Echocardiography is an examination technique that provides images of cardiac and great vessel anatomy and blood flow by means of ultrasound. Although ultrasound may be applied by different techniques and in different forms (M-mode, two-dimensional, spectral and color flow Doppler imaging), all are encompassed in the term echocardiography. While ultrasound appeared to have promise as a screening tool, it later became apparent that its potential benefit was limited by the experience of the physician or technologist performing the examination. In many cases obstetricians, or primary care physicians are not able to analyze a view of the heart and unless they are obvious, many congenital heart diseases remain undetected.

Our goal is to teach medical students, residents and primary care physicians how to read, analyze echo data, and make diagnoses. In our research we explored the way in which we can couple the newest multimedia technology with theories of learning and reasoning. Our teaching support is divided into two sections:

Fetal Echo Expert System (FetEx) a computer based instructional program that includes a step-by-step tutorial, a library of definitions of congenital heart diseases, graphic images, digitized echocardiograms, and an expert system designed to improve consistence and uniformity of diagnosis.

World Wide Web (WWW) Fetal Echocardiography Homepage that contains a library of fetal echo data which can be viewed directly on line or downloaded to a local drive for later use. Since there is a growing collection of material in both preclinical and clinical areas on the World Wide Web this page also contains links to other sources of information on the Internet. The URL (Uniform Resource Locator) for this page is: http://www.med.upenn.edu/~biocbiop/local_pages/wrob_lab/fetex.htm

In the near future we are going apply the hyper-bulletin board exchange (HBBX) technology to make use of this page as a real-time consulting platform, where the image files of JPEG, AVI, or GIF types could be transmitted to an echo specialist for consultation or diagnosis. The homepage is coded in HTML (Hypertext Markup Language) with Java scripts and applets.

Paper:

INTRODUCTION
In the United States about 32,00 babies are born each year with heart defects. Until recently, little could be done for unborn babies suffering from anatomical abnormalities. Now improved diagnostic techniques and better understanding of fetal pathophysiology make therapy for a fetus an option1. To take advantage of this opportunity heart diseases must be detected early enough. The advent of ultrasound has overcome many of the diagnostic limitations of X-ray and has virtually eliminated the need for fetal exposure to ionizing radiation. With these advantages and vast improvements in technology and equipment, the use of ultrasound in obstetric practice has grown rapidly. While it appeared to have promise as a screening tool, it later became apparent that its potential benefit was limited by the experience of the physician or technologist performing the examination. In many cases obstetricians, or primary care physicians are not able to analyze a view of the heart and unless they are obvious, many congenital heart diseases remain undetected. On June 20, 1995 Heidi Evans of the Wall Street Journal, wrote the article entitled ³Doctors Who Perform Fetal Sonograms Often Lack Sufficient Training and Skill². In this article, a prominent Professor of Radiology, Dr. Roy Filly, from the University of California Medical Center in San Francisco stated: ³Sonography is rife with virtually untrained practitioners who are treating this imaging tool like an open cash register drawer².

The goal of this project is to develop a set of computer-based tools for effective teaching of medical students, residents, obstetricians, and primary care physicians how to read, and analyze echo data, to support the process of detection of congenital heart diseases, and make patients that normally would not be referred to a cardiologist, or referred too late, will get there early enough for a diagnosis and possible treatment.

RESULTS
To accomplish this goal we created the Fetal Echo Expert System and Fetal Echocardiography Homepage. Fetal Echo Expert System is a software tool designed to support a process of detection of congenital heart diseases. It includes a step-by step tutorial, a library of congenital heart diseases, graphic images, digitized echocardiograms and an expert system that can support the process of making diagnoses2,3. The subsequent upgraded versions of the program were presented at the American College of Cardiology meetings in Atlanta 1994, New Orleans 1995, Orlando 1996, Anaheim 1997, and at the Radiological Society of North America meeting in Chicago 1994 and in 1996. The abstracts have been published in the Journal of American College of Cardiology4,6,7 and Radiology5. The Fetal Echocardiography Homepage contains a library of cases that can be viewed directly on-line or downloaded to a local drive for later use as a source of reference data. The Fetal Echocardiography Homepage is located at the University of Pennsylvania Medical School web server www.med.upenn.edu (the opening screen is shown in Fig. 2) and the URL (Universal Resource Locator) for this page is:
http://www.med.upenn.edu/~biocbiop/local_pages/wrob_lab/fetex.html

Fig.1 Opening screen of the Fetal Echocardiography Homepage

Fig. 2 Library of Fetal Echo Data

The opening screen for this page is shown in Figure 1. The Library of ultrasound data, as shown in Figure 2, consists of two units containing pictures of a normal, and abnormal fetal heart. The library is in a permanent development. New pictures are being added as we obtain interesting cases. At this moment only static pictures (2D echo, color Doppler, M-mode) are available from the Fetal Echocardiography Homepage, but in the near future we plan to incorporate also whole studies in the AVI format.

Fig. 3 Library of a normal heart pictures

Fig. 4 The library of abnormalities

The list of the normal heart views is shown in Figure 3, and the list of abnormalities in Figure 4. Presented echocardiograms contain the most typical views characteristic of a particular abnormality. For example a four chamber view related to the hypoplastic left heart syndrome (HLHS) is shown in Figure 5.

Fig. 5 Four Chamber View of HLHS

Fig.6 Links to other sites

The Fetal Echocardiography Homepage contains also links to the most important sites dedicated to ultrasound imaging and echocardiography. A list of included links is shown in Figure 6.

The Fetal Echocardiography Homepage was created in August 1996. Since then it has already been referenced in all large WWW databases like Altavista, Yahoo, or Web Crawler as well as in the medical databases dedicated to cardiology and ultrasound like Med Web, Intermedics, Medical Ultrasound Imaging WWW Information and Sites, and many others. Most of cardiology related sites worldwide maintain a link to this page. Since August 5, 1996 when the counter on the page was installed, over 3000 hits have been registered.

REFERENCES
1. Adzick N.S., Ballard R., Crombleholme T.M., Forouzan I., Graham E., Morgan M.A., Rose N. C. Fetal Therapy Saves Lives. PENN Today Vol 6 Number 2, page 9-10 (1996).
2. Wróblewski K.P., Wróblewski P.M., Tian Z.Y., Fetal Echo Expert System, Computers in Healthcare Educational Symposium: The Virtual Medical School, April 24-26, 1996.
3. http://jeffline.tju.edu/CWIS/OAC/hslc/sym96/abstracts/wroblewski.html
4. Wróblewski K, Tian Z.Y., Fetal Echo Expert System, J.Am.Coll.Cardiology 1994, A53
5. Tian Z.Y., Wróblewski K., Fetal Echo Expert System, Radiology 193(P), 480 (1994).
6. Wróblewski K, Tian Z.Y., Multimedia Instructional System for Fetal Echo, J.Am.Coll.Cardiology 1995, 181A (1995).
7. Tian Z.Y., Wróblewski P.M., Wroblewski K, Multimedia system for Fetal Echo Analysis, J.Am.Coll.Cardiology 1996, 9A (1996).