range distances and medium range bandwidth and is therefore attractive for a variety of in-vivo laboratory experiences involving stimulation and/or monitoring of different physiological parameters on freely-moving animals. In this paper the main features of the optoelectronic transmission are presented making a comparison with other approaches namely electric and fiberoptic cabling and RF links. The diffused channel is characterized in terms of attenuation bandwidth and S/N ratio showing that it is suitable for transmission of biological signals in a typical laboratory environment. A two-way transmission system is described that has been specifically designed for telemetry on small animals. The system consists of a pair of LED/photodiode transmitters and receivers. The mobile unit has been implemented in surface mount technology (SMT) to achieve adequate compactness. The link offers an accuracy of 0. 5in amplitude and a signal bandwidth from d. c. to 1KHz and operates for over 15 hours with two standard lithium batteries. This system is being routinary used for in-vivo polarographic determinations of brain neurotransmitters and their metabolites (DOPAC and 5-HIAA) on freely-moving rats. Moreover it is pointed out that the optoelectronic approach can eliminate the severe crosstalk interference which has so far prevented the concurrent pickup of low-level electrophysiological signals during polarographic determinations.

The project Mobimed started in 1988. The purpose of the project was to develop a telemedicine system where patient information text as well as data reflecting the status of various physiological parameters could be transmitted from a mobile terminal to a resident terminal at a hospital or similar place. The information transmitted was to be so comprehensive that a physician at the hospital together with the personnel attending the patient could make a diagnosis and suggest therapy. At the hospital all transmitted data should be stored automatically. Since September 1989 a prototype system is running in Sweden with one ambulance connected to two hospitals. This system is using the Mobitex* and speech transmission system for data transmission. As a first step the project is oriented towards ECG-monitoring. Mobimed has also been developed for laptop computers using the ordinary telephone network. In this case Mobimed can be used at home or anyplace where wireless transmission is not required. 1.

This paper presents some legal aspects of " rationing model'' for health care in Canada context. More questions are raised than answered. In appendix statistical tables are provided for health care costs in Canada. 1.

Fetal Heart Rate(FHR) is one of the important features of fetal biophysical activity and its long term monitoring is used for the antepartum(period of pregnancy before labour) assessment of fetal well being. But as yet no successful method has been proposed to quantitatively represent variety of random non-white patterns seen in FHR. Objective of this paper is to address this issue. In this study the Box-Jenkins method of model identification and diagnostic checking was used on phonocardiographic derived FHR(averaged) time series. Models remained exclusively autoregressive(AR). Kalman filtering in conjunction with maximum likelihood estimation technique forms the parametric estimator. Diagnosrics perfonned on the residuals indicated that a second order model may be adequate in capturing type of variability observed in 1 up to 2 mm data windows of FHR. The scheme may be viewed as a means of data reduction of a highly redundant information source. This allows a much more efficient transmission of FHR information from remote locations to places with facilities and expertise for doser analysis. The extracted parameters is aimed to reflect numerically the important FHR features. These are normally picked up visually by experts for their assessments. As a result long term FHR recorded during antepartum period could then be screened quantitatively for detection of patterns considered normal or abnonnal. 1.

Regulation of health care telecommunications is fragmented in Canada. Further neither the legislative nor the administrative nor the judicial processes have managed to respond successfully to the impact of telecommunications technology. The result is a legal environment that is necessarily speculative for both telecommunications service providers and health care personnel and facilities. Critical issues include ensuring confidentiality for sensitive patient records and health information liability of telecommunications service providers for inaccurate transmission liability of health care providers for use or non-use of telecommunications services. Limitation of legal liability for both telecommunications and health care service providers is likely to be most effective when based on contract but the creation of the necessary contracts is potentially unduly cumbersome both legally and practically. 1. CONSTITUTIONAL ASPECTS Telecommunications systems that are empowered to operate or connect cross provincial or international boundaries are subject to federal regulation bu the scheme is incomplete in respect of a system set up as a provincial agency. Health care on the other hand is very much a matter of provincial rather than federal authority as a matter of strict law but the fiscal strength of the federal government enables it to provide money to the provinces for financing health care and to4 use this as a device for securing compliance with certain federal standards. Nevertheless the political willingness of the federal health authorities to impose standards on the provinces

Hardware costs for telecommunications circuits can account for a maj or portion of total costs in Third World telem1icine progranis based on voice comunications. This is due to the relatively high cost associated with developing voice based coirimunications links to remote and isolated areas which are not already equipped with them. Iveloping satellite links specifically for telemedicine can be particularly expensive . However, more arid more remote and isolated areas in the Third World are already being sewed today by modern thin-route telecommunications systems . This is being done by exbending line of sight radio systems into remote areas using the so called point-to-multipoint microwave radio tecbnology. Point-to--multipoint radio systems have already been installed in several African and South American countries through a variety of financing arrangements such as funding by international agencies as well as funding by the countries theitselves. These systems reach into areas where health care seivices are often marginal. Health care workers — es, nurses , mid—wives and doctors , many, if not the majority of whom are women - often lack the support system that would provide for skills upgrading to allow them to benefit from the latest medical knowledge and advances. They also often lack the means to keep in touch with what is going on in the health field in other parts of their own country. By capitalizing on existing telecommunications links into such areas, telemedicine programs can be inlemented at costs far below those requiring the building of new networks for the purpose. This paper explores the possibilities of using existing telephone networks for implementing telemedicine projects in remote areas of the third world.

Telecommunications in medicine is still in a primitive state. The system is not well organized and most elements are not connected in a viable manner. Several attempts have been made to create a total system including the development of health care programs for Indians using telecommunicatons the creation of the Emergency Medical system and the development of new methods of handling patient raecords.