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Small Animal/Exotics Compendium January 2000 EMERGING TECHNOLOGY V Telesonography * Marc Papageorges, DVM, MS, PhD
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
T he primary obstacle to more
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-
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
the level of medicine, increase client
satisfaction, limit professional liabili-
ty, and increase job satisfaction.
Telesonography also eliminates
travel time and costs associated with
practitioner training and referrals to
specialists. Telesonography consulta-
tions cost between $25 and $50 per
case, 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 to
individual needs and performed as of-
ten as required. The idea is not to re-
place scientific literature, seminars,
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-
uled rounds or training sessions through
interactive consultations (i.e., video-
conferencing). The possibilities de-
pend on the type of telemedicine sys-
tem installed and how much a
practitioner wants to rely on the sys-
tem.
Store-and-Send Systems
In store-and-send telemedicine sys-
tems, still images are stored in the
practitioner’s computer and sent by
modem to a remote computer for re-
view by specialists at their conve-
nience. Store-and-send formats can
also use short (8- to 12-second) se-
radiology. In the United States, approx-
imately 500 practices are presently
using telesonography to enhance their
practice value.
Advantages of Telesonography
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
■ 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
*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.
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 Small Animal/Exotics Teleconsultants American College of Veterinary Radiology c/o Tom Nyland,
Compendium January 2000
Small Animal/Exotics
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
TABLE I
Budgeting Videoconferencing Services
Item
Cost ($)
Videoconferencing software and camera
Dedicated telephone line (ISDN)
Consultant fees
1000
70–100/mo
120–200/hr
503-752-2511
www.acvr.ucdavis.edu
Animal Medical Imaging
16390 87 th 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
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.
VETMED
Larry P. Tilley, DVM,
and associates
22 Descanso Road
Santa Fe, NM 87505-9125
Interactive Consultations
800-214-9760
Email:TILLEY@compuserve.com
www.vetmedfax.com
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-
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
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-
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 Compendium January 2000 TABLE II Budgeting Telesonography Services Telesonography Systems and
Small Animal/Exotics
Compendium January 2000
TABLE II
Budgeting Telesonography Services
Telesonography Systems
and Software Vendors
DVM Communications
Item
Cost ($)
3645
Warrensville Center Road
Ultrasound machine
25,000
Suite 212
Cleveland, OH 44122
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)
2500
800-417-9707
0–6000
0–10/case
Email: DVMcom.com
www.dvmcom.com
25–50/case
2500
500
3000
Total
33,000 to 39,000 + 0–60/case
Remote Veterinary
Consultants
100 Chastain Center Road
Suite 100
Kennesaw, GA 30114
800-553-3265
Lease
700/mo
Email:bcampbell@remotevet.com
www.remotevet.com
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.
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.
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?
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-
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 kidney plus any additional views that show focal abnormalities: three sagittal (one of the pelvis with measurements, one lateral to the pelvis, and one medial to the pelvis) and three transverse (one of the pelvis with measurements, one cranial to the pelvis, and one caudal to the pelvis)

Liver—Minimum of eight images plus any additional views that show focal abnormalities:

Communication information Veterinarian’s name Hospital or practice name and address Telephone and fax numbers Email address (optional)

Patient and medical information Degree of urgency (stat.) Owner’s name Patient’s name Patient’s species, breed, sex, age, and weight Chief owner complaint Patient history Pertinent laboratory results and results of other diagnostic studies Reason(s) for ultrasonography Your ultrasound findings Diagnostic differentials Working diagnosis Any specific questions

Image information Images should be labeled if obvious anatomic landmarks are not included (location and transducer orientation)

 

seven sagittal (one of the caudate lobe plus the right kidney, one of the vena cava and hepatic veins, one of the gallbladder, one of the cystic/ common bile duct, one of the left medial lobe, one of the left lateral lobe, and one of the liver and spleen) and one transverse that includes the gallbladder

Spleen—Minimum of seven images plus any additional views showing focal abnormalities: four sagittal (one including the splenic vein, one lateral to the splenic vein, one medial to the splenic vein, and one with the spleen against the liver) and three transverse (one including the splenic vein, one cranial to the splenic vein, and one caudal to the splenic vein)

Urinary bladder—Minimum of six images plus any additional views showing focal abnormalities:

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

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

practitioners become more accurate diagnosticians.

and de- gree of urgency are standard requirements. Practitioners practitioners become more accurate diagnosticians.