Abstract: On June 26-27, 1998, doctors at UCSF Stanford Health Care consulted via the Internet with pediatricians at Xi'an Medical University Hospital in Xi'an, China, on the cases of two critically ill children. Stanford School of Medicine Information Technologies (medIT), in cooperation with Sun Microsystems and others, developed an architecture that allowed the doctors to use Internet video, audio, whiteboard, and browser applications to confer and review the medical cases; and to webcast the entire session across the Internet via RealMedia. Secretary of State Madeleine Albright and other ranking members of the Clinton Delegation to China attended the session.
IntroductionBackground: Internet-based telemedicine, though in its early stages of development, is of great importance in less-developed countries, where advanced medical facilities and expertise are concentrated in major cities, and inaccessible to large segments of the population who reside in outlying areas. Telemedicine systems can allow practitioners in regional and rural hospitals and clinics to draw on the resources of major medical centers. Many hospitals in China, such as Peking Union Medical College Hospital, have acquired video-based teleconferencing systems and are delivering telemedical services. These services are far too expensive for the use of the average Chinese citizen. Internet-based consultation systems have been used to distribute telemedicine at extremely low cost. In the spring of 1995, the case of a patient with heavy metal poisoning was sent from Beijing to the U.S. Respondents around the world sent suggestions for treatment over the Internet by e-mail. However, text-based e-mail does not provide the capability for radiological imaging, transmission of sound files (such as the output of a stethoscope), and in particular the real-time direct interaction of medical colleagues, which is seen to be crucial in facilitating consultation. The Internet now holds the promise of providing this type of interaction at much lower cost than proprietary videoconferencing systems.
Goals of the Demonstration: The high-end telemedical technology systems that are being used in the U.S., U.K., and Israel, cannot be deployed widely in China, or operated on a routine, day-to-day basis. What are needed are low-end systems that match the capacities of existing network infrastructure and computers, such as the Internet-based applications that were demonstrated at Xi'an Medical University and UCSF Stanford during this demonstration. The challenge is to deliver benefits of modern medicine to locations that are last in line to receive them, using applications that will work reliably and on a day-to-day basis in the most difficult environments. Making use of the publicity surrounding the Clinton visit to China, it was hoped that a convincing demonstration of real-time Internet-based telemedical consultation (the first of its kind) would pave the way and lead to future advances.
The Event: On June 26-27, 1998, doctors at Xi'an Medical University (western China) and at UCSF Stanford Health Care (California, USA) participated in the first real-time medical consultation between China and the United States over the Internet, on behalf of two critically ill children. The demonstration, which coincided with President Clinton's visit to China, was designed to highlight U.S.-China cooperation in medicine and technology and underscore the role that telemedicine can play in improving patient care. The consultation used Internet technology, which allows for real-time communication and sharing of information, including images of the participants, photographs, medical records and other graphics, and voice communications. The nonprofit organization Bridge to Asia conceived and organized the demonstration, which was hosted by UCSF Stanford Health Care. The technology was installed and managed by Stanford medIT (in the U.S.), and engineers from XMU (in China), with support from Sun Microsystems.
Participants: In China, the event was presided over by Secretary of State Madeleine Albright and Secretary of Commerce William Daley, both of whom addressed the audiences in California and Xi'an with speeches praising the technological cooperation and emphasizing the importance of medical, educational, and cultural exchanges between the U.S. and China. "This is indeed a very impressive set-up and an impressive achievement, and as we inaugurate this link between Xi'an and The Stanford Medical Center, we use technology the way it should be usedto save and improve people's lives," said Albright. "It is a sign of how quickly the newest information technology is coming to China and how far reaching its effects will be."
The other U.S. dignitaries were Senators John D. Rockefeller, Daniel Akaka, and Max Baucus; and Representatives Edward J. Markey, John Dingell, and Lee Hamilton.
The UCSF/Stanford physicians providing the consultation were Dr. Daniel Bernstein, Chief of Pediatric Cardiology and Associate Professor of Pediatrics, Stanford; Dr. David Stevenson, Neonatologist, Stanford; Dr. Joseph Kitterman, Professor of Pediatrics and Neonatologist, UCSF; and Dr. David Teitel, Professor of Pediatrics and Chief of Pediatric Cardiology, UCSF. Said Dr. Teitel, on the subject of telemedicine, "I think it's clear that patients gain a tremendous amount when physicians are able to communicate and share critical diagnostic information and images in real time."The Patients: The doctors discussed treatment for what had been diagnosed as viral myuocarditis, an inflammation of the muscular walls of the heart, in a 12-year-old girl who had been suffering from shortness of breath, fatigue, and abnormal heart rhythms. They also reviewed treatment for a male infant who was born by Cesarean section on June 13 and was suffering from brain damage due to a lack of oxygen and decreased blood flow at birth.
Technology and ArchitectureOverview: There were two technological challenges to the telemedicine demonstration. One was facilitating the actual conference, with video, audio, shared whiteboard, and image viewers (for radiological images)ideally using lightweight and widely available applications. The second was capturing all of the audio and video, digitizing it into RealMedia, and streaming it out live, so people world-wide could witness the event online. The final architecture was a bit complex, but very robust and functional. Two Sun workstations were installed on each end, running a suite of freeware Internet conferencing applications, browsers, image viewers, and supporting software. The full video output from one of the conference workstations was captured with a high-end scan converter and streamed into an onsite PC running Windows 95 and RealPublisher; this machine converted the video (and audio, captured from a conference phone) into RealMedia, which it streamed across the local network to another PC (in the next building) running RealServer. From there, the audio/video stream was sent out over the Internet. The video feed was also sent to a large display device in the U.S. conference room, for the edification of live participants as well as captured directly by the various camera crews in attendance for broadcast on news programs.
The Complete Architecture of the Setup on the U.S. End
Hardware & Software (for the videoconference): On each side, two Sun Ultra 5s (one with 24-bit graphics capability), both running SunOS 5.6, were utilized for the conferencing applications. Sun desktop cameras and microphones, as well as standard VHS video camcorders, were used for audio and video capture. The workstations on both ends ran a suite of TCP/IP conferencing applications from Berkeley Labs: vic (video), vat (audio), and wb (shared whiteboard space). [Documentation available at <http://www-nrg.ee.lbl.gov/>.] All machines ran the Sun HotJava web browser and the RealPlayer streaming media player from RealNetworks. Unix talk was utilized for some technical interchange.
Hardware & Software (for the webcast): A HyperConverter 1024 Scan Converter was used to capture the full video feed from the main conferencing workstation. [Information on this product available at <http://www.pcvideo.com/1280ds.htm>.] A high-end table-top conference phone, with direct RCA audio out, was ultimately brought in for the audio portion. (The TCP/IP-based audioconference link was judged too spotty (see below) for use in the actual event, and was supplanted by telephony.) A Windows 95 box onsite ran the RealPublisher 5.0 software to capture, and convert in real time, the audio and video streams. These streams were run across the LAN to a Windows NT server running RealServer 5.0, with a 100-stream license, and out to the Internet. A link to this RealMedia stream was provided on the official web site. [Information on RealPublisher and RealServer available at <http://www.real.com/>.]
Network: The machines on the Stanford end were connected via 10 megabit ethernet to the SUNet backbone, and through BBNPlanet to the Internet. In Xi'an, the machines were connected to CMINET (the Chinese Medical Information Network) to CERNNET (the principle backbone in China) to the Internet. Two satellite hops and a microwave link were involved in getting Internet traffic from the U.S. to Xi'an (in rural western China).
HurdlesInfrastructure: One of the catch phrases of the event was was to show "the Internet in China as it is, not as we wish it to be." In numerous tests over a period of several weeks leading up to the event, attempts were made to secure, and make best use of, bandwidth into Xi'an Medical University. It was particularly critical to experience some success in our testing, as a number of the "dry run" sessions were attended (frequently without advance warning) by members of the U.S. State Department advance team; their impressions would dictate whether this consultation was included on the schedules of the visiting U.S. delegation. During one State Department visit, a camera went out; during another, one of the workstations in China crashed and wouldn't come back up. These situations were handled smoothly on a case-by-case basis. But, overall, experiences of limited bandwidth, packet loss, and low video frame rates were acute in numerous tests. Compression of the video was optimized, but it was ultimately decided that the spottiness of the audio stream would be too frustrating for the dignitaries, and (to a lesser extent) the physicians. As a result, we reluctantly decided to use a telephone conference call for the audio portion of the live event.
The total bandwidth into XMU was extremely limited, so some steps were taken in advance to address this. The microwave link from Xi'an to Beijing was overheating in the sun during the day, so the dish was upgraded a few days before the event. Preparations were also made to cut off all other Internet traffic from XMU during the period of the demonstration. Additionally, during testing the night before, we experienced interference in the video stream from China which was unrelated to the Internet transport. We determined that this was caused by on-off cycling of air conditioning units at XMU; consequently, people at XMU were cut off from their climate control (as well as the Internet) for a short time.
The Internet-based video, shared whiteboard, and shared image viewing eventually went over extremely well. Although video-taped welcomes and introductions were not shipped to China in time for the event, digitized RealMedia versions of these materials were transferred electronically, an unexpected coup for the Internet.
Architecture for the webcast: One of the main architectural challenges was how to capture various video sources (two conferencing windows, the whiteboard, images in a browser, etc.), as well as audio (complicated by the use of telephony), and convert it all into one audio/video stream for RealCasting. Several strategies were considered, but ultimately we concluded we had to pull the full video feed from the main workstation (on its way to the monitor). The HyperConverter 1024 scan converter, with its 13W3 Sun video connector, solved that problem for a relatively modest price ($1,395). The direct RCA audio out on the conference phone solved our problem of capturing both ends of the dialogue. The scan converter and the phone were both run directly to the PC running RealPublisher, resulting in a very good quality RealMedia stream.
U.S. vs. China: Time zone, language, and cultural differences were issues to be dealt withbut none proved serious. Most of the live tests were conducted in the evening on the U.S West Coast, to coincide with morning in Xi'an. The great majority of the Chinese technicians and physicians had a very good command of Englishthough on some occasions it was helpful to have a bilingual participant who was familiar with medical terminology (James Bair, the Director of International Medical Services for UCSF Stanford Health Care). Finally, the cultural differences were inconsequential, and the engineers definitely spoke the same language.
ResultsOn the evening of the event, introductory comments were made by Secretaries Albright and Daley, and the Internet link was established. The U.S. physicians consulted, in pairs, on the two different cases (neonatology and pediatric cardiology) for about two hours. They viewed CT and lung x-ray images in an image viewer and browser, asked questions, and provided opinions to their colleagues in China. They also exchanged e-mail addresses (using the whiteboard application) to facilitate follow-up.
Several multimedia materials (a welcome and introduction of the physicians, a video tour of pediatric facilities at UCSF/Stanford) were prepared but not used in the actual event (they are available on the site). The live webcast of the actual event was not ultimately approved by the People's Republic of China, or the U.S. State Department, a mildly disappointing turn of events. The initial consultation and preparatory session of the night before was successfully webcast, proving the viability of the architecture. But the main event, with the dignitaries, was blacked out from the Net, though not from traditional media.
The event received coverage from the New York Times, the L.A. Times, the San Jose Mercury News, the China Press, and Sing Tao Daily; as well as CNN International and San Francisco area local broadcast news.
The Main Screen of the Event. Counterclockwise from top left: the consulting physicians in the U.S.; a chest x-ray of the infant; a web browser with a screen from the official site; in China, Secretary of State Madeleine Albright using the system (assisted by Robert Yung, CTO Sun Microsystems Asia).
The Web SiteA complete informational site was created in conjunction with the event. Information, images, multimedia, and future plans continue to be available on the web at http://telemed.stanford.edu/.