Digestive Endoscopy 2016; 28: 92–97
doi: 10.1111/den.12508
How I do it
Remote transmission of live endoscopy over the Internet: Report from the 87th Congress of the Japan Gastroenterological Endoscopy Society Shuji Shimizu,1,2 Takao Ohtsuka,4 Shunichi Takahata,4 Eishi Nagai,4 Naoki Nakashima2,3 and Masao Tanaka4 1
Department of Endoscopic Diagnostics and Therapeutics, 2Telemedicine Development Center of Asia, 3Medical Information Center, Kyushu University Hospital, and 4Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Live demonstration of endoscopy is one of the most attractive and useful methods for education and is often organized locally in hospitals. However, problems have been apparent in terms of cost, preparation, and potential risks to patients. Our aim was to evaluate a new approach to live endoscopy whereby remote hospitals are connected by the Internet for live endoscopic demonstrations. Live endoscopy was transmitted to the Congress of the Japan Gastroenterological Endoscopic Society by 13 domestic and international hospitals. Patients with upper and lower gastrointestinal diseases and with pancreatobiliary disorders were the subjects of a live demonstration. Questionnaires were distributed to the audience and were sent to the demonstrators. Questions concerned the quality of transmitted images and sound, cost, preparations, programs, preference of style, and adverse events. Of the audience, 91.2% (249/273) answered favorably regarding the
transmitted image quality and 93.8% (259/276) regarding the sound quality. All demonstrators answered favorably regarding image quality and 93% (13/14) regarding sound quality. Preparations were completed without any outsourcing at 11 sites (79%) and were evaluated as ‘very easy’ or ‘easy’ at all but one site (92.3%). Preparation cost was judged as ‘very cheap’ or ‘cheap’ at 12 sites (86%). Live endoscopy connecting multiple international centers was satisfactory in image and sound quality for both audience and demonstrators, with easy and inexpensive preparation. The remote transmission of live endoscopy from demonstrators’ own hospitals was preferred to the conventional style of locally organized live endoscopy.
INTRODUCTION
The most common approach is to invite all the specialists to one hospital to view various sessions prepared in one place, so that the audience can appreciate the skillful techniques and have direct communication with demonstrators at the specific venue. However, live endoscopy does have disadvantages, as pointed out by Cotton.2 Experts may be unfamiliar with supporting teams, equipment, room settings, and patients. Demonstrators need to perform in an unfamiliar atmosphere, leading to increased stress and risk of unwanted incidents. The preparation of various patients in multiple rooms for many demonstrations, all within the same location, also demands a tremendous organizational effort. Many of these problems would be solved if the experts could stay in their own hospitals in their routine settings together with their own staff. However, it remains technically difficult to transmit images of satisfactory quality to remote sites, especially overseas, and to do so within a limited budget. We established a new telemedicine system in 2002, and have had over 10 years of experience of remote medical education with developing technologies.3 Here we propose a new approach
ANY NEW ENDOSCOPIC procedures, such as endoscopic ultrasonography (EUS), narrow-band imaging (NBI), and endoscopic submucosal dissection (ESD), have been introduced in recent years, and the education of young doctors or doctors in rural areas and developing countries is of utmost and continuing importance. Among the numerous approaches to study, such as reading textbooks/journals, watching recorded videos, using simulators, or participating in workshops/seminars, every method has its own advantages and disadvantages.1 Live demonstration is the most exciting and educational way to watch whole procedures in real clinical settings, and has therefore been organized on many occasions worldwide.
M
Corresponding: Shuji Shimizu, Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan. Email: [email protected] Received 10 May 2015; accepted 22 June 2015.
bs_bs_banner
92
Key words: education, international, internet, live demonstration, telemedicine
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2016; 28: 92–97
Remote transmission of live endoscopy
to live endoscopy, based on the results of our programs at the 87th Congress of the Japan Gastroenterological Endoscopy Society (JGES87).
PROCEDURES AND TECHNIQUES Programs GES87 WAS HELD at the International Congress Center in Fukuoka, Japan, and was attended by more than 6000 participants. Live demonstrations were organized for 2 days on 15–16 May 2014, and were divided into four sessions, the details of which are summarized in Table 1. One session took place in the morning for 2 h and in the afternoon for 2.5 h. Thirteen hospitals, five from Japan and eight from abroad, were connected for 15 live demonstrations. One hospital (National Taiwan University Hospital, Taiwan) presented both lower gastrointestinal and pancreatobiliary sessions, and another (Fukuoka University Chikushi Hospital, Japan) broadcasted upper gastrointestinal sessions using two demonstrators. Photos taken at the main venue and the two local endoscopic stations are shown in Figure 1.
J
Systems Depending upon the availability in each hospital, two videoconferencing systems were used: a digital video transport system (DVTS), which requires 30 megabits per second (Mbps), and a high-definition (HD)-compatible H.323 system, which runs on a bandwidth of 1–4 Mbps.4,5 Each hospital was connected one-to-one to the congress venue, where the images and sound were mixed. Eleven of the hospitals were affiliated with the university that used the research and education
93
network (REN) and the other two, Kyoto Second Red Cross Hospital in Japan and the Asia Institute of Gastroenterology in India, were key hospitals in the regions that used commercial Internet. Demonstrations from each site were shown on the main screen one by one by switching the connection at the venue. Each hospital obtained approval from its ethical committee, and written informed consent was obtained from each patient. Patients’ names or faces were never shown on the screen to protect their privacy, and all other private information was strictly controlled. Four hospitals used encryption programs depending on their security policy.
Questionnaires Questionnaires were distributed to the participants at the venue and also sent to the live demonstrators to evaluate the quality of the transmission as well as the system used in the congress. Details are shown in Table 2, and the results from a total of four sessions were analyzed.
Evaluation by the audience Among 905 sheets distributed, 276 (30.5%) were collected with replies. The respondents consisted of 172 (62%) doctors and 31 (11%) non-doctors, with 73 (26%) unknown. Two hundred and forty-seven (89%) were Japanese and 29 (11%) were non-Japanese. Three and eight unanswered replies for image quality and the program, respectively, were excluded from the analysis. There were also three unanswered replies each for the evaluation of live endoscopy, direct communications, and preference for the system. Figure 2 shows the evaluation of image quality, image movement, sound quality, and the programs. Regarding image
Table 1 Session profiles of live endoscopy demonstrations held at JGES87 at the International Congress Center in Fukuoka, Japan Session
Hospital
City
Country
System
Internet
Encryption
Upper GI
Fukuoka Univ. Chikushi Hospital Lyell McEwin Hospital, Univ. of Adelaide Zhongshan Hospital, Fudan Univ. Prince of Wales Hospital, Chinese Univ. of Hong Kong Kobe Univ. Hospital National Taiwan Univ. Hospital Hiroshima Univ. Hospital Kyoto Second Red Cross Hospital Konkuk Univ. Medical Center National Taiwan Univ. Hospital Kurume Univ. Medical Center Asan Medical Center, Univ. of Ulsan Siriraj Hospital, Mahidol Univ. Asian Institute of Gastroenterology
Fukuoka Adelaide Shanghai Hong Kong Kobe Taipei Hiroshima Kyoto Seoul Taipei Kurume Seoul Bangkok Hyderabad
Japan Australia China China Japan Taiwan Japan Japan Korea Taiwan Japan Korea Thailand India
H.323 H.323 DVTS DVTS H.323 H.323 DVTS DVTS DVTS H.323 H.323 DVTS DVTS H.323
REN REN REN REN REN REN REN Commercial REN REN REN REN REN Commercial
None None None IPsec AES None None IPsec None None None None IPsec None
Lower GI
Pancreatobiliary-1
Pancreatobiliary-2
AES, Advanced Encryption Standard; DVTS, digital video transport system; GI, gastrointestinal; IPsec, Internet Protocol Security; REN, research and education network; Univ., University.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
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Digestive Endoscopy 2016; 28: 92–97
S. Shuji et al.
Figure 1 (A) Center screen in the main venue shows the live demonstration from a remote station. Chairpersons are on the left and the discussants are on the right side of the stage. (B) The Shanghai team demonstrated peroral endoscopic myotomy from China. (C) Lithotomy of bile duct stones was demonstrated by Konkuk University Medical Center in Seoul, Korea.
quality, 137 (50.2%) participants replied ‘very good’, 112 (41.0%) ‘good’, 22 (8.1%) ‘poor’, and two (0.7%) ‘very poor’. For image movement, the respective results were 182 (65.9%), 78 (28.3%), 16 (5.8%), and 0 (0%); for sound quality, 141 (51.1%), 118 (42.8%), 16 (5.8%), and one (0.4%); and for the programs, 131 (48.9%), 125 (46.6%), 11 (4.1%), and one (0.4%). More than 90% of the participants evaluated all four items favorably. Concerning the performance of live endoscopy in general, 228 (83.5%) totally agreed, 42 (15.2%) agreed, three (1.1%) disagreed, and no-one totally disagreed. Regarding direct communication of the endoscopist with the venue, 194 (71.1%) totally agreed, 58 (21.2%) agreed, 12 (4.4%) disagreed, and nine (3.3%) totally disagreed. When asked the preference, 220 (80.6%) preferred the style carried out during this congress, whereas nine (3.3%) preferred the conventional style whereby all the endoscopists are invited to one hospital and the demonstrations are carried out locally; 44 (16.1%) had no preference (Fig. 3A).
Evaluation by the demonstrators Replies were collected from all live demonstrators except for one who was one of the two demonstrators in the same hospital in the same upper gastrointestinal session. All 14 responders had previous experience as a live demonstrator. Regarding image quality, nine (64%) participants replied ‘very good’, five (36%) ‘good’, 0 (0%) ‘poor’, and 0 (0%) ‘very poor’. For image movement, the respective results were 11 (79%), three (21%), 0 (0%), and 0 (0%); for sound quality, six (43%), seven (50%), 0 (0%), and one (7%); and for sound delay during communications, 10 (71%), three (21%), one (7%), and 0 (0%). More than 90% of the demonstrators evaluated all four items favorably. Three (21%) institutions partially outsourced the system preparations for live endoscopy, but 11 (79%) asked their own staff for total technical support. Two (14%) said that the preparations were ‘very easy’, 11 (79%) ‘easy’, one (7%) ‘difficult’, and none ‘very difficult’. Six (43%) replied that
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2016; 28: 92–97
Remote transmission of live endoscopy
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Table 2 Questionnaires distributed to the participants and demonstrators of JGES87 Questions Questions to audience (1) Image quality (2) Image movement (3) Sound quality (4) Program (5) What do you think about live endoscopy? (6) What do you think about the operators having direct communication with the main venue? (7) Live demonstrations are remotely shown from their own hospitals this time. What is your opinion? Questions to demonstrators (1, 2, 3) Same as those to audience (4) Sound delay (5) Preparations (6–1) Cost of the preparations (6–2) Cost of the preparations (7) What do you think about the operators having direct communication with the main venue? (8) Same as #(7) to audience †
‡ §
Very good Very smooth Very good Very good Totally agree Totally agree
Good Smooth Good Good Agree Agree
Poor Sluggish Poor Poor Disagree Disagree
Very poor Very sluggish Very poor Very poor Totally disagree Totally disagree†
I like this style better
I like the conventional way better‡
No difference
Very big Very difficult Very expensive Outsourced Very stressful
Big Difficult Expensive Not outsourced§ Stressful
Small Easy Cheap
Very small Very easy Very cheap
Not stressful
Not stressful at all
A moderator besides him/her should have communication.
Demonstrators are invited to a hospital and all the demonstrations are shown there. Only with your own staff.
When asked about any adverse effects during or after the demonstration, everyone answered that they encountered no adverse effects.
DISCUSSION EMOTE EDUCATION USING the Internet has recently become practical in medicine as information and communications technology has continued its rapid advancement. Reports on teleconferences and live demonstrations between remote sites have been increasing in number.6–8 However, in endoscopy, live demonstrations are more often carried out locally than remotely, and only sporadic reports are seen.9,10 This is the first trial of live endoscopy over the Internet with various international and domestic connections and systematic evaluations. One of the major obstacles to tele-endoscopy was the inevitable deterioration of image quality during transmission. It had been a challenge to preserve the quality of moving images to the level satisfactory for medical use.11,12 However, new technologies (e.g. DVTS), together with a network large enough to secure this system in practice, overcame this technological limitation and were applied first to surgery between Japan and Korea.13 Being recognized as very practical and useful, this system expanded rapidly into other geographical
R
Figure 2 Evaluation of audience questionnaires.
the required cost was ‘very cheap’ and six (43%) ‘cheap’. Two (14%) answered ‘expensive’ and no-one answered ‘very expensive’. With respect to stress during live endoscopy, three demonstrators (21%) answered ‘not stressful at all’, 10 (71%) ‘not stressful’, one (7%) ‘stressful’, and none ‘very stressful’. When asked for their preference, 12 (86%) preferred the style carried out during this congress, whereas no-one preferred the conventional style and two (14%) answered that there was no difference (Fig. 3B).
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
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S. Shuji et al.
Figure 3 Preference of style for live endoscopy by the (A) audience and (B) demonstrators.
regions and various medical fields.14–16 Further technologies, including HD-H.323, followed later to provide more options.4,5 As clearly shown in our questionnaire results, the image and sound quality of live endoscopy reached the level whereby both audience and demonstrators were satisfied. Another sizeable problem involved the cost of the preparations. For many live demonstrations, technical preparations proved too difficult to be managed by hospital staff and had to be totally outsourced, especially when a satellite was used. Consequently, organization of live endoscopy required a huge budget. However, as shown by the results of our study, the situation has now changed in that all technical preparations have become easy enough to be managed within the hospital by the in-house staff, resulting in a large cost reduction. For one hospital that answered ‘partly outsourced’, ‘expensive’ in cost, and ‘difficult’ in preparation, it was the first time a live demonstration was shown in this institution, so the newly linked REN had to be paid for and all of the technical preparations had to be started from scratch. In fact, in five of the 13 participating hospitals, the system was newly established, but another four hospitals, where REN had already been established, did not encounter any financial or technical difficulties. In the other hospital that answered ‘partly outsourced’ and ‘expensive’, other intra-hospital workshops were simultaneously held, which was why it happened to encounter a shortage of its own engineering staff. Now that these two major limitations have been solved, the new era of live endoscopy seems to have dawned. On comparing this new style of live demonstration using the Internet with the conventional approach organized locally, 80.6% of the audience and 85.7% of the demonstrators favored this new style, and no demonstrator preferred the conventional way. If live endoscopy can be transmitted as described, its biggest advantage is that the demonstrators can stay in their own endoscopic suites, using their own equipment and working with their own staff, in a familiar and friendly atmosphere. Doctors
can take care of their own patients with full communication, and not have to worry about medical license issues and special malpractice coverage abroad. This approach not only saves time and travel expenses for busy doctors, but can also greatly reduce the potential risk to their patients, as they do not have to cope with the fatigue incurred through long overseas trips and jet lag.17 In addition, in contrast to the style whereby one hospital has to organize sessions by preparing multiple patients in many endoscopic rooms, each connected hospital only needs to prepare one or two patients using one room, which is much easier and less chaotic for both the demonstrators and their hospitals. Cotton,2 who vividly revealed the potential problems of live endoscopy more than 10 years ago, stated ‘soon such videoconferencing will be possible directly on the World Wide Web, so that interested parties can choose from a menu of experts working from their own medical centers’. We believe that we have taken a step forward in realizing his dream. However, there are still some issues of concern in organizing live endoscopy, including pressure on the demonstrators and possible adverse effects. Regardless of these possible drawbacks, the questionnaires on the performance of live endoscopy itself showed 98.9% favorable replies, implying that a majority does want to watch live demonstrations and is willing to accept some potential risks because of the educational value that can be obtained only from live procedures. Although 13 (93%) demonstrators replied that it was not stressful to do live demonstrations, one, for whom this was his second experience as a demonstrator, answered that it was stressful. We believe that it is better to have another moderator for communication alongside the demonstrator so that the live endoscopist can concentrate more on the procedure and thus reduce the stress, although the questionnaire results did report direct communication to be acceptable. Although this issue remains controversial, conditions should greatly depend on the demonstrator’s experience. Regarding adverse effects, no complication was reported in our series, and no
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2016; 28: 92–97
Remote transmission of live endoscopy
statistically significant increase in complications during live endoscopy has been reported in the literature.18–20 One more important issue to be addressed is patient privacy during transmission over the Internet. The basic idea is that maximum caution is placed in each endoscopic room and that no private information on the patient is disclosed or transmitted during the demonstration. Therefore, no special protection is necessarily required on the Internet. However, depending on the rules of the ethical committee in each hospital, some did use additional encryption programs to meet their criteria and further secure the protection. From our experience in JGES87, we conclude that live demonstration of endoscopy is very useful and is accepted by the audience, and that remote transmission is another promising approach to live endoscopy. It is now technically feasible for live demonstration of endoscopy to be organized by hospital staff and has cost benefits especially when used internationally. Considering the efficacy of remote education, we strongly hope that the technologies described herein can be applied not only to live demonstrations at large congresses, but also to daily communications between hospitals, and to share new knowledge and advanced skills while educating health-care providers worldwide.
ACKNOWLEDGMENTS HE AUTHORS ARE grateful for the cooperation and expertise of the entire medical and engineering staff in the supporting program organization and network preparations at all of the hospitals and medical centers involved. We are particularly grateful to Kyushu University engineering staff for technical preparations and to the APAN-NOC and TEIN-NOC teams for intensive network preparations. This project was funded in part by Grant-in-Aid No. 23256005 for Scientific Research from the Japan Society for the Promotion of Science.
T
CONFLICT OF INTERESTS UTHORS DISCLOSE NO conflicts of interest for this article.
A
REFERENCES 1 Waye JD. Continuing education in endoscopy: live courses or video format? Gastrointest. Endosc. 2000; 52: 447–51. 2 Cotton PB. Live endoscopy demonstrations are great, but. Gastrointest. Endosc. 2000; 51: 627–9. 3 Shimizu S, Kudo K, Antoku Y, Hu M, Okamura K, Nakashima N. Ten-year experience of remote medical education in Asia. Telemed. J. E. Health. 2014; 20: 1021–6.
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4 Cao MD, Shimizu S, Antoku Y et al. Emerging technologies for telemedicine. Korean J. Radiol. 2012; 13: S21–30. 5 Murad FM, Banerjee S, Barth BA et al. Image management systems. Gastrointest. Endosc. 2014; 79: 15–22. 6 Merrell RC, Doarn CR. Distance learning and telemedicine. Telemed. J. E. Health 2014; 20: 505–6. 7 Shimizu S, Han HS, Okamura K, Nakashima N, Kitamura Y, Tanaka M. Technologic developments in telemedicine: state-ofthe-art academic interactions. Surgery 2010; 147: 597–601. 8 Eliyahu S, Roguin A, Kerner A et al. Patient safety and outcomes from live case demonstrations of interventional cardiology procedures. JACC Cardiovasc. Interv. 2012; 5: 215–24. 9 Lee SP, Lee HL, Hahm JS, Choi HS, Joe I, Shimizu S. International live endoscopic multichannel demonstration using superfast broadband internet connections. Clin. Endosc. 2012; 45: 73–7. 10 Shimizu S, Itaba S, Yada S et al. Significance of telemedicine for video image transmission of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography procedures. J. Hepatobiliary Pancreat. Sci. 2011; 18: 366–74. 11 Rabenstein T, Maiss J, Naegele-Jackson S et al. Tele-endoscopy: influence of data compression, bandwidth and simulated impairments on the usability of real-time digital video endoscopy transmissions for medical diagnoses. Endoscopy 2002; 34: 703–10. 12 Heatley DJ, Bell GD. Telemedicine in gastrointestinal endoscopy. Endoscopy 2003; 35: 624–8. 13 Shimizu S, Nakashima N, Okamura K et al. International transmission of uncompressed endoscopic surgery images via super-fast broadband Internet connections. Surg. Endosc. 2006; 20: 167–70. 14 Huang KJ, Cen G, Qiu ZJ, Jiang T, Cao J, Fu CY. Application of international videoconferences for continuing medical education programs related to laparoscopic surgery. Telemed. J. E. Health 2014; 20: 157–60. 15 Colin K, Shimizu S, Okamura K, Lomanto D, Tanaka M, Toouli J. High definition digital video links for surgical training. J. Telemed. Telecare 2006; 12: S26–8. 16 Shimizu S, Nakashima N, Okamura K, Tanaka M. One hundred case studies of Asia-Pacific telemedicine using a digital video transport system over a research and education network. Telemed. J. E. Health 2009; 15: 112–7. 17 Wootton R, Bahaadinbeigy K, Hailey D. Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review. BMC Health Serv. Res. 2011; 11: 185. 18 Schmit A, Lazaraki G, Hittelet A, Cremer M, Le Moine O, Deviere J. Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations. Endoscopy 2005; 37: 695–9. 19 Liao Z, Li ZS, Leung JW et al. How safe and successful are live demonstrations of therapeutic ERCP? A large multicenter study. Am. J. Gastroenterol. 2009; 104: 47–52. 20 Ridtitid W, Rerknimitr R, Treeprasertsuk S, Kongkam P, Khor CJ, Kullavanijaya P. Outcome of endoscopic retrograde cholangiopancreatography during live endoscopy demonstrations. Surg. Endosc. 2012; 26: 1931–8.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
doi: 10.1111/den.12508
How I do it
Remote transmission of live endoscopy over the Internet: Report from the 87th Congress of the Japan Gastroenterological Endoscopy Society Shuji Shimizu,1,2 Takao Ohtsuka,4 Shunichi Takahata,4 Eishi Nagai,4 Naoki Nakashima2,3 and Masao Tanaka4 1
Department of Endoscopic Diagnostics and Therapeutics, 2Telemedicine Development Center of Asia, 3Medical Information Center, Kyushu University Hospital, and 4Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Live demonstration of endoscopy is one of the most attractive and useful methods for education and is often organized locally in hospitals. However, problems have been apparent in terms of cost, preparation, and potential risks to patients. Our aim was to evaluate a new approach to live endoscopy whereby remote hospitals are connected by the Internet for live endoscopic demonstrations. Live endoscopy was transmitted to the Congress of the Japan Gastroenterological Endoscopic Society by 13 domestic and international hospitals. Patients with upper and lower gastrointestinal diseases and with pancreatobiliary disorders were the subjects of a live demonstration. Questionnaires were distributed to the audience and were sent to the demonstrators. Questions concerned the quality of transmitted images and sound, cost, preparations, programs, preference of style, and adverse events. Of the audience, 91.2% (249/273) answered favorably regarding the
transmitted image quality and 93.8% (259/276) regarding the sound quality. All demonstrators answered favorably regarding image quality and 93% (13/14) regarding sound quality. Preparations were completed without any outsourcing at 11 sites (79%) and were evaluated as ‘very easy’ or ‘easy’ at all but one site (92.3%). Preparation cost was judged as ‘very cheap’ or ‘cheap’ at 12 sites (86%). Live endoscopy connecting multiple international centers was satisfactory in image and sound quality for both audience and demonstrators, with easy and inexpensive preparation. The remote transmission of live endoscopy from demonstrators’ own hospitals was preferred to the conventional style of locally organized live endoscopy.
INTRODUCTION
The most common approach is to invite all the specialists to one hospital to view various sessions prepared in one place, so that the audience can appreciate the skillful techniques and have direct communication with demonstrators at the specific venue. However, live endoscopy does have disadvantages, as pointed out by Cotton.2 Experts may be unfamiliar with supporting teams, equipment, room settings, and patients. Demonstrators need to perform in an unfamiliar atmosphere, leading to increased stress and risk of unwanted incidents. The preparation of various patients in multiple rooms for many demonstrations, all within the same location, also demands a tremendous organizational effort. Many of these problems would be solved if the experts could stay in their own hospitals in their routine settings together with their own staff. However, it remains technically difficult to transmit images of satisfactory quality to remote sites, especially overseas, and to do so within a limited budget. We established a new telemedicine system in 2002, and have had over 10 years of experience of remote medical education with developing technologies.3 Here we propose a new approach
ANY NEW ENDOSCOPIC procedures, such as endoscopic ultrasonography (EUS), narrow-band imaging (NBI), and endoscopic submucosal dissection (ESD), have been introduced in recent years, and the education of young doctors or doctors in rural areas and developing countries is of utmost and continuing importance. Among the numerous approaches to study, such as reading textbooks/journals, watching recorded videos, using simulators, or participating in workshops/seminars, every method has its own advantages and disadvantages.1 Live demonstration is the most exciting and educational way to watch whole procedures in real clinical settings, and has therefore been organized on many occasions worldwide.
M
Corresponding: Shuji Shimizu, Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan. Email: [email protected] Received 10 May 2015; accepted 22 June 2015.
bs_bs_banner
92
Key words: education, international, internet, live demonstration, telemedicine
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2016; 28: 92–97
Remote transmission of live endoscopy
to live endoscopy, based on the results of our programs at the 87th Congress of the Japan Gastroenterological Endoscopy Society (JGES87).
PROCEDURES AND TECHNIQUES Programs GES87 WAS HELD at the International Congress Center in Fukuoka, Japan, and was attended by more than 6000 participants. Live demonstrations were organized for 2 days on 15–16 May 2014, and were divided into four sessions, the details of which are summarized in Table 1. One session took place in the morning for 2 h and in the afternoon for 2.5 h. Thirteen hospitals, five from Japan and eight from abroad, were connected for 15 live demonstrations. One hospital (National Taiwan University Hospital, Taiwan) presented both lower gastrointestinal and pancreatobiliary sessions, and another (Fukuoka University Chikushi Hospital, Japan) broadcasted upper gastrointestinal sessions using two demonstrators. Photos taken at the main venue and the two local endoscopic stations are shown in Figure 1.
J
Systems Depending upon the availability in each hospital, two videoconferencing systems were used: a digital video transport system (DVTS), which requires 30 megabits per second (Mbps), and a high-definition (HD)-compatible H.323 system, which runs on a bandwidth of 1–4 Mbps.4,5 Each hospital was connected one-to-one to the congress venue, where the images and sound were mixed. Eleven of the hospitals were affiliated with the university that used the research and education
93
network (REN) and the other two, Kyoto Second Red Cross Hospital in Japan and the Asia Institute of Gastroenterology in India, were key hospitals in the regions that used commercial Internet. Demonstrations from each site were shown on the main screen one by one by switching the connection at the venue. Each hospital obtained approval from its ethical committee, and written informed consent was obtained from each patient. Patients’ names or faces were never shown on the screen to protect their privacy, and all other private information was strictly controlled. Four hospitals used encryption programs depending on their security policy.
Questionnaires Questionnaires were distributed to the participants at the venue and also sent to the live demonstrators to evaluate the quality of the transmission as well as the system used in the congress. Details are shown in Table 2, and the results from a total of four sessions were analyzed.
Evaluation by the audience Among 905 sheets distributed, 276 (30.5%) were collected with replies. The respondents consisted of 172 (62%) doctors and 31 (11%) non-doctors, with 73 (26%) unknown. Two hundred and forty-seven (89%) were Japanese and 29 (11%) were non-Japanese. Three and eight unanswered replies for image quality and the program, respectively, were excluded from the analysis. There were also three unanswered replies each for the evaluation of live endoscopy, direct communications, and preference for the system. Figure 2 shows the evaluation of image quality, image movement, sound quality, and the programs. Regarding image
Table 1 Session profiles of live endoscopy demonstrations held at JGES87 at the International Congress Center in Fukuoka, Japan Session
Hospital
City
Country
System
Internet
Encryption
Upper GI
Fukuoka Univ. Chikushi Hospital Lyell McEwin Hospital, Univ. of Adelaide Zhongshan Hospital, Fudan Univ. Prince of Wales Hospital, Chinese Univ. of Hong Kong Kobe Univ. Hospital National Taiwan Univ. Hospital Hiroshima Univ. Hospital Kyoto Second Red Cross Hospital Konkuk Univ. Medical Center National Taiwan Univ. Hospital Kurume Univ. Medical Center Asan Medical Center, Univ. of Ulsan Siriraj Hospital, Mahidol Univ. Asian Institute of Gastroenterology
Fukuoka Adelaide Shanghai Hong Kong Kobe Taipei Hiroshima Kyoto Seoul Taipei Kurume Seoul Bangkok Hyderabad
Japan Australia China China Japan Taiwan Japan Japan Korea Taiwan Japan Korea Thailand India
H.323 H.323 DVTS DVTS H.323 H.323 DVTS DVTS DVTS H.323 H.323 DVTS DVTS H.323
REN REN REN REN REN REN REN Commercial REN REN REN REN REN Commercial
None None None IPsec AES None None IPsec None None None None IPsec None
Lower GI
Pancreatobiliary-1
Pancreatobiliary-2
AES, Advanced Encryption Standard; DVTS, digital video transport system; GI, gastrointestinal; IPsec, Internet Protocol Security; REN, research and education network; Univ., University.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
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Digestive Endoscopy 2016; 28: 92–97
S. Shuji et al.
Figure 1 (A) Center screen in the main venue shows the live demonstration from a remote station. Chairpersons are on the left and the discussants are on the right side of the stage. (B) The Shanghai team demonstrated peroral endoscopic myotomy from China. (C) Lithotomy of bile duct stones was demonstrated by Konkuk University Medical Center in Seoul, Korea.
quality, 137 (50.2%) participants replied ‘very good’, 112 (41.0%) ‘good’, 22 (8.1%) ‘poor’, and two (0.7%) ‘very poor’. For image movement, the respective results were 182 (65.9%), 78 (28.3%), 16 (5.8%), and 0 (0%); for sound quality, 141 (51.1%), 118 (42.8%), 16 (5.8%), and one (0.4%); and for the programs, 131 (48.9%), 125 (46.6%), 11 (4.1%), and one (0.4%). More than 90% of the participants evaluated all four items favorably. Concerning the performance of live endoscopy in general, 228 (83.5%) totally agreed, 42 (15.2%) agreed, three (1.1%) disagreed, and no-one totally disagreed. Regarding direct communication of the endoscopist with the venue, 194 (71.1%) totally agreed, 58 (21.2%) agreed, 12 (4.4%) disagreed, and nine (3.3%) totally disagreed. When asked the preference, 220 (80.6%) preferred the style carried out during this congress, whereas nine (3.3%) preferred the conventional style whereby all the endoscopists are invited to one hospital and the demonstrations are carried out locally; 44 (16.1%) had no preference (Fig. 3A).
Evaluation by the demonstrators Replies were collected from all live demonstrators except for one who was one of the two demonstrators in the same hospital in the same upper gastrointestinal session. All 14 responders had previous experience as a live demonstrator. Regarding image quality, nine (64%) participants replied ‘very good’, five (36%) ‘good’, 0 (0%) ‘poor’, and 0 (0%) ‘very poor’. For image movement, the respective results were 11 (79%), three (21%), 0 (0%), and 0 (0%); for sound quality, six (43%), seven (50%), 0 (0%), and one (7%); and for sound delay during communications, 10 (71%), three (21%), one (7%), and 0 (0%). More than 90% of the demonstrators evaluated all four items favorably. Three (21%) institutions partially outsourced the system preparations for live endoscopy, but 11 (79%) asked their own staff for total technical support. Two (14%) said that the preparations were ‘very easy’, 11 (79%) ‘easy’, one (7%) ‘difficult’, and none ‘very difficult’. Six (43%) replied that
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Table 2 Questionnaires distributed to the participants and demonstrators of JGES87 Questions Questions to audience (1) Image quality (2) Image movement (3) Sound quality (4) Program (5) What do you think about live endoscopy? (6) What do you think about the operators having direct communication with the main venue? (7) Live demonstrations are remotely shown from their own hospitals this time. What is your opinion? Questions to demonstrators (1, 2, 3) Same as those to audience (4) Sound delay (5) Preparations (6–1) Cost of the preparations (6–2) Cost of the preparations (7) What do you think about the operators having direct communication with the main venue? (8) Same as #(7) to audience †
‡ §
Very good Very smooth Very good Very good Totally agree Totally agree
Good Smooth Good Good Agree Agree
Poor Sluggish Poor Poor Disagree Disagree
Very poor Very sluggish Very poor Very poor Totally disagree Totally disagree†
I like this style better
I like the conventional way better‡
No difference
Very big Very difficult Very expensive Outsourced Very stressful
Big Difficult Expensive Not outsourced§ Stressful
Small Easy Cheap
Very small Very easy Very cheap
Not stressful
Not stressful at all
A moderator besides him/her should have communication.
Demonstrators are invited to a hospital and all the demonstrations are shown there. Only with your own staff.
When asked about any adverse effects during or after the demonstration, everyone answered that they encountered no adverse effects.
DISCUSSION EMOTE EDUCATION USING the Internet has recently become practical in medicine as information and communications technology has continued its rapid advancement. Reports on teleconferences and live demonstrations between remote sites have been increasing in number.6–8 However, in endoscopy, live demonstrations are more often carried out locally than remotely, and only sporadic reports are seen.9,10 This is the first trial of live endoscopy over the Internet with various international and domestic connections and systematic evaluations. One of the major obstacles to tele-endoscopy was the inevitable deterioration of image quality during transmission. It had been a challenge to preserve the quality of moving images to the level satisfactory for medical use.11,12 However, new technologies (e.g. DVTS), together with a network large enough to secure this system in practice, overcame this technological limitation and were applied first to surgery between Japan and Korea.13 Being recognized as very practical and useful, this system expanded rapidly into other geographical
R
Figure 2 Evaluation of audience questionnaires.
the required cost was ‘very cheap’ and six (43%) ‘cheap’. Two (14%) answered ‘expensive’ and no-one answered ‘very expensive’. With respect to stress during live endoscopy, three demonstrators (21%) answered ‘not stressful at all’, 10 (71%) ‘not stressful’, one (7%) ‘stressful’, and none ‘very stressful’. When asked for their preference, 12 (86%) preferred the style carried out during this congress, whereas no-one preferred the conventional style and two (14%) answered that there was no difference (Fig. 3B).
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Figure 3 Preference of style for live endoscopy by the (A) audience and (B) demonstrators.
regions and various medical fields.14–16 Further technologies, including HD-H.323, followed later to provide more options.4,5 As clearly shown in our questionnaire results, the image and sound quality of live endoscopy reached the level whereby both audience and demonstrators were satisfied. Another sizeable problem involved the cost of the preparations. For many live demonstrations, technical preparations proved too difficult to be managed by hospital staff and had to be totally outsourced, especially when a satellite was used. Consequently, organization of live endoscopy required a huge budget. However, as shown by the results of our study, the situation has now changed in that all technical preparations have become easy enough to be managed within the hospital by the in-house staff, resulting in a large cost reduction. For one hospital that answered ‘partly outsourced’, ‘expensive’ in cost, and ‘difficult’ in preparation, it was the first time a live demonstration was shown in this institution, so the newly linked REN had to be paid for and all of the technical preparations had to be started from scratch. In fact, in five of the 13 participating hospitals, the system was newly established, but another four hospitals, where REN had already been established, did not encounter any financial or technical difficulties. In the other hospital that answered ‘partly outsourced’ and ‘expensive’, other intra-hospital workshops were simultaneously held, which was why it happened to encounter a shortage of its own engineering staff. Now that these two major limitations have been solved, the new era of live endoscopy seems to have dawned. On comparing this new style of live demonstration using the Internet with the conventional approach organized locally, 80.6% of the audience and 85.7% of the demonstrators favored this new style, and no demonstrator preferred the conventional way. If live endoscopy can be transmitted as described, its biggest advantage is that the demonstrators can stay in their own endoscopic suites, using their own equipment and working with their own staff, in a familiar and friendly atmosphere. Doctors
can take care of their own patients with full communication, and not have to worry about medical license issues and special malpractice coverage abroad. This approach not only saves time and travel expenses for busy doctors, but can also greatly reduce the potential risk to their patients, as they do not have to cope with the fatigue incurred through long overseas trips and jet lag.17 In addition, in contrast to the style whereby one hospital has to organize sessions by preparing multiple patients in many endoscopic rooms, each connected hospital only needs to prepare one or two patients using one room, which is much easier and less chaotic for both the demonstrators and their hospitals. Cotton,2 who vividly revealed the potential problems of live endoscopy more than 10 years ago, stated ‘soon such videoconferencing will be possible directly on the World Wide Web, so that interested parties can choose from a menu of experts working from their own medical centers’. We believe that we have taken a step forward in realizing his dream. However, there are still some issues of concern in organizing live endoscopy, including pressure on the demonstrators and possible adverse effects. Regardless of these possible drawbacks, the questionnaires on the performance of live endoscopy itself showed 98.9% favorable replies, implying that a majority does want to watch live demonstrations and is willing to accept some potential risks because of the educational value that can be obtained only from live procedures. Although 13 (93%) demonstrators replied that it was not stressful to do live demonstrations, one, for whom this was his second experience as a demonstrator, answered that it was stressful. We believe that it is better to have another moderator for communication alongside the demonstrator so that the live endoscopist can concentrate more on the procedure and thus reduce the stress, although the questionnaire results did report direct communication to be acceptable. Although this issue remains controversial, conditions should greatly depend on the demonstrator’s experience. Regarding adverse effects, no complication was reported in our series, and no
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statistically significant increase in complications during live endoscopy has been reported in the literature.18–20 One more important issue to be addressed is patient privacy during transmission over the Internet. The basic idea is that maximum caution is placed in each endoscopic room and that no private information on the patient is disclosed or transmitted during the demonstration. Therefore, no special protection is necessarily required on the Internet. However, depending on the rules of the ethical committee in each hospital, some did use additional encryption programs to meet their criteria and further secure the protection. From our experience in JGES87, we conclude that live demonstration of endoscopy is very useful and is accepted by the audience, and that remote transmission is another promising approach to live endoscopy. It is now technically feasible for live demonstration of endoscopy to be organized by hospital staff and has cost benefits especially when used internationally. Considering the efficacy of remote education, we strongly hope that the technologies described herein can be applied not only to live demonstrations at large congresses, but also to daily communications between hospitals, and to share new knowledge and advanced skills while educating health-care providers worldwide.
ACKNOWLEDGMENTS HE AUTHORS ARE grateful for the cooperation and expertise of the entire medical and engineering staff in the supporting program organization and network preparations at all of the hospitals and medical centers involved. We are particularly grateful to Kyushu University engineering staff for technical preparations and to the APAN-NOC and TEIN-NOC teams for intensive network preparations. This project was funded in part by Grant-in-Aid No. 23256005 for Scientific Research from the Japan Society for the Promotion of Science.
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CONFLICT OF INTERESTS UTHORS DISCLOSE NO conflicts of interest for this article.
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