Simple, Reliable Telemedicine Videoconferencing using Apple Laptop Computers and iChat Software

 

- by Sunil Bhatt

 

 

INTRODUCTION -- What Is Telemedicine?

Telemedicine is a well-established technique that allows face-to-face communication between health care providers in different locations. At its most basic, telemedicine is like a “videophone”, consisting of a camera and microphone in one place sending video and audio to speakers and a monitor in another place. In practice, telemedicine generally consists of two computers, monitors, cameras, speakers and microphones linked through the Internet. Telemedicine allows live, detailed communication between practitioners within a state or across the world.

Telemedicine has many uses. First, it allows a physician in one location to discuss cases with a physician in another location in detail that is impossible with telephone or e-mail. During telephone discussions, discussants must verbally describe physical findings. CT, MRI and other images similarly cannot be shared. Medical e-mail discussions lack interaction in real time, and it can often take several days to satisfactorily discuss and resolve a clinical problem. Unlike with e-mail or telephone, with telemedicine the discussants are talking in real time and can share video images – simultaneously looking at the same patient, the same X-ray, the same endoscopic photograph. For example, a surgeon in one place can make a drawing or demonstrate a photograph or X-ray and point out relevant features to a surgeon in another location in a way that is not possible with other methods of communication and which is more precise and detailed than speech or writing alone. Secondly, with appropriate cameras and endoscopes, a consultant at one end of the telemedicine link can guide a technician on site with the patient to obtain the appropriate history and physical examination and review lab studies. With telemedicine, the patient’s distance from an expert is no longer a barrier, and a patient can receive care from an expert across the globe as if they were seated together in the same exam room.

Telemedicine is especially useful in rural or developing areas of the world where access to specialists is limited. Using telemedicine a physician (or trained technician) on site with the patient can provide information to physician who specializes in that problem but who is located in a “center of excellence” elsewhere. The on site physician can obtain a history in advance or the specialist can obtain the history in direct discussion with the patient via the video monitor. The on site physician can then perform the appropriate physical examination under the guidance of the specialist located thousands of miles away. Endoscopes can be attached to the system, and manipulated by the on site physician providing real time images to the specialist, bringing advanced diagnostic techniques to remote areas. With appropriate equipment, a specialist using telemedicine can even guide a less experienced surgeon through complex surgery.

Telemedicine allows for the exchange of medical photographs, x-rays and other images, endoscopy, and video clips as well as live video and audio conversations. Telemedicine is a very flexible technology limited only by the creativity of the user.

 

HOW TELEMEDICINE WORKS

Techniques of telemedicine and videoconferencing are well described elsewhere. Currently there are many types of telemedicine systems in use in hospitals in the US and abroad. In general, these systems are expensive, complex and, like most computer-based systems, often have compatibility issues. They can be difficult to learn and may even require IT support to run them. In India, where our system was used, the Apollo system of video conferencing is in place, using satellite data transfer to connect over 60 hospitals throughout the country and its neighbors. Each of the locations requires full time trained technicians and IT support to help in running the technology necessary to have a video conference. The system is usually a large fixed monitor and computer setup in a special room devoted to telemedicine, and so is not easily portable to the exam room, or the operating room. Endoscopes cannot be easily connected to the system, and only hospitals within the Apollo group may participate.

My goal was to create a system of telemedicine that would be easy to set up, inexpensive, reliable and portable. Such a system would be particularly attractive in areas of the world where costly systems, IT support and bulky or complex setup would pose problems. The system described in detail below meets these goals - requiring only two Apple Macintosh laptop computers (MacBooks), and a high-speed Internet connection. The built in hardware and software contained in the MacBook permits live video and audio discussion of the history, examination, diagnosis and counseling between the patient and practitioner in the clinic or in the field and a consultant in a medical center. With the addition of endoscopes and digital cameras, advanced techniques such as patient endoscopy and review of X-ray studies are easily achieved. Furthermore, the consultant can remotely oversee and guide treatments and procedures performed by the practitioner on the patient.

 

OUR EXPERIENCE WITH TELEMEDICINE IN RURAL INDIA

The system was set up, tested and implemented during a recent trip providing charity ENT Head and Neck surgery care at the Saduguru Seva Sangh Trust charitable hospital in rural Madhya Pradesh, India (www.sadgurutrust.org). This hospital cares primarily for patients with eye disorders and general surgery issues, and previously had no knowledge or expertise in the field of otolaryngology/ head and neck surgery. We had previously visited the facility with the intent of training local caregivers in the diagnosis and treatment of otolaryngology disorders. While the local practitioners were adept in developing these skills, we wanted to arrange a telemedicine link that would allow ongoing oversight and training of the practitioners on site, as well as examination, discussion and treatment in real time of patients with complex conditions. Otolaryngology was a particularly challenging field for which to set up a telemedicine program, since many of the areas afflicted--within the eardrum, middle ear, nasal and sinus passages and throat--cannot be adequately examined except with the use of endoscopes.

 

 

ANALYSIS OF THE APPLE LAPTOP BASED TELEMEDICINE SYSTEM

Strengths

Cost. The system described is simple and relatively inexpensive, with the cost for a basic system of approximately $2200 (i.e. 2 MacBooks). There is no need to purchase additional software as iChat videoconference software is included with all MacBooks. Similarly, current MacBooks are sold with an integrated camera, microphone and speaker hardware and do not need the purchase or installation of other hardware to conduct a basic telemedicine videoconference. This cost estimate, of course, does not include the cost of medical equipment that would ordinarily be needed for care of the patient. In our case, endoscopes were usually used to examine patients with otolaryngology disorders. If endoscopes are to be employed, a digital AV converter is also necessary. Macintosh compatible devices are readily available at low cost. The Formac device we used cost $100.

Ease of use. The integrated nature of the hardware and software make the MacBook remarkably easy to use for telemedicine. There is no time spent on software installation, hardware driver issues, or compatibility problems. The iChat system and the MacBook are quite user friendly; I was able to train the local practitioner, who had no computer skills, to set up and initiate a telemedicine videoconference within fifteen minutes without the need of tech support, or a dedicated operator.

Reliability. Like all computer-based systems iChat will have an occasional glitch. This usually relates not to the hardware and software itself, but to the reliability of the underlying Internet connection, which, in rural areas, can break down, especially if power supplies are irregular.

Image quality. In all medical systems, image quality is important to provide accurate examination of the patient and review of X-ray or endoscope images. Using the built in Apple cameras and microphone, the image and sound quality is excellent, even when communicating with doctors across the globe. The video quality is as good or better than the dedicated telemedicine system used by Apollo.  The quality of the image is related to Internet speed, so slower speed connections or the use of slower speed Wi-Fi connections can degrade the image. We sent reliably excellent images at a speed of 3 Mbps and received good to very good images at a speed of 2 Mbps . Consequently, the image seen at the facility with the lower speed connection may be superior to the image seen at the facility with the higher speed connection.

Mobility. Because Mac Laptops are being used rather that stationary or bulky equipment, the system is highly portable. I was able to transport all of the necessary equipment in a carryon suitcase when traveling, including computer, endoscopes, cables and AV converter. Of course, an Internet connection is required within a cable’s reach of the computer.

Multiple discussants. Apple Mac OS Leopard software (OS 10.5 and above), permits up to 10 sites to participate in the videoconference. This software also enables discussants at one site to manipulate data and images on the screen of another discussant. With this feature, a consultant can point out important areas on a photograph or video clip to discussants at another site without needing to transfer the image (although mage transfer is also easily accomplished on this system). 

 

Weaknesses

Internet requirements. The system requires a high-speed connection. While I have listed this as a weakness, all telemedicine systems require a high speed internet connection. Even in remote areas, however, hospitals and clinics will often have an area with high-speed Internet service. In practice,  at speeds less 2 Mbps the video image is suboptimal and are prone to breakdown or disconnection. Live typed messaging and audio, however, work well with much lower bandwidth requirements than video. In general, we could not obtain satisfactorily stable video images with WiFi, and recommend a cable connection. It is not necessary to be adjacent to the high-speed connection; in one case we ran a cable 100 feet from the connection point to a MacBook located in the clinic that had no computer connection. We are investigating the possibility of using this system in remote villages in conjunction with a mobile satellite based Internet connection.

Compatibility. iChat software is designed to run only on Macintosh computers. While it is compatible with AOL Instant messenger software, which runs on Windows computers, I have not been successful in running full videoconferencing between MacBook and Windows computers. It appears that the newest AIM (AOL Instant Messenger) software does not support iChat video capabilities and often Windows firewall issues prevent video communication. As a result, only typed live messaging is currently possible between this system and PC based systems. Hopefully these issues will be addressed in newer versions of AIM.

Privacy issues. The video information that is sent over the Internet is not encrypted, however if one signs up for a Mobile Me account with Apple (cost $99 per year) the chat content will be automatically encrypted (http://www.apple.com/mobileme/features/mac.html) . Please make sure to check that your computer recognizes your Mobile Me account.

 

Step-by-Step Setup of a Telemedicine Videoconference using Apple Laptop Computers

I will first outline the needed equipment for a basic telemedicine videoconference. Following this is a list of additional equipment used to add endoscopy and photography capabilities. The subsequent section outlines a step-by-step connection of hardware and implementation of software for a basic conference. Lastly, I will explain how to hookup of the hardware and software for a conference that uses endoscopy and photography.

Basic setup list and specifications:

A basic telemedicine conference requires only 2 MacBooks, an Internet connection and appropriate cables.

This is a list of the materials we used, their specifications and purpose:


1.) Two
(2) Apple MacBooks ($2200) running operating system OS 10.4 or above (http://store.apple.com/us)
     

    - Recent MacBook models have an integrated camera, speaker, and microphone

    - iChat software is pre-installed in every MacBook at the time of purchase
      

    - Outside the US, MacBooks can be purchased through www.apple.com, select the appropriate country from the pop up menu at the bottom of this web page.


2.) Plug adaptor ($39) to power the laptop if in another country--Apple MacBook will run on either 110V or 240V using the standard AC             powercord. An adaptor is need to connect the power cord to the local socket/pin arrangement. Apple sells a convenient international adaptor pack.  (http://store.apple.com/us/product/M8794G/B?mco=MTIxODk3Mw)

3.) Cat-5 cable with high-speed Internet connection. During our study, the Internet connection speed in India was 2 Mbps in India and in the US was 3 Mbps.


This is all the equipment that is needed to conduct a thorough telemedicine video conference in many medical specialties.

 

 

Endoscopy equipment list and specifications:

This equipment is NOT needed for basic telemedicine discussions. Since our work involved otolaryngology, we used the following equipment to perform detailed internal examinations including otoscopy (examining the ear drum and middle ear) and endoscopy of the nose, sinuses, and larynx (voice box). A digital still camera and remote camera were used to transmit CT scan pictures and other live images respectively. This equipment could similarly be used to provide images for almost all other medical/surgical specialties:


1.) Freestanding Apple iSight Camera ($100). Used along with a bright (halogen) flashlight to examine parts of the body that could not easily be placed in front of the MacBook’s integrated camera e.g. a patient’s throat (The freestanding iSight camera is no longer manufactured, but used models are still available on Ebay and other manufacturers make similar Apple compatible webcams)

2.) A variety of endoscopes were used for examination:

-Rigid sino-nasal endoscope: 0 degrees and 30 degrees Used for examining the nose, sinuses, and larynx.(pricing varies – these were donated to us by the Storz company   http://www.karlstorz.com/cps/rde/xchg/SID-BD904F38-0C116B3D/karlstorz-en/hs.xsl/45.htm.

-These are the standard endoscopes used for office exam in the US, no special version is needed for telemedicine.


-Video-Otoscope (pricing varies—these were donated to us by the Storz company, see link above). Used for examining the ear canal, ear drum, and middle ear. A standard otoscope will not accommodate the video coupler of a medical chip camera, so an otoendoscope is used. This type of videootoscope is commonly used in US offices to take photographs of the eardrum, and to display abnormalities to patients in offices and in hearing aid dispensaries.


3.) Light sources for endoscopes

-either a battery powered portable lithium light source or a standard desktop halogen light source were used.

-cost: used equipment, donated by Storz (http://www.karlstorz.com/cps/rde/xchg/SID-BD904F38-0C116B3D/karlstorz-en/hs.xsl/45.htm)


4.) Olympus “chip” Camera with standard endoscope coupler 

-OLYMPUS | AR-TL (JAPAN)

-to gather the images from the endoscope for processing

-cost: used equipment, donated by Lowell General Hospital, Lowell, Massachusetts

 

5.) Digital Signal Processor

-OLYMPUS | OTV-S4

-converts the chip camera signal into a usable signal for the Audio Digital converter

-cost: used equipment, donated by Massachusetts ENT Associates, Chelmsford, Massachusetts

 

6.) Analog Digital Converter

- Formac S/n: 200141231 (FORMAC STUDIO Family Nr:FS 10)

-converts signal from digital signal processor to Mac compatible firewire output

-cost $100 (www.formac.us/)

 

7.) Firewire cable (included with digital converter)

-Connects Digital Converter to computer

 

8.) 110V-240V Transformer may be needed for the Analog Digital converter and digital signal processor if they run on voltage different from the host country.

  1. -MacBook will run on any voltage without the need for a transformer

  2. -cost $20, commercially available

 

  9.)  Plug Adaptors for Analog Digital converter and digital signal processor, and MacBook if using the equipment in another country. cost approximately $15, commercially available

 

  10.) Defogging solution for endoscopes, (dilute solution of dish washing soap will also work)

 

  11.) Standard retail digital camera (approx. $150). We used a Canon PowerShot SD800IS which provided excellent photographs of CT scans and surgery for transmission, review and discussion during videoconferences. Also, cable to connect digital camera to MacBook (comes with camera)

 

Conducting a Video conference: Step-by-step

 

This is our technique for conducting a basic telemedicine videoconference:

 

Connect the Macbook to the Internet and test connection

1) Plug Cat-5 cable from internet source into MacBook

2)Turn on MacBook

3) Make sure the Airport Wi-Fi is disabled (use Apple Help if unfamiliar with how to do this)

4) Check the Internet connection by opening Safari or other Internet browser. Open a website--for example, Google. (If this does not work your Internet connection is faulty. Use Network Diagnostics feature on the MacBook to make sure your Internet connection runs smoothly before proceeding)

 

Obtain A SCREEN NAME to use for iChat and AIM (AOL Instant Messenger)

A screen name is a way to identify participants in a web chat; you will invite others to participate in a conference by sending an invitation to their screen name and vice versa. You will keep a list of participants’ screen names on your “Buddy List” The Buddy List will also tell you if these participants are currently online or not.

To get a screen name enter http://dashboard.aim.com/aim in the browser and click on the AIM.com menu in the upper left corner. (.mac and mobile me users see below “to add a .mac user to your buddy list”).  Choose “Make a Screen Name”. (these screen locations were correct for AIM.com as of 9/08). On the next page choose “Create an Account” and Continue.

On the next page, fill in all of the required information in order to get a screen name and Submit

Each participant in the conference will need a screen name e.g. the doctor or facility at each conference location.

 

Open iChat Software

Once you have a screen name, click on the iChat icon in the Apple dock at the bottom of the screen (a blue bubble containing a camera white video camera icon). if it is not in the Dock, find iChat in the Applications folder. (Finder>Macintosh HD>Applications will show it. Drag and drop the iChat icon into the Apple dock, then click it to open it.

When iChat opens for the first time enter your screen name and password into the window and complete the steps to set up your account.

Once iChat recognizes your screen name, open up the buddy list (Go to the window menu, then choose AIM Buddy list from the drop-down menu)

After the first use, iChat will open automatically with your screen name and show you your buddy list

 

 

 

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To Add Conference Participants (“BUDDIES”)


Click on the “+” in the bottom left hand corner of the buddy list

A drop down menu will open. Click on “Add Buddy”

A new window will pop up

Choose AIM (not Mobile Me or Mac.com) from the menu just to the right of the Account Name field. Then enter the screen name (buddy or account name) that other participants have obtained earlier at AIM.com (see above)

(The other fields are optional)


The Buddy List

The buddy list window shows the status of all of the screen names that you have entered.

If a “buddy” (i.e. another conference participant) is online then there will be a colored dot to the left of their name.


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If it is green then the buddy’s status is “available”, and they are using their computer and can be contacted to have a conference.


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   If it is yellow, the buddy’s status is “idle”. The length of time that they have been inactive will be displayed below their name. They can be contacted, but only if they are currently seated at their computer. If they have left their computer they may not respond.


INSERT PICTURE 4

   If the dot is red, the buddy is away. If you try to contact this person, but they will probably not respond because they have left the computer and have listed themselves as unavailable.


You can change your own green/ yellow/ red status that others see by clicking on the down arrow in the upper left corner of the Buddy List window, just below your screen name.


Look again at the line with the screen name of one of your “buddies” (participants) There will be one of 3 possible listings:  a telephone, a camera icon, or no icon based upon the capabilities of their computer, (there may also be a cartoon figure that this buddy has selected to signify themselves)

 

Most participants--and any participant with a MacBook--will have a camera icon to the right of their name:

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  or

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 This means that this participant has the appropriate hardware and software to engage in text chats, audio chats, or video chats. If, instead of a green camera icon, they have the letter A they have text chat only capabilities--text chat is essentially the same as IM, SMS or instant messaging. Similarly, a

INSERT PICTURE 7

  icon to the right of their name means that person can perform text chats or audio chats but not video chats; an audio chat is similar to a telephone conversation.


Some discussants may have placed a photograph or a cartoon icon representing themselves as well.


Start simply by doing a Text Conference

 

INSERT PICTURE 8         After you add someone to your buddy list you can perform a text chat with him or her.

Click on their name on the buddy List window so that it is highlighted.

The very bottom of the buddy list WINDOW has 4 small icons, all in black and white: the letter A, a phone, a camera icon and two rectangles (for sharing computers)

Click on the “A” icon at the very bottom of the window.

A chat window will open between you and the other participant, and list their screen name at the top

 

 

At the other end, the invited person will see a window inviting them to participate in the chat. IN ORDER TO START the conference the invited person needs to respond to the invitation – this will not always be obvious to them - you may need to prompt them by typing to them: “click on the window to accept the invitation”. This is further described below (see “RECEIVING CHATS”)

Begin typing a message to the participant – keep your first message brief, and hit enter/return to send it to them.

Invite them to type back.

 

 

When the other participant starts typing a response (but before they have hit return, you will see a “…” next to their icon.

 


Move on to an Audio Conference

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The next step is to try an audio conference.

You will be able to talk to each other through the built in speaker and microphone similar to a telephone conversation (hence the telephone icon).

In the buddy list, click on the screen name of the person you would like to chat with (make sure that they are available, i.e. have a green dot next to their name. )

Next, click on the black telephone icon at the BOTTOM of the buddy list window

A window will pop-up and it will say “waiting for response from:”

 

At the other end, the invited person will see a window inviting them to participate in the chat. IN ORDER TO START the conference the invited person needs to respond to the invitation – you may need to prompt them by sending them a text chat telling them how to click on the window to accept the invitation. This is described below (see “RECEIVING CHATS”)

If the person accepts your invitation to conference, the window will then say “Starting audio chat” and you will be able to hear them, and they can hear you.

If they choose not to accept your invitation or do not respond at all, then your window will say that they have “declined your invitation”. You may need to try this a couple of times before everyone is familiar with sending and receiving invitations.

 


Finally, a Video Conference

INSERT PICTURE 10

 

In the same way as Audio chat, begin by clicking on the person with whom you would like to chat and highlight their name.

Click on the black camera icon at the bottom of the window

A window will pop-up showing you the view from your own MacBook camera – this is the mirror image of what the other person will see when the conversation begins. Tip: Make sure the room is well lit, with a light in front of you, not behind you. Also place the Macbook camera at eye level (e.g. on a stack of books on a desk) to create a more natural appearing conversation.

 

A window will pop-up: “waiting for response from:”

The other participant will need to agree to the invitation as they did for the audio chat – again, they may need a prompt if they are not familiar with this.

If they agree, your window will say “Starting video chat”. The window with your video image will switch to the view from their camera and you will be able to see and hear them. The telemedicine videoconference is under way!

If they choose not to accept your invitation or do not respond, your window will read that they have “declined your invitation”


To End the Video or Audio Conference

Close the window by clicking on the red circle in the upper left hand corner: this will end the chat.

 

Receiving Chats

If someone invites you to conference with them a window will pop up that looks like this: 


INSERT PICTURE 11


In order to conference with them, you must “accept their invitation” To do this, click ANYWHERE in this window. The window will expand and these three buttons will appear at the bottom:


INSERT PICTURE 12


Click on the Accept button to start the video chat.

 

To Log off, or change your “Buddy list” STATUS

Changing your status indicates to others whether you are available for a conversation or not, but it lets you remain online in case someone needed to contact you. At the top of the buddy window will be the word “available” accompanied by a green light. To change your status, click on the arrow next to the word “available”, and the drop down menu will allow you to change your status. To log off entirely, quit iChat as you would any other Apple application.


Full Screen


Click on

INSERT PICTURE 13

at the bottom of the window to go to full screen mode.

 

To use the free standing iSight Camera

You can use an auxiliary webcam to examine areas that are not amenable to the built in camera on the MacBook:


1) Plug the ISight webcam into the computer. If this is not an apple product, you may need first to ensure that the appropriate drivers are in place for the web cam to run properly.

2) To switch from the built in MacBook camera to the web came during the video chat, go to “iChat” menu (upper left hand corner of the screen) , go to preferences choose the green Video Tab, next click on the “Camera” drop down menu and choose “iSight” (not built in iSight) or other web cam, and the image should switch. To switch back to the built in camera follow the same directions and select “built in iSight” from the menu.


To See you Conference Statistics

Go to Video drop-down menu at the top of the screen and select Connection Doctor

This will show you how good your connection is with the other person, during a video or audio conference.


Limiting the Bandwidth

If you are in a remote area with only a certain amount of bandwidth, you may want to limit the bandwidth used. Although this may lower the quality it will allow for more successful conferences.


Taking Snapshots during the Videoconference

During a video conference you can take snapshots of anything visible to the other discussant’s camera. For example, if a patient displays an abnormal lesion or mass in front of the camera, it can be documented. Similarly if the endoscopes are being used, snapshots of live endoscopy views can be recorded.

To take a snapshot, go to the Video menu at the top of the screen and choose “take snapshot”

The snapshot will appear on your desktop.


To Conference with Multiple Participants:

If you would like to have a conference with multiple sites, do the following:

First make sure that all sites/ people you wish to confer with have screen names listed in your buddy list. If not, see above for how to obtain screen names, and how to add them to your buddy list. Next  make sure that all discussants are online and available, with a green dot next to their screen name, and that the green icon to the right of their name looks like this: 

INSERT PICTURE 14


Highlight one of the discussants screen name and click on the black camera icon at the bottom of the window to invite them. Once they have accepted and the conference as begun, click on the “+” sign at the bottom of the Video Chat window (the window with the video image, not the Buddy List window), and choose the other person with whom you would like to chat. Continue to do this if you would like to talk with more people. iChat permits up to 10 conference participants. Adding more participants may require more network bandwidth to maintain stable video images.


To add a .MAC user to your buddy list

If you would like to add users with a .Mac account (instead of AIM account)

Click on the “+” in the bottom left hand corner of the buddy list

A drop down menu will open. Click on “Add Buddy”

A new window will pop up

Choose Mobile Me or .Mac (not AIM) from the menu just to the right of the Account Name field. Then enter the screen name (buddy or account name) that other participants have obtained earlier (see above)

The other fields are optional


Sending Photos, video clips and documents via iChat during a video conference

In the iChat version 4.0.5 and later, a discussant is able to send files such as medical pictures, videos and documents with ease. This is extremely helpful for sharing CT images, pictures of patients, before and after photos and video clips from surgery or endoscopy.


To send a picture during a conference start by having the desired photographs, video clips or documents on your MacBook prior to the conference.

To do this for photographs (e.g. a photo of a CT scan picture), plug your digital camera into the computer using the USB cable provided with the camera . iPhoto will automatically open as ask if you want to import the pictures.

Upload the desired pictures into iPhoto.

Similarly, digital video clips can be uploaded, or be recorded from the iSight camera or built in MacBook camera using iMovie software included in the MacBook


Start the conference as usual.

Next, right click (or use hit control and mouse click at the same time) on the screen name

Choose “Send File” from the drop down menu.

A “Choose File” window will open.

On the left hand side of the window select “Pictures” (or highlight the file containing the image, video clip or document that you wish to send)

Next find the photograph you would like to send and choose the file.

The recipient’s computer will show a window that says “Incoming File Transfer”

The sender will have a similar window

To receive the image, the recipient must click anywhere on this window

It will expand and will show 3 choice at the bottom: Block, Decline, and Save.

When the intended recipient clicks “Save”, a window will open labelled “File transfer” and show the progress of the file import.

Once the transfer is complete, the recipient can click on the icon to open the document /photo/ video clip.

(The file is saved in the downloads folder and can be accessed there and moved to another folder or the desktop if preferred)


Photographs and other media can also be sent prior to a conference, in a similar manner.




Setup and use of endoscopy and photography during telemedicine videoconferencing


When we conducted conferences involving otoscopy or nasal and throat endoscopy the following hardware/ endoscopes were attached before turning on the MacBook:


1) Attach any necessary plug adaptors and power transformers.

2) Plug in the digital signal processor

3) Put the correct end S-video cable into the Y/C port on the back of the digital signal processor

4) Connect the other end of the S-video cable into S-video IN jack on the back of the Analog Digital converter

5) Plug the firewire cable from Analog Digital converter into the MacBook

6) Plug the chip camera into the digital signal processor.

7) Attach the endoscope to the chip camera ocular coupler

8) Attach the light source to the endoscope

9) Plug the Internet (cat-5) cable directly into the Mac

10) Connect the MacBook to a power supply using the necessary adapters.

11) Turn on the Digital Signal Processor

12) Turn on the Analog Digital converter

13) Turn on the light source

14) Turn on the MacBook, open iChat and begin a video conference as described earlier.

15) Once a video chat is running, to switch from the built in MacBook camera to the chip camera do the following: go to “iChat” menu, click iChat, (at the top of the screen, upper left hand corner of the screen) a drop down menu will appear - then click Preferences > Green Audio/Video Tab > Camera menu > Digital Video converter (not built in iSight or iSight)

To revert to the camera image, follow the same sequence, but choose built in iSight ( iChat> Preferences > Green Audio/Video Tab > Camera menu>built in iSight)

Note:

The iChat system always shows a mirror image of the person who is using the computer, this can be a nuisance when using the endoscopes, however, the doctor on the other end will see the actual image.





EXAMPLE OF A VIDEO CONFERENCE

 

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Here is all of the necessary equipment for a basic telemedicine video conference—just a MacBook and Internet connection.


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The auxiliary iSight camera is shown attached to the MacBook

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Shown is a sinus/ nasal telescope with light cable, and videootoscope (center) Similar equipment would allow endoscopic telemedicine of almost any part of the body.

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Above is all the equipment necessary to do telemedicine with endoscopes: Analog-digital converter (top), halogen light source (middle – optional – a small portable light source will also work), Digital Signal processor (bottom), plugged into this is the endoscope chip camera. Also shown are the endoscope and videootoscope with light cables

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The telemedicine conference begins from the Macbook in Madhya Pradesh, India with a videoconference invitation sent to a cancer surgeon in Andover, Massachusetts.

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The consultant is shown in the large image in the center of the screen on the Indian computer. What the consultant sees is displayed on the right of the screen and in the upper left corner of the consultant image

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The telemedicine discussion has begun…A patient’s condition is being discussed between the caregiver on site with the patient in India and the expert consultant in the US.

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In this picture an iSight camera is being used to show areas of the patient’s body further from the built in camera

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Otoscopy is performed by a medical student under the direction of the surgeon in the United States. The image of the eardrum is displayed on the MacBook screen.
I

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This is a snapshot of the screen at the US end. This is the view of the eardrum during otoscopy as seen by the specialist in the US.

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In this picture nasal endoscopy is being performed.

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This is an example of a medical photograph that can be transferred and discussed.

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The chat is complete and the computer is disconnected.





TROUBLESHOOTING



BUDDY WINDOW WON’T POP UP

Go to “window” drop down menu at top of screen and then select your screen name


ICHAT WON’T OPEN AND YOUR BUDDY LIST IS DISCONNECTED

Check your Internet connection and make sure that they cat-5 cable is securely in the computer.

Quit iChat and try to open it again in a few minutes.


I GET AN ERROR MESSAGE WHEN I TRY TO CONTACT ANOTHER MAC USER

This may occur either because the Internet connection is faulty OR because there is inadequate bandwidth

Make sure cat-5 cable is securely in computer

Make sure Airport is turned off, so that wi-fi is inactive

Open Google to check the network connection

If it does not work, go to network diagnostics and go through the steps to get the Internet working

Try communicating via text instead of audio or video. If you are able to talk by text, but audio or video fails, then the cause is inadequate bandwidth – the Internet connection should be by cable not wi-fi, at a speed of at least 2 Mbps at both ends

If you cannot communicate through any means, quit iChat and trying again


I CAN’T SEE ANY OF MY BUDDIES

There is a small arrow to the left of the gray bar that says buddies click on it so that it is  pointing downward and your buddies will be visible.


THE CAMERA IMAGE IS POOR

Make sure that the lighting is good and the laptop is positioned at eye level.


You may also have a bandwidth issue.

Make sure that both computers are connected directly to an Internet connection with a cat-5 cable.

Make sure others are not using the same Internet connection