183 Teleeducation and telepathology for open and distance education Janusz Szymas Department of Clinical Pathology, Karol Marcinkowski University of Medical Sciences, Przybyszewski Str. 49, 60-355 Poznan, Poland Tel.: +48 61 8691498; E-mail: jszymas@ampat.amu.edu.pl. Our experience in creating and using telepathology system and multimedia database for education is described. This program packet currently works in the Department of Pathol- ogy of University Medical School in Poznan. It is used for self-education, tests, services and for the examinations in pathology, i.e., for dental students and for medical students in terms of self-education and individual examination services. The system is implemented on microcomputers compatible with IBM PC and works in the network system Netware 5.1. Some modules are available through the Internet. The pro- gram packet described here accomplishes the TELEMIC sys- tem for telepathology, ASSISTANT, which is the adminis- trator for the databases, and EXAMINATOR, which is the executive program. The realization of multi-user module al- lows students to work on several working areas, on random be chosen different sets of problems contemporary. The pos- sibility to work in the exercise mode will image files and questions is an attractive way for self-education. The stan- dard format of the notation files enables to elaborate the re- sults by commercial statistic packets in order to estimate the scale of answers and to find correlation between the obtained results. The method of multi-criterion grading excludes un- limited mutual compensation of the criteria, differentiates the importance of particular courses and introduces the quality criteria. The packet is part of the integrated management in- formation system of the department of pathology. Applica- tions for other telepathological systems are presented. Keywords: Telepathology, teleeducation, automated score, teleteaching 1. Introduction Teleeducation is the use of multimedia communi- cation components in teaching, education, and ex- amination at a distance. The most important factors, which have influenced the distance education, were broadband telecommunication links and development of electronic multimedia techniques [5,10,14,15]. The speed of exploring new technical, biological or social information is increasingly combined with the task of shortening the gap between theoretical explo- ration and practical application. The period of transfer- ring the collected information from specialized centers to interested students has to be shortened, and those countries that can provide their students with the lat- est science in the shortest time are in an advantage. In addition, the absolute and relative number of stu- dents is increasing. The more detailed the education, the more specialized teachers are needed, and, consec- utively, the more expensive is the education. Teleedu- cation is an appropriate technical solution fulfilling the needs of economy and essential application [2,11,14, 17]. Education is closely associated with results in sci- entific research. The volume of medical information is constantly growing, being estimated to double every 5 years. As a consequence, an increase in the demand for rapid access to the latest results of scientific research, new therapies, and effects of new medicines to be im- plemented in related education systems is observed. To solve this problem on a continuous basis, it is appropri- ate to develop a system of central medical information that would be accessible to students, trainees, or doc- tors at any time. Such a system should offer access to various sources of information by means of electronic mail or on-line communication [1,6,7,13]. There is the conviction that expanded network sys- tems in medicine will become, apart from the indus- try or service sector, the main force enhancing the de- velopment of digital and broadband telecommunica- tions. Research results of these institutions must be available for medical education immediately. The nat- ural application of teleeducation is the use of video- conferences for transmitting a surgery course or for re- mote access to multimedia databases. In addition, med- ical professionals require continuous education and training to maintain and improve their skills. Applica- tion of teleconferencing can accomplish official train- ing programs from specialized medical centers located Analytical Cellular Pathology 21 (2000) 183–191 ISSN 0921-8912 / $8.00  2000, IOS Press. All rights reserved 184 J. Szymas / Teleeducation and telepathology for open and distance education in large cities to local hospitals, private institutes and homes. It could be used in training of specialized med- ical staff: physicians, nurses and therapists. Patient’s relatives can be trained by observation and interactive guidance to care for the patient at home or in small care units. The appearance of new diseases and outbreaks of epidemics following natural disasters require imme- diate access to information of treatment and methods for adequate examination and prophylaxis. New tech- nologies allow the transfer of knowledge from the most accomplished scientific personalities and lecturers to persons who have never entered a lecture room [2,10]. Without any technical difficulty it is possible to or- ganize telelectures with interactive telecommunication between the teachers and students who could attend the presentation at home. These offerings will alter the world of education and training by specific distributed networks and digitized interactive television sessions. 2. Telepathology The development of computer science and dissem- ination of microcomputers permit the use of the tech- niques of electronic data interchange in all departments of pathology. Production and communication of dig- ital images is now daily used among pathologist in- volved in histopathological diagnosis, for staff meet- ing, for continuous education or for second opinion [7, 10]. Due to decrease in price of the imaging systems, new range of users will have the opportunity to share image information locally, abroad or global. Static- imaging and dynamic-imaging are the two major com- peting technologies of telepathology [10]. Telepathology is the diagnostic work of a patholo- gist at a distance using telecommunication links [10]. It includes specific application fields, which require specific technical solutions. These include frozen sec- tion service, expert consultations, remote control mea- surements, and education and training. Applications effect, all aspects of diagnosis, especially those in- volved in the daily workflow of a pathologist [7]. The image quality, transfer rates, and screen resolution of telepathology systems are sufficient for an additional or primary judgment of histological slides and cyto- logical smears. It is, therefore, possible to include this technique into inter-laboratory quality control of all steps of diagnostic procedures and to use this technique for quality assurance and control [7]. Telepathology is, therefore, not a substitute of conventional diagnos- tic procedures but a real improvement in the world of pathology [6–10]. It is of importance to consider the fact that pathology is a unique scientific specialty, which requires complex and careful testing, comparative studies, and ethic con- trol in new diagnostic strategies. Moreover, there is a need for a rapid exchange of information within the framework of cooperation between various clinics of a particular specialty or specific units of pathology such as neuropathology, dermatopathology, lung pathology, etc. The main relevance of telepathology lies in its ca- pability to link electronically pathologists in remote hospitals to larger or specialized pathology institutes. This may become even more important due to cur- rent increase in sub-specialization and the demand for more precise diagnosis and consultation in diffi- cult cases [10]. A network connecting small clinics or laboratories to larger and more specialized units, and to highly specialized reference centers may im- prove the professional standard of health care ser- vices and education. For a wider use, a technologi- cal standardization will be required, since the exis- tence of several types of computers and numerous im- age manipulation programs have resulted in a prolif- eration of file formats. However, every potential user or client of telepathology should keep in mind, that standardization also includes legal and ethic issues such as patient confidentiality or potential malprac- tice [10]. An adaptation of work guidelines and proto- cols is required. For the transmission of the digitized images from a telemicroscope to the remote diagnos- tic video monitor, different technologies such as or- dinary telephone lines, broadband telecommunications channels, or the Internet can be used. The transmit- ted images may serve for primary pathological diag- nosis, teleconsultation, quality assurance, proficiency tests, or distance learning. Some countries have intro- duced and consequently fund projects for telepathol- ogy for education in pathology as a project of rele- vant national interest. For example, such a project is headed by the Institute of Pathology at the University of Udine, and currently involves additional four Ital- ian universities (Ancona, Bari, Ferrara, Sassari). Such activity will allow collaboration among participating pathological departments and will also boost other medical disciplines, becoming in this way a model which can be adopted for problem-based medical edu- cation [1]. J. Szymas / Teleeducation and telepathology for open and distance education 185 3. The Internet The installed network is based on standard proto- cols and communication tools, with particular atten- tion to the Internet. Both main sets of its protocols, i.e., e-mail and WWW, allow the pathologist easy ac- cess to network resources. The main network activi- ties are: development of collaborative research projects based on telematic tools; creation of multimedia case archives for education and continuous education; col- laborative authoring of multimedia educational mate- rial; quantitative pathology studies, study and applica- tion of telematic methods for quality control in surgi- cal anatomic pathology. The Internet allows a direct interaction and real-time discussion between the stu- dent and the professor at any distance. Increasingly, nearly every field of human knowledge and informa- tion is available on the Internet, often presented in an attractive manner. Telecommunication in science will prepare the field of combined research and might bridge the increasing gaps between the scientists work- ing at the bases in the different specialized research ar- eas such as molecular biology. Relatively inexpensive tools may allow pathologist to increase collaboration, not only in the now traditional telepathology fields such as telediagnosis and remote consultation, but also for educational and quality control aims. Furthermore, every form of collaboration has a secondary effect on continuous education of the students and pathologists. 4. Telepathology as a tool for medical education 4.1. Practical course of Gross Pathology on Web server The information service on Web server can be used for the course of gross pathology with weekly classes during the semester curriculum. Standard technologies like HTML and JavaScript may be used for the in- formation service. As soon as the results of an au- topsy were available, a short clinical description of the case was presented on the pathology’s web site (http:// www.mi.med.uni-goettingen.de/PathologieLehre/) to- gether with a small number of questions guiding the students through the case [6]. These questions were discussed in the subsequent class. The evaluation was carried out with a semistructured questionnaire. The answers were subsequently classified and analyzed by descriptive statistics. The study was performed to de- termine the feasibility of a comparative, objective as- sessment of the learning outcome in users and non- users of the service. With a relatively simple, straight- forward technological approach, a favorable response of the students has been achieved. A majority of the students uses the information service on a regular basis and considers it a useful information source. The tech- nologic and organizational design of the service per- mits a flexible improvement of contents on the basis of the survey results and of the teachers’ experiences. 4.2. Virtual slide as teaching tool A virtual slide is a fully digital representation of the histological specimen by means of a series of static color images (800 × 600 pixels, 24-bit) taken at low (5×), medium (10×, 20×) and high power objective (40×, 63×). The implemented architecture of the sys- tem is constituted of two modules. The first module al- lows the acquisition of images by an automated capture of image of the entire specimen. All images are storage on magnetic or optical devices. In combination with clinical and radiological data a construction of the vir- tual case is possible (Fig. 1). The second module per- mits the examination of the virtual case, and consists of a user-friendly interface. The pathologist can select and visualize all images of interest. The software mod- ules are written in Java. The users interface is based on the TELEMIC system [16]. By viewing a virtual slide, the students can screen the slide at low-magnification, and examine areas of interest at (Fig. 2) higher mag- nification. The student examines the slide similar to a consultant pathologist and renders a remote diagnosis by examining the slide through a robotic microscope. The aim of this tool is to provide the students with case-based information for the practical experiences in pathology and the next higher class is specifically pre- pared for these causes. The students perform the pre- sentation, and the teacher can more effectively focus an differential diagnoses and the diagnostic strategy. 4.3. Continuous education Continuous education in pathology is possibly by and of the international servers dedicated to cooper- ative work and to publish images (Fig. 3) and clin- ical reference databases by a telepathology network. The first step, the cooperation was achieved by def- inition of communication standards as a set of uni- vocally identified high quality JPEG images, a coded data sheet and a clinical document. For this new tools for accessing, communicating and displaying images 186 J. Szymas / Teleeducation and telepathology for open and distance education Fig. 1. Screen of data base of text and image files for the construction of virtual case. Management system is based on MySQL, HTTP and PHP languages. associated with clinical data activity also developed. The intercommunication server allows the exchange of standardized folders through the Internet or ISDN. It also provides archiving facilities. Until now, the inter- communication server – ADICAP server at CRIHAN- ROUEN – is used by 600 pathologists and hematol- ogists through 200 workstations [2]. It allows the ex- change of information for scientific publication and for second opinion service. Three series of publication has been launched: An atlas of pathology, distributed worldwide by the Springer-publishing company, Sémi- naires de Pathologie (mainly yearly French scientific communications distributed through scientific associa- tions) and Tutorial Series. Editing is made by an scien- tific association or by the individual author. The pub- lished volume measures about 1000 folders of ten im- ages per year. 4.4. Multimedia database for self-education and testing A prime concern of evaluation is to monitor the stu- dents’ experiences with the information service, en- abling its continuous and systematic improvement. For evaluation of students’ knowledge most departments use test questions. The test questions have been used in our Department of Pathology for over 25 years to ver- ify the students’ knowledge. They had been collected in a preliminary note and issued some years ago. This edition enclosed 1412 questions [3]. However, it was not in a friendly form for teaching aid, for both the self-education of students and their self-determination. The elaboration included neither the right answer, nor the images. Therefore, the idea emerged to establish a system, managing the multimedia examination ques- tions databases. The program packet was implemented on microcomputers compatible with IBM PC which works under the network system Netware 5.10 (Nov- ell) for 50 users. The software is written in Clipper and Pascal languages. The packet consists of two function- ally individual programs: ASSISTANT, which is the administrator for the databases, and EXAMINATOR, which is the executive program [4]. These two pro- grams are implemented in the technique of pull-down J. Szymas / Teleeducation and telepathology for open and distance education 187 Fig. 2. User’s interface of TELEMIC system for the display of virtual slide with visible area of interest at the higher magnification. menu, message and selection windows. This way it is easier to be operated by inexperienced users. 4.5. System of multi-criterion grading of students When classifying students according to the arith- metic mean of their scores served disadvantages have to be taken into account [12]. The new procedure di- vides students into categories related to the accepted grade scale. This procedure takes into consideration the importance of particular sections and the influence of the assistant in charge of particular course compart- ments. We suggest the division of students into five cat- egories, each consisting of two subcategories. In addi- tion, this procedure qualifies some students beside the multiple-choice exam for an oral exam inactive in or- der to give them a better grade. Exemplary application of this method was tested on a group of 358 dental stu- dents previously graded by “the method of mean” in pathology. The method of multi-criterion grading ex- cludes unlimited mutual compensation of the criteria, differentiates the importance of particular courses, and introduces a quality criterion that was not used before, i.e., the category of person conducting the course sec- tion. It allows to define the group of “questionable” students who should take an additional oral examina- tion in order to be graded properly. Creating and using the system of multi-criterion grading of students in the pathology course is an improvement and given a more objective and flexible time [12]. 5. Examples of the program use This program packet is currently working in the De- partment of Pathology of University Medical School in Poznan. It is used for self-education, tests, services and the examination in pathology, for all dental stu- dents in the Medical Department and for self-education and individual examination services for medical stu- dents. The results together with the notes obtained for their activities in practical classes create the basis to credit particular sections and the final examination. The implementation of this packet with test question set helps to standardize the teaching results in pathol- ogy in Poland. This packet is part of the integrated management information system of the pathology de- partment [13]. 188 J. Szymas / Teleeducation and telepathology for open and distance education Fig. 3. Gallery of microscopic pictures of basic pathology of the central nervous system at the WWW server. 5.1. ASSISTANT The ASSISTANT program creates and defines any database [4]. It enables the import of text files and im- ages, which will be displayed on request. The images are stored in separate files. The program has no restric- tion concerning the image file format because it uses the external-display program. It is also an instrument to understand the database administration, which in- cludes the questions. Regarding the possibility of many thematically different databases, it enables to create a separate configuration for each of them, which is called the project session. This project includes answer mode, the time of answering, number of the question, method of question selection from the base, and masking them. Except these functions, the ASSISTANT program en- ables to review the reports of the sessions that have been hold before and also to prepare the data for statis- tical analysis. 5.2. EXAMINATOR The EXAMINATOR is an executive program cre- ated for self-education or examination of students. The configured file created by the ASSISTANT program is the base of this program operation. This file is invisible to the user. After calling the executive program it starts to work according to the session project which had been created before. The program ask for the name of the student and informs about numerical buttons which may be used by the examined person in order to an- swer the questions. The number of the answer buttons must be in accordance with the number of available an- swers. If a picture is available, picture key is visible in the message line. After every answer, the system in- J. Szymas / Teleeducation and telepathology for open and distance education 189 forms whether the answer is right and indicates the ac- tual percent and numerical answer account of the ex- amined person. The examination ends by display of the examination time and the results. This information is then stored (see also Figs 4–6). 5.3. NOS NOS is software for the above-described system of multi-criterion grading of students [12]. It allows recording and updating personal data from students, their grades from particular course sections and from the final examination. It also allows to store data from previous years in the so-called archives. The main screen consists of three parts: the main menu, which contains basic options, the working part, and the bot- tom line with information about conducted operations. The main menu consists of six commands, i.e., add, find, delete, review or modify the data about assistants into running the courses. The Dentistry command can add, find, delete, review, and modify data of students. The data contain the following fields: credit book num- ber, group, name and surname, assistant, year of stud- ies, choice of exam dates (repeats), and the final grade. The Calculations command allows to perform: Clas- sify and Results. The first one classifies all students from the group processed, the second one allows to search for certain categories. Fig. 4. Beginning of the exam with giving the family and first name. Below the information about conditions of an examination mode established by ASISTANT program is displayed. Fig. 5. Display of summary of final result at the examination end. 190 J. Szymas / Teleeducation and telepathology for open and distance education Fig. 6. Implementation of EXAMINATOR program on the WWW server for self-testing, available through the Internet. NOS co-operates with the database about students, set up in STUDENT [15]. Classifying a student into a proper category is obtained by choosing the com- mand and establishing the access paths to the database and the archives. After typing the credit book num- ber, the monitor displays a window of dialogue with the student’s data and suggested final grade. If the stu- dent is to take an additional oral examination, the grade will be accompanied by the comment: suggested. This grade can be changed later. The procedure also allows to store in a current catalogue only data about students who are not yet classified. Outranking coefficients can be displayed, which may appear helpful in case of doubts about the correctness of classification. 5.4. TELEMIC This telepathology system is based on a fully auto- mated microscope Axioplan2 that is directed by JAVA programs through a standard Internet browser. The re- mote microscope can be is assessed through a web- page on the website (http://mic.amu.edu.pl/). The ma- jor functions include the control of the stage and the control of microscope. The microscope and camera control software was integrated into an Internet server. The server executes these commands, converts the cap- tured images into compressed JPEG image files and distributes these image files to the all connected telemi- croscopy clients. The number of students that can be connected to one microscope server is limited only by capacity of RAM memory. Each function can be con- trolled either by the mouse or the keyboard. The use of the Internet is not a necessity for the telemicroscopy software. The system is used in a local area network (LAN), which connects classrooms with the laboratory of the Pathological Department. Further features of the telemicroscopy system can be seen on the WWW page http://ampat.amu.edu.pl/. 6. Perspectives The major gains in health in the 20th century were primarily the result of improvements in public health including sanitation and immunization. Global health improvements will occur in the 21st century by improvement in information gathering and shar- ing. One way to improve health training and research is to improve the education. One of the most impor- tant aspects is the globalization of education. In the J. Szymas / Teleeducation and telepathology for open and distance education 191 next century transnational training and global lecture- shareware training will be available. Faculties will thus share their best, most passionate multimedia data on the Internet. Quality control systems and statistical quality assurance on the Internet will take place to monitor lectures given by experts all over the world. References [1] V. Della Mea, P. Cataldi, A. Marzola, L. Mariuzzi, G. Mas- sarelli, R. Ricco, M. Scarpelli and C.A. Beltrami, The Ital- ian Network of Telepathology: principles and first results. Ab- stracts. Vth European Congress on Telepathology, Elec. J. Pathol. Histol. 6(2) (2000), No. 002-12. [2] J. Diebold, C. Got, J. Hémet and E. Martin, Continuing Educa- tion and Telepathology. Abstracts. Vth European Congress on Telepathology, Elec. J. Pathol. Histol. 6(2) (2000), No. 002-12. [3] P. Gabryel, J. Szymas, W. Salwa-Zurawska and M. Gawron- ski, Test Questions on Pathomorphology. Part I. Examination Questions, Poznan, 1990 (in Polish). [4] M. Gawronski and J. Szymas, The packet of teaching programs – ASSISTANT and EXAMINATOR version 2.5. Operating in- struction, Poznan, 1992 (in Polish). [5] K. Kayser and C. Kayser, Telepathology – aspects of social in- fluence and quality control, Elec. J. Pathol. Histol. 3(3) (1996), No. 963-04. [6] K. Kayser, G. Kayser and S. Zink, New technical aspects in telepathology, Elec. J. Pathol. Histol. 6(3) (2000), No. 003-04. [7] K. Kayser and G. Kayser, Basic Aspects of and recent de- velopment of telepathology in Europe with specific emphasis on quality assurance, J. Anal. Quant. Cytol. Histol. 21 (1999), 319–328. [8] K. Kayser, Telemedizin, Wiener Klin. Wschr. 108 (1996), 932– 940. [9] K. Kayser, Telepathology in Europe. Its practical use, Arch. Anat. Cytol. Pathol. 43 (1995), 196–199. [10] K. Kayser, J. Szymas and R. Weinstein, Telepathology. Telecommunication, Electronic Education and Publication in Pathology, Springer-Verlag, 1999. [11] F. Leiner and L. Füzesi, Internet-based Support in Medical Ed- ucation: Practical Course of Gross Pathology. Abstracts. Vth European Congress on Telepathology, Elec. J. Pathol. Histol. 6(2) (2000), No. 002-12. [12] R. Slowinski, B. Wolynska, M. Kaczalski and J. Szymas, The method of multi-criterion grading of students in course of pathomorphology. Second National Conference “Computers in Medicine”, 1994, Lodz, pp. 101–106 (in Polish). [13] J. Szymas and R. Dubiel, The integrated management informa- tion system of pathomorphology department, in: IX National Conference of Biocybernetics and Biometrical Engineering. Conference Materials, Vol. II, Gdansk, 1992, pp. 315–318 (in Polish). [14] J. Szymas and M. Gawronski, Multimedia data base and man- agement system for self-education and testing the students’ knowledge on pathomorphology, Pol. J. Pathol. 44 (1993), 183–188. [15] J. Szymas and J. Jelonek, STUDENT – Computer management system for didactic in department of pathology, in: Second National Conference “Computers in Medicine”, Lodz, 1994, pp. 111–116 (in Polish). [16] J. Szymas and G. Wolf, Real-time microscopy through the In- ternet, Elec. J. Pathol. Histol. 4 (1998), No. 983-07. [17] B. Wolynska, M. Kaczalski and J. Szymas, Computerized eval- uation of students’ knowledge in a course of pathology, Elec. J. Pathol. Histol. 6(2) (2000), No. 002-05. 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