W. Röckelein, U. Schächinger, S.P. Stieglitz, M. Nerlich
Dept. For Trauma Surgery, University of Regensburg Medical Centre, Germany

Abstract: In the eastern Bavarian area there are two unique projects for medical communication and cooperation. Both the "Telemedicine Network Eastern Bavaria", a lean telemedicine network for teleconsultations and second opinions, and the NOAH project, a wireless communication system linking the on-scene physician with the dispatch centre and the emergency room, are presented and first results are given.


Eastern Bavaria is a rural area usually associated with its deep forests and the national park "Bavarian Forest". Yet it is on the technological frontier with re-gard to communication and cooperation in medicine: The "Telemedicine Network Eastern Bavaria" links all the hospitals in the area and the NOAH project employs a mobile PC with a wireless communication link for the on-scene physician. These achievements are partly due to a unique organisation, the RESCU.

RESCU - Regensburg Emergency Services Centre at the University

RESCU (RZR – "Rettungszentrum Regensburg" in German) is a joint working group of active emergency physicians and paramedics as well as representatives of organisations and public authorities being involved in the emergency care system in the Regensburg area. Its general aim is the improvement of emergency care in eastern Bavaria including neighbour countries.
The integration of all parties involved in the emer-gency  care system and its round table character provides a unique chance to optimise the system, especially through the realisation of innovative concepts and strategies. 21 study groups within RESCU have been established to focus on different topics in the field of emergency medicine, communication and management.
Under the auspices of the RESCU both the Tele-medicine Network Eastern Bavaria and NOAH have been developed and implemented.

Telemedicine Network Eastern Bavaria

Eastern Bavaria has several special structural fea-tures:

a sparse population, a high number of patients per GP and area coverage only through rural hospitals with the Regensburg University Hospital as a medical centre. Therefore close cooperation and communication be-tween the hospitals and the medical centre is necessary. Joint discussions on patient records including X-rays or CT-scans need more sophisticated solutions than the analogue telephone network could provide. The "Tele-medicine Network Eastern Bavaria" is a realisation of a lean telemedicine network using low-cost PC-based standard video conferencing systems as opposed to full-blown tele-radiology systems. It is a closed medical intranet (using TCP/IP and ISDN) for the region of eastern Bavaria. It is used mainly for teleconsultations and second opinions. During a period of 6 months 203 teleconsultations among 15 participants have been evaluated [2]. A total of 697 images were digitised and transmitted. In 95% of the cases these images were considered to be of at least sufficient quality to be able to give advice. In 23% of the cases an immediate video-conference was scheduled. Among other savings, an expensive patient transport could be avoided or re-scheduled (land based instead of helicopter transport) in 14 cases and an express courier could be avoided in 24 cases. Even when a secondary transport was necessary the teleconsultation provided better co-ordination and enhanced planning certainty.

NOAH - Emergency Organisation and Administration Aid

The German Emergency Care System is a rather so-phisticated one, operating in the "Stay and Treat" way. The on-scene physician is well-equipped, the German ambulance car is sometimes dubbed an "intensive-care unit on wheels". However, occasional negative head-lines such as "Emergency Patient Tourism" have provoked a thorough deficit analysis which has revealed two weak points: communication and documentation. The communication system presently used is rather outdated, employing analog voice radio and analog telephone communication [3]. The standardized docu-mentation form [4] is most often filled out incompletely and/or inconsistently or is even missing altogether. NOAH, short for "Notfall Organisations- und Arbeits-Hilfe" intends to address both of these communication and documentation shortcomings. Each on-scene physician is equipped with a mobile PC fitted with a digital radio-modem. The system provides a direct, digital communication channel from the on-scene physician to the emergency physician right from the first vital minutes of the treatment of the emergency patient. It also provides an easy-to-fill-out variant of the paper form mentioned above. The software is developed for a standard PC platform and runs under Windows 3.1 or Windows 95/98/NT.

The PC currently (NOAH II) used is the "FORTÉ Wireless CommPad" ® from Motorola, Israel. It features a backlit VGA-compatible LCD display with a pen-based interface, an internal radio-modem, an exchange-able internal battery providing 4 to 8 hours of operation, a 486DX processor and a vehicle docking station. It is operational in a wide temperature/humidity range and has a shock-proof water-resistant design. A close-up under winter-conditions is shown in figure 1. 

Figure 1: Forte with NOAH in the snow 

Current developments incorporate the computer in the on-scene physicians vest, eliminating the need for an extra item to carry to the emergency scene. The NOAH-Vest employs the Xybernaut MA IV ® . It features a touch-sensitive Flat-Panel-Display on the left sleeve of the vest. The other MA IV’s components are distributed in the vest, making the weight hardly noticable. Another advantage of the Xybernaut computer is that it has enough CPU power for the next additions to the NOAH-System: Voice-Control, transmission of still pictures from the emergency scene and GPS-based location of the on-scene physician in the dispatch center. A typical course of events with the NOAH is as fol-lows. The on-scene physician is alarmed via NOAH and can see the all details of the emergency during the ap-proach. He/She can enter the status codes ("on the move", "arrived at the emergency scene", etc.) with NOAH. During the first minutes of the treatment he/she enters a so called "First Message", which requires only 10 to 15 seconds. This message contains basic informa-tion like sex, age and the injuries of the patient. It helps the dispatch centre (if the on-scene physician desires so) to make an informed recommendation where to bring the patient. This message is also forwarded to the emer-gency room of the destination hospital, where it can help to start appropriate preparations for the patient. When the on-scene physician finds the time he can already bring up the documentation masks and give further information to the emergency room. Results from the first phase are as follows (see [1]). The usage of the NOAH-system is practicable. "First message" information can be fed in less than 15 sec-onds. Practical application of this system has shown a significant improvement in time and in the information content submitted to the destination. The destination hospital is informed of the incoming patient a lot earlier and much more thoroughly (see figure 2). There was an average time saving of 20 minutes in comparison to conventional data transfer.

Figure 2: Information Level at Destination Hospital during Emergency Treatment

NOAH is a joint development effort by the Department for Trauma Surgery of the University Hospital Regensburg, the Department for Business Informatics III of the University of Regensburg and the company Kratzer Communication, Munich under the auspices of the RESCU. NOAH II will be introduced in a broad field trial in the whole region of the dispatch centre Regensburg starting fall 1999.