The assessment of the degree of organization and the classification of atrial fibrillation (AF) according to the types defined by Wells usually resorts to the visual inspection of bipolar intraatrial electrograms. The focus of this study was to test seven parameters aimed to quantify the degree of organization of the electrograms, and then to design a final classification scheme based on a multidimensional, minimum-distance analysis. The following parameters were tested: mean atrial period (AP) and its coefficient of variation (CV); number of points lying at the baseline (NO) and the Shannon entropy (EN) of the amplitude probability density function (APDF); depolarization width (F-WIDTH); and correlation waveform analysis (CWA) and electrogram bandwidth (BW). The signal database consisted in a set of 160 AF strips of Type I, II, and III AF, scored by an expert cardiologist (60 Type I, 40 Type II, 60 Type III) and further divided in a training set (60) and a test set (100). Strips were 6 seconds long and were recorded with 5-mm interspace bipolar catheters from electrically induced (n = 13) and chronic (n = 10) patients. A classification algorithm based on a minimum-distance (Mahalanobis distance) discriminant analysis was tested. Using a single parameter, the best discriminations were provided by NO, F-WIDTH, and CV. F-WIDTH was found strongly inversely correlated to NO (r = -0.90). Of all the two-parameter combinations, CV-NO provided the best classification: 92 of 100 segments were correctly classified with sensitivity > 90% and specificity > 92%. A further improvement was obtained by including BW as a third parameter (93/100 correctly classified). The use of more than three parameters not only failed to improve, but even degraded the classification.

Telemedicine represents a valid aid in rehabilitation process. A remote therapist in a telerehabilitation program could monitor daily motion activity and assign motion-rehabilitation tools on the basis of the fall risk. However, one problem is detection of the fall risk itself. Web-based video-camera images alone do not help the remote assessment of the fall risk using the most commonly used qualitative tests based on visual observation. A novel wearable system to assess fall risk in telerehabilitation has been proposed based on an Inertial Measurement Unit and a medical protocol. It provides a score in four levels (1: no fall risk; 4: major fall risk). The telemedicine tool is integrated to the Global System for Mobile communication (GSM) net. Each component of the wearable system has been designed and integrated. Each component in the system has been tested individually and in a closed loop. One subject was monitored in a telemedicine link. The test showed a high degree of acceptance. The tool will be furnished to subjects along with a homecare device for daily routine monitoring of motion activity and could eventually be integrated with other systems designed to monitor other physiological parameters along with different aids and monitoring tools.

The remarkable development of telemedicine applications has brought about the need for a telemedicine quality control system to prevent application failures and guarantee users. The aim of this paper was to report on the setup of a quality control system and validate it on a testing set of telemedicine products and services. The quality control system followed two main phases. Phase I was focused on data acquisition and preliminary evaluation of the telemedicine products and services. A classification form and an informative questionnaire were used to gather all the relevant information about the telemedicine application under test. Phase II was focused on evaluation and quality control of the telemedicine product. A Technical File and a Quality Assessment Checklist were used to assess the telemedicine product and service. The telemedicine quality control system was suitable for the efficient evaluation of telemedicine applications. A quality level was assigned to each product according to a threshold and an algorithm. All telemedicine products tested passed the test with a quality level higher than the threshold. The quality control system assured the definition of standardized quality levels for the telemedicine products and services. The study presented in this paper could be useful for promoting the use of standardized telemedicine applications, and therefore speeding up their integration process in the national health service.

Tele-echocardiography could be a useful means for investigating heart pathologies on remotely-located patients. At present, the main drawback with tele-echocardiography is the lack of a thorough protocol for the assessment of the diagnostic accuracy of the transmitted images. Diagnostic accuracy in tele-echocardiography is not only a function of quantitative parameters but also of the subjective decision of the operator depending on his/her a priori knowledge based on complex internal models. In the framework of three Italian projects, we defined and validated a wide-ranging protocol that considers not only the most common quantitative parameters in medical imaging, but also the use of a dynamic phantom, and subjective/partially subjective evaluations. The validation of tele-echocardiography systems chosen from those evaluated in the projects showed that the protocol was feasible. It permitted access to the degradation of the transmitted images and correlate quantitative and subjective analyses. The protocol was found suitable for tele-echocardiography systems but also for other tele-imaging applications, where medical decision making is based on dynamic images.

Because no study has been done so far that fully assesses all the aspects that concur to achieve the quality of telemedicine applications, the authors propose a set of tools and procedures for Telemedicine Quality Control. A set of quality control procedures were developed in order to furnish tools to assess telemedicine products and/or services. The procedures were then submitted to manufacturers of telemedicine applications. An Informative Questionnaire and a Classification Form were specifically designed for maximizing the acquisition of data on the products/services. The other tools, a Technical File and a Quality Assessment Checklist (QACL), were intended to both evaluate and improve the quality of the telemedicine applications. The tools were continuously upgraded according to the manufacturer's suggestions. Because of the synergy that ensued, each tool was designed to cover a wide range of aspects for the evaluation of the telemedicine products and services. Thus, the Informative Questionnaire became the core tool for acquiring the information, whereas the QACL was the core evaluation tool. The proposed tools have been used in an integrated manner, and constitute a full quality control process for the assessment of telemedicine products.

Health Technology Center (HealthTech), a nonprofit research and education organization that develops objective technology forecasts, hosted an expert panel discussion aimed at delineating the future of remote health services (RHS). RHS is defined as involving patient care interactions that are geographically disparate and enabled by telecommunications, information technology, and sensor technology. Key players involved are physicians and nonphysician clinicians, sick or healthy individuals, and their friends or family. An expert panel gathered October 2006, in San Francisco, CA, to respond to the forecasts generated by HealthTech regarding the expected impact of RHS on health care in the next 2 to 5 years and beyond. The panel consisted of a carefully selected group of experts representing diverse viewpoints, and included clinicians, providers, engineers, lawyers, consumer representatives, policy makers, developers, representatives of large employers, academics, and workforce experts. The interaction of the interdisciplinary expert panel produced a number of key implications pertaining to the delivery of RHS and its influence on the healthcare industry. Drivers and barriers to the diffusion of RHS were delineated, and the full potential value of the technology to patients, health delivery systems, and health plans was analyzed in depth. The expert panel provided a plethora of information predicting the future course of RHS and its impact on health delivery. While the complete report and set of forecasts that stems from this research are proprietary, this paper offers a summary of that meeting.

The authors proposed a real-time algorithm to quantify AF organization from multielectrode basket catheter (MBC) recordings. The algorithm is based on a fast method to estimate the number of points along the baseline of a single bipolar electrogram (number of occurrences, NO). They have already proven this parameter to be effective at discriminating AF organization according to Wells' criteria. Special attention has been paid to ventricular far-field artifacts, as they proved they can significantly bias the degree of organization. To fulfill the constraints of a real-time application, a ventricular blanking procedure was implemented and validated. Bipolar electrograms were obtained from MBC in the right atrium in 17 informed patients with chronic AF. The results of NO computations were displayed as three-dimensional color-coded maps of organization by interpolating the measurements obtained at the locations of catheter bipoles. The proposed method allows real-time estimation of the organization of the atrial electrograms according to Wells' criteria. The estimation has a temporal resolution of 2 seconds, is robust to far-field ventricular artifacts, and interpolates the data available to furnish a single global map of the entire atrium. Further studies devoted to the analysis of individual and common patterns of the regional distribution of AF organization are needed to assess the usefulness of this approach for electrophysiological studies and therapeutic applications.

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