AurisView

ESIA has developed Aurisview, a user-friendly software package to capture and store all the clinical information necessary for an ear consultation. It forms a complete ear and hearing medical record of a patient. AurisView is completely web-based, with all the necessary security and access controls.

There are five major elements:

• Patient information: patient demographics are stored in a database, which can be searched using a simple search function. A list of previous sessions for the patient is shown, together with the type of information stored. 
• Imaging: The live video signal from the video-otoscope is shown on the computer screen in full size. A foot pedal allows the image to be captured, and then displayed as a thumbnail image at the side of the screen. A series of images for each ear can be stored. These can then be reviewed in full size. Images are automatically stored with the patient’s other data, without the need to record image names or folders. Images can be stored on the computer, or on a networked computer. 
• Clinical history: The clinical history is gathered using a pro-forma set of questions relating to ear discharge, hearing, pain, tinnitus and balance. These are automatically stored with the patient’s data. 
• Audiology: pure-tone or screening audiometry can be recorded. Other audiological data can also be stored, such as speech audiometry and tympanometry. 
• Reporting and assessment: Patients can be 'referred' to another clinician: ear specialist, GP, audiologist, speech therapist, etc. Assessment and reports are available as soon as they are completed. Printed reports can be generated as PDFs for printing, or email to a specialist.

Training
The focus of training should be the safe use of the video-otoscope to collect excellent quality images. The training should cover the set up and care of the equipment and the use of the software. Other aspects could be background information on ear anatomy, hearing and hearing loss, diseases of the middle ear and management of middle ear disease.

Case Study A – Kolkata, India
ESIA set up an ear telemedicine system in Kolkata (Calcutta), India in May 2007, in partnership with Calcutta Stations Mission (CSM). CSM provides primary care for people who normally have no access to medical care, as well as formerly homeless children, now cared for in homes such as Loretto School for Girls, and Don Bosco School for Boys.
The equipment consisted of a MedRx video-camera with a firewire camera, AurisView software on a Apple MacBook laptop running Windows XP, and a GSI screening audiometer.
Training was provided by ESIA for CSM staff and volunteers. The equipment is used to screen the children for ear disease. If ear disease was seen, or hearing loss was measured, the children were referred for further attention to an ENT.

Case Study B – Pilbara 
In 2008 a system was set up by the WA Country Health Services in collaboration with the Aboriginal Medical Services in Roebourne and South Hedland. AurisView will be installed on laptop computers. A MedRX video-otoscope with a digital camera was used. Training and support on imaging was be provided by ESIA.

Essential equipment

Video-otoscope: 
A set of good quality images is essential for the assessment of the external ear canal and tympanic membrane. The important factors to consider when selecting a video-otoscope are: image quality, safety, method of focusing, colour balance, depth of field, and the balance of the device with the attached cables when it is held in one hand and versatility for other telemedicine applications. 
Although a large range of devices is available, an investment about approximately US$7,000 to 10,000 is required in a video-otoscope. Our studies show that the MedRx video-otoscope is the most suitable: it produces high quality images, safe to use, has a fixed focus; The battery powered model with a digital (FireWire) video camera requires only one thin cable connection to a computer and no special digitising electronics. 
Other devices also produces very good images, and some inexpensive devices (approx $2000) producing slightly inferior images are available.

Software: 
The primary requirements for the software are that it is easy to use and captures and transmits all the images and data with minimal operator intervention. The imaging functions should allow the operator to concentrate on safe practice and producing good quality images. A foot switch to control the digitising of a series of images can facilitate this. There should be provision for entry and storage of the patient details, a clinical history and other data, such as audiometry and tympanometry results. Compression of the digitised images is advisable to avoid having to transmit and store very large amounts of data. 

Audiometry and tympanometry: 
A screening hearing test and tympanometry are essential in making a diagnoses. A range of suitable devices are available. Training is essential, especially in choosing a suitable space for testing, working with children, safe use of the tympanometer and troubleshooting. 

Research and publications

Image Compression:
For efficient transmission of images, digital image compression is required that does not affect the diagnostic quality of the images. Objective and subjective tests of a series of images showed that images could be compressed to 3% to 5% of original size, while maintaining diagnostic quality.

Eikelboom RH, Mbao M, Atlas MD, Mitchell I, Coates H (2001) Compression of video-otoscope images for tele-otology: A pilot study. Engineering in Medicine and Biology Society, 2001. Proceedings of the 23rd Annual International Conference of the IEEE, 4:3517-3520.

Video-otoscope Selection:
The video-otoscope to be used at the remote site must produce high quality images, and be safe and easy to use. The quality of images produced by five video-otoscopes were objectively tested. A consultative process was used to determine ease of use and safety.
A number of devices based on the rod-telescope optical system produced very good images. A video-otoscope that did not require manual focusing was selected for the system.

Mbao MN, Eikelboom RH, Atlas MD, Gallop M (2003) Evaluation of video-otoscopes suitable for tele-otology, Telemedicine Journal and e-Health, 9(4):325-330.

Validation:
A blinded study was conducted to determine the validity of the system. Assessments of 66 children in a remote site made by conventional means were compared to those made by telemedicine. There was a statistically significant level of agreement between the two methods, and no case of serious ear disease was missed.
Therefore, a system incorporating a set of high quality images, a hearing test and a clinical history enables a reliable method of a telemedicine ear consultation.

Eikelboom RH, Mbao MN, Atlas MD, Coates H, Gallop MA (2005) Validation of tele-otology to diagnose ear disease in children, International Journal of Pediatric Otorhinolayngology, 69(6):739-744.

Training:
Training is an essential element of the implementation of a telemedicine system. A multimedia course was developed to include instruction on ear disease, hearing disorders, tele-otology and safety. Practical components of the course covered the use of the video-otoscope and software.

Dinh Q, Eikelboom RH, Atlas MA, Weber S, Mbao MN, Gallop MA (2003) A tele-otology course as a means of addressing the shortage of primary health care physicians in Aboriginal communities, HIC2003 RACGP12CC Handbook of Abstracts, (eds E Coiera, C Simpson), Health Informatics Society of Australia and Royal Australian College of General Practitioners, 92-93.

Eikelboom RH, Weber S, Atlas MA, Dinh Q, Mbao MN, Gallop MA (2003) A tele-otology course for primary care providers, Journal of Telemedicine and Telecare, 9(3), S19-22.

Other related publications - click here:  

Collaborations:

• WA Country Health Service
• Calcutta Stations Mission (CSM) 
• Meekatharra Hospital
• Sonic Innovations (Australia): Supply of video-otoscopes and audiometry equipment.
• GN-Otometrics, Copenhagen. Denmark.