Abstract
Introduction
According to the World Health Organization, telemedicine is the use of information and communication technologies for purposes of service, education, and research, especially for remote or geographic away areas. 1 –3 Brazil is a country of continental dimensions that has about 61 million inhabitants under 17 years old, 4 and ∼335,000 physicians registered on the Federal Council of Medicine. 5 Of these, about 1.9% are accredited by the Brazilian College of Radiology, 6 and of these, ∼5% have specialized training in pediatric radiology. Thus, the use of information and communication technology for education, actualization, collaborative research, and second opinions provides national integration, as well as connections with international excellence centers.
The Brazilian Federal Government created two telehealth programs with national coverage. The Telemedicine University Network, 7 by the Science and Technology Ministry, is an Internet network dedicated to health that connects public university hospitals, with possibility of international connections. The Brazilian E-Health Program, by the Health Ministry, implements e-health networks and connects health professionals of remote municipalities with university hospitals. In this national network, different working groups have been created; among these, the pediatric radiology group has the highest coverage in teleradiology. 8
This article aims to show the experience gained over 5 years with the Brazilian Pediatric Teleradiology Program in the use of teleconferencing and a virtual learning environment for continuing medical education, integration of services, and collaborative research.
Materials and Methods
From March 2005 to October 2010, virtual meetings were monthly held by teleconference for anatomical–clinical–radiological sessions and hot topics lessons, with general physicians, pediatricians, general and pediatric radiologists, and graduate and postgraduate medical students as the target audience.
Teleconferences included simultaneous videoconference and Web conference technologies. The videoconferencing system uses a multipoint control unit (MCU), a gatekeeper and a codec (Tandberg 6000 MXP; Cisco, San Jose, CA) to connect the University Hospitals by using the backbone, funded by the Brazilian Government. This MCU is responsible for managing multipoint conferences, and at the endpoints, a Tandberg 6000 MXP Codec integrator provides all the necessary components needed to simplify custom integrations, which use a customers' access into the protocol H.323 (a standard for codification and decoding of the flow of audio and video data). To make use of a virtual room at MCU, a minimum demanded speed of 2GB is requested and it is necessary that the endpoints are registered in a gatekeeper, a component that controls admission and also authorizes the incoming calls. In the Telehealth's Center, at the University Hospital Pedro Ernesto of the State University of Rio de Janeiro, the endpoint is linked to a work station with a Web server that transmits the videoconference's audio and video to remote points with minimum demanded speed requested of 256 kilobits per second (Kbps). The management Web software used was Adobe Connect Pro (Burlington, NJ), installed in a Dell server, Windows Server 2008, Intel Xeon Processor E5450, 3 GHz, and a random access memory of 4GB. The combination of both technologies was made through the capture of the audio using a soundboard and also of the codec video using a capture card that are sent to a workstation and distributed to the points connected to the Web conference. Remote access to the Web conference was made through a Web browser that will demand only a plugin, whose installation is going to be required at the first access to a virtual room of the Web conference.
In videoconferencing all the participants could interact orally like face to face, and by Web conferencing the remote participants could send questions and comments using a chat feature. All the lecturers' presentations used Microsoft Office PowerPoint software. The use of videos and animations was not allowed by the association of both technologies. The teleconferencing system is demonstrated below (Fig. 1).
Summary of the teleconferencing system.
In 2008, a virtual learning environment was implemented, using an open-source software (Moodle; Martins Dougiamas, Perth, Australia). This allowed asynchronous integration between the participants and reuse of all teleconferences, which were recorded, as well as other educational materials produced and used by the program. For the anatomical–clinical–radiological sessions, for example, the methodology included previous release of the monthly cases; discussion forums among the groups; and after the teleconference, the release of the recorded teleconference and references as well as reopening the forums for further discussion when necessary.
The program has the accreditation of the Brazilian College of Radiology and is supported by the Telehealth Center of the State University of Rio de Janeiro.
Results
In total, 58 teleconferences were held, consisting of 29 anatomical–clinical–radiological sessions; 28 lectures, of which 6 were taught by foreign teachers located in Canada (2), the United States (2), Germany (1), and Chile (1); and 1 interactive virtual symposium. The average number of synchronously connected points by videconferencing was 12, with 39 by Web conferencing, and an average of 450 participants in each event. Altogether, including synchronous participation in teleconferences and asynchronous participation in the virtual learning environment, 27 institutions in 14 Brazilian states and nine instituitions in other countries have participated in the program.
Fifty-five percent of the anatomical–clinical–radiological sessions were of abdominal cases, 35% of thoracic themes, and 10% of neural tumors. Abdominal themes provoked more questions from the participants, more frequently about tumor cases. Of thoracic themes, tuberculosis (80%) and lymphoma (20%) were the problems involved. The teaching themes with research included MRI of neural lesions (90%) more frequently, followed by new image protocols for pediatric radiation protection. The participation from other countries was more significant in these themes.
At this writing, 318 users are registered in the virtual learning environment, with a total of 14,678 accessions to the site (
In September 2010, the first Virtual Synchronous Symposium in Pediatric Radiology occurred, with the principal topics of children's urinary infections and bladder dysfunction. It included South American and Caribbean participants and was 5 h long.
Discussion
For the radiology specialist, regular education is among the three main professional pillars, together with service and research. Telemedicine is bringing great paradigm changes in the context of these pillars, especially with increasing access to the Internet, although there are still some questions, such as norms and ethics. 2,9 –16 For distance education, advantages include expanded coverage and reduced costs and displacement. In addition, professional recertification is facilitated and physicians' interest in participating in such events increases. 17 –22
In teleradiology, some articles dedicated to continuing medical education have been published; some used filing systems and provided images as a source of information and consultation 23 –26 ; others recorded classes to be reused. 27 –29
This article presents the Brazilian experience in the combination of videoconference and Web conference to real-time interactive sessions and in the use of a virtual learning environment in association, allowing reuse of the content, a theme we did not find in related publications in radiology. This innovative distance learning initiative has demonstrated the feasibility of improvement in training staff in pediatric radiology as well as in training technical teams to provide support using different technologies for teleconferencing and in the use of a virtual learning environment. Further, the program experience, gained in 5 years, has shown a new approach in integrating services and developing collaborative research between medical and technological teams. The educational methodologies chosen allow people in different locations to connect simultaneously, with the possibility to have questions and comments from all the participants, and the recorded session allows a reuse of the produced material at any time.
Some authors 30,31 have published studies about the use of isolated technologies in teleconferencing in radiology case discussion with positive assessment from the participants, but with audio and images problems reported, probably, due to limitations in connectivity. This work demonstrates the impact and coverage of teleconferencing use in a country of continental dimension like Brazil that includes public university hospitals, municipal health centers and excellence centers in other countries, without presenting significant problems in meeting quality. Although we did not apply any formal request evaluating audio or image quality, we did not have any complaint from the locals' coordinators, probably because of the support given by government projects in providing telemedicine-dedicated networks. On the other hand, participation by voice and image via videoconference, and by chat via Web conference, allowed all users to feel truly included in the sessions.
In addition, the use of a virtual learning environment allows the continuation of events with positive results like those obtained by Sparacia et al.,
32
who evaluated two educational projects in radiology using virtual learning environments. One project was NeuroRAD, a virtual learning comunity in neuroradiology, which used Moodle as a platform, and the other project was PediatricEducation.org, a library and a virtual learning comunity in pediatrics whose content is developed by a pediatrician and a pediatric radiologist. It uses Manila (Danville, CA), a paid software platform. In 1 year, NeuroRAD provided two courses and 18 recorded lessons, 20 review articles, and 37 clinical cases. They experienced 9,959 accesses, with an average of 5 min and 32 s spent per visit. In that year, 152 people registered to participate in the courses, but only 83 completed them. In PediatricEducation.org, a case was added per week and at the time of the study publication, 20 cases involving pediatric radiology were available. Accesses were 9,100, with an average of 1 min and 35 s spent per visit. In the year under analysis, 475 individuals were registered in the community. The average user permanence time at our program's site was estimated at 45 min, significantly higher than theirs, possibly because our users mostly watched recorded teleconferences. NeuroRAD and
In this Brazilian program, the greatest advantage of the association of a virtual learning environment with the teleconferences was the possibility for graduating students, residents, fellows, and even pediatricians, especially those located at isolated regions, to reuse the educational materials produced and used by the program, besides the possibility to access the release of the case discussion before the anatomical–clinical–radiological sessions.
This positive experience has been cited by other authors 33 as an educational experience in a television program format for conventional and Internet broadcast. That article described that the Web site received 2,378 accesses to programs with recorded conferences between October 2007 and December 2009. Those accesses were not included in this article because of the impossibility of users' quality assessment in this type of format. Further, this format of educational material providing was discontinued to comply with a Federal Medical Council resolution.
International Radiology Societies are increasingly incorporating technology for continuing education and recertification, 34 –37 but with only radiologists as the target audience, and with costs, even if implicit. This program has the distinction of uniting the content displayed in recorded live teleconferences in a virtual learning environment, without costs since it is funded by the Brazilian government and is available for all physicians who have interest in pediatric radiology.
Conclusions
The association of teleconference technologies with a virtual learning environment has demonstrated the feasibility to improvements in training staff in pediatric radiology even in isolated regions.
Footnotes
Disclosure Statement
No competing financial interests exist.