Associate Professor Computing and Communications Center Kyushu University Hospital, Japan.
Chairman, Medical Working Group of Asia-Pacific Advanced Network and Associate Professor, Department of Endoscopic Diagnostics and Therapeutics.
Assistant Professor Department of Medical Informatics.
The Asia-Pacific Advanced Network (APAN) is a network communication system that can transmit real-time, high-quality moving digital video (DV) images over Internet Protocol (IP). We are now able to use international submarine fiber-optic cable networks in the Asia Pacific region for broadband transmission. The distribution of medical information by means of DV over IP beyond national borders makes medical staff keenly aware of differences in medical services between countries and uncovers the relative advantages and disadvantages of each.
In February 2003, Japanese and Korean medical groups collaborated to use the Korea-Japan Cable Network (KJCN) for medical purposes. AQUA (Asia-Kyushu Advanced medical network) joined the Asia Pacific Advanced Network (APAN) consortium in January 2004 (APAN-Honolulu). After three subsequent demonstrations of telemedical conferencing during APAN meetings, which are held twice a year, the medical working group was formally approved by APAN by a vote during the APAN-Taipei meeting in August 2005. We met many medical doctors/researchers at each APAN meeting and therefore built a human network to help expand our project. We also gained partner institutions in Asia-Pacific countries through our attendance at each APAN meeting by asking different institutions to the stations. Thus, we established multiple stations during and after each APAN meeting by adding new institutions /countries (Figure 1).
We used public optic submarine cables for international connections and for domestic research and educational networks in Asia Pacific countries. From Japan, we connected the QGPOP (domestic) network and the Korea Advanced Research Network (KOREN) via the Asia Pacific International Infrastructure (APII) (1 Gbps), which uses the KJCN. In China, we connected to the China Education and Research Network (CERNET) through the KOREN-CERNET submarine link (155 Mbps). In Taiwan, we used the Academic Service Network (ASnet), with the connection from Super SINET or Asia Pacific Advanced Network-Japan (APAN-JP) at 1 Gbps through an optic submarine cable, which was prepared by ASnet. In Thailand, we connected to the Thai Social Scientific, Academic and Research Network (ThaiSarn) via Super SINET (45 Mbps). The United States was connected through the TransPAC network. Australia’s Research and Education Network (AARNet) was connected to Abilene from APAN-JP. We did not have a direct connection with Singapore; thus, we used a combination of the Japan- Taiwan connection and the ASnet-Singapore connection (155 Mbps), using the Advanced Research and Education Network (SingAREN) in Singapore.
Trans-Eurasia Information Network 2 (TEIN2), which was launched in 2006, made connections to South Asian and European countries easier. We connected Vietnam, Hong Kong and Indonesia in the summer of 2006 and the Philippines, Malaysia and India in the winter of 2007. We also changed the route to Singapore and Thailand in 2006, because we were able to directly connect to these countries via Japan Gigabit Network 2 (JGN2) from Japan. Additionally, we used the Asia Broadband program line (ASIA-BB) for the connection to Thailand starting in late 2005.
Since the beginning of the project, we have thought that high-quality moving images are essential for medical purposes. We have used DV over IP in this network for transmission of moving images with standard definition. We usually use the Digital Video Transport System (DVTS) over IP. DVTS is open source freeware, downloadable from a Web site. Thus, terminal stations are inexpensive enough to be set up throughout the Asia-Pacific region. We also transmit High Definition Television (HDTV) images compressed by Mpeg2 on the network. The quality of transmitted moving DVTS images is as good as that of the original digital video. A frame rate of 30 per second was obtained by 30 Mbps bandwidth, and the images were smooth and not sluggish. The sound was clear, however, audio jitter was sometimes present during the entire course due to packet loss. The time delay was less than 0.3 sec between Japan and Korea and slightly longer for other countries (maximum 1.0 sec), which made for minimal to no stress at each endpoint. During live transmissions, we used the AR550S (Allied Telesis Co.) VPN router at each station as a security system to protect patients’ privacy.
We conducted an increasing number of events over the past 4 years, for a total of 96 by March 2007 (Figure 1). The percentage of multiple-station events (three stations or more) increased each year—reaching 50% in 2006—although the technical level of these events is higher than that of peer-to-peer connections. When an event has multiple stations, we often use a QualImage/Quatre system (Information Services International-Dentsu, Ltd., Tokyo, Japan) that can integrate four DV signals into one digital image without analog conversion. At the APAN-Manila meeting in January 2007, we connected eight stations in eight countries. The number of events has increased gradually every year (Figure 1), the total number of stations involved in each event has increased more rapidly (14 stations in 2003; 50 in 2004; 59 in 2005; 89 in 2005; 86 between January and March 2007).
Interactive Communication Between Hundreds of Doctors
For effective teleconferencing, we always transmit moving images and voice in both directions, and we use additional transmission to show other images. Usually, the surgeon has a high level of experience with regards to the technique being presented or is using a cutting-edge device. The surgeon can hear and talk to other stations during the procedure if he/she allows it. Thus, we can communicate interactively with the surgeon from remote areas. Another use of transmission of live images is telementoring.
We have transmitted live demonstrations of medical procedures in actual patients to international academic meeting venues. We are able to introduce a procedure to hundreds of specialists in the field in different countries. For example, we connected the venue of the 94th Annual Meeting of the Japanese Urological Association in Fukuoka, Japan, and an operating room at Hanyang University Hospital in Seoul, Korea. We transmitted a live endoscopic urological surgery to the venue, where more than 700 urologists were present. The urologists were able to learn about the procedure and discuss the surgery with doctors and the surgeon at the Korean station.
This project has played two roles with respect to satisfactory growth of the network in the Asia Pacific region. First, it has served as the hub of the telemedical network within the Asia Pacific region. While the project promoted the exchange of medical knowledge only between Japan and Korea in the first year, after our involvement in several APAN meetings, many more Asia Pacific countries have participated in the project. We have already connected 13 countries and a total of 274 stations, and we plan to expand throughout the Asia-Pacific region. Second, it has functioned as the communication center for medical knowledge and network technology. Those in the medical field want to use advanced information and communication technologies for multimedia and high-speed transmission of high-quality moving images to exchange medical knowledge with their colleagues in remote places. However, such contact has either been sporadic or not well integrated.
The online and offline activities of this project function to close the IT gap between the well-served and underserved areas. In the future, we will add other technologies to our system to improve telecommunication efficiency.
For example, we want to facilitate transmission of high definition moving images, and try stereoscopy images and image processing. In conjunction with participation in APAN meetings, we have established a high-quality video transmission system over IP throughout the Asia Pacific region that is easy to use, reliable and economical. This useful system is a promising tool for the standardisation of medical systems and medical procedures in the Asia Pacific region.