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    • Clinical Applications - Diagnostic Services *I2, *II3, *III6B 1. Pettersson, H. and Holmer, N. G. (Department of Diagnostic Radiology, Lund University Hospital, County of Malmohus, Sweden. Teleradiology in southern Sweden--a tool for reorganization of health care and for education. Computer Methods & Programs in Biomedicine. 1998 Aug-1998 Sep 30; 57(1-2):13-9. Call Number: *I2, *II3, *III6B Abstract: The county organization, including health care, is reorganized in the province of Scania in southern Sweden. As part of the restructuring of health care, a program for digitalization of the departments of diagnostic imaging, as well as for teleradiology, has been set up. Standards for network, radiology information systems, and workstations have been settled, and teleradiology links both for on-call consultations and for on-line consultations day-time have been implemented, mainly running at 10 Mb/s. Further digitalization and implementation of teleradiology is planned for the nearest years. Parallel to this, a video conference system including several disciplines, hospitals and health care levels in the whole of southern Sweden has been implemented. The links are now also used for education, both in the province and internationally *I 2, *III 6 A, III 6 B* 1. Giovas, P.; Papadoyannis, D.; Thomakos, D.; Papazachos, G.; Rallidis, M.; Soulis, D.; Stamatopoulos, C.; Mavrogeni, S., and Katsilambros, N. (1st Department of Propaedeutic Medicine, Athens University School of Medicine, Greece.). Transmission of electrocardiograms from a moving ambulance. Journal of Telemedicine & Telecare 1998;4 Suppl 1:5-7. ISSN: 1357-633X. Call Number: *I 2, *III 6 A, III 6 B* Abstract: Delay is the enemy for patients with acute myocardial infarction. It would be helpful for the hospital cardiologist to interpret the patient's electrocardiogram (ECG) before the arrival of the ambulance. The aim of our study was to determine whether ECG transmission from an ambulance is feasible and to assess the time savings. An ambulance was equipped with an ECG recorder, which was connected to a notebook computer and coupled to a cellular telephone for transmission to a hospital-based station. Paramedics needed 2 min (SD 0.5) to record the ECG on the move and 34 s (SD 14) to transmit it. The ambulance arrived 15.5 min (SD 6.5) after reception. The time between arrival and ECG diagnosis, for a control group patient, was approximately 9.5 min (SD 3.5). Therefore, pre-hospital ECG diagnosis took place 25 min (SD 7.5) before in-hospital diagnosis. We conclude that ECG transmission from a moving ambulance is feasible, reduces in-hospital delays and allows faster triage in critical cardiac cases. *II 3, *II 5, *III 6 B 1. Bonnin, A. (Service de Radiologie A, Groupe hospitalier Cochin, Paris). [Medical tele-imaging: a good chance for the future]. [French]. Bulletin De l Academie Nationale De Medecine. 1999; 183(6):1123-34; discussion 1134-6. Call Number: *II 3, *II 5, *III 6 B Abstract: Tele-imaging is an important part of telemedicine: it includes the transmission of medical digital images and plays a role in all fields of telemedicine, such as expertise, consultation, teaching and research. Tele-imaging has been made possible through the digitalization of medical imaging. There are two possibilities: either digitalization of conventional radiological film or direct acquisition of digital images. The transmission of medical imaging requires a high data rate so as to obtain a good quality transmission of the initial images in a reasonable delay. In order to deal with the great amount of information to be stocked and transmitted, a compression of the data, without loss of information, is usually necessary. Interactivity is very important in all these types of transmissions. These tele-transmission techniques are already used world wide, especially in Japan and in the United States, to help in therapeutic or diagnostic decisions. In France, we have been performing real time interactive tele-imaging sessions between radiology and endocrinology 1
    • departments of Hotel Dieu in Montreal and Hopital Cochin in Paris. This experimental device includes a visual-conference link between the medical teams and a real time link between two CT scanners. The CT scanner slices appear simultaneously both CT scanner screens; it is even possible to guide a CT scanner examination using remote control from the other hospital. We have successfully repeated the experiment between Cochin and a private hospital in Paris. In the case of the "Prison de la Sante", we have been using telemedicine in order to reduce problematic transfers of prison inmates. Moreover, access to doctors in the prison is sometimes difficult. The system ensures the daily transmission of X-rays, which are immediately read by radiologists at Cochin. In the past, 50 to 70 X-rays had to be read during one weekly visit. Medical tele-imaging raises certain legal, ethical and economic issues, such as problems concerning confidentiality, the right to compensation, patient information. It would be interesting in this context to open a discussion on the possible dangers of telemedicine, its value for the patients and the physicians, its role in emergency care, and the possibility of creating imaging data storage that may help radiologists in making diagnoses, especially for unusual images. Drawbacks not to be ignored: Poor digital images could lead to difficulties in their reading and interpretation. There is still a debate as to whether tele-diagnosis is reliable or not. Further evaluations must be made to as certain the effectiveness of these techniques. A certain dehumanization of medicine due to an increase in the distance between the physician and patient is another difficult issue. The great number of people involved in the process of tele-imaging could confuse the issue of determining individual responsibility. Such consultations of experts may reduce the freedom of patients to choose their doctor. Tele-consultation must not be performed without the patient's consent. If consent was not obtained before tele-transmission, the patient should be informed after the procedure; and the use of tele-consultation should be mentioned in the report. The utilization of public networks could lead to the manipulation of data as well as undermine confidentiality. These pitfalls must be avoided. Lastly, the financial ramifications of these new technologies must not be overlooked *II 3, *II 6 A, *III 6 B 1. Landwehr, J. B. Jr; Zador, I. E.; Wolfe, H. M.; Dombrowski, M. P., and Treadwell, M. C. (Division of Maternal-Fetal Medicine, Hutzel Hospital/Wayne State University, Detroit, Michigan, USA.). Telemedicine and fetal ultrasonography: assessment of technical performance and clinical feasibility. American Journal of Obstetrics & Gynecology. 1997 Oct; 177(4). CODEN: 846-8; ISSN: 0002-9378. Call Number: *II 3, *II 6 A, *III 6 B Abstract: OBJECTIVE: Our aim was to determine the performance and clinical feasibility of telesonography for the interpretation of fetal anatomic scans sent from a remote location compared with those obtained at a tertiary care prenatal ultrasonography center. STUDY DESIGN: Routine ultrasonographic studies from 35 patients were remotely interpreted. Evaluation included a blinded comparison of the sonographer's assessment of 38 fetal structures with that of the physician at the tertiary care center. Technical evaluation included system reliability and the number of digital telephone lines required for adequate real-time visualization. RESULTS: The mean gestational age at the time of the ultrasonography was 25.84 +/- 6.8 weeks (range 14 to 38). There was complete consistency of interpretation for 25 of 38 (66%) fetal structures. Thirteen structures had discrepancies in visualization, reflecting a difference in the adequacy of visualization, not the normalcy or identity of the structures. Three digital (integrated switching digital network, ISDN) telephone lines were required for real-time visualization. CONCLUSION: Our preliminary experience supports telesonography as a clinically useful tool for remote interpretation of fetal ultrasonographic examinations. Further studies are warranted for the continued evaluation of this emerging technology. *II 3 *III 6B 1. Johansen, I. [Experiences with teleradiology in general practice in Oppland]. [Norwegian]. Tidsskrift for Den Norske Laegeforening. 2000 Jun 20; 120(16):1896-8. Call Number: *II 3, *III 6B Abstract: BACKGROUND: Our aim was to evaluate one year of operation of a newly established 2
    • teleradiology service for people in Mid- and North Gudbrandsdalen (30,000 inhabitants). In Otta, one radiographer works with digital pictures (phosphorus plate technology). Pictures are sent to the local hospital in Lillehammer (115 kilometres away) by a broadband network (for health services only) for radiological evaluation. MATERIAL AND METHODS: We have measured the scope of the service, patient satisfaction, management stability and efficiency, and financial aspects (the latter are not included in this article). RESULTS: Over one year we have examined 3,081 persons (skeleton, thorax, sinuses). A majority of patients (90%) thought it was better for them to be examined at Otta. Waiting time was short, rarely more than one week. No re-examinations due to insufficient picture quality were required. Some expected and some unexpected problems occurred. Pictures from 37 patients were lost and could not be radiologically evaluated. The lead time from when pictures were taken to when the requisitioning doctor received the report, was too long (one to three weeks). The digital pictures are not easily available to hospital physicians. Copies must be made on film. INTERPRETATION: Our experience is positive. Most problems will be solved by storing copies at Otta, by better organisation of the radiologic service, and by establishing a digital picture archiving and communication system (PACS) at the hospital 2. Strickland, N. H. (Hammersmith Hospital Department of Imaging, Imperial College of Science, Technology and Medicine, London, UK). [The filmless hospital: 3-year experience at the Hammersmith Hospital, London]. [French]. Bulletin De l Academie Nationale De Medecine. 1999; 183(8):1615-23; discussion 1624-5. Call Number: *II 3 *III 6B Abstract: A hospital-wide PACS (Picture Archiving and Communication System) is a computerised electronic system which entirely replaces conventional x-ray film by acquiring, archiving, transmitting and displaying digital images on a network of workstations throughout the hospital. Such a system has been operating without film for 3 years now at Hammersmith Hospital, London. PACS has a number of advantages over conventional films. These include time savings, reliability of the system, space savings, economies in consumables and personnel, reduced patient irradiation, efficiency of data management, accessibility of images and teaching benefits. The disadvantages of PACS are: its cost, the need for specialised personnel for its installation and maintenance, training of users, the possibility of breakdown, and data security issues. PACS has altered the work patterns of all its users, including non-radiologist clinicians, radiologists and radiographers. PACS is a step on the way to achieving the future objectives of teleradiology and the complete electronic patient record *II 3, *III 6 A, *III 6 B 1. Phillips, C. M.; Burke, W. A.; Allen, M. H.; Stone, D., and Wilson, J. L. (Section of Dermatology, East Carolina University School of Medicine, Greenville, NC, USA.). Reliability of telemedicine in evaluating skin tumors. Telemedicine Journal. 1998 Spring; 4(1). CODEN: 5-9; ISSN: 1078-3024. Call Number: *II 3, *III 6 A, *III 6 B Abstract: OBJECTIVES: To determine the reliability of videoconferencing technology in evaluating skin tumors, the impact of the technology on the clinicians' degree of suspicion that a skin tumor is malignant, and the recommendation to do a biopsy. MATERIALS AND METHODS: Four skin cancer screenings were conducted at rural health care facilities in eastern North Carolina that were connected to East Carolina University School of Medicine. A dermatologist saw the patients in person at the local facility, and the same patient was seen by a dermatologist via a T-1 connection to Greenville, North Carolina. RESULTS: The two physicians were in absolute agreement on 59% of the 107 skin tumors evaluated. There were five lesions identified by the on-site dermatologist as a probable or definite malignancy. The degree of concern about a lesion being malignant and the decision whether to do a biopsy were not significantly different, as shown by kappa analysis. CONCLUSION: The concern about the malignancy of a particular skin lesion and the recommendation whether to do a biopsy were not significantly affected by telemedicine technology. *II 3, *III 6 B 1. Adeyinka, M. (Instituut Voor Telemedische Applicaties, Laboratorium Voor Biomedische Informatica, The 3
    • Netherlands. Telepathological (image transmission) configuration. Journal of Telemedicine & Telecare 1996;2 Suppl 1:21-4. ISSN: 1357-633X. Call Number: *II 3, *III 6 B Abstract: The Laboratory for Biomedical Informatics (LBMI) has developed a digital microscope control module incorporated into an image analysis system. This is now equipped with an ISDN switch box for linking up with a remote computer-based station for delivering histopathological services. The FRAME, client/server integrated software, was developed to initiate the communication link, adjust the microscope settings, acquire and transmit images. This LBMI telepathology initiative employs simple solutions to arrive at the point of prototyping and demonstrating the state of the art on the one hand and encountering the prevailing problems in order to deliberate on possible remedies on the other. 2. Davis, M. C. (Med-Tel International Corporation, McLean, VA 22102, USA.). MR teleradiology network serving remote imaging centers. Journal of Digital Imaging. 1998 Aug; 11(3 Suppl 1). CODEN: 88-92; ISSN: 0897-1889. Call Number: *II 3, *III 6 B Abstract: The operational experience of a commercial teleradiology practice utilizing a wide-area ISDN network linking six imaging centers located in two states will be reviewed. Open magnet designs were chosen to complement existing high-field units available in each community. Image data was first acquired than transmitted without compression at 128 Kbytes/s to a central reading site located in McLean, Virginia for interpretation by a team of radiologists. Average transmission time was 6-8 minutes. System design allows optimal utilization of radiologists expertise in imaging interpretation while reserving the on-site patient management responsibilities such as gadolinium contrast injections and sedation to a nonradiologists physician and/or nurse practitioner. Over 15,000 teleradiology readings have been rendered via this network by January 1998. 3. Doolittle, M. H.; Doolittle, K. W.; Winkelman, Z., and Weinberg, D. S. (Department of Biomedical Engineering, University of North Carolina School of Medicine, Chapel Hill, USA.). Color images in telepathology: how many colors do we need?. Human Pathology. 1997 Jan; 28(1). CODEN: 36-41; ISSN: 0046-8177. Call Number: *II 3, *III 6 B Abstract: It is generally assumed that for telepathology, accurate depiction of microscopic images requires the use of "true color" (ie, 24 bits, eight bits each for red, green, and blue) in the digitized image used for transmission. If such a 24-bit color image file, which provides a palette of 16.7 million colors, could be reduced in size by decreasing the possible numbers of colors displayed in the image to 8 bits (palette of 256 colors), the image files would require less storage space, could be transmitted more rapidly, and would require less telecommunications bandwidth. However, such color reduction must not result in detectable image degradation, especially if the images are to be used for diagnosis. Therefore, we performed a carefully controlled study to determine whether pathologists could detect differences in the quality of microscopic images that were reduced from 24 to 8 bits of color. Thirty pathologists were each asked to view a set of 30 image pairs displayed on a computer monitor. Each image pair consisted of the original 24-bit color version and an 8-bit color- reduced version, derived using an adaptive color reduction algorithm with diffusion dithering. Observers were asked whether they could detect any difference in quality between the image pairs. Then, regardless of their answer, they were asked to choose the better quality image of the pair. Overall, there was not a statistically significant ability to consciously detect differences between the image pairs (P < .750). However, when forced to choose, there was a significant preference for the 8-bit images as being of "better quality" (P < .005). We conclude that telepathology applications may be able to take advantage of adaptive color reduction algorithms to reduce image file size without sacrificing image quality. Additional studies must be performed to determine the minimal image requirements for accurate diagnosis by telepatholgy. 4. Franken, E. A. Jr; Berbaum, K. S.; Brandser, E. A.; D'Alessandro, M. P.; Schweiger, G. D., and Smith, W. L. (Department of Radiology, University of Iowa College of Medicine, Iowa City 52242, USA.). Pediatric radiology at a rural hospital: value of teleradiology and subspecialty consultation. AJR. 4
    • American Journal of Roentgenology. 1997 May; 168(5). CODEN: 1349-52; ISSN: 0361-803X. Call Number: *II 3, *III 6 B Abstract: OBJECTIVE: We performed a field study and subsequent laboratory investigation of pediatric radiology at a small rural hospital. Our investigation had three components: to describe the characteristics of pediatric radiology in a rural primary care facility, to test the diagnostic accuracy of interpretation of pediatric images transmitted by teleradiology, and to compare relative diagnostic accuracy of general and pediatric radiologists who interpreted pediatric images at a rural institution. MATERIALS AND METHODS: All 196 pediatric radiographs obtained during a 4-month period comprised the database from which we determined practice characteristics. Reports of 153 unselected cases interpreted by general radiologists using teleradiology were compared with interpretation of the same cases by a pediatric radiologist who interpreted the original radiographs. Discrepant cases were further investigated by a receiver-operating-characteristic curve experiment in which general and pediatric radiologists interpreted each case twice: once viewing teleradiologic images and once viewing the original radiographs at another setting. We then compared interpretive accuracy of observers and techniques. RESULTS: The pediatric radiographs were predominantly simple examinations for common acute disease, particularly pneumonia and fractures. Discrepancies of interpretation between teleradiology and original radiographs, which occurred in 13% of images, showed no significant difference in accuracy of interpretation for either teleradiologic images or original radiographs. Likewise, we found no significant advantage for accuracy of interpretation by general or pediatric radiologists. Receiver-operating-characteristic analysis of 18 discrepant cases showed slightly increased accuracy for interpretation of original radiographs by pediatric subspecialists. CONCLUSION: Simple pediatric radiographs obtained at a rural primary care institution and transmitted by teleradiology can be adequately interpreted by general radiologists. 5. Frey, G. D. and Spicer, K. M. (Department of Radiology, Medical University of South Carolina, Charleston 29425, USA). Teleradiology: technology and practice. Journal of Digital Imaging. 1999 May; 12(2 Suppl 1):226-7. Call Number: *II 3, *III 6 B Abstract: Teleradiology increases the ability of radiologists to provide service to remote and underserved locations as well as coverage at times when direct reading of images is not possible. Good practices for teleradiology are described in the American College of Radiology (ACR) teleradiology standard. Teleradiology equipment is converging with picture archiving and communications systems (PACS) equipment so that diagnostic interpretation from remote locations is possible. Image capture can be directly from digital modalities or by film scanner. Transmission speed is still an issue. High transmission speeds were difficult to achieve but recent improvements may increase speeds and decrease costs 6. Furness, P. N. (University of Leicester, Department of Pathology, Leicester General Hospital, U.K. The use of digital images in pathology. [Review] [16 refs]. Journal of Pathology. 1997 Nov; 183(3). CODEN: 253-63; ISSN: 0022-3417. Call Number: *II 3, *III 6 B Abstract: Digital images are routinely used by the publishing industry, but most diagnostic pathologists are unfamiliar with the technology and its possibilities. This review aims to explain the basic principles of digital image acquisition, storage, manipulation and use, and the possibilities provided not only in research, but also in teaching and in routine diagnostic pathology. Images of natural objects are usually expressed digitally as 'bitmaps'--rectilinear arrays of small dots. The size of each dot can vary, but so can its information content in terms, for example, of colour, greyscale or opacity. Various file formats and compression algorithms are available. Video cameras connected to microscopes are familiar to most pathologists; video images can be converted directly to a digital form by a suitably equipped computer. Digital cameras and scanners are alternative acquisition tools of relevance to pathologists. Once acquired, a digital image can easily be subjected to the digital equivalent of any conventional darkroom manipulation and modern software allows much more flexibility, to such an extent that a new tool for scientific fraud has been created. For research, image enhancement and analysis is an increasingly powerful and affordable tool. Morphometric measurements are, after many predictions, at last beginning to be part of the toolkit of the diagnostic pathologist. In teaching, the potential to create dramatic yet informative presentations is 5
    • demonstrated daily by the publishing industry; such methods are readily applicable to the classroom. The combination of digital images and the Internet raises many possibilities; for example, instead of seeking one expert diagnostic opinion, one could simultaneously seek the opinion of many, all around the globe. It is inevitable that in the coming years the use of digital images will spread from the laboratory to the medical curriculum and to the whole of diagnostic pathology. [References: 16] 7. Halliday, B. E.; Bhattacharyya, A. K.; Graham, A. R.; Davis, J. R.; Leavitt, S. A.; Nagle, R. B.; McLaughlin, W. J.; Rivas, R. A.; Martinez, R.; Krupinski, E. A., and Weinstein, R. S. (Department of Pathology, The University of Arizona, Tuscon 85724, USA.). Diagnostic accuracy of an international static- imaging telepathology consultation service. Human Pathology. 1997 Jan; 28(1). CODEN: 17-21; ISSN: 0046-8177. Call Number: *II 3, *III 6 B Abstract: Static-image and dynamic- (real-time) image telepathology are competing technologies. Although some studies suggest that the diagnostic accuracy of the dynamic-image telepathology approaches the accuracy of light microscopy, few reports have documented the diagnostic accuracy of static-image telepathology as used in the setting of an actual surgical pathology consultation practice. We report the results of an analysis of 171 telepathology consultation cases submitted to the Arizona-International Telemedicine Network (AITN). Digital images were submitted by pathologists from six participating institutions in Arizona, Mexico, and China. Telepathologists could render a telepathology diagnosis (TP) or defer rendering a diagnosis to obtain additional video images, glass slides for detailed analysis, or to obtain tissue blocks for special studies such as immunohistochemistry. The telepathologists rendered diagnoses for 144 cases and deferred 27 cases. Two pathologists retrospectively evaluated-glass slides from each case and rendered a consensus glass slide (GS) "truth" diagnosis. There was 88.2% concordance between TP and GS diagnoses (127 of 144 diagnoses). Concordance of 96.5% was achieved for clinically important diagnoses (139 of 144 diagnoses). Telepathologists deferred making a diagnosis to obtain glass slides for conventional light microscopy in 14 cases (8.1%) and for results of immunohistochemistry studies in 13 cases (7.6%). Thus, correct diagnoses were rendered by static-image telepathology in 127 of 171 cases (74.3%) at the time of telepathology diagnostic sessions. Inappropriate field selection and sampling biases of referring pathologists, as well as a tendency of static-image telepathologists to underestimate the complexity of some cases, may reduce the value of consultations based on the viewing of static images. 8. Kovalerchuk, B.; Ruiz, J.; Vityaev, E., and Fisher, S. (Department of Computer Science, Central Washington University, Ellensburg 98926-7520, USA.). Prototype Internet consultation system for radiologists. Journal of Digital Imaging. 1998 Aug; 11(3 Suppl 1). CODEN: 22-6; ISSN: 0897-1889. Call Number: *II 3, *III 6 B Abstract: The overall purpose of this study is to develop a prototype radiological consultation system. We concentrate our work on prototype software environment for the system. The system provides a second diagnostic opinion based on similar cases, incorporating the experience of radiologists, their diagnostic rules and a database of previous cases. The system allows a radiologist to enter the description of a particular case using the lexicon such as BI-RADS of American College of Radiology and retrieve the second diagnostic opinion (probable diagnosis) for a given case. The system also allows a radiologist to get other important information too. These advances are based on a new computational intelligence technique and first-order logic. We implemented a rule-based prototype diagnostic system. Two experimental Internet versions are currently available on the web and are under testing and evaluation of design. The diagnosis is based on the opinions of radiologists in combination with the statistically significant diagnostic rules extracted from the available database. 9. Mistak, E. J.; Loushine, R. J.; Primack, P. D.; West, L. A., and Runyan, D. A. (Endodontic Residency Program, U.S. Army Dental Activity, Fort Gordon, GA, USA.). Interpretation of periapical lesions comparing conventional, direct digital, and telephonically transmitted radiographic images. Journal of Endodontics. 1998 Apr; 24(4). CODEN: 262-6; ISSN: 0099-2399. Call Number: *II 3,*III 6 B 6
    • Abstract: The purpose of this study was to evaluate direct digital radiography (DDR) and telephonically transmitted images versus conventional radiography in the interpretation of artificial periapical bone lesions. Five teeth were chosen from four cadaver jaw specimens. Three types of DDR images were evaluated: DDR stored images, DDR transmitted images, and DDR reversed images. A total of 150 DDR computer monitor images and 56 D-speed film images were evaluated by three endodontists and one endodontic graduate student. The Wilcoxon signed-ranks test was used for statistical analyses of the results. DDR reversed images were statistically inferior to DDR stored images, DDR transmitted images, and conventional radiography images (p < 0.0001). There were no statistically significant differences between DDR stored images, DDR transmitted images, and conventional film images in the ability of the evaluator to identify artificial periapical bone lesions (p > 0.05). 10. O'Sullivan, D. C.; Averch, T. D.; Cadeddu, J. A.; Moore, R. G.; Beser, N.; Breitenbach, C.; Khazan, R., and Kavoussi, L. R. (Brady Urological Institute, and Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.). Teleradiology in urology: comparison of digital image quality with original radiographic films to detect urinary calculi. Journal of Urology. 1997 Dec; 158(6). CODEN: 2216-20; ISSN: 0022-5347. Call Number: *II 3, *III 6 B Abstract: PURPOSE: Teleradiology systems are now being evaluated as a mechanism to provide rapid, accurate and cost-effective diagnostic radiographs to off-site physicians. Little data are available on the role and safety of teleradiology in urology. To address these issues a personal computer based system was developed to assess the diagnostic accuracy and ease of use of transmitted digital images when evaluating for urinary calculi. MATERIALS AND METHODS: A total of 100 plain abdominal scout films from excretory urograms performed during acute urological referrals was digitized on a laser scanner. The 10 megabyte files were transferred over public telephone lines and written to compact disks. The images were viewed on a 1280 x 1640 resolution monitor using "Imager-3D" software run on a 133 MHz. pentium personal computer with 32 megabytes of random access memory. Two faculty urologists and 2 urology fellows each looked at 50 original radiographs and 50 digital images. Diagnostic interpretations of the presence and location of calculi were recorded, and confidence in the diagnosis, assessment of image quality and diagnostic difficulty were scored using a numerical scale. RESULTS: The accuracy for all readers was 86.5% for plain radiographs and 81.5% for digital images (p >0.2). There was no statistical difference between faculty and fellows. Diagnostic accuracy did not differ between plain films and screen images when the results were assessed with respect to image quality, diagnostic difficulty or the reader confidence in the diagnosis (p >0.1). Compared to plain films, more screen images were classified as lower image quality (60 versus 40%) and the diagnostic confidence was lower (low and medium grade 50 versus 35%), although this did not interfere with diagnostic accuracy. CONCLUSIONS: These data imply that a high quality affordable teleradiology system is effective and accurate compared to plain films for assessing urinary calculi. 11. Okada, D. H.; Binder, S. W.; Felten, C. L.; Strauss, J. S., and Marchevsky, A. M. (Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA). "Virtual microscopy" and the internet as telepathology consultation tools: diagnostic accuracy in evaluating melanocytic skin lesions. American Journal of Dermatopathology. 1999 Dec; 21(6):525-31. Call Number: *II 3, *III 6 B Abstract: The Internet offers a widely available, inexpensive tool for telepathology consultations. It allows the transfer of image and text files through electronic mail (e-mail) or file transfer protocols (FTP), using a variety of microcomputer platforms. We studied the use of the Internet and "virtual microscopy" tools for the diagnosis of 35 skin biopsies, including a variety of benign and malignant melanocytic lesions. Digitized images from these lesions were obtained at 40x and 100x optical magnification, using a high resolution digital camera (Microlumina, Leaf Systems, Southborough, MA), a light microscope with a phototube adapter and a microcomputer with a Pentium 166 MHz microprocessor. Two to four images of each case were arranged on a "canvas" to represent the majority or an entire biopsy level, using Photoshop software (Adobe Systems Inc., San Jose, CA). The images were compressed using Joint Photographers Expert Group (JPEG) format. The images 7
    • were then viewed on a computer video monitor in a manner that closely resembles light microscopy, including scrolling by using the "hand tool" of Photoshop and changing magnification digitally up to 4 times without visible image degradation. The image files, ranging in size from 700 kilobytes to 2.1 megabytes (average 1.6 megabytes) were attached to e-mail messages that contained clinical information, using standard Multipurpose Internet Mail Extension (MIME) protocols and sent through the Internet, for interpretation by a dermatopathologist. The consultant could open the images from the e-mail message, using Microsoft Outlook Express (Microsoft Corp., Redmond, WA) and Photoshop software, scroll them, change magnification and render a diagnosis in a manner that closely simulates light microscopy. One hundred percent concordance was obtained between the telepathology and traditional hematoxylin and eosin slide diagnoses. The Internet and relatively inexpensive "virtual microscopy" tools offer a novel technology for dermatopathology consultations. Potential applications of this technology to pathology and technical problems posed by the use of an open, widely distributed network to share sensitive medical information are discussed 12. Phillips, L. A.; Phillips, K. L.; Gahm, T.; Lai-Goldman, M.; Needham, L. B.; Wray, B. E., and Macri, T. F. (Roche Image Analysis Systems, Inc., Elon College, NC 27244, USA.). Quantitative DNA ploidy analysis of breast carcinoma: a study of the effects of joint photographer experts group (JPEG) compression on DNA ploidy images. Diagnostic Cytopathology. 1996 Sep; 15(3). CODEN: 231-6; ISSN: 8755-1039. Call Number: *II 3, *III 6 B Abstract: Telepathology usage in the past has typically been a qualitative procedure rather than a quantitative measurement. DNA ploidy using image analysis has been favorably compared to DNA ploidy analysis by flow cytometry in numerous publications. A step from DNA ploidy analysis using conventional image analysis to DNA ploidy analysis using stored images allows DNA ploidy analysis by image cytometry to become a powerful tool in telepathology. Remote DNA ploidy analysis using stored images has an impact on the field of pathology, as not every hospital or laboratory can afford to perform this type of specialized testing. However, images have large data files and require lengthy transmission times over communication systems to other computers. Joint Photographer Experts Group (JPEG) compression is a computer algorithm that allows the file size of an image to be reduced in order to decrease transmission times to another computer. A study was initiated to investigate the effects of JPEG compression on images of Feulgen stained breast tumor touch preps and the resulting DNA ploidy histograms. 13. Pysher, L. and Harlow, C. (Centura Health System/St. Thomas More Hospital, Canon City, CO 81212, USA). Teleradiology using low-cost consumer-oriented computer hardware and software. AJR. American Journal of Roentgenology. 1999 May; 172(5):1181-4. Call Number: *II 3, *III 6 B Abstract: OBJECTIVE: Our study was a practice audit to evaluate the feasibility of using low-cost, consumer-oriented computer hardware and software to perform after-hours teleradiology consisting predominantly of CT images. MATERIALS AND METHODS: We performed a prospective study of 137 consecutive emergent CT scans of the head obtained after business hours. The scans were digitized using a consumer-oriented, low-cost flatbed scanner and sent to on-call radiologists for interpretation. Preliminary reports were then telephoned to the referring physician. Another radiologist who was unaware of the preliminary report evaluated the hard-copy images. RESULTS: Combining cases with minor discrepancies and those of complete agreement, we found a 96% concordance. Five major discrepancies (4%) were found. No adverse outcomes resulted. Discrepancies were caused by interobserver variation rather than by the quality of the digitized images. CONCLUSION: Our results support the use of consumer-oriented, low-cost computer hardware and software for emergent teleradiology in which most of the transmitted studies consist of CT images of the head 14. Schwarzmann, P.; Schmid, J.; Binder, B., and Burkart, J. (Institut fur Physikalische Elektronik, University of Stuttgart, Germany.). Field test to evaluate telepathology in telemedicine. Journal of Telemedicine & Telecare 1996;2 Suppl 1:17-20. ISSN: 1357-633X. Call Number: *II 3, *III 6 B 8
    • Abstract: Telepathology is currently performed only on prototype systems. The application of telepathology consultations differs from the conventional procedure because of the technical and cost restrictions. This paper outlines technical concepts and the principal hardware and software modules necessary for telemicroscopy equipment. A field test to gather information concerning the user needs and to evaluate parameters of telepathology consultation sessions is reported. 15. Slomka, P. J.; Elliott, E., and Driedger, A. A. (Department of Diagnostic Radiology, University of Western Ontario, London, Canada). Java-based remote viewing and processing of nuclear medicine images: toward "the imaging department without walls". Journal of Nuclear Medicine. 2000 Jan; 41(1):111-8. Call Number: *II 3, *III 6 B Abstract: In nuclear medicine practice, images often need to be reviewed and reports prepared from locations outside the department, usually in the form of hard copy. Although hard-copy images are simple and portable, they do not offer electronic data search and image manipulation capabilities. On the other hand, picture archiving and communication systems or dedicated workstations cannot be easily deployed at numerous locations. To solve this problem, we propose a Java-based remote viewing station (JaRViS) for the reading and reporting of nuclear medicine images using Internet browser technology. METHODS: JaRViS interfaces to the clinical patient database of a nuclear medicine workstation. All JaRViS software resides on a nuclear medicine department server. The contents of the clinical database can be searched by a browser interface after providing a password. Compressed images with the Java applet and color lookup tables are downloaded on the client side. This paradigm does not require nuclear medicine software to reside on remote computers, which simplifies support and deployment of such a system. To enable versatile reporting of the images, color tables and thresholds can be interactively manipulated and images can be displayed in a variety of layouts. Image filtering, frame grouping (adding frames), and movie display are available. Tomographic mode displays are supported, including gated SPECT. RESULTS: The time to display 14 lung perfusion images in 128 x 128 matrix together with the Java applet and color lookup tables over a V.90 modem is <1 min. SPECT and PET slice reorientation is interactive (<1 s). JaRViS could run on a Windows 95/98/NT or a Macintosh platform with Netscape Communicator or Microsoft Intemet Explorer. The performance of Java code for bilinear interpolation, cine display, and filtering approaches that of a standard imaging workstation. CONCLUSION: It is feasible to set up a remote nuclear medicine viewing station using Java and an Internet or intranet browser. Images can be made easily and cost-effectively available to referring physicians and ambulatory clinics within and outside of the hospital, providing a convenient alternative to film media. We also find this system useful in home reporting of emergency procedures such as lung ventilation-perfusion scans or dynamic studies 16. Weinstein, L. J.; Epstein, J. I.; Edlow, D., and Westra, W. H. (Department of Pathology, The University of Kentucky College of Medicine, Lexington, USA.). Static image analysis of skin specimens: the application of telepathology to frozen section evaluation. Human Pathology. 1997 Jan; 28(1). CODEN: 30-5; ISSN: 0046-8177. Call Number: II B, *II 3, *III 6 B Abstract: Although the ability to transmit high-resolution images of histopathological sections could have a profound impact on the practice of pathology, the application of video microscopy to the daily activities of surgical pathology has not been rigorously evaluated. In particular, certain aspects of video microscopy relating to frozen section evaluation have not been adequately assessed. We conducted a retrospective analysis of 48 excisional skin biopsy specimens encompassing a spectrum of benign and malignant lesions. To simulate an actual frozen section evaluation, only original frozen section slides were evaluated. Fields were selected and digitized (Roche Image Analysis System) by a pathology resident. Two sets of diagnoses were subsequently rendered by a surgical pathologist, the first set based on the digitized images and the second based on direct microscopic examination of the histological slides. The two sets of diagnoses were compared, and the concordance rates were as follows: malignant diagnoses, 100%; benign diagnoses, 100%; positive margins, 96%; negative margins, 99%. One (4%) of the 25 positive margins was indexed as negative by image analysis. Conversely, one (1%) of the 121 negative margins was indexed as positive by image analysis. In both of these cases, error was attributable to selection and digitization of an 9
    • inappropriate field. We conclude that telepathology of static images is an accurate method of evaluating frozen sections of skin lesions. Potentially, this technology could be applied to the frozen section evaluation of other lesions as well. Static image analysis is, however, susceptible to errors induced by inappropriate field selection, emphasizing the need for trained and skillful personnel on both sides of the video camera. 17. Weinstein, M. H. and Epstein, J. I. (Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, USA.). Telepathology diagnosis of prostrate needle biopsies. Human Pathology. 1997 Jan; 28(1). CODEN: 22-9; ISSN: 0046-8177. Call Number: II B, *II 3, *III 6 B Abstract: We conducted a prospective analysis of the diagnostic accuracy of a static-image telepathology system (Roche RIAS, Elon College, NC) in the interpretation of needle biopsies of the prostate (NBx). Two hundred consecutive cases received in consultation were included. Each case was examined by one of the researchers (MHW), and images were captured either according to the areas of concern designated by the referring pathologist (set A; 100 cases) or according to the judgment of MHW (set B; 100 cases). The other researcher (JIE) daily rendered diagnoses first on the video images and then by direct microscopy. Accuracy of video diagnosis was categorized as 0 (correct), 1 (minor error), 2 (major error), or 3 (deferred). An average of 5.49 images were captured per case in set A, and 5.28 for set B. Seventy-seven, 9, 9, and 5 cases were categorized as 0, 1, 2, and 3, respectively, for set A, and 78, 17, 1, and 4 cases, respectively, for set B. Video versus direct diagnoses for the type 2 errors were five carcinoma versus markedly atypical, two carcinoma versus atypical, one carcinoma versus nonspecific granulomatous prostatitis, and two benign versus atypical. In these difficult NBx, telepathology allowed an essentially correct diagnosis in almost all of the cases. The number of images required was reasonable, and the images were of excellent quality. However, the accuracy varied from set A to set B, with the fractions of nondeferred cases that were given an essentially correct video diagnosis totaling 91% and 99%, respectively (P < .01). Accuracy of telepathology diagnosis using static images may depend on the person capturing the images, even in the case of small biopsies. 18. Winokur, T. S.; McClellan, S.; Siegal, G. P.; Reddy, V.; Listinsky, C. M.; Conner, D.; Goldman, J.; Grimes, G.; Vaughn, G., and McDonald, J. M. (Department of Pathology, University of Alabama at Birmingham, 35233, USA.). An initial trial of a prototype telepathology system featuring static imaging with discrete control of the remote microscope. American Journal of Clinical Pathology. 1998 Jul; 110(1). CODEN: 43-9; ISSN: 0002-9173. Call Number: *II 3, *III 6 B Abstract: Routine diagnosis of pathology images transmitted over telecommunications lines remains an elusive goal. Part of the resistance stems from the difficulty of enabling image selection by the remote pathologist. To address this problem, a telepathology microscope system (TelePath, TeleMedicine Solutions, Birmingham, Ala) that has features associated with static and dynamic imaging systems was constructed. Features of the system include near real time image transmission, provision of a tiled overview image, free choice of any fields at any desired optical magnification, and automated tracking of the pathologist's image selection. All commands and images are discrete, avoiding many inherent problems of full motion video and continuous remote control. A set of 64 slides was reviewed by 3 pathologists in a simulated frozen section environment. Each pathologist provided diagnoses for all 64 slides, as well as qualitative information about the system. Thirty-one of 192 diagnoses disagreed with the reference diagnosis that had been reached before the trial began. Qf the 31, 13 were deferrals and 12 were diagnoses of cases that had a deferral as the reference diagnosis. In 6 cases, the diagnosis disagreed with the reference diagnosis yielding an overall accuracy of 96.9%. Confidence levels in the diagnoses were high. This trial suggests that this system provides high-quality anatomic pathology services, including intraoperative diagnoses, over telecommunications lines. *II 3, *III 6 B 1. Okumura, A.; Suzuki, J.; Furukawa, I.; Ono, S., and Ashihara, T. (NTT Optical Network Systems 10
    • Laboratories, Kanagawa, Japan. Signal analysis and compression performance evaluation of pathological microscopic images. IEEE Transactions on Medical Imaging. 1997 Dec; 16(6). CODEN: 701-10; ISSN: 0278-0062. Call Number: *II 3, *III 6 B Abstract: Digitizing high-quality microscopic images and developing input/output technology for displaying those results is critical to telepathology in which pathological microscopic images are transferred to remote locations where they are diagnosed by specialists. This paper will discuss the results achieved by directly digitizing (nonfilm process) pathological microscopic images at a 2k x 2k resolution, and then using a super-high-definition imaging system to analyze their signals and evaluate compression performance. We will start off by digitizing samples that a pathologist will actually use in making a diagnosis, and then analyze their color distribution and spatial frequencies characteristics by comparing them to general images. This will make it apparent that such pathological images characteristically contain high spatial frequency in their chrominance components. We will also discuss the evaluation results of color differences for L*a*b* space and compression ratios achieved when using JPEG to encode pathological images. We will also present a subjective evaluation of the influence subsampling of chrominance components has on image quality. *II 3, *III 6 B (GERMAN) 1. Beier, J.; Sell, C.; Hosten, N.; Fleck, E., and Felix, R. (Strahlen- und Poliklinik, Virchow Klinikum, Medizinische Fakultat der Humboldt-Universitat zu Berlin.). [Multi-media presentation of radiologic image data with the Internet]. [German]. Radiologe. 1997 Jan; 37(1). CODEN: 98-103; ISSN: 0033-832X. Call Number: *II 3, *III 6 B (GERMAN) Abstract: AIM: Recent developments of the Internet (World Wide Web) allow the integration of audio, video, digital film sequences, and three-dimensional data. The applicability of these innovations for medical documentation is demonstrated. METHODS: Our existing software for medical image processing and 3D reconstruction was extended to provide images, film sequences, and complex 3D models in an Internet-compatible data format. RESULTS: The multimedia results of the image processing were integrated into Internet documents. Specialized programs are no longer necessary for visualization. The Internet software allows for user-friendly handling and interactive presentation of the 2D and 3D data. CONCLUSIONS: The Internet offers public-domain software for display of images, audio/video, and 3D data. Thus, the tools of the Internet represent an ideal basis for local hospital information systems, computer-aided medical education, and teleconferencing. *II 3, *III 6 B, 1. O'Hare, N. J.; Wallis, F.; Kennedy, J. M.; Hickey, E.; McDermott, G. J.; Dowling, A.; Murphy, J., and Malone, J. F. (Medical Physics and Bioengineering Department, St. James's Hospital, Dublin, Ireland.). Specification and initial evaluation of a multiple application teleradiology system. British Journal of Radiology. 1996 Aug; 69(824). CODEN: 735-42; ISSN: 0007-1285. Call Number: *II 3, *III 6 B, Abstract: The digitization and transmission of medical images is becoming increasingly more important and available. The selection of appropriate clinical applications for teleradiology systems is an important factor in determining the success of such ventures. In this paper, the selection of such applications and the evaluation of the teleradiology system is described. The system (LIAISON, CAPTEC Ltd, Malahide, Ireland) is PC based and is capable of digitization and transmission of three categories of medical images: (1) plain film radiographs; (2) CT film data and (3) video sequences such as ultrasound scans. A comprehensive technical evaluation was carried out on the acquisition and display station in which various parameters such as spatial resolution, signal-to-noise ratio (SNR), and distortion were investigated. Results showed that the system performed well within specifications. An exploratory clinical evaluation was performed using a case mix of subtle fractures, chests and dislocations, and CT scans. Here the system performed well with a diagnostic accuracy of 95% for the digital image compared with the analogue image. 11
    • *II 3, *III 6 B, *II 5 1. Parasyn, A.; Hanson, R. M.; Peat, J. K., and De Silva, M. (Sydney University Medical School, Australia.). A comparison between digital images viewed on a picture archiving and communication system diagnostic workstation and on a PC-based remote viewing system by emergency physicians. Journal of Digital Imaging. 1998 Feb; 11(1). CODEN: 45-9; ISSN: 0897-1889. Call Number: *II 3, *III 6 B, *II 5 Abstract: Picture Archiving and Communication Systems (PACS) make possible the viewing of radiographic images on computer workstations located where clinical care is delivered. By the nature of their work this feature is particularly useful for emergency physicians who view radiographic studies for information and use them to explain results to patients and their families. However, the high cost of PACS diagnostic workstations with fuller functionality places limits on the number of and therefore the accessibility to workstations in the emergency department. This study was undertaken to establish how well less expensive personal computer-based workstations would work to support these needs of emergency physicians. The study compared the outcome of observations by 5 emergency physicians on a series of radiographic studies containing subtle abnormalities displayed on both a PACS diagnostic workstation and on a PC-based workstation. The 73 digitized radiographic studies were randomly arranged on both types of workstation over four separate viewing sessions for each emergency physician. There was no statistical difference between a PACS diagnostic workstation and a PC-based workstation in this trial. The mean correct ratings were 59% on the PACS diagnostic workstations and 61% on the PC-based workstations. These findings also emphasize the need for prompt reporting by a radiologist. *II 3, *III 6 B, *III 6 A 1. Larson, A.; Lynch, D. A.; Zeligman, B.; Harlow, C.; Vanoni, C.; Thieme, G., and Kilcoyne, R. (Department of Radiology, University of Colorado Health Sciences Center, Denver 80262, USA.). Accuracy of diagnosis of subtle chest disease and subtle fractures with a teleradiology system. AJR. American Journal of Roentgenology. 1998 Jan; 170(1). CODEN: 19-22; ISSN: 0361-803X. Call Number: *II 3, *III 6 B, *III 6 A Abstract: OBJECTIVE: This study compared conventional thoracic and skeletal radiographs with 12-bit digitized images of the same radiographs in terms of subjective image quality and accuracy of diagnosis of subtle disease. MATERIALS AND METHODS: Thirty-six chest radiographs with normal findings, 48 chest radiographs with abnormal findings, 29 skeletal radiographs with normal findings, and 26 skeletal radiographs with abnormal findings were included in this study. The images were chosen for the subtlety of their findings (nodules, pneumothoraces, interstitial lung disease, fractures). Each set of images was laser-digitized and viewed independently by three radiologists at a teleradiology workstation with a 1280 x 1024 pixel matrix monitor equipped with an eight-bit-per- pixel gray-scale display. All images were viewed at maximum resolution. After review of the digitized images for image quality and for the presence of abnormalities, each radiologist analyzed the analog images in a similar way. RESULTS: Sensitivities for detecting nodules, pneumothoraces, and interstitial lung disease on digitized chest radiographs were 58%, 75%, and 90%, respectively, compared with 62%, 79%, and 92%, respectively, on the original radiographs. Sensitivity for fracture detection on digitized bone radiographs was 87% compared with 88% on analog radiographs. None of these differences was statistically significant. CONCLUSION: Digitization of radiographs for primary diagnosis by teleradiology results in a slight decrease in sensitivity for detection of subtle abnormalities, provided that the images are viewed at maximum resolution. 2. Weinberg, D. S. (Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA. How is telepathology being used to improve patient care?. [Review] [20 refs]. Clinical Chemistry. 1996 May; 42(5). CODEN: 831-5; ISSN: 0009-9147. Call Number: *II 3, *III 6 B, *III 6 A Abstract: Telepathology, as a subspecialty of telemedicine, involves the use of telecommunications technologies to transmit images to distant sites for the purpose of communicating diagnostic information or for teaching. Recent advances in technology have greatly increased the feasibility of 12
    • performing diagnosis by telepathology, but there are still significant obstacles to implementation. In this review, I will discuss the technologies and organizations involved in telepathology, with examples of current practice in the US and abroad. [References: 20] *II 3, *III 6 B, II A 1. Engelmann, U.; Schroter, A.; Baur, U.; Werner, O.; Goransson, B.; Boralv, E.; Schwab, M.; Muller, H.; Bahner, M., and Meinzer, H. P. (Division of Medical and Biological Informatics, Deutsches Krebsforschungszentrum, Heidelberg, Germany. Experiences with the german teleradiology system MEDICUS. Computer Methods & Programs in Biomedicine. 1997 Sep; 54(1-2). CODEN: 131-9; ISSN: 0169-2607. Call Number: *II 3, *III 6 B, II A Abstract: This paper introduces the teleradiology system, MEDICUS, which has been developed at the Deutsches Krebsforschungszentrum (German Cancer Research Center) in Heidelberg, Germany. The system is designed to work on ISDN lines as well as in a local area network. The global software architecture is explained in the article. Special attention has been given to the design of the user interface and data security, integrity and authentication. The software has been evaluated in a German field test at 13 radiology departments in university clinics, small hospitals, private practices and research institutes. More than 30 thousand images have been transmitted using this system during a 9 month period. Realized application scenarios are: in-house communication, image and report delivery to referring hospitals, remote reporting, radiotherapy treatment planning and research cooperation. Experience has shown that the system is easy to use and saves time. It obviates the need for patient transport and reduces film costs. Experiences of individuals while using the system during the field test helped define the functionality of the second generation teleradiology system which is even more flexible and is also available as a commercial product. 2. Krause, M.; Brado, M.; Schosser, R.; Bartsch, F. R.; Gerneth, M., and Kauffmann, G. (Department of Radiodiagnostics, Radiological Clinic, University of Heidelberg, Germany.). Diagnostic accuracy in remote expert consultation using standard video-conference technology. European Radiology. 1996; 6(6). CODEN: 932-8; ISSN: 0938-7994. Call Number: *II 3, *III 6 B, II A Abstract: An international multicenter study (Germany, Sweden, and Switzerland) was performed to investigate the feasibility and diagnostic reliability of standard video-conferencing (VC) technology for remote expert consultation in radiology. Three high-spatial-resolution films (hand-bone, mammography, chest) and two low-spatial-resolution image sets (liver CT and MRI) were studied (total 446 images taken from different examinations). The images were recorded by a video camera, transmitted via public broadband networks, and displayed on a video monitor. The resolution of the recorded images varied from 2.4 lp/mm to 4.8 lp/mm at maximum zoom. After 3-4 months, the images were reexamined using conventional light-box reading. Diagnostic reliability was evaluated by receiver operating characteristics (ROC) analysis. With video conferencing, there was a noticeable loss of diagnostic accuracy for the high-spatial-resolution films, whereas for liver CT and liver MRI images VC reading seemed to be satisfactory (average area value difference < 0.02). 3. Orphanoudakis, S. C.; Kaldoudi, E., and Tsiknakis, M. (Institute of Computer Science, Foundation for Research and Technology-Hellas, Crete, Greece. Technological advances in teleradiology. European Journal of Radiology. 1996 Jun; 22(3). CODEN: 205-17; ISSN: 0720-048X. Call Number: *II 3, *III 6 B, II A Abstract: Teleradiology consists of a set of added-value telematic services, implemented over an advanced telecommunications infrastructure and supported by different information technologies and related applications. The main goal of teleradiology is to provide different levels of support for remote diagnostic imaging procedures. This paper considers technological advances in this important area, including a discussion of the various added-value telematic services, applications supporting these services, and the required information technology and telecommunications infrastructure. Teleradiology is also considered in the general context of an integrated regional health telematics network, emphasizing its role and its interaction with other information and networking services. 13
    • 4. Ricke, J.; Kleinholz, L.; Hosten, N.; Bergh, B.; Zielinski, C.; Thomsen, J.; Vierroth, V.; Emmel, D.; Kanzow, J., and Felix, R. (Strahlenklinik und Poliklinik, Virchow-Klinikum, Medizinische Fakultat der Humboldt- Universitat zu Berlin.). [Teleradiology: use of multimedia PC for access to electronic patient records and teleconsultation]. [German]. Rofo. Fortschritte Auf Dem Gebiete Der Rontgenstrahlen Und Der Neuen Bildgebenden Verfahren. 1996 Aug; 165(2). CODEN: 188-91; ISSN: 0936-6652. Call Number: *II 3, *III 6 B, II A Abstract: A PC-platform is presented using internet technology on Ethernet (local) or ISDN (external) for access to digital hospital infrastructures comprising electronic multimedia patient records integrating information systems of all clinical departments. In addition, a videoconferencing system is implemented for teleconsulting, and a document camera allows transmission of analogue data. In combination with the multimedia-PC. Ethernet as well as ISDN offer satisfying performance for transmission of medical data including images. In 20 cases, visualisation of the electronic patient record, an average CT with report and 58 GIFF Images', or transfer of an ACR-NEMA file from CT, took seconds (Ethernet) or up to 3.5 minutes (ISDN - 58 CT images and report). 5. Stormer, J.; Bolle, S. R.; Sund, T.; Weller, G. E., and Gitlin, J. N. (Department of Radiology, University Hospital of Tromso, Norway.). ROC-study of a teleradiology workstation versus film readings. Acta Radiologica. 1997 Jan; 38(1). CODEN: 176-80; ISSN: 0284-1851. Call Number: * II 3, *III 6 B, II A Abstract: PURPOSE: We have used receiver operating characteristic (ROC) analysis to compare screen assessment of digitized radiographic films transmitted by a teleradiology system, with evaluation of the original radiographs on film. MATERIAL AND METHODS: The material contained 120 cases (about 50% with selected pathology) that were difficult to diagnose. Four radiologists each evaluated half of the cases on film, and half on computer screen. The screen display was 1024 x 836 pixels with 8 bits/pixel. RESULTS: We found the accuracy and sensitivity of the teleradiology system to be clearly inferior to film evaluation. CONCLUSION: Improvement is needed both in the teleradiology system, and in the training of radiologists to work on the electronic workstation. *II 3, *III 6 B, II A (GERMAN) 1. Hacklander, T. and Modder, U. (Institut fur Diagnostische Radiologie der Heinrich-Heine Universitat, Dusseldorf.). [Use of an image serve for external communication in a radiologic department]. [German]. Radiologe. 1996 Apr; 36(4). CODEN: 368-73; ISSN: 0033-832X. Call Number: *II 3, *III 6 B, II A (GERMAN) Abstract: In radiology picture information is increasingly acquired digitally. Image postprocessing is sometimes carried out via the picture archiving and communication system (PACS). In this paper we present a strategy for the simple implementation of an external picture communication system. METHODS: Image transfer for the entire radiology department is carried out through a single image server, which physically and logically separates the PACS from the external network. The server is organized as an image mailbox system. For each user the images can be transferred to their respective mailbox from the radiology department. However, direct access to the image archive is prevented by the system. RESULTS: Because the networks are separate, a high degree of access security is guaranteed. New users can easily be added to the server without additional configuration of the PACS. System usage has received wide acceptance within the department and with external users. CONCLUSIONS: The integration of an image server into a PACS has proved to be non- problematic. The concept allows for more effective information sharing in the field of teleradiology. *II 3, *III 6 B, II A, *III 6 A 1. Berry, R. F. and Barry, M. H. (Department of Radiology, Queen Elizabeth II Health Sciences Centre, Halifax NS.). Evaluation of a personal-computer-based teleradiology system serving an isolated Canadian community. Canadian Association of Radiologists Journal. 1998 Feb; 49(1). CODEN: 7-11; ISSN: 0846-5371. 14
    • Call Number: *II 3, *III 6 B, II A, *III 6 A Abstract: OBJECTIVE: To evaluate a personal-computer-based teleradiology system for the interpretation of radiologic studies from an isolated community. METHODS: During a 5-month study period, 240 radiologic studies from the Grand Manan Hospital, Grand Manan, NB, were digitized and transmitted via telephone lines to the Saint John Regional Hospital, NB, for interpretation. The first 110 cases were interpreted with the use of a 1 K x 1 K monitor, and the remaining cases were interpreted with a 2 K x 2 K monitor. The teleradiology image reports were compared with the plain film reports for each case and discrepancies were identified. A panel reviewed all clinically significant discrepant cases to determine the source of the discrepancy. RESULTS: There was 90.9% concordance between the teleradiology and plain film reports in the studies interpreted with the 1 K x 1 K monitor and a 88.4% concordance in the studies interpreted with the 2 K x 2 K monitor. Only 1.7% (4/240) of the discrepancies were attributed to an inadequate teleradiology digital image. CONCLUSION: A personal-computer-based teleradiology system can be used to provide diagnostic imaging service of high quality to an isolated community. *II 3, *III 6 B, II B 1. Flandrin, G. (Division of Hematology, Hopital Necker, Paris, France. flandrin:necker,fr). Image bank, diagnostic codification and telediagnosis in hematology. Leukemia & Lymphoma. 1997 Mar; 25(1-2). CODEN: 97-104; ISSN: 1042-8194. Call Number: *II 3, *III 6 B, II B Abstract: Recent technological improvements which permit transmission and discussion of color images with good resolution and in real time may become very useful for hematological and histopathological applications. The workstations used a PC Pentium, 16 Mo RAM 1,6 Go of hard disk, including a laser-reader for CD-ROM and network cards. Applications are developed under Windows 95. The system allows to digitalize, compress and decompress any kind of colored or black and white images according to the International Norms, JPEG. The storage is managed by a specific software according to specific classification for diagnostic nomenclature. It can store typical, less typical and atypical images of examples of pathology which can contribute to the constitution of a digitized bank of images and CD-ROM. The system used have been launched to allow pathology image transmission on ISDN networks for diagnosis assessment. Standardization of nomenclature which has been achieved both for immunophenotyping and cytogenetics is necessary for the cyto-anatomical lesions in the specialized field of hematology. In using the major published recommendations (FAB, EGIL, REAL etc.), a comprehensive approach of nomenclature for our image data base is proposed through a 500 item Thesaurus, which have been written simultaneously as a multilangage version. *II 3, *III 6 B, II C 1. Loane, M. A.; Gore, H. E.; Corbett, R.; Steele, K.; Mathews, C.; Bloomer, S. E.; Eedy, D. J.; Telford, R. W., and Wootton, R. (Institute of Telemedicine and Telecare, Queen's University, Belfast, Northern Ireland.). Effect of camera performance on diagnostic accuracy: preliminary results from the Northern Ireland arms of the UK Multicentre Teledermatology Trial. Journal of Telemedicine & Telecare. 1997; 3(2). CODEN: 83-8; ISSN: 1357-633X. Call Number: *II 3, *III 6 B, II C Abstract: The diagnostic accuracy of realtime teledermatology was measured using two different video cameras. One camera was a relatively low-cost, single-chip device (camera 1), while the other was a more expensive, three-chip camera (camera 2). The diagnosis obtained via the videolink was compared with the diagnosis made in person. Sixty-five new patients referred to a dermatology clinic were examined using camera 1 followed by a standard face-to-face consultation on the same day. A further 65 patients were examined using camera 2 and the same procedure implemented. Seventy-six per cent of conditions were correctly diagnosed by telemedicine using camera 2 compared with 62% using camera 1. A working differential diagnosis was obtained in 12% of cases using camera 2 compared with 14% using camera 1. The percentage of 'no diagnosis', wrong and missed diagnoses was halved using camera 2 compared with camera 1. These results suggest that the performance of the more expensive camera was superior for realtime teledermatology. 15
    • *II3, *III6B 1. Mun, S. K.; Levine, B.; Cleary, K., and Dai, H. (ISIS Center, Department of Radiology, Georgetown University Medical Center, Washington, DC 20007, USA. Deployable teleradiology and telemedicine for the US military. Computer Methods & Programs in Biomedicine. 1998 Aug-1998 Sep 30; 57(1-2):21-7. Call Number: *II3, *III6B Abstract: The US military has been an effective proponent of digital imaging and teleradiology for the past 15 years. A digital imaging network that can eliminate the use of X-ray film can make the requirements simpler for military medicine. X-ray film requires the storage of new, unexposed films that have a fixed shelf life, and the storage and use of chemicals and water for processing. In some deployed situations, the chemical discharge has to be collected and shipped out of the deployed area. The technology of electronic imaging is therefore intrinsically important to military medicine. In December of 1995, the US government started to deploy 20000 US troops to Bosnia-Herzegovina as part of NATO's peace keeping operation (IFOR). A full complement of medical support facilities was to be established in the Bosnia region and Hungary where the deployment was staged. Primetime III was a project to deploy telemedicine and teleradiology capabilities linking these medical treatment facilities (MTF). The deployment of telemedicine was not the responsibility of our engineering team. This paper deals with the deployable teleradiology (DEPRAD) system that was installed by the ISIS Center at a number of facilities for filmless radiology and teleradiology services *II 3, *IV, *III 6 B (GERMAN) 1. Ricke, J.; Wolf, M.; Hosten, N.; Zielinski, C.; Liebig, T.; Lopez-Hanninen, E.; Lemke, A. J.; Siekmann, R.; Stroszczynski, C.; Schauer, W.; Amthauer, H.; Kleinholz, L., and Felix, R. (Strahlenklinik und Poliklinik, Virchow-Klinikum, Medizinische Fakultat, Humboldt-Universitat zu Berlin.). [How certain is teleradiological telediagnosis for the tomographic procedure?]. [German]. Rofo. Fortschritte Auf Dem Gebiete Der Rontgenstrahlen Und Der Neuen Bildgebenden Verfahren. 1997 Mar; 166(3). CODEN: 243-7; ISSN: 0936-6652. Call Number: *II 3, *IV, *III 6 B (GERMAN) Abstract: PURPOSE: To define the value of teleradiographic studies, a comparison was carried out between digitised copies of CT examinations of the skull with the original images. Differences in image quality obtained from a digital scanner and a camera were quantified. MATERIAL AND METHOD: 56 CT examinations of the skull, 28 of which had discrete abnormalities, were chosen for ROC analysis. The original films were digitised with a Vidar VXR-12 scanner and Panasonic WV-160 and WV-BP 500 cameras. The images were evaluated by five radiologists after image transfer with Video Conference software to a personal computer. RESULTS: For the analysis of the films the area under the ROC curve was 0.91 +/- 0.04, for the digital scanner it was 0.85 +/- 0.04, for camera WV-BP 500 0.89 +/- 0.06 and for camera WE-160 0.87 +/- 0.09. Comparison with the film findings showed. a minimal p-value of 0.17 which indicated that there was no significant reduction in diagnostic value following digitization. CONCLUSION: The probable reason for the slight deterioration using the digital scanner was the reduction to 75 dpi compared with 134 dpi on the CT films. The cameras produce image noise comparable to CT with low window settings and reduced local resolution. We expect similar results for CT with soft tissue windows or for MRT of the skull. Conventional radiographs containing high local resolution, wide grey scale and low image noise would presumably make higher demands on methods of digitization. *III 6B 1. Abdullah, B. J.; Ng, K. H., and Pathmanathan, R. (Department of Radiology, University of Malaya Medical Centre, Kuala Lumpur). The impact of teleradiology in clinical practice--a Malaysian perspective. Medical Journal of Malaysia. 1999 Jun; 54(2):169-74. Call Number: *III 6B Abstract: Teleradiology is the most mature and rapidly evolving specialty in telemedicine. The use of teleradiology has grown tremendously during the past few years. This article describes the role of teleradiology in health care along with a brief history of its development in tandem with advances in 16
    • telecommunications and computer technologies. Teleradiology standards, image acquisition, data compression, transmission and image interpretation are summarised. The impact of teleradiology in the practice of radiology, traces the evolution of the modality especially in the Malaysian perspective and its current and future role are discussed 2. al-Taei, M. K.; Pan, Y., and Lu, D. M. (Zhejiang University, Hangzhou, China. An Internet-based telediagnosis system for Chinese medicine. Journal of Telemedicine & Telecare. 6 Suppl 1:S63-5, 2000. Call Number: *III 6B Abstract: The Internet is becoming an increasingly popular medium for communication and is being used more and more for telemedicine. Telediagnosis is one of the most developed components of telemedicine. We have designed and partly implemented a telediagnostic system, using the Internet as the means of communication, to enhance access to specialists and health providers in Chinese medicine 3. Ashcroft, R. E. and Goddard, P. R. (University of Bristol, Centre for Ethics in Medicine, UK). Ethical issues in teleradiology. [Review] [31 refs]. British Journal of Radiology. 2000 Jun; 73(870):578-82. Call Number: *III 6B Abstract: Teleradiology is the electronic transmission of radiographic images from one geographic location to another for the purposes of diagnosis and/or consultation. It raises interesting ethical and practical issues which have received relatively little attention in the radiology or ethics literature to date. These include confidentiality, data security and technological reliability, consent, competence, interprofessional and professional-patient relationships, and the organization of medical services. This paper reviews these issues, discussing how far these are new concerns in radiological practice, and makes suggestions for minimum ethical and professional standards for teleradiological practice. [References: 31] 4. Cho, P. S.; Lindsley, K. L.; Douglas, J. G.; Stelzer, K. J., and Griffin, T. W. (University of Washington School of Medicine, Department of Radiation Oncology, Seattle 98195-6043, USA). Digital radiotherapy simulator. Computerized Medical Imaging & Graphics. 1998 Jan-1998 Feb 28; 22(1):1-7. Call Number: *III 6B Abstract: We describe a prototype digital radiotherapy simulator which consists of a conventional simulator gantry, digital spot imager, and image correction and reconstruction software. The ability of the digital spot imager to acquire a diagnostic quality image directly in digital format during simulation offers unique possibilities in clinical practice. Applications include prescription of multileaf collimator, on-line patient setup verification, remote consultation and treatment planning. In addition, we discuss the possibility of using the digital simulator as a volume-CT scanner capable of obtaining three-dimensional anatomical information in a single scan 5. Dawson, P. J.; Johnson, J. G.; Edgemon, L. J.; Brand, C. R.; Hall, E., and Van Buskirk, G. F. (James A. Haley Veterans' Hospital, and the Department of Pathology & Laboratory Medicine, University of South Florida College of Medicine, Tampa 33612-4798, USA). Outpatient frozen sections by telepathology in a Veterans Administration medical center. Human Pathology. 2000 Jul; 31(7):786-8. Call Number: *III 6B Abstract: A relatively simple telepathology system is described for evaluating the margins of excision of cutaneous basal and squamous carcinomas. The system uses a microscope with a built-in television camera, but no eyepieces. The image is projected onto an adjacent monitor and transmitted by T1 line at 768 Kbs to a remote, large screen monitor. The microscope is operated by the surgeon under the telephone direction of the pathologist at the remote site. In a series of 66 cases involving more than 400 individual tissue blocks, we have had only 2 cases with false-negative interpretations and 2 in which the block was not fully displayed on the frozen section. In 15 cases, 1 or more surgical margins were positive, and the surgeon proceeded to excise additional tissue. Our success is attributed to dedicated involvement by the surgeon, very high-quality frozen sections, and the 17
    • experience of the pathologist 6. Engelmann, U.; Schroter, A.; Baur, U.; Werner, O.; Schwab, M.; Muller, H., and Meinzer, H. P. (Deutsches Krebsforschungszentrum, Abt. Medizinische und Biologische Informatik, Heidelberg, Germany. A three-generation model for teleradiology. IEEE Transactions on Information Technology in Biomedicine. 1998 Mar; 2(1):20-5. Call Number: *III 6B Abstract: This paper proceeds from the definition of teleradiology. It identifies three different generations of teleradiology systems and includes those systems that are not regarded as teleradiology systems by the authors. A list of requirements pertinent to users of first-generation teleradiology systems is introduced. Most of the requirements have been realized in a new generation teleradiology system called CHILI 7. Gomez, E. J.; del Pozo, F.; Ortiz, E. J.; Malpica, N., and Rahms, H. (Grupo Bioingenieria y Telemedicina, Universidad Politecnica de Madrid, Spain. A broadband multimedia collaborative system for advanced teleradiology and medical imaging diagnosis. IEEE Transactions on Information Technology in Biomedicine. 1998 Sep; 2(3):146-55. Call Number: *III 6B Abstract: This paper presents a new telemedicine system currently in routine clinical usage, developed within the European Union (EU) ACTS BONAPARTE project (1). The telemedicine system is developed on an asynchronous transfer mode (ATM) multimedia hardware/software platform comprising the following set of telemedicine services: synchronous cooperative work, high- quality video conference, multimedia mail, medical image digitizing, processing, storing and printing, and local and remote transparent database access. The medical information handled by the platform conforms to the Digital Imaging and Communications in Medicine (DICOM) 3.0 medical imaging standard. The telemedicine system has been installed for clinical routines in three Spanish hospitals since November 1997 and has been used in an average of one/two clinical sessions per week. At each clinical session, a usability and clinical evaluation of the system was carried out. Evaluation is carried out through direct observation of interactions and questionnaire-based subjective data. The usability evaluation methodology and the results of the system usability study are also presented in this article. The experience gained from the design, development, and evaluation of the telemedicine system is providing an indepth knowledge of the benefits and difficulties involved in the installation and clinical usage of this type of high-usability and advanced multimedia telemedicine system in the field of teleradiology and collaborative medical imaging diagnosis 8. Hayward, T. and Mitchell, J. (Women's and Children's Hospital, Adelaide, Australia. Teleradiology at the tertiary-level Women's and Children's Hospital in South Australia. Telemedicine Journal. 2000 Summer; 6(2):205-11. Call Number: *III 6B Abstract: This article relates to a teleradiology trial undertaken in 1998-1999 at the Women's and Children's Hospital (WCH) in Adelaide, the capital of South Australia. The trial involved linking the hospital to a range of rural and remote sites in South Australia and the Northern Territory. The main aim of the project was to evaluate the advantages, limitations, benefits, and costs of a teleradiology service provided by WCH. The major finding from the study is that for a tertiary hospital providing second opinions in complex medical cases, a new form of business justification is required for teleradiology. The justification would include an emphasis on the range of high-level services that a subspecialist hospital such as the WCH can provide. The justification would also include the range of benefits to different parties, particularly the patient, and the intangible nature of many of the benefits 9. Hazebroucq, V. (MCU-PH de Radiologie, m:edecin agr:e:e par la Cour d'Appel de Paris, et coordinateur du dipl:ome d'imagerie m:edico:l:egale, Universit:e Ren:e Descartes, Paris V, France). [Medico-legal aspects of thoracic imaging in 2000]. [Review] [23 refs] [French]. Revue De Pneumologie Clinique. 2000 Apr; 56(2):156-62. 18
    • Call Number: *III 6B Abstract: The radiologist's responsibility for the radiographic procedure concerns control of the indication and patient information and consent, as well as the examination procedure itself, including safety measures, interpretation, report delivery, and patient follow-up until referral to a colleague. Details on five specific medico-legal points are examined here: 1) patient information and consent, a problem recently brought to the forefront by the recent French Supreme Court decision, 2) lung cancer unrecognized on a radiography, 3) implications of complementary examinations related to the discovery of a suspect lesion, 4) fortuitous discovery of a malignant lesion in a patient undergoing exploration for another reason, 5) questions of a legal and ethical nature raised by the development of telemedicine. [References: 23] 10. Holdrinet, R. S. (Academisch Ziekenhuis St. Radboud, afd. Hematologie, HB Nijmegen. [Comments on separate consultations for second opinions (comment) (see comments)]. [Review] [3 refs] [Dutch]. Nederlands Tijdschrift Voor Geneeskunde. 1999 Dec 4; 143(49):2452-4. Call Number: *III 6B Abstract: Second opinion consultations are an accepted phenomenon in daily clinical practice. In well defined situations such a consultation may be welcomed as a mean to obtain proper medical counselling and advice. However, to preserve a good doctor-patient relationship it is of utmost importance for what reason and by whom such a consultation is initiated. Setting up a specific second opinion outpatient clinic, where oncological patients are welcomed without prior knowledge of the primary consultant, is medically unnecessary and may well be the wrong solution for counselling problems that may originate in busy surgeries of general hospitals. [References: 3] 11. Holtan, A. (University of Tromso, Norway. Patient reactions to specialist telemedicine consultations--a sociological approach. Journal of Telemedicine & Telecare. 1998; 4(4):206-13. Call Number: *III 6B Abstract: A sociological study was made of patient experiences of telemedical specialist consultations in northern Norway. The study made use of a qualitative methodological approach. The data were collected through unstructured in-depth interviews of patients or the parents of very young patients. The patients were referred for a telemedical otolaryngology consultation in a randomly selected period of three months. Of a total of 35 patients, 15 refused to participate in the study. Of the 20 remaining, three were excluded for practical and financial reasons. The telemedicine consultation consisted of a general practitioner examining patients endoscopically and realtime transmission of the examination to a specialist by means of a videoconferencing system. Video-communication seemed to restrict personal contact with the specialist. In spite of that, it was not the video-communication itself but the social situation that mattered to the patients. Compared with an ordinary medical consultation, a telemedical consultation represented a wider interaction system, with more channels for access, inspection and information, which gave the patients different options for participation in the consultation 12. Karasti, H.; Reponen, J.; Tervonen, O., and Kuutti, K. (Department of Information Processing Science, University of Oulu, Oulu University Hospital, Finland. The teleradiology system and changes in work practices. Computer Methods & Programs in Biomedicine. 1998 Aug-1998 Sep 30; 57(1-2):69-78. Call Number: *III 6B Abstract: After the design and development of the teleradiology system, a work practice oriented approach was used to gain a more holistic understanding of the relationship between the emerging work practice and the newly implemented technology, and to provide information for redesigning the system. The approach which utilized ethnographically informed fieldwork and cooperative workshops was introduced. Cooperation, the chain of tasks, and articulation work of teleradiology work practice were described, with the focus on image interpretation in particular. From the point of view of radiologists image interpretation work, a report was made on how these findings influenced the evaluation and redesign of the system. Furthermore, the problematics of distributed 19
    • collaboration, reorganization of work, and education are emphasized 13. Kroeker, K. I.; Diamond, R.; Jennett, P. A., and Johnston, R. V. (Department of Clinical Affairs, Calgary Regional Health Authority, Alberta, Canada). Video-capture teleradiology for the after-hours reading of computerized tomography scans. Journal of Telemedicine & Telecare. 2000; 6(4):229-32. Call Number: *III 6B Abstract: We evaluated the after-hours support that radiologists could provide from their homes to an urban hospital for reading emergency computerized tomography (CT) scans. During a six-month study period, 36 CT scans were acquired using a video-capture card in a PC and transmitted via an ordinary telephone line. The teleradiology interpretation and the formal report (from the hard copy) were compared with a reference or gold standard interpretation made by a radiologist and an emergency physician for 31 of the 36 cases. In comparison with the gold standard, there were 26 correct diagnoses by teleradiology (84%) and five incorrect (16%). Head CT scans accounted for 74% of the transmitted scans and all five of the cases with discrepant diagnoses. The cause of the single clinically relevant discrepancy was found to be unrelated to the use of teleradiology. In comparison with the formal report, the accuracy of the teleradiologist was not significantly different for all categories combined or for head CT scans alone. Video-capture technology provided a reliable means of transmitting CT scans for after-hours interpretation in emergency cases 14. Leao, J. C. and Porter, S. R. (Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University of London, England). Telediagnosis of oral disease. Brazilian Dental Journal. 1999; 10(1):47-53. Call Number: *III 6B Abstract: Computers have increasingly found application in dentistry over the past 15 years, but at present there has been no investigation of the application of the Internet for distance diagnosis purposes in oral medicine. As a consequence, the objective of this article was to determine the acceptability to patient and clinician of the distant diagnosis of common orofacial diseases using the Internet. The study group comprised 20 patients who attended the Oral Medicine unit of the Eastman Dental Institute and Hospital, London, UK, for the diagnosis and management of oral mucosal diseases. Digital images of each patient's oral mucosal lesion were captured and stored on a personal computer and later transmitted via the Internet to a distant site. Patients were asked to complete a self-administered questionnaire detailing their opinion of the use of an intra-oral camera and a group of clinicians were asked to compare and contrast the original and transmitted images. The majority of patients found the procedure of recording images of their mouth very comfortable, were happy to view the inside of their mouths, and found the procedure generally useful in understanding their clinical problem. The clinicians were often not able to differentiate between the original and transmitted image but were able to accurately diagnose the patient's oral mucosal problems in 64% of the instances. The results of the present study suggest that telediagnosis of orofacial disease may be a feasible prospect 15. Li, H. K.; Tang, R. A.; Oschner, K.; Koplos, C.; Grady, J., and Crump, W. J. (Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch, Galveston, Texas, USA). Telemedicine screening of glaucoma. Telemedicine Journal. 1999 Fall; 5(3):283-90. Call Number: *III 6B Abstract: OBJECTIVES: Glaucoma is a major cause of blindness. More than 80,000 Americans suffer permanent vision loss from the disease. Widespread screening is fundamental in limiting the incidence of glaucoma-associated blindness. This pilot study explored the use of stereo digital images taken at a primary care center for telemedicine review by an off-site specialist as a means of screening for glaucoma. MATERIALS AND METHODS: Thirty-two diabetic patients were screened at a family medicine clinic. None had previously been diagnosed with glaucoma. A senior optometry student took stereoscopic digital and 35-mm optic disc photographs with a nonmydriatic retinal camera. The digital images were forwarded to a remote ophthalmologist for review. The conventional color stereo slide pairs of the same eyes were subsequently reviewed for comparison. Agreement on signs of glaucomatous disc changes between the two imaging systems was analyzed. RESULTS: Twenty-six of 32 eyes' digital and 35-mm photographs were analyzed. Six of 32 eyes 20
    • (18.8%) could not be compared due to lack of matching 35-mm slides or digital images. Out of 26 eyes, lamina cribosa visibility was undeterminable in 8 eyes' digital images and 3 other eyes' 35-mm slides. Agreement among digital images and 35-mm slides of the remaining eyes was: 100%-vertical elongation, barring of vessels, bayoneting of vessels, and drance hemorrhage; 96.2%-focus notching of rim and rim pallor; 93.3%-lamina cribosa visability; 92. 3%-overpass cupping; 88.5%-focal enlargement; 84.6%-parapapillary halo; 80%-nerve fiber visibility; 65.4%-parapapillary atrophy. Parapapillary halo (p = 0.046) and nerve fiber layer visibility (p = 0.18) were detected on some 35- mm slides but not seen on matching digital views. CONCLUSION: Evaluations of cup-to-disc ratio (C/D) using both methods were in general agreement. However, some digital images were noted as too dark for assessing fine glaucomatous disc changes. Stereo digital images taken with a nonmydriatic camera by nonophthalmic photographers is a promising alternative for glaucoma screening in primary care settings. Telemedicine offers efficient communications with off-site glaucoma specialists. A larger study population is necessary to determine the overall effectiveness of using stereo digital imagery and teleophthalmology for glaucoma screening 16. Neri, E.; Thiran, J. P.; Caramella, D.; Petri, C.; Bartolozzi, C.; Piscaglia, B.; Macq, B.; Duprez, T.; Cosnard, G.; Maldague, B., and De Pauw, J. (Department of Oncology, University of Pisa, Italy. Interactive DICOM image transmission and telediagnosis over the European ATM network. IEEE Transactions on Information Technology in Biomedicine. 1998 Mar; 2(1):35-8. Call Number: *III 6B Abstract: The European High-Performance Information Infrastructure in Medicine, n(o)B3014 (HIM3) project of the Trans-European Network--Integrated Broadband Communications (TEN-IBC) program, started on March 1996 and finished on February 1997, aimed to test the medical usability of the European asynchronous transfer mode (ATM) network in medical image transmission. The Department of Radiology, University of Pisa, Pisa, Italy, and St-Luc University Hospital, Brussels, Belgium, involved in the project as healthcare partners in the radiological domain, established several connection sessions finalized to test the usability of Digital Imaging and Communication (DICOM) image transmission and interactive telediagnosis tools in the daily radiological practice. The Pisa site was connected to the Italian ATM pilot (Sirius Network) through the Tuscany metropolitan area network (MAN), while St-Luc University Hospital was connected to Belgium ATM network through the Brussels MAN. By means of international connections provided by the European JAMES project, a link between the two sites was established, connecting both national ATM networks. Due to the large variety of hardware present in the medical centers, multiplatform software tools were used and tested: central test node (CTN) release 2.8 [3], VAT [6], NV-3.3 [7], and IDI (UCL homemade multiplatform teleradiology tool for interactive visualization and processing of DICOM images). During the telediagnosis session, lead by radiologists in both hospitals, each site submitted neuroradiological clinical cases to the other for remote consultation. The connection, available for a period of two weeks, at 2-Mbit/s bandwidth, allowed the transmission of MR images (256 x 256 x 12 bit) and simultaneous multimedia interactive discussion of the cases. Both off-line transmission and review of the images, using the CTN DICOM transfer routines, and on-line interactive image discussion, using the IDI telediagnosis software, were tested successfully from the technical and medical point of view 17. O'Neill, S. K.; Allen, D., and Brockway, P. D. (Keeweetinok Lakes Regional Health Authority, Slave Lake, Alberta, Canada. The design and implementation of an off-the-shelf, standards-based tele-ultrasound system. Journal of Telemedicine & Telecare. 6 Suppl 2:S52-3, 2000. Call Number: *III 6B Abstract: We developed an off-the-shelf system to transfer DICOM-compliant ultrasound images from a small rural hospital in northern Alberta to an urban radiology clinic in Calgary. The transfer time was less than 30 s per image. The radiologist could then review the case and release the patient. The radiologist could also switch to realtime videoconferencing mode and direct the rural ultrasound technician to obtain additional images of the patient 18. Pavlopoulos, S.; Berler, A.; Kyriacou, E., and Koutsouris, D. (Department of Electrical and Computer 21
    • Engineering, National Technical University of Athens, Zografou, Greece). Design and development of a multimedia database for emergency telemedicine. Technology & Health Care. 1998 Sep; 6(2-3):101-10. Call Number: *III 6B Abstract: Recent studies conclude that early and specialised pre-hospital patient management contributes to emergency cases survival. Recent developments in telecommunication and medical informatics by means of telemedicine can be extremely useful to accomplish such tasks in a cost- effective manner. Along that direction, we have designed a portable device for emergency telemedicine. This device is able to telematically "bring" the expert doctor at the emergency site, have him perform an accurate diagnosis, and subsequently direct the Emergency Medical Technicians on how to treat the patient until he arrives to the hospital. The need for storing and archiving all data being interchanged during the telemedicine sessions is very crucial for clinical, legal and administrative purposes. For this, we have developed a multimedia database able to store and manage the data collected by the AMBULANCE system. The database was equipped with a user-friendly graphical interface to enable use from computer naive users. Furthermore, the database has the possibility to display, in an standard way, ECG's, X-ray, CT and MRI images. The application is password protected with a three-level hierarchy access for users with different privileges. The scope of this application is to enhance the capabilities of the doctor on duty for a more precise and prompt diagnosis. The application has the ability to store audio files related to each emergency case and still images of the scene. Finally, this database can become a useful multimedia tool which will work together with the AMBULANCE portable device, the HIS and the PACS of the hospital. The system has been validated in selected non-critical cases and proved to be functional and successful in enhancing the ability of the doctor's on duty for prompt and accurate diagnosis and specialised pre-hospital treatment 19. Petrovichev, N. N.; Shabalova, I. P.; Sokolova, V. K.; Chistiakova, O. V.; Kareva, L. P.; Kovrigina, A. M.; Fedoseev, V. N.; Shchipalkin, V. I., and Solomatina, T. P. [Feasibilities of cytological diagnosis in the static telepathology mode]. [Russian]. Klinicheskaia Laboratornaia Diagnostika. 1999 Feb; (2):21-4. Call Number: *III 6B Abstract: Results of cytological diagnosis in the static telepathology mode are analyzed. Three expert cytologists made the diagnosis on the basis of images of cytological preparations obtained from 94 patients with tumors of soft tissues and bones. A total of 113 diagnoses were correct: benign or malignant type of the tumor and its histological type were identified. In general, a total of 152 (88.9%) diagnoses were correct as regards their significance for treatment strategy. Errors classified as groups 3 and 4 were the most significant (erroneous assessment of tumor type--benign or malignant--in 6.4% cases). Analysis of discrepancies between cytological and pathoanatomical diagnoses and data of routine optic microscopy of similar cytological preparations of the same material (bone and soft tissue tumors) showed the same value: 6.8% of cytological and pathoanatomical diagnoses were at disagreement (groups 3 and 4 of errors). Therefore, telepathology can be resorted to for consultations and discussion of obscure cases. It is particularly important for a morphologist to discuss complex cases by means of telepathology at a specialized institution, distant from him or her 20. Pickett, S. M. and van der Heide, G. W. (Faculty of Health, Queensland University of Technology, Brisbane). Medicolegal risk in telemedicine: risk control in teleradiology [see comments]. Medical Journal of Australia. 1999 Nov 15; 171(10):563-5. Call Number: *III 6B Abstract: Teleradiology, the largest single application of telemedicine in Australia, has the potential to improve healthcare access, delivery and standards, but also raise complex new legal and ethical issues. In the absence of any cases of alleged negligence in teleradiology before the courts, a hypothetical case reveals some of the medicolegal risks. These may be minimised by measures including adherence to the Royal Australian and New Zealand College of Radiologists' guidelines on teleradiology 22
    • 21. Singson, R. P.; Natarajan, S.; Greenson, J. K., and Marchevsky, A. M. (Department of Pathology, Cedars Sinai Medical Center, Los Angeles, CA, USA). Virtual microscopy and the Internet as telepathology consultation tools. A study of gastrointestinal biopsy specimens [see comments]. American Journal of Clinical Pathology. 1999 Jun; 111(6):792-5. Call Number: *III 6B Abstract: Telepathology (TP) is the practice of pathology at a distance using videomicroscopy and telecommunication tools. We explore the use of "virtual microscopy" techniques and the Internet as tools for TP gastrointestinal biopsy consultations. Thirty-five gastrointestinal biopsy specimens were photographed in Los Angeles by using a high-resolution digital camera, a light microscope, and a Pentium 166 microcomputer. Several (2-8) digital photomicrographs were collected at 40x or 100x optical magnification, using 2,700 x 3,400 pixel resolution. The photomicrographs illustrated all the tissue fragments present in 1 of the biopsy levels. They were saved in medium compression JPEG image format. These images can be magnified digitally up to 600% without visible degradation and scrolled at different magnifications on a video monitor, simulating examination under a light microscope. The images files (281 to 3,324 KB) were attached to e-mail messages containing patient information and sent through the Internet to Michigan for interpretation using a Power Macintosh 7100 system. The e-mail process was successful in 100% of instances; 2 files were corrupted owing to user error and had to be resent. Additional photos were requested in 1 case. In 33 of 35 cases, there was diagnostic concordance between the original and the TP diagnoses. The 2 discrepancies were due to diagnostic disagreement. This technology offers pathologists relatively inexpensive and effective tools for gastrointestinal TP consultations 22. Wellnitz, U.; Fritz, P.; Voudouri, V.; Linder, A.; Toomes, H.; Schmid, J.; Binder, B., and Schwarzmann, P. (Robert Bosch Hospital, Department of Pathology, Stuttgart, Germany). The validity of telepathological frozen section diagnosis with ISDN-mediated remote microscopy. Virchows Archiv. 2000 Jul; 437(1):52-7. Call Number: *III 6B Abstract: We investigated 109 randomly selected frozen section specimens from lung surgery patients in a retrospective blind mode using telepathology equipment. The telepathology system applied (HISTKOM) used one ISDN B-channel and telemicroscopy with a remotely operated robotic microscope. The performance of telepathological frozen section diagnosis was compared with that of conventional frozen section diagnosis. The false-positive rate achieved was identical for both methods. The sensitivity (P=0.03), but not the specificity, was significantly lower for the telepathological method. The time needed to establish a diagnosis with the remote microscope was too high; therefore, upgrading to multichannel technology is recommended. The quality of the images transmitted was judged to be sufficient by the pathologists involved in the study. In conclusion, with further technical improvements in telemicroscopy and additional experience in telepathology, remote diagnosis seems to be feasible 23. Yogesan, K.; Cuypers, M.; Barry, C. J.; Constable, I. J., and Jitskaia, L. (Centre for Ophthalmology and Visual Science, Lions Eye Institute, University of Western Australia, Australia. Tele-ophthalmology screening for retinal and anterior segment diseases. Journal of Telemedicine & Telecare. 6 Suppl 1:S96-8, 2000. Call Number: *III 6B Abstract: A digital indirect ophthalmoscope (DIO) was developed and tested for use in tele- ophthalmology screening for posterior and anterior segment diseases. Using custom software, images from the DIO were digitized, compressed, stored and transmitted to a centralized eye clinic for interpretation. A total of 43 subjects were primarily screened for glaucoma using the DIO, a hand-held fundus camera and a stereo fundus camera. The photographic slides from the stereo fundus camera used as gold standards. Images (390 x 300 pixels x 3 bits) were stored using a laptop computer together with patient information. Image quality received at the central eye clinic was good and showed adequate diagnostic information. An ophthalmologist estimated cup-disc ratios and graded the quality of the images. The sensitivity and specificity of each instrument was calculated. A high sensitivity and specificity was found when using the DIO, indicating that it could be used in tele-ophthalmic screenings. Further modifications are needed to make the instrument more user- friendly and to enable it to be used with undilated pupils, so that it can be easily operated by health- 23
    • care personnel in remote areas. The camera can also be used to image gross external eye pathology *III 6 A, II F,*III 6 B 1. Shimmura, S.; Shinozaki, N.; Fukagawa, K.; Shimazaki, J., and Tsubota, K. (Department of Ophthalmology, Tokyo Dental College, Ichikawa, Chiba, Japan.). Real-time telemedicine in the clinical assessment of the ocular surface. American Journal of Ophthalmology. 1998 Mar; 125(3). CODEN: 388-90; ISSN: 0002-9394. Call Number: *III 6 A, II F,*III 6 B Abstract: PURPOSE: To report the feasibility of real-time video and audio transmission of slit-lamp images of the eye using conventional telephone systems. METHOD: We analyzed the feasibility and benefits of telemedicine in the diagnosis and follow-up of ocular surface disorders in referral patients using a real-time audio-video system that functions through integrated services digital network lines at a transmission speed of 384 kilobytes per second. RESULTS: Real-time slit-lamp images obtained through integrated services digital network lines offered satisfactory visual resolution of the ocular surface for the diagnosis and follow-up of ocular surface and corneal disease, while simultaneous audio transmission allowed for direct communication with the patient and attending physician when necessary. CONCLUSION: Telemedicine using conventional telecommunication infrastructures offers sufficient information for the diagnosis and follow-up of ocular surface disorders in referral patients. *III 6 A, II L, *III 6 B 1. Crump, W. J.; Kumar, R.; Orsak, G., and Pfeil, T. (Department of Family Medicine, University of Texas Medical Branch, Galveston 77555-1123, USA.). A field trial of 2 telemedicine camera systems in a family practice. Archives of Family Medicine. 1998 Mar-1998 Apr 30; 7(2). CODEN: 174-6; ISSN: 1063-3987. Call Number: *III 6 A, II L, *III 6 B Abstract: Previous reports of telemedicine consultations have demonstrated that the technology is effective but inefficient. Little attention has been directed to the use of telemedicine in a primary care practice, especially the use of the medical peripheral devices. We used a functioning primary care practice as a telemedicine test bed, providing unselected patients in the study group. The goal was to study the performance of a new generation of a compact set of medical peripheral devices specifically designed for telemedicine examinations. In a 3-week field trial, 2 second-generation camera systems were used by physician faculty and residents in family practice to examine the skin, ears, and pharynx of 34 patients, ranging in age from 10 months to 78 years. Evaluations by the clinicians and patients were obtained. The average duration of an examination using these systems was 2 minutes. Patients' response was uniformly positive. A "pistol grip" video otoscope obtained an acceptable image, unless canal debris obscured the view. The system that provided pneumatic otoscopy was preferred, with some modifications necessary to obtain an airtight seal. The preferred skin camera was one that provided an image of a size that clinicians were most accustomed to viewing, although stability of this handheld camera was a problem. This camera also worked well to visualize the pharynx, especially in children with symptoms of pharyngitis. Color was deemed important in all 3 anatomical areas, and using auto-white balance and excluding fluorescent lights were preferred. Thus, the second-generation telemedicine peripheral devices were effective for use in a group of unselected primary care patients. These camera systems can be used by nursing personnel and require a minimum of time per examination. *III 6 A, *III 6 B 1. Krupinski, E.; Maloney, K.; Hopper, L., and Weinstein, R. (Department of Radiology, University of Arizona, Tucson 85724, USA.). Evaluation of radiologist performance using telemedicine services. Journal of Digital Imaging. 1997 Aug; 10(3 Suppl 1). CODEN: 83-5; ISSN: 0897-1889. Call Number: *III 6 A, *III 6 B Abstract: Observer performance of radiologists using a telemedicine service was evaluated. 24
    • Diagnoses between the rural and consulting radiologists agreed 84% of the time. The main reason for disagreement was extent of lesion rather than type or absence/presence. Consulting times and image quality were considered adequate. 2. Mitchell, J. G. and Disney, A. P. (John Mitchell, John Mitchell & Associates, Unley, South Australia. Clinical applications of renal telemedicine. Journal of Telemedicine & Telecare. 1997; 3(3). CODEN: 158-62; ISSN: 1357-633X. Call Number: *III 6 A, *III 6 B Abstract: In 1994, a telemedicine network was established linking the renal unit at The Queen Elizabeth Hospital to three satellite dialysis centres in South Australia. In the first two and a half years of operation, the telemedicine equipment was used on over 6000 occasions. Interviews were conducted with 18 medical, nursing and allied health staff and dialysis patients. The main finding was that the full range of staff, from surgeons and nephrologists to allied health staff and nurses, were able use the technology successfully for clinical purposes. A second finding was that the technology enabled staff to perform a wide range of clinical procedures, from routine outpatient consultations and monitoring infections to making decisions about retrieval or confirming decisions to operate. A third finding was that telemedicine enabled the renal unit to provide improved services in which teams of staff at the different sites cooperated in ways that were not possible before the telemedicine links became available. *III 6 A, *III 6 B, *II 3 1. Tachakra, S.; Freij, R.; Mullett, S., and Sivakumar, A. (Accident and Emergency Department, Central Middlesex Hospital, London, UK.). Teleradiology or teleconsultation for emergency nurse practitioners?. Journal of Telemedicine & Telecare 1996;2 Suppl 1:56-8. ISSN: 1357-633X. Call Number: *III 6 A, *III 6 B, *II 3 Abstract: Twenty radiographs showing subtle orthopaedic findings were transmitted to three emergency physicians. Fifty-seven of the 60 attempted diagnoses were correct. We found the primary radiographic film had to be well centred, exposed, true and penetrated for successful transmission. There is a considerable element of familiarization with the technology. The software should permit simultaneous annotation from the two sites and additional cameras are necessary to enable emergency nurse practitioners (ENPs) to show the injured part. The 20 radiographs took 120 min to interpret with teleradiology rather than 10 min of viewing conventional films. The extra time for teleradiology is due to readers asking for multiple areas of the radiographic image to be enlarged before making a decision. We feel that ENPs should not engage in teleradiology but rather telemedical consultation. *III 6A *III 6B 1. Demartines, N.; Freiermuth, O.; Mutter, D.; Heberer, M., and Harder, F. (Department of Surgery, University Hospital of Basle, Switzerland. Knowledge and acceptance of telemedicine in surgery: a survey. Journal of Telemedicine & Telecare. 2000; 6(3):125-31. Call Number: *III 6A *III 6B Abstract: A questionnaire was sent to the chief surgeons at 141 Swiss hospitals to evaluate their knowledge and acceptance of telemedicine in surgery. The response rate was 69%. Ninety-three per cent of all surgical departments used computer technology, 85% regularly used the Web and 88% had an internal hospital network. ISDN lines were used in 58% of the participants' hospitals. While 35% of respondents had participated at least once in networking, only 8% regularly used telemedicine. The opinion was that access to therapeutic advice (87%) was a better use of telemedicine than was obtaining a primary diagnosis (24%), although the majority accepted the principle of making (91%) and receiving (94%) a remote diagnosis. The survey suggested that surgeons are interested in telemedicine and open to its development, although their experience and knowledge are limited. Therefore, telemedicine in surgery may be advanced by creating surgical networks for teleconsultation and tele-education 25
    • *III 6 B 1. Allaert, F. A.; Weinberg, D.; Dusserre, P.; Yvon, P. J.; Dusserre, L.; Retaillau, B., and Cotran, P. (Department of Medical Informatics, University of Dijon, France.). Evaluation of an international telepathology system between Boston (USA) and Dijon: glass slides versus telediagnostic television monitor. Journal of Telemedicine & Telecare 1996;2 Suppl 1:27-30. ISSN: 1357-633X. Call Number: *III 6 B Abstract: A telepathology network developed by Resintel (Dijon) has proved valuable in interactive situations, where two physicians converse by telephone, showing each other the part of the lesion they wish to discuss. In future this interactive process could be replaced by an electronic mailing service in which a limited number of images are taken from the slide, but this technique needs to be assessed in comparison with traditional microscopic diagnosis, when the pathologist can screen the entire slide. The present study compared diagnoses achieved through the traditional methods of current pathology practice with diagnoses achieved through a selection of images on a telediagnostic TV monitor. The kappa coefficient between the two protocols was 0.26 (SE = 0.06), which allows us to conclude that there is a fair reliability between video and glass slide diagnoses. 2. Anquetil, R.; Barberteguy, R.; Bernou, J. M.; Labes, P., and Belhomme, C. (SAMU 40, Service Dr Cazaugade, CH Layne, Avenue Cronstadt, 40024 Mont-de-Marsan cedex). [Analysis of inter- hospital teleradiology consultation in Aquitaine: a 2 year follow-up study in Mont-de-Marsan's Emergency Department]. [French]. Journal De Radiologie. 1999 Dec; 80(12):1643-7. Call Number: *III 6 B Abstract: PURPOSE: This paper relates a technical and functional study of teleradiology network after two years of duty in Mont-de-Marsan's general hospital. MATERIALS AND METHODS: We studied from november 1995 to november 1997, the following items: the number of transmitted files, the medical departments involved, the degree of emergency, the purpose of the transmission, the number and type of images, if patient's transfer is wished or not, and the way the answer is given. RESULTS: During this 2-year period, 94 files were transmitted mainly to the University Hospital. The radiology department was the main user (36%), followed by the emergency department (29%). A notion of emergency occurred in 63% of the cases. Most of the cases where for radiodiagnosis (48%), and therapeutic advice (42%), mainly in neurosurgery. Each file consisted of 3 to 4 images of which 77% were CT-Scan. The patient transfer was wished for in 13 files. Answer was given by computerised methods in 43% of the cases, and otherwise by telephone. CONCLUSION: Despite a better medical management of patients, this network is underused. The main reasons being the lack of information, the lack of time and the fact the network has not yet found its place in our professional environment 3. Baker, S. R. and Festa, S. (Department of Radiology, University of Medicine and Dentistry New Jersey-New Jersey Medical School, Newark, USA. The use of teleradiology in an emergency setting with speculation on the near future. [Review] [19 refs]. Radiologic Clinics of North America. 1999 Sep; 37(5):1035-44. Call Number: *III 6 B Abstract: None of these models will automatically come to pass but all are possible today. Radiologists have to realize that the teleimaging era for emergency patients is here to stay. Successful utilization for good and gain may no longer be accomplished by a reliance on old or outmoded practice assumptions. The virtual turf, prepared by the rapidity of the remote transmission of electronically generated pictures, is a real phenomenon for which radiology has and will play a major role. The practice opportunities may not be vast in scope, but on a regional basis the imaging landscape is still green and up for grabs. [References: 19] 4. Buxton, P. J. (Royal Hospital Haslar, Hants, UK. Teleradiology--practical aspects and lessons learnt. European Journal of Radiology. 1999 Nov; 32(2):116-8. Call Number: *III 6 B Abstract: Teleradiology is the most widely practised form of telemedicine and the necessary equipment is readily available. The limiting technical factor is often the communication links 26
    • between the two sites. A balance must be struck between the degree of image compression and the transmission time. Non technical issues such as organisation of staff and medico-legal aspects must also be considered. Many problems can be avoided by written protocols and agreements 5. Casey, F.; Brown, D.; Corrigan, N.; Craig, B. G.; Quinn, M.; McCord, B.; Rogers, J., and Mulholland, H. C. (Department of Paediatric Cardiology, Royal Belfast Hospital for Sick Children, Belfast, UK.). Value of a low-cost telemedicine link in the remote echocardiographic diagnosis of congenital heart defects. Journal of Telemedicine & Telecare 1998;4 Suppl 1:46-8. ISSN: 1357-633X. Call Number: *III 6 B Abstract: We established a low-cost telemedicine link from a district general hospital to the regional paediatric cardiology department about 120 km away. The link was used to transmit echocardiographic images of newborn infants suspected of having congenital heart disease (CHD) to the referral centre, with simultaneous video and audio contact for consultation. Echocardiograms were transmitted for 61 patients suspected of having CHD, aged from 1 to 42 days. The transmitted images were of adequate quality for the paediatric cardiologist to make a diagnosis in 59 (97%). Congenital heart abnormalities were diagnosed in 38 (64%). Twelve patients (20%) had major CHD diagnosed on the transmitted scan and required transfer to the regional cardiology unit either urgently or electively after initial measures to stabilize the patient. Our findings suggest that, for babies suspected of having CHD, ultrasound images of diagnostic quality can be obtained and transmitted using a low-cost telemedicine system. 6. de Lusignan, S.; Althans, A.; Wells, S.; Johnson, P.; Vandenburg, M., and Robinson, J. (Department of General Practice and Primary Care, St George's Hospital Medical School, London, UK. A pilot study of radiotelemetry for continuous cardiopulmonary monitoring of patients at home. Journal of Telemedicine & Telecare. 6 Suppl 1:S119-22, 2000. Call Number: *III 6 B Abstract: We have conducted a trial of a wireless device for continuous cardiopulmonary monitoring. Its performance, user acceptance and safety were assessed for monitoring in the patient's home. The study included 20 patients: six with chronic obstructive pulmonary disease, six with chronic heart failure, seven with atrial fibrillation and palpitations, and one with a snoring problem. The system recorded the heart rate and respiratory rate, blood pressure, electrocardiogram and body temperature. The results were transmitted automatically to a central monitoring station. The accuracy of the measurements was checked by a comparison system and also by conventional measurements performed by a nurse. The system was acceptable to patients and functioned satisfactorily in the home. An important facet of home telemonitoring may turn out to be its greater reliability in collecting objective data 7. Della Mea, V.; Cataldi, P.; Boi, S.; Finato, N.; Dalla Palma, P., and Beltrami, C. A. (Institute of Pathology, University of Udine, Italy. Image sampling in static telepathology for frozen section diagnosis. Journal of Clinical Pathology. 1999 Oct; 52(10):761-5. Call Number: *III 6 B Abstract: BACKGROUND: A frozen section diagnostic service is often not directly available in small rural or mountain hospitals. In these cases, it could be possible to provide frozen section diagnosis through telepathology systems. Telepathology is based on two main methods: static and dynamic. The former is less expensive, but involves the crucial problem of image sampling. AIMS: To characterise the differences in image sampling for static telepathology when undertaken by pathologists with different experience. METHODS: As a test field, a previously studied telepathology method based on multimedia email was adopted. Using this method, three pathologists with different levels of experience sampled images from 155 routine frozen sections and sent them to a distant pathology institute, where diagnoses were made on digital images. After the telepathology diagnoses, the glass slides of both the frozen sections and the definitive sections were sent to the remote pathologists for review. RESULTS: Four of 155 transmissions were considered inadequate by the remote pathologist. In the remaining 151 cases, the telepathology diagnosis agreed with the gold standard in 146 (96.7%). There was no significant divergence between the three 27
    • pathologists in their sampling of the images. Each case comprised five images on average, acquired in four minutes. The overall time for transmission was about 19 minutes. CONCLUSIONS: The results suggest that in routine frozen section diagnosis an inexperienced pathologist can sample images sufficiently well to permit remote diagnosis. However, as expected, the internet is too unreliable for such a time dependent task. An improvement in the system would involve integrated real time features, so that there could be interaction between the two pathologists 8. Della Mea, V.; Cataldi, P.; Boi, S.; Finato, N.; Della Palma, P., and Beltrami, C. A. (Department of Pathology, University of Udine, Italy. Image selection in static telepathology through the Internet. Journal of Telemedicine & Telecare 1998;4 Suppl 1:20-2. ISSN: 1357-633X. Call Number: *III 6 B Abstract: A telepathology study was carried out to examine the differences occurring when the images were selected by an experienced pathologist, a junior pathologist and a first-year resident. One hundred and fifty-five consecutive frozen-section pathology cases were collected and sent for consultation to a remote experienced pathologist using multimedia email. Local diagnoses (as reported in the files of the Institute, not from the image selector) and remote diagnoses (based on the images) were compared with those performed on paraffin-embedded sections. Acquisition time and number of selected images were recorded for each case and used to compare the different behaviour of the three local pathologists. Of the 155 cases sent by telepathology, four were considered insufficient for a diagnosis by the remote pathologist and thus the diagnosis was postponed. In the remaining 151 cases, the overall diagnostic agreement between remote and definitive diagnosis was 96.7%. The results indicate that in the routine diagnostic work of a frozen-section service, an inexperienced pathologist can select images which are sufficiently informative for a remote diagnosis, in a sufficiently short time. 9. Della Mea, V.; Cortolezzis, D., and Beltrami, C. A. (Institute of Pathology, University of Udine, Italy. The economics of telepathology--a case study. Journal of Telemedicine & Telecare. 6 Suppl 1:S168-9, 2000. Call Number: *III 6 B Abstract: There are several obstacles that slow down the diffusion of telepathology. One is related to uncertainty about the economic consequences of its adoption, possibly more so than in other fields of telemedicine. We have evaluated the economics of telepathology when used to provide a frozen- section service to a mountain hospital, in comparison with three current alternatives. In the specific situations studied, no one model was always less expensive than the others. In particular, owing to the very low cost of the ambulance service provided by the Red Cross, the ambulance model was least expensive when dealing with up to 73 frozen sections a year, while at higher case-loads telepathology was cheaper. If ambulance transfer is neglected, telepathology appears to be the most convenient approach to the remote frozen-section service. Although the consultant pathologist costs more than telemedicine, during free time he/she could perform other (routine) work, thus reducing the real cost of frozen sections 10. Delta Mea, V.; Cataldi, P.; Pertoldi, B., and Beltrami, C. A. (Institute of Pathology, University of Udine, Italy. Dynamic robotic telepathology: a preliminary evaluation on frozen sections, histology and cytology. Journal of Telemedicine & Telecare. 5 Suppl 1:S55-6, 1999. Call Number: *III 6 B Abstract: We evaluated the diagnostic efficacy of a dynamic robotic telepathology system for the delivery of pathology services to distant hospitals. The system provided static/dynamic features and the remote control of a robotic microscope using four ISDN lines. For evaluation purposes, 184 consecutive cases were diagnosed at distance using the system. The cases were 60 frozen sections, 64 cases of gastrointestinal pathology and 60 cases of urinary cytology. The telemedicine diagnoses obtained in this way were compared with traditional microscopic diagnosis. Diagnostic agreement ranged from 90% in urinary cytology to 100% in frozen sections. The results suggest that a dynamic robotic telepathology system can be a useful tool for supporting the pathology practice of isolated hospitals 28
    • 11. Doolittle, G. C.; Yaezel, A.; Otto, F., and Clemens, C. (Division of Oncology, University of Kansas Medical Center, Kansas City 66160-7353, USA. Hospice care using home- based telemedicine systems. Journal of Telemedicine & Telecare 1998;4 Suppl 1:58-9. ISSN: 1357-633X. Call Number: *III 6 B Abstract: A pilot study of telenursing for terminally ill patients at home was launched as a collaborative effort between KUMC and the Kendallwood Hospice. The service used the public telephone network. Interactive video equipment was installed in the homes of three nurses who received after-hours calls and in the homes of six hospice patients living in either Kansas or Missouri. Data concerning the utilization patterns were gathered for two separate three-month periods. Patients and caregivers reported general satisfaction with the telehospice system. Both the nurses and social worker providers became comfortable about video-calls. Nurses conducted video- assessments to determine whether an 'in person' visit was necessary. This was particularly helpful for rural patients who were living a long way from the base station. In addition, Kendallwood serves an urban population and, in certain areas, night-time nursing visits raise safety concerns. 12. Engelmann, U.; Schroter, A.; Baur, U.; Werner, O.; Schwab, M.; Muller, H., and Meinzer, H. P. (German Cancer Research Center, Dept. Medical and Biological Informatics, Heidelberg, Germany. The evolution of a German teleradiology system. Medinfo. 9 Pt 1:255-60, 1998. Call Number: *III 6 B Abstract: This paper describes the evolution of a german teleradiology system. The development started from simple image file transfer, continued with a dedicated teleradiology system and ended up with a general radiology workstation with teleradiology features. The main features, advantages and drawbacks of the different generations are described. The own developments are compared with developments at other places. The influence by standards is also included in this investigation. The latest systems are mainly used by the radiologists and the image transfer for scientific cooperation is nowadays just one of several application fields of teleradiology 13. Feussner, H.; Wilhelm, D.; Etter, M., and Siewert, J. R. (Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universitat Munchen. [Second opinion in tumor surgery. Valuable--but needing improvement]. [German]. MMW Fortschritte Der Medizin. 2000 Jan 27; 142(4):22-5. Call Number: *III 6 B Abstract: In complicated oncological cases, a second opinion is desirable, also in the view of the care-providing surgeon. It serves interdisciplinary therapeutic planning, and helps improve the quality of treatment. In the case of highly consequential interventions, the patient has a legal right to a second opinion. On a practical level, however, the implementation of this possibility encounters problems: organizational shortcomings, incomplete patient documentation, the stresses of patient transportation, loss of valuable time, in particular in the case of postal consultation, following consultation in a center the carrying out of treatment there, whether at the urging of the doctors there or the patient himself, lack of remuneration for the efforts of the consultants. Today, however, all the necessary technical facilities are in place to enable various experts to be consulted, virtually simultaneously, on any case, via video-conferencing 14. Finley, J. P.; Sharratt, G. P.; Nanton, M. A.; Chen, R. P.; Bryan, P.; Wolstenholme, J., and MacDonald, C. (Department of Pediatric Cardiology, IWK Grace Health Centre, Halifax, Nova Scotia, Canada. Paediatric echocardiography by telemedicine--nine years' experience. Journal of Telemedicine & Telecare. 1997; 3(4). CODEN: 200-4; ISSN: 1357-633X. Call Number: *III 6 B Abstract: In 1987 we established a realtime echocardiography service by telemedicine from the paediatric cardiology department of a tertiary-care hospital in Halifax. The service was initially provided to single regional hospital but was expanded to six regional hospitals in the three Canadian Maritime Provinces. The system used a dial-up broadband video-transmission service provided by the telephone companies. Records of all transmissions were kept prospectively and reviewed to 29
    • January 1997. A total of 324 transmissions were made. During 1995-96 there were 135 studies: 69 (51%) were urgent examinations of newborn children and 30 (22%) were urgent examinations of older children; repeat studies and postoperative checks (usually for pericardial effusion) accounted for the other 36 studies (27%). The images were of broadcast quality except in five cases where problems with transmission or poor sedation occurred. A comparison of 26 transmitted studies with repeat, 'in person' studies showed no important discrepancies in diagnosis. During the two-year study period, the cost of the network (equipment leasing costs and telecommunications costs) was C$90,000. Use of the telemedicine network saved unnecessary patient transfer in 31 cases. The cost of the transportation avoided was C$100,000-C$118,000. This review confirms our preliminary findings that broadband echocardiography transmission provides a service comparable in availability and accuracy to that provided in our paediatric cardiology division. 15. Flandrin, G. (Laboratoire central d'Hematologie, Hopital Necker-Enfants malades, Paris). [Telemedicine and telepathology in hematology]. [French]. Bulletin De l Academie Nationale De Medecine. 1998; 182(5):1037-42; discussion 1042-4. Call Number: *III 6 B Abstract: Long distance transmission by the telephone network have offered new facilities in transmitting images in real time. Pathologists and other specialists like radiologists are now using these transmissions of digitalised pictures, both for diagnostic support and for constituting image data base for teaching purposes. Haematological application of this new method is shown as a particularly good example 16. Galvez, J.; Howell, L.; Costa, M. J., and Davis, R. (Department of Pathology, University of California, Davis, Medical Center, Sacramento, USA.). Diagnostic concordance of telecytology and conventional cytology for evaluating breast aspirates. Acta Cytologica. 1998 May-1998 Jun 30; 42(3). CODEN: 663-7; ISSN: 0001-5547. Call Number: *III 6 B Abstract: OBJECTIVE: To evaluate the diagnostic concordance between static electronic images versus glass slides for breast fine needle aspiration (FNA) cytology. STUDY DESIGN: Nine malignant and 12 benign breast FNA cases were imaged using the Roche Image Manager, at a resolution of 1,024 x 768 pixels. A cytotechnologist or pathology resident selected five to nine representative images per case. Case histories and images were assembled into hypertext documents. Two pathologist blindly made diagnoses for each case based on the images and the clinical history and independently made diagnoses for the glass slides, also evaluating each set of images and glass slides for a list of cellular features. RESULTS: The two pathologist had concordance rates of 90.5% and 66.7% between their image and glass diagnoses. For each pathologist's discordant cases, 100.0% and 85.7%, respectively, were due chiefly to suspicious rather than definitive diagnoses. CONCLUSION: Evaluation of the electronic images indicated that almost all the cellular features were comparable to those viewed though a microscope. 17. Glombitza, G.; Evers, H.; Hassfeld, S.; Engelmann, U., and Meinzer, H. P. (Deutsches Krebsforschungszentrum, Division of Medical and Biological Informatics/H0100, Heidelberg, Germany). Virtual surgery in a (tele-)radiology framework. IEEE Transactions on Information Technology in Biomedicine. 1999 Sep; 3(3):186-96. Call Number: *III 6 B Abstract: This paper presents telemedicine as an extension of a teleradiology framework through tools for virtual surgery. To classify the described methods and applications, the research field of virtual reality (VR) is broadly reviewed. Differences with respect to technical equipment, methodological requirements and areas of application are pointed out. Desktop VR, augmented reality, and virtual reality are differentiated and discussed in some typical contexts of diagnostic support, surgical planning, therapeutic procedures, simulation and training. Visualization techniques are compared as a prerequisite for virtual reality and assigned to distinct levels of immersion. The advantage of a hybrid visualization kernel is emphasized with respect to the desktop VR applications that are subsequently shown. Moreover, software design aspects are considered by outlining functional openness in the architecture of the host system. Here, a teleradiology workstation was 30
    • extended by dedicated tools for surgical planning through a plug-in mechanism. Examples of recent areas of application are introduced such as liver tumor resection planning, diagnostic support in heart surgery, and craniofacial surgery planning. In the future, surgical planning systems will become more important. They will benefit from improvements in image acquisition and communication, new image processing approaches, and techniques for data presentation. This will facilitate preoperative planning and intraoperative applications 18. Gu, J. (Institute of Molecular Morphology, Mount Laurel, NJ 08054, USA. Recent advances in telepathology. Cell Vision. 1998 Jan-1998 Feb 28; 5(1). CODEN: 62-6; ISSN: 1073-9511. Call Number: *III 6 B Abstract: Telepathology is to transform microscopic and gross images of pathological specimen into digital forms and transmit them electronically to remote sites for consultation and collaboration. Many benefits can be derived from telepathology. Although still at its initial developing stage, this technology is beginning to change the way pathological practice is conducted. With the rapid advancement of computer and telecommunication sciences, telepathology is increasingly becoming more feasible and practical for pathologists. This review gives a comprehensive account of the recent development in telepathology, discusses its functionality, applications, limitations and potential, and serves as an introduction to this rapidly evolving field. 19. Harrison, P. V.; Kirby, B.; Dickinson, Y., and Schofield, R. (Dermatology Department, Queen Victoria Hospital, Morecambe, Lancashire, UK.). Teledermatology--high technology or not?. Journal of Telemedicine & Telecare 1998;4 Suppl 1:31-2. ISSN: 1357-633X. Call Number: III 6 B* Abstract: As an alternative to attending a conventional dermatology clinic, patients had a high- resolution conventional photographic image taken by a professional medical photographer. The photographic images were viewed by a dermatologist together with referral details from the general practitioner and any other relevant information from the patient's notes. From the images, a dermatological diagnosis was derived and a management plan for each patient instituted. After treatment, histological assessment of the tumours allowed diagnostic accuracy to be determined. The preliminary diagnostic accuracy (71%) was greater than that of the referring general practitioners (49%). However, when the diagnostic ability of the method to detect the nature of malignant lesions was examined, telemedicine was able to detect malignancies in 94% of cases compared with only 70% detected by general practitioners. The results of the present study indicate that teledermatology is achievable using a low-technology, low-cost approach. 20. Haugen, O. A.; Halvorsen, T. B.; Aarset, H.; Ovrehus, T. A.; Torp, S. H.; Edna, T. H., and Ruud, S. (Avdeling for Patologi Regionsykehuset i Trondheim). [Telepathology in Mid-Norway (see comments)]. [Norwegian]. Tidsskrift for Den Norske Laegeforening. 1999 Jan 30; 119(3):355-8. Call Number: *III 6 B Abstract: Telepathology can provide frozen section service to hospitals without a pathology service of their own. Using a dynamic-robotic system with 6 ISDN B-channels (Telemed A200, AM Elektronikk A/S, Oslo, Norway), the pathologists at the University Hospital in Trondheim, Norway during a three-year period from 1995 successfully performed 116 diagnostic sessions for two rural Norwegian hospitals. In 90% of the cases a diagnosis was provided. There was no false positive diagnosis and only 3% false negative cases without clinical consequence. Deferred cases (10%) were mainly due to poor quality of the frozen sections and a conservative attitude among the pathologists. It is concluded that the diagnostic accuracy is good, but for safety reasons telepathology should be offered on a regular basis, so that the skills of the technicians and pathologists involved are kept up. In Mid-Norway, five more hospitals will be included in a telemedicine network comprising eight hospitals in the region 21. Johnson, P. (Telemonitoring Research Centre, John Radcliffe Hospital, Oxford, UK. paul.johnson:obs- The clinical and economic advantages of remote, community-based physiological assessment. Journal of Telemedicine & Telecare 1998;4 Suppl 1:64-6. ISSN: 1357-633X. Call Number: III 6 B* 31
    • Abstract: A prospective study documented the nutritional intakes of a large cohort of pregnant women living in Portsmouth and investigated the independent relationships of smoking, dietary intake and other maternal socio-economic factors on outcome and cardiorespiratory function of the child during sleep at home at three weeks and three months of age. Unattended overnight cardiorespiratory recording was performed and the data stored in local memory before transmission on demand via modem to Oxford next morning. The telemetry of the physiological data, entirely managed by part-time community nurses in Portsmouth, was very successful. Despite some losses, which included transmission failures, electrode or lead disconnection, and monitor malfunction, 92% of the physiological data were analysed at Oxford. Personalized physiological monitoring in the community provides an opportunity for new evidence bases that will enable a new level of individualized care. 22. Jukic, D. M. and Bifulco, C. B. (Departments of Dermatopathology and Pathology Informatics, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA. Telepathology and pathology at distance: an overview. [Review] [45 refs]. Croatian Medical Journal. 1999 Sep; 40(3):421-4. Call Number: *III 6 B Abstract: Telepathology is probably the latest addition to the world of pathology. The costs of pathologic tests have increased, the requirements for shortened turnaround time are omnipresent and we are all aware of the current litigious environment. Telepathology is one of the answers to at least some of these requests. Here we review the current status of telepathology in the world of telemedicine; compare differences, similarities and applications of static and dynamic telepathology; and give a short introduction to the basic setup of a telepathology laboratory. [References: 45] 23. Kangarloo, H.; Valdez, J. A.; Yao, L.; Chen, S.; Curran, J.; Goldman, D.; Sinha, U.; Dionisio, J. D.; Taira, R.; Sayre, J.; Seeger, L.; Johnson, R.; Barbaric, Z., and Steckel, R. (Department of Radiological Sciences, UCLA School of Medicine, Los Angeles, CA 90024, USA). Improving the quality of care through routine teleradiology consultation. Academic Radiology. 2000 Mar; 7(3):149-55. Call Number: *III 6 B Abstract: RATIONALE AND OBJECTIVES: The hypotheses of this study were as follows: (a) University subspecialty radiologists can provide consultations effectively to general radiologists as part of routine clinical operations; (b) these consultations will improve the quality of the final radiologic report; and (c) the consultations will improve the care process and may save money, as well. MATERIALS AND METHODS: For 2,012 consecutive computed tomographic or magnetic resonance (MR) imaging studies, the initial interpretations provided by radiology generalists were subsequently reviewed by specialists, with a final consensus report available. "Truth" was established by final consensus reports. To control for potential bias, 150 adult MR imaging and 250 pediatric radiologic studies were interpreted initially by specialists and then by generalists. Again, truth was established by final consensus reports. RESULTS: There was disagreement between generalist and specialist radiologist interpretations in 427 (21.2%) of the cases reviewed. These disagreements were stratified further by independent specialists, who graded them as important, very important, or unimportant. Differences were considered important or very important in 99% of the cases reviewed. CONCLUSION: Consultations by subspecialty radiologists improved the quality of the radiology reports studied and, at least in some cases, improved the process of care by eliminating unnecessary procedures or suggesting more specific follow-up examinations. The consultation services can be provided cost-effectively from the payer's perspective and may save additional costs when unnecessary procedures can be eliminated 24. Kirkpatrick, A. W.; Brenneman, F. D.; McCallum, A.; Breeck, K., and Boulanger, B. R. (Vancouver Hospital & Health Sciences Centre, British Columbia, Canada. Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals. Journal of Trauma-Injury Infection & Critical Care. 1999 Jun; 46(6):1017-23. Call Number: *III 6 B Abstract: BACKGROUND: Teleradiology is one form of telemedicine that would allow the transmission of radiographs before the transfer of acutely traumatized patients between referring and 32
    • receiving hospitals. The purpose of this study was to evaluate the potential impact of a prehospital teleradiology system on trauma patient management and transfer. METHODS: Forty-four injured adults referred to a trauma center were included. The history, physical examination, and radiographic findings reported by the referring physician to the receiving physician were documented. The plain radiographs of the chest, pelvis, and cervical spine taken at the referring hospital were obtained after patient transfer. For each case, two reviewers blinded to the case (surgeon [S] and emergency department physician [E]) and one reviewer not blinded to the case were individually presented with the referring physician's report and the radiographs. The reviewers were surveyed as to the implications of viewing the plain radiographs taken at the referring hospital before patient transfer. RESULTS: Overall, the blinded reviewers felt that viewing the radiographs before transfer would have influenced care in 40% and 38% of cases as judged by (S) and (E), respectively, with a crude agreement of 67.5% (kappa level, 0.32). The blinded reviewers (S and E) commonly noted the following four changes in management as a result of viewing the referred radiographs: requested further clinical history (S, 18%; E, 23%), suggested further pretransfer interventions (S, 38%; E, 30%), suggested further pretransfer diagnostic tests (S, 25%; E, 13%), and emphasized precautions during transfer (S, 28%; E, 30%). The nonblinded reviewer suggested potential influence in the management of at least 65% of the cases. CONCLUSION: This study suggests that viewing the radiographs of acutely injured trauma patients has the potential to influence many aspects of the management of interhospital transfer 25. Kobak, K. A.; Taylor, L. H.; Dottl, S. L.; Greist, J. H.; Jefferson, J. W.; Burroughs, D.; Mantle, J. M.; Katzelnick, D. J.; Norton, R.; Henk, H. J., and Serlin, R. C. (Dean Foundation for Health, Research and Education, Middleton, Wis 53562, USA. A computer-administered telephone interview to identify mental disorders [see comments]. JAMA. 1997 Sep 17; 278(11). CODEN: 905-10; ISSN: 0098-7484. Call Number: *III 6 B Abstract: CONTEXT: Common mental disorders are often not identified in primary care settings. OBJECTIVE: To evaluate the validity and clinical utility of a telephone-assisted computer- administered version of Primary Care Evaluation of Mental Disorders (PRIME-MD), a brief questionnaire and interview instrument designed to identify psychiatric disorders in primary care patients. DESIGN: Comparison of diagnoses obtained by computer over the telephone using interactive voice response (IVR) technology vs those obtained by a trained clinician over the telephone using the Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID). A subsample also received the clinician- administered version of PRIME-MD. PATIENTS: Outpatients (N=200) from 4 primary care clinics, an eating disorders clinic, an alcohol treatment facility, psychiatric outpatients, and community controls. SETTING: Interviews conducted by telephone, except for face-to-face administration of PRIME-MD, which was conducted at either the primary care clinic or a research clinic. MEASUREMENTS AND MAIN RESULTS: Prevalence rates for any psychiatric disorder were similar between diagnoses made by the computer and those made by a mental health professional using the SCID (60.0% vs 58.5%). Prevalence rates for individual diagnoses were generally similar across versions. However, primary care patients reported twice as much alcohol abuse on the computer (15.0%) as on either the SCID (7.5%) or the clinician-administered PRIME-MD (7.5%). Using the SCID as the criterion, both the computer- and clinician-administered versions of PRIME- MD demonstrated high and roughly equivalent levels of sensitivity and specificity. Overall agreement (K) for any diagnosis was 0.67 for the computer-administered PRIME-MD and 0.70 for the clinician-administered PRIME-MD. CONCLUSIONS: The computer-administered PRIME-MD appears to be a valid instrument for assessing psychopathology in primary care patients. Interactive voice response technology allows for increased availability, and provides primary care physicians with information that will increase the quality of patient care without additional physician time and at minimal expense. 26. Lee, B. R.; Allaf, M.; Moore, R.; Bohlman, M.; Wang, G. M.; Bishoff, J. T.; Jackman, S. V.; Cadeddu, J. A.; Jarrett, T. W.; Khazan, R., and Kavoussi, L. R. (Department of Urology, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA). Clinical decision making using teleradiology in urology [see comments]. AJR. American Journal of Roentgenology. 1999 Jan; 172(1):19-22. 33
    • Call Number: *III 6 B Abstract: OBJECTIVE: Using a personal computer-based teleradiology system, we compared accuracy, confidence, and diagnostic ability in the interpretation of digitized radiographs to determine if teleradiology-imported studies convey sufficient information to make relevant clinical decisions involving urology. Variables of diagnostic accuracy, confidence, image quality, interpretation, and the impact of clinical decisions made after viewing digitized radiographs were compared with those of original radiographs. MATERIALS AND METHODS: We evaluated 956 radiographs that included 94 IV pyelograms, four voiding cystourethrograms, and two nephrostograms. The radiographs were digitized and transferred over an Ethernet network to a remote personal computer-based viewing station. The digitized images were viewed by urologists and graded according to confidence in making a diagnosis, image quality, diagnostic difficulty, clinical management based on the image itself, and brief patient history. The hard-copy radiographs were then interpreted immediately afterward, and diagnostic decisions were reassessed. All analog radiographs were reviewed by an attending radiologist. RESULTS: Ninety-seven percent of the decisions made from the digitized radiographs did not change after reviewing conventional radiographs of the same case. When comparing the variables of clinical confidence, quality of the film on the teleradiology system versus analog films, and diagnostic difficulty, we found no statistical difference (p > .05) between the two techniques. Overall accuracy in interpreting the digitized images on the teleradiology system was 88% by urologists compared with that of the attending radiologist's interpretation of the analog radiographs. However, urologists detected findings on five (5%) analog radiographs that had been previously unreported by the radiologist. CONCLUSION: Viewing radiographs transmitted to a personal computer-based viewing station is an appropriate means of reviewing films with sufficient quality on which to base clinical decisions. Our focus was whether decisions made after viewing the transmitted radiographs would change after viewing the hard-copy images of the same case. In 97% of the cases, the decision did not change. In those cases in which management was altered, recommendation of further imaging studies was the most common factor 27. Lesher, J. L. Jr; Davis, L. S.; Gourdin, F. W.; English, D., and Thompson, W. O. (Department of Medicine, Medical College of Georgia, Augusta 30912-3190, USA.). Telemedicine evaluation of cutaneous diseases: a blinded comparative study. Journal of the American Academy of Dermatology. 1998 Jan; 38(1). CODEN: 27-31; ISSN: 0190-9622. Call Number: *III 6 B Abstract: BACKGROUND: Numerous telemedicine programs have been created in the United States, but studies documenting the fidelity and effectiveness of telemedicine for evaluation of skin diseases are lacking. OBJECTIVE: We attempted to determine the percentage of encounters in which two different dermatologists, one using telemedicine and one on-site, could independently arrive at the same primary diagnosis. METHODS: Two clinical telemedicine sites linked through the Georgia Statewide Telemedicine Program were used in this study of 60 patients with skin problems. One dermatologist evaluated the patients on telemedicine (interactive television) and a second then took the patients into a separate examination room and evaluated them on-site. Each investigator recorded their diagnoses with no discussion with each other. As a control group, the investigators independently and in a blinded fashion (to each other's diagnoses) recorded diagnoses for a group of patients from a third dermatologist's clinic. Raw data were evaluated and classified by this third dermatologist who assigned diagnoses to categories of complete agreement, partial agreement, or disagreement. RESULTS: There were no significant differences with regard to disagreement. However, there was a higher probability of complete agreement between the two dermatologists when each examined the patient on-site and in person than when one evaluated the patient on telemedicine and one examined the patient on-site and in person. CONCLUSION: Our results suggest that telemedicine is an effective means of diagnosing cutaneous diseases. However, because partial interobserver agreement on diagnoses was greater for the telemedicine group than for the control group (p < 0.05), it is likely that optimum use of medical assistants at the remote site will be necessary to increase the likelihood of complete agreement on diagnoses among dermatologists using interactive television. 28. Lowitt, M. H.; Kessler, I. I.; Kauffman, C. L.; Hooper, F. J.; Siegel, E., and Burnett, J. W. (Department of 34
    • Dermatology, University of Maryland School of Medicine, and Baltimore Veterans Affairs Medical Center, 21201, USA. Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement. [Review] [19 refs]. Archives of Dermatology. 1998 Apr; 134(4). CODEN: 471-6; ISSN: 0003-987X. Call Number: *III 6 B Abstract: OBJECTIVE: To compare physician and patient impressions and interphysician diagnostic agreement between live teledermatology and in-person examinations. DESIGN: Paired video and in- person examinations with different dermatologists. SETTING: An urban Veterans Affairs dermatology clinic. PATIENTS: One hundred thirty-nine patients. MAIN OUTCOME MEASURES: Satisfaction questionnaires and interphysician diagnostic agreement. RESULTS: Patient and physician satisfaction was high. Agreement between video and in-person diagnoses was 80%. CONCLUSIONS: Physicians and patients were satisfied with teledermatology examinations. Diagnostic agreement between in-person and video dermatologists was high. [References: 19] 29. McLaughlin, W. J.; Schifman, R. B.; Ryan, K. J.; Manriquez, G. M.; Bhattacharyya, A. K.; Dunn, B. E., and Weinstein, R. S. (Department of Pathology, Arizona Health Services Center, Tucson, USA.). Telemicrobiology: feasibility study. Telemedicine Journal. 1998 Spring; 4(1). CODEN: 11-7; ISSN: 1078-3024. Call Number: *III 6 B Abstract: BACKGROUND: Rural hospitals generally lack staffing with infectious disease specialists or pathologists. Without on-site pathologists, the range of microbiology services offered by clinical laboratories may be limited as well. OBJECTIVE: To study the feasibility of using static-image telepathology to evaluate Gram stains of microbiologic preparations. MATERIALS AND METHODS: In this retrospective feasibility study, three pathologists evaluated Gram stains of slides from 50 cases by two viewing modalities: static-image telepathology and conventional light microscopy. Digital video images of slides were captured at two magnifications (using 40x and 100x objective lenses) at 1024 x 768 x 24-bit color and transmitted over standard telephone lines at 14,400 kbps. Pathology reports and culture results served as "truth diagnoses." Categories of interpretations were correct, minor discrepancy, or major discrepancy with regard to the implications for patient care. RESULTS: The diagnostic accuracy of video image readings and conventional light microscopy readings were nearly identical, with no statistically significant differences in the performances of specialty and nonspecialty pathologists (P > 0.05). The mean accuracies of readings of the video images and light microscopy images were 95.3% and 95.4%, respectively. Taking into account the time required by a referring pathologist to capture video digital images, telemicrobiology was somewhat less efficient than conventional light microscopy. CONCLUSIONS: Pathologists can accurately evaluate digital video images of preselected fields on Gram-stained slides. In clinical practice, however, a limiting factor may be the availability of local personnel qualified to select the microscopic fields for evaluation by telepathologists. The adequacy of the video images suggests that telepathology may also be used for remote supervision of quality assurance programs in microbiology laboratories, as well as for remote proficiency training of laboratory personnel. 30. Murphy, J. M.; O'Hare, N. J.; Wheat, D.; McCarthy, P. A.; Dowling, A.; Hayes, R.; Bowmer, H.; Wilson, G. F., and Molloy, M. P. (Diagnostic Imaging Department, St James's Hospital, Dublin, Republic of Ireland). Digitized mammograms: a preliminary clinical evaluation and the potential for telemammography. Journal of Telemedicine & Telecare. 1999; 5(3):193-7. Call Number: *III 6 B Abstract: We performed a preliminary clinical evaluation of digitized mammograms to assess whether digital images suitable for telemammography could be obtained. Thirty mammograms were digitized at a resolution of 4000 x 4000 pixels and 12 bit/pixel. The series contained 17 carcinomas in 16 patients. Five consultant radiologists reported both the original mammograms and the digitized images. There was agreement between the reports of the mammograms and the digitized images in relation to whether a suspicious lesion was present or not in 95% of cases. No study considered benign on viewing the film images was interpreted as malignant on reporting the digitized images. This suggests that film digitizers may allow a digital image of a mammogram of acceptable quality for telemammography to be obtained in the absence of a purpose-built digital mammography system 35
    • 31. Parmar, V. S.; Stanitski, D. F., and Stanitski, C. L. (Children's Hospital of Michigan, Detroit, USA). Interpretation of radiographs in a pediatric limb deformity practice: do radiologists contribute? Journal of Pediatric Orthopedics. 1999 Nov-1999 Dec 31; 19(6):732-4. Call Number: *III 6 B Abstract: Orthopaedic surgeons make treatment decisions based on their interpretation of patient radiographs. Radiologists' reports of these radiographs are routine but may add little to the patient's management. The authors prospectively compared data initially recorded by a pediatric orthopaedist in the assessment of teleoroentgenograms obtained over a 3-month period in a limb deformity clinic with the subsequent reports of these studies by pediatric radiologists. Two hundred and sixty-four (100%) anatomic axes of femora and tibiae were measured and reported by the surgeon compared to 1.9% by the radiologist. Limb lengths were recorded 100% of the time by the orthopaedist and by the radiologist in 80% of cases. Abnormal bone quality was present in 43 of 264 (16.2%) limb segments and reported in all involved cases by the orthopaedist. Only 26 (9.8%) of the abnormalities were noted by the radiologist. Only eight of 20 (35%) physeal abnormalities such as rickets were noted by the radiologist in contrast to 20 of 20 (100%) noted by the surgeon. There were no findings described by the radiologist not previously reported by the orthopaedic surgeon. In no case did the radiology interpretation influence clinical management decisions 32. Raab, S. S.; Zaleski, M. S.; Thomas, P. A.; Niemann, T. H.; Isacson, C., and Jensen, C. S. (Department of Pathology, University of Iowa, Iowa City 52242-1009, USA.). Telecytology: diagnostic accuracy in cervical-vaginal smears [see comments]. American Journal of Clinical Pathology. 1996 May; 105(5). CODEN: 599-603; ISSN: 0002-9173. Call Number: *III 6 B Abstract: Although cervical-vaginal telecytology is a promising tool, diagnostic accuracy has not been extensively evaluated. The authors examined the accuracy of five cytotechnologists who retrospectively reviewed 50 cervical-vaginal smears using the video monitor, and 2 months later, using the light microscope. Accuracy was expressed in terms of crude agreement with the original diagnosis and number of false positives (FPs) and false negatives (FNs). With a greater than one step difference as discrepant, the group crude agreement using the video monitor and the light microscope was 85.6% and 95.6%, respectively. The group number of FNs and FPs for the light microscope was 8 and 7, respectively, and for the video monitor was 34 and 7, respectively. There was a wide range of individual performance. We conclude that accuracy of telecytology is high, but less than that of light microscopy. The major reason for lower telecytologic accuracy was undercalling dysplasia. 33. Rissam, H. S.; Kishore, S.; Srivastava, S.; Bhatia, M. L., and Trehan, N. (Department of Telecardiology, Escorts Heart Institute and Research Centre, New Delhi.). Evaluation of cardiac symptoms by trans- telephonic electro-cardiographic monitoring (TTEM): preliminary experience. Indian Heart Journal. 1998 Jan-1998 Feb 28; 50(1). CODEN: 55-8; ISSN: 0019-4832. Call Number: *III 6 B Abstract: Between May 1996 and May 1997, a total of 398 patients (321 males, 77 females) were registered at our institute for trans-telephonic electro-cardiographic monitoring (TTEM). Their age ranged from one month to 95 years. Almost two-third (67%) of patients were from Delhi and one- third (33%) from other places in India and neighbouring countries. Clinical profile of these patients was post-bypass surgery, post-myocardial infarction, chest pain for evaluation, post-percutaneous transluminal coronary angioplasty, chronic stable angina, evaluation of palpitations, arrhythmias, and pace-maker follow-up. Out of 664 symptomatic transmissions, 568 (86%) were received for cardiac symptoms and 96 (14%) for non-cardiac symptoms. Seventy-nine percent patients had chest pain or palpitations at the time of transmission, whereas 21 percent had other symptoms like chest discomfort, breathlessness or dizziness. The electro-cardiograms were transmitted within one hour of the onset of chest pain in 84 percent, palpitations in 78 percent and dizziness in 75 percent. Of patients with symptomatic transmissions, 628 (95%) required either reassurance or drug-dose adjustment and outpatient department review. Only 36 (5%) patients were hospitalised as an emergency, and out of these only 19 (3%) needed acute management. In conclusion, trans-telephonic electro-cardiographic monitoring is a very convenient and an 'all-time-available' monitoring facility for establishing patient-physician contact in the shortest time. It is useful in rendering instant advice 36
    • for hospitalisation in emergency situations while avoiding unnecessary visits to the hospital. 34. Shanit, D.; Lifshitz, T.; Giladi, R., and Peterburg, Y. (Israel Center of Telemedicine and Telecare, Ben- Gurion University of the Negev, Israel.). A pilot study of tele-ophthalmology outreach services to primary care. Journal of Telemedicine & Telecare 1998;4 Suppl 1:1-2. ISSN: 1357-633X. Call Number: III 6 B* Abstract: We have begun a randomized study of tele-ophthalmology. General practitioners in two participating health centres in the Negev region of Israel, serving a local population of 40,000, were invited to participate. The study group consisted of 50 consecutive patients attending the general eye outpatient clinic and 50 consecutive patients suffering from various retinal diseases attending a hospital outpatient clinic. The initial assessment was carried out via the tele-ophthalmology system. There was then a face-to-face re-examination of the same patients, in randomized order, by the same ophthalmologist on the same day, at an outpatient ophthalmology clinic. 35. Sixsmith, A. J. (Department of Primary Care, University of Liverpool, UK). An evaluation of an intelligent home monitoring system. Journal of Telemedicine & Telecare. 2000; 6(2):63-72. Call Number: *III 6 B Abstract: A trial was performed of an intelligent monitoring system which used sensors in the home to identify emergencies by detecting deviations from normal activity patterns. The field trial lasted three months. Twenty-two elderly people agreed to participate. Their ages ranged from early 60s to over 85, with two-thirds in the age range 75-84 years. They lived in four different localities within the UK--Ipswich, Northumberland, Merseyside and Nottingham. A total of 61 alerts was recorded, at a mean frequency about one alert per month per client. Of the 61 alerts generated, 46 were classified as false alerts and the other 15 as genuine, although no real emergencies occurred during the study. Many people in the field trial reported enhanced feelings of safety and security, which could help to stimulate independence and help them to remain living in their own homes. The monitoring system increased the care choices available to elderly people and supported and enhanced the carer's role 36. Takahashi, M.; Mernyei, M.; Shibuya, C., and Toshima, S. (Department of Pathology, SRL, Inc., Hachioji). [Present and prospects of telepathology]. [Japanese]. Rinsho Byori - Japanese Journal of Clinical Pathology. 1999 Jan; 47(1):27-30. Call Number: *III 6 B Abstract: Nearly ten years have passed since telepathology was introduced and real-time pathology consultations were conducted. Long distance consultations in pathology, cytology, computed tomography and magnetic resonance imaging, which are referred to as telemedicine, clearly enhance the level of medical care in remote hospitals where no full-time specialists are employed. To transmit intraoperative frozen section images, we developed a unique hybrid system "Hi-SPEED". The imaging view through the CCD camera is controlled by a camera controller that provides NTSC composite video output for low resolution motion pictures and high resolution digital output for final interpretation on computer display. The results of intraoperative frozen section diagnosis between the Gihoku General Hospital 410 km from SRL showed a sensitivity of 97.6% for 82 cases of breast carcinoma and a false positive rate of 1.2%. This system can be used for second opinions as well as for consultations between cytologists and cytotechnologists 37. Trippi, J. A.; Kopp, G.; Lee, K. S.; Morrison, H.; Risk, G.; Jones, J. H.; Cordell, W. H.; Chrapla, M., and Nelson, D. (Department of Cardiology, Methodist Hospital of Indiana, Indianapolis, USA.). The feasibility of dobutamine stress echocardiography in the emergency department with telemedicine interpretation. Journal of the American Society of Echocardiography. 1996 Mar-1996 Apr 30; 9(2). CODEN: 113-8; ISSN: 0894-7317. Call Number: *III 6 B Abstract: Dobutamine stress echocardiography (DSE) was performed on 26 patients admitted for chest pain deemed at low risk for myocardial infarction. Pharmacologic stress in the emergency department on a 24-hour basis was administered by nurses and echocardiographic ultrasonographers with electrocardiograms and echocardiograms being interpreted through telemedicine relay by an off-site cardiologist. Target heart rate was achieved in 84% of patients with an average peak 37
    • dobutamine dose of 48 microg/kg/min. Echocardiographic transmission to the cardiologist over standard telephone lines took 9 minutes per quad-screen cine-loop display. The entire protocol added 2.2 hours to the emergency room evaluation. The one patient out of 26 who had incipient myocardial infarction was diagnosed by resting echocardiography. The remaining 25 patients were found clinically to have no infarction or ischemia. Of these, 22 out of 25 had normal DSE in the emergency department; three had wall motion abnormalities on peak stress images. Another three patients had other cardiac diseases documented by echocardiography. Evaluation of chest pain on a 24-hour basis with DSE with telemedicine interpretation appears to be a rapid and safe means of screening patients at low risk in the emergency department. Further experience with this modality is needed before all patients should be enrolled or early discharge of patients on the basis of DSE can be advised. 38. Tsuchihashi, Y.; Okada, Y.; Ogushi, Y.; Mazaki, T.; Tsutsumi, Y., and Sawai, T. (Hospital Department of Pathology, Kyoto Prefectural University of Medicine, Japan. The current status of medicolegal issues surrounding telepathology and telecytology in Japan. Journal of Telemedicine & Telecare. 6 Suppl 1:S143-5, 2000. Call Number: *III 6 B Abstract: The medicolegal issues surrounding telepathology and telecytology in Japan have been partly resolved since the government declared that telediagnosis in these fields using a microscope is essentially a medical practice between doctors. Thus it does not contravene article 20 of the law pertaining to medical practice in Japan, which states that there must be an actual face-to-face encounter between the doctor performing any diagnostic or treatment episode and the patient. It is, however, only beginning to be recognized that the medicolegal issues surrounding telepathology and telecytology depend on factors such as the type of system used (e.g. active versus passive). In an active diagnostic system, the telepathologist or telecytopathologist can control a robotic microscope at the remote site, while in a passive diagnostic system the telepathologist or telecytopathologist makes the diagnosis based on the microscope images that have been selected, and transmitted, by someone in the remote hospital. In the former case the interpreting telepathologist or telecytopathologist must assume most of the responsibility for the diagnostic process, while in the latter more responsibility must be assumed by those at the remote site. The duties and responsibilities of all participants in the telediagnostic process, whatever the system employed, must be determined. We have established working guidelines for telepathological and telecytological diagnoses to help achieve this and hence ensure safe and effective clinical practice 39. van der Stelt, P. F. (Department of Oral and Maxillofacial Radiology, Academic Center for Dentistry Amsterdam, The Netherlands. Principles of digital imaging. Dental Clinics of North America. 2000 May; 44(2):237-48. Call Number: *III 6 B Abstract: Electronic sensors in diagnostic radiology are gradually replacing radiographic film. The advantages of this new technology include a lower radiation dose to the patient, an almost instantaneous availability of images without the need for chemical film processing, and the possibility of image enhancement and computer-aided feature extraction. Digital radiography is a promising technology, opening the door to new diagnostic procedures not available with traditional film-based imaging 40. Vazir, M. H.; Loane, M. A., and Wootton, R. (Department of Pathology, Antrim Hospital. A pilot study of low-cost dynamic telepathology using the public telephone network. Journal of Telemedicine & Telecare. 1998; 4(3):168-71. Call Number: *III 6 B Abstract: A pilot trial of a low-cost telepathology system was conducted. A video-codec operating to the CIF standard was used to transmit pictures over the public telephone network. Twenty-seven specimens from the routine pathology workload of a district hospital were examined. The average length of time spent examining each specimen was 14 min (range 2-40). The telepathology diagnoses were judged by conventional light microscopy of the specimens, performed by the same observer at a later date, and by a different observer. For the same observer, 23 diagnoses were correct (85%) by telepathology, three were acceptable (11%) and one was incorrect (4%). The 38
    • results were slightly worse for a different observer: 21 diagnoses were correct (78%) by telepathology, five diagnoses were acceptable (19%) and one diagnosis was incorrect (4%). The technique was slower than conventional dynamic telepathology (such as that based on communication by ISDN or leased circuits) and picture quality was poor by comparison. However, these are not necessarily disadvantages in the context of the developing world, and since only a telephone connection is required, the technique could become an important method of improving the distribution of scarce resources, such as pathology expertise 41. Weinberg, D. S.; Allaert, F. A.; Dusserre, P.; Drouot, F.; Retailliau, B.; Welch, W. R.; Longtine, J.; Brodsky, G.; Folkerth, R., and Doolittle, M. (Brigham and Women's Hospital, Boston, MA 02115, USA.). Telepathology diagnosis by means of digital still images: an international validation study [see comments] [published erratum appears in Hum Pathol 1996 Sep;27(9):1001]. Human Pathology. 1996 Feb; 27(2). CODEN: 111-8; ISSN: 0046-8177. Call Number: *III 6 B Abstract: Telepathology affords the means to provide pathological diagnosis and consultation to remote sites. However, before telepathology can become an acceptable medical tool, it will be vital to determine the diagnostic accuracy of this technology. We report the results of a single-blind study of the accuracy of diagnosis performed using computerized still images obtained from a telepathology workstation used in a French telepathology network. Four pathologists, each working alone, reviewed a total of 200 cases of routine surgical pathology (50 cases each), and performed diagnosis based on both computer CD-ROM still images (CD) and conventional glass slides (GS). Concordance between GS and CD diagnosis, as well as accuracy, were determined. Other factors related to performance were also measured, including diagnostic certainty, reasons for uncertainty, and causes of diagnostic error. Overall, there was good agreement between CS and CD diagnosis. There was 87.5% concordance between CS and CD diagnosis, and comparison to consensus (correct) diagnosis showed accuracy of 95.5% and 88.5% for GS and CD diagnosis, respectively. Marked variability in accuracy of CD diagnosis was observed among the four pathologists, and issues related to image selection and/or quality appeared responsible for 60% of the diagnostic errors. The lack of sufficient images and clinical information were frequently cited as reasons for diagnostic uncertainty, as well as feelings of insufficient expertise. It is likely that the opportunity for interaction with the referring pathologist and the use of subspecialty consultants would likely improve the performance of telepathology. 42. Winokur, T. S.; McClellan, S.; Siegal, G. P.; Redden, D.; Gore, P.; Lazenby, A.; Reddy, V.; Listinsky, C. M.; Conner, D. A.; Goldman, J.; Grimes, G.; Vaughn, G., and McDonald, J. M. (Department of Pathology, UAB Cancer Center, University of Alabama at Birmingham 35233, USA). A prospective trial of telepathology for intraoperative consultation (frozen sections). Human Pathology. 2000 Jul; 31(7):781-5. Call Number: *III 6B Abstract: Telepathology is a maturing technology that, for a variety of reasons, has not been widely deployed. In addition, clinical validation is relatively modest compared with accepted telemedicine applications such as teleradiology. A prototype telepathology system (Tele-Path(sm)) featuring high- resolution images selected from a remote microscope site has been developed at the University of Alabama at Birmingham (UAB). To validate the diagnostic efficacy of the system, a prospective study was undertaken of parallel diagnoses by conventional microscopy and telepathology with a remotely operated microscope. Slides from 99 intraoperative consultations from 29 tissue/ organ sites in the University of Alabama Hospitals by 9 academic pathologists were used in the study. Each microscopic and telepathology diagnosis was compared with the final diagnosis rendered by a referee pathologist. Diagnoses were classified as correct, false positive, or false negative or classification error. Of the 99 frozen sections evaluated, 3 cases were deferred. Of the remaining 96 cases, 2 received incorrect diagnoses in both the microscopic and telepathology arms of the study. Three errors occurred only in the telepathology arm. There was 1 false-positive diagnosis, 1 false- negative diagnosis, and 1 classification error. Statistical analysis indicated no significant difference between telepathology and conventional microscopy. Qualitative data indicated that the pathologists were generally satisfied with the performance of the system. Telepathology using this system paradigm is sufficiently accurate for real time utilization in a complex surgical environment. 39
    • Telepathology therefore may be an effective model to support the surgical services of hospitals lacking full-time pathology coverage, resulting in full-time access to anatomic pathology services 43. Wirthlin, D. J.; Buradagunta, S.; Edwards, R. A.; Brewster, D. C.; Cambria, R. P.; Gertler, J. P.; LaMuraglia, G. M.; Jordan, D. E.; Kvedar, J. C., and Abbott, W. M. (Department of Surgery, Massachusetts General Hospital, Boston 02114, USA.). Telemedicine in vascular surgery: feasibility of digital imaging for remote management of wounds. Journal of Vascular Surgery. 1998 Jun; 27(6). CODEN: 1089-99; discussion 1099-100; ISSN: 0741-5214. Call Number: *III 6 B Abstract: PURPOSE: Telemedicine coupled with digital photography could potentially improve the quality of outpatient wound care and decrease medical cost by allowing home care nurses to electronically transmit images of patients' wounds to treating surgeons. To determine the feasibility of this technology, we compared bedside wound examination by onsite surgeons with viewing digital images of wounds by remote surgeons. METHODS: Over 6 weeks, 38 wounds in 24 inpatients were photographed with a Kodak DC50 digital camera (resolution 756 x 504 pixels/in2). Agreements regarding wound description (edema, erythema, cellulitis, necrosis, gangrene, ischemia, and granulation) and wound management (presence of healing problems, need for emergent evaluation, need for antibiotics, and need for hospitalization) were calculated among onsite surgeons and between onsite and remote surgeons. Sensitivity and specificity of remote wound diagnosis compared with bedside examination were calculated. Potential correlates of agreement, level of surgical training, certainty of diagnosis, and wound type were evaluated by multivariate analysis. RESULTS: Agreement between onsite and remote surgeons (66% to 95% for wound description and 64% to 95% for wound management) matched agreement among onsite surgeons (64% to 85% for wound description and 63% to 91% for wound management). Moreover, when onsite agreement was low (i.e., 64% for erythema) agreement between onsite and remote surgeons was similarly low (i.e., 66% for erythema). Sensitivity of remote diagnosis ranged from 78% (gangrene) to 98% (presence of wound healing problem), whereas specificity ranged from 27% (erythema) to 100% (ischemia). Agreement was influenced by wound type (p < 0.01) but not by certainty of diagnosis (p > 0.01) or level of surgical training (p > 0.01). CONCLUSIONS: Wound evaluation on the basis of viewing digital images is comparable with standard wound examination and renders similar diagnoses and treatment in the majority of cases. Digital imaging for remote wound management is feasible and holds significant promise for improving outpatient vascular wound care. III 6 B* (CHINESE) 1. Yang, Y.; Xueji, F.; Liu, Z.; Wang, L., and Ke, W. (Fuzhou University.). [The development of CTTM-1000 distant electrocardiogram central ambulatory monitoring system]. [Chinese]. Chung-Kuo I Liao Chi Hsieh Tsa Chih Chinese Journal of Medical Instrumentation. 1997 Jan; 21(1). CODEN: 1-7, 32; ISSN: 1000-6974. Call Number: III 6 B* (CHINESE) Abstract: This article introduces a new electrocardiogam telephone transmitting and central ambulatory monitoring (receiving) system, and a device used for monitoring and transmitting the user's electrocardiogram. We also give some detailed discussion about the real time the flow display of ECG, and the signal preprocessing method based on the design of optimum FIR linear phase digital filter for the detection of QRS complexes. *III 6 B (FRENCH) 1. Bahon, J.; Molinie, V.; Creusy, C., and Marsan, C. (Laboratoire d'Anatomie et Cytologie Pathologiques, Faculte Libre de Medecine, Lille.). [Telepathology and "small cells" in cervical-vaginal smears: a new tool for diagnosis and teaching?]. [French]. Archives d Anatomie Et De Cytologie Pathologiques. 1997; 45(1). CODEN: 22-7; ISSN: 0395-501X. Call Number: *III 6 B (FRENCH) Abstract: The identification of small cells in cervical/vaginal smears is usually considered as a difficult task, as well when they are examined through a classical light microscope or thanks to a 40
    • teletransmission system. In this paper, we have compared both methods. 53 cases of smears with small cells were examined by two pathologists. The different types of small cells were described. The results and the discrepancies were studied. The reliability was rather good (45/53 cases, 84.6%). The main images were recorded onto a videotape for teaching purposes. *III 6 B (GERMAN) 1. Steffen, B.; Gianom, D.; Winkler, C.; Hosch, H. J.; Oberholzer, M., and Famos, M. (Chirurgische Klinik, Spital Oberengadin, Samedan.). [Frozen section diagnosis using telepathology]. [German]. Swiss Surgery. 1997; 3(1). CODEN: 25-9; ISSN: 1023-9332. Call Number: *III 6 B (GERMAN) Abstract: DEFINITION: Since 1992 we transfer digitalized frozen section images by means of videomicroscope and a personal computer through the public telephone network (ISDN) to the Institut of Pathology at the University Hospital in Basel. The aim of this study is to determine whether the quality of frozen section diagnosis obtained by telepathology is comparable to the conventional one. METHOD: The frozen section diagnoses by telepathology from Oct. 1992 to May 1996 (n = 94) are compared to the paraffin sections performed in each case after the primary examination. The result is then compared to the well documented data of conventional frozen section diagnosis in the literature. RESULTS: From Oct. 1992 to May 1996 we performed 94 frozen sections. In 84 cases the diagnosis was correct compared to the paraffin section (89%). The sensitivity to detect a malignant tumor was 92%, the specifity 100%. Four examinations were not conclusive and one examination had to be canceled because of technical problems. DISCUSSION: In the literature, 92% of malignancy is diagnosed by conventional frozen section [1]. Telepathology gives the same result. *III 6 B, *II 3 1. Adachi, H.; Inoue, J.; Nozu, T.; Aoki, H., and Ito, H. (First Department of Pathology, Faculty of Medicine, Tottori University, Yonago, Japan.). Frozen-section services by telepathology: experience of 100 cases in the San-in District, Japan. Pathology International. 1996 Jun; 46(6). CODEN: 436-41; ISSN: 1320-5463. Call Number: *III 6 B, *II 3 Abstract: The early experience is reported here of the use of intra-operative frozen-section service by telepathology using the integrated Service Digital Network (ISDN), a commercially available system that is being connected between the Department of Pathology of Tottori University and Matsue City Hospital, a distance of 30 km. The transfer rate is currently 64 kbit/s. The frozen-section service was conducted for a total of 117 tissue specimens (organs) from 100 patients between August 1993 and May 1995. The average time taken for examination of each specimen of frozen section was 13 min, ranging between 2 and 42 min. The average number of transmitted images was 6.2. Six cases necessitated more than 11 transmitted images to make a diagnosis, while 13 cases could be diagnosed from two images only. Correct and permissible diagnoses were obtained in 109 (93.2%) out of 117 specimens when comparing the telepathology diagnosis with that of direct microscopy. Improper or misdiagnosis was made for eight cases (specimens), which were misinterpreted as papillary carcinoma in Basedow's disease, adenoma and hyperplasia in two pheochromocytomas, solid-tubular carcinoma in phyllodes tumor, mastopathy in invasive carcinoma, metastatic carcinoma in astrocytoma, follicular lymphoma in reactive hyperplasia, and lymphadenitis in follicular lymphoma. In retrospect, diagnosis of these cases should have been deferred. From the results, it was concluded that the intraoperative frozen-section service by telepathology may be a worthwhile substitute for hospitals with limited accessibility to local pathology service, in spite of pitfalls in some cases. Well prepared, high-quality frozen section, sufficient verbal communication with surgeons, and a rather conservative attitude on the part of a well-trained pathologist seem to be the essential ingredients for reaching an accurate decision when using telepathology. 2. Della Mea, V.; Puglisi, F.; Forti, S.; Delendi, M.; Boi, S.; Mauri, F.; Dalla Palma, P., and Beltrami, C. A. (Department of Pathology, University of Udine, Italy. Expert pathology 41
    • consultation through the Internet: melanoma versus benign melanocytic tumours. Journal of Telemedicine & Telecare 1997;3 Suppl 1:17-9. ISSN: 1357-633X. Call Number: *III 6 B, *II 3 Abstract: Twenty consecutive cases of melanocytic lesions were chosen from the archives of the archives of the institute of Anatomic Pathology at Santa Chiara Hospital, Trento. Representative images were acquired at a spatial resolution of 512 x 512 pixels, saved in IPEG format and delivered to the remote pathologist by multimedia internet electronic mail. Six cases were diagnosed as benign melanocytic lesions by the local pathologist. Of the 20 cases transmitted, each with an average of 5.3 images, the remote pathologist suggested a diagnosis of malignancy in nine cases while 10 cases were thought to be benign. In one case the images were not considered sufficient for diagnosis. Overall, the diagnostic agreement between local and remote pathologist was 79% (kappa = 0.58, P = 0.002). This preliminary study suggest that telepathology by internet electronic mail can be a valuable tool for remote consultation in dematopathology, as well as for other diagnostic fields where expert consultation is necessary. 3. Evers, H.; Mayer, A.; Engelmann, U.; Schroter, A.; Baur, U.; Demiris, A. M.; Giess, C.; Wolsiffer, K., and Meinzer, H. P. (Div. Medical and Biological Informatics, Deutsches Krebsforschungszentrum, Heidelberg, Germany. Extending a teleradiology system by tools for visualization and volumetric analysis through a plug-in mechanism. International Journal of Medical Informatics. 1999 Feb-1999 Mar 31; 53(2-3):265-75. Call Number: *III 6 B, *II 3 Abstract: This paper describes ongoing research concerning interactive volume visualization coupled with tools for volumetric analysis. To establish an easy to use application, the three-dimensional- visualization has been embedded in a state of the art teleradiology system, where additional functionality is often desired beyond basic image transfer and management. Major clinical requirements for deriving spatial measures are covered by the tools, in order to realize extended diagnosis support and therapy planning. Introducing a general plug-in mechanism, this work exemplarily describes the useful extension of an approved application. Interactive visualization was achieved by a hybrid approach taking advantage of both the precise volume visualization based on the Heidelberg ray-tracing model and the graphics acceleration capabilities of modern workstations. Several tools for volumetric analysis extend the three-dimensional-viewing. They are controlled by adequate input devices to select locations in the data volume, measure anatomical structures or initiate a segmentation process. Moreover, a haptic interface can be connected to provide a more realistic feedback while navigating within the three-dimensional-reconstruction. The work is closely related to research in the field of heart, liver and head surgery. In cooperation with our medical partners the development of tools as presented facilitates the integration of image analysis into the clinical routine *III 6 B, *II 3 (GERMAN) 1. Partan, G. and Hruby, W. (Rontgeninstitut und Ludwig Boltzmann-Forschungsinstitut fur digitale Radiographie und interventionelle Radiologie im Donauspital des Sozialmed, Wien.). [Digital radiology]. [Review] [28 refs] [German]. Zeitschrift Fur Arztliche Fortbildung Und Qualitatssicherung. 1997 Jul; 91(4). CODEN: 301-8; ISSN: 1431-7621. Call Number: *III 6 B, *II 3 (GERMAN) Abstract: Digital radiology is the integration of established and new digital imaging modalities into a system which enables the filmless communication of radiological information. It is becoming an indispensable tool in daily medical practice, and yields improved, faster medical communication, reduces the patient's dose and saves 307 307 archivation costs. Some knowledge of the inherent features of digital images and some open-mindedness for a change in viewing and workflow habits is necessary to make full profit of these possibilities. This paper describes digital radiography and the aspects of radiological networking based on 5 years experience with one of the very first filmless radiology departments worldwide. [References: 28] *III 6 B, *II 3, *II 4 42
    • 1. Berger, S. B. and Cepelewicz, B. B. (Department of Diagnostic Imaging, Yale University School of Medicine, New Haven, CT 06504, USA.). Medical-legal issues in teleradiology [see comments]. [Review] [36 refs]. AJR. American Journal of Roentgenology. 1996 Mar; 166(3). CODEN: 505-10; ISSN: 0361-803X. Call Number: *III 6 B, *II 3, *II 4 Abstract: With the advent of high-speed, high-resolution digital imaging and network transmission, teleradiology promises to dramatically change the mechanism for interpreting radiologic images and the traditional relationships between radiologists and patients and referring physicians. We discuss the current status of medical-legal issues pertaining to privacy, licensing, credentialing, liability, and fraud for teleradiology. Special emphasis is placed on the technical factors that may result in differences in image properties, consequently affect radiologic diagnosis, and bring the potential for liability. [References: 36] *III 6 B, *II 3, *III 6 A 1. Maddison, I. (Department of Radiology, Central Middlesex Trust, London, UK.). The Internet and radiology. [Review] [8 refs]. British Journal of Radiology 1997 Nov;70 Spec No:S194-9. ISSN: 0007-1285. Call Number: *III 6 B, *II 3, *III 6 A Abstract: Basic Internet structures are introduced. Extrapolation from these basic structures may give clues to some future developments in radiology, including education and image interpretation. Cooperation between radiology professionals is no longer limited by geographical location and will allow the contributions from individuals to be judged by their creativity and content, regardless of their origin. The solution complex problems, such as information overload at the workstation, will need as many active minds as can be recruited. [References: 8] *III 6 B, *II 3, II A 1. Maldjian, J. A.; Liu, W. C.; Hirschorn, D.; Murthy, R., and Semanczuk, W. (Department of Radiology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark 07103, USA.). Wavelet transform-based image compression for transmission of MR data [published erratum appears in AJR Am J Roentgenol 1997 Sep;169(3):919]. AJR. American Journal of Roentgenology. 1997 Jul; 169(1). CODEN: 23-6; ISSN: 0361-803X. Call Number: *III 6 B, *II 3, II A Abstract: OBJECTIVE: The purpose of this study was to develop an effective, inexpensive teleradiology image-transmission system for transfer of MR studies using wavelet transform image compression. CONCLUSION: We describe an efficient system for implementing teleradiology capability for transmission of diagnostic MR images. The system uses the wavelet transform to achieve greater than 90% image compression, with standard modern transmission times of less than 5 sec per compressed image. The method is inexpensive and can be implemented using commonly available workstation and MR scanner capabilities. 2. Parisi, S. B.; Mogel, G. T.; Dominguez, R.; Dao, H., and Cramer, T. J. (Department of Radiology, Brooke Army Medical Center, Ft. Sam Houston, San Antonio, TX 78234, USA.). The effect of 10 : 1 compression and soft copy interpretation on the chest radiographs of premature neonates with reference to their possible application in teleradiology. European Radiology. 1998; 8(1). CODEN: 141-3; ISSN: 0938-7994. Call Number: *III 6 B, *II 3, II A Abstract: The aim of the study was to assess the potential application of teleradiology in the neonatal intensive care unit (NICU) by ascertaining whether any decrease in conspicuity of anatomic detail or interventional devices in the chest radiographs of premature infants is caused by picture archiving and communication system (PACS)-based soft copy interpretation of 10 : 1 compressed images. One hundred digital chest radiographs of low-birthweight infants were obtained in the NICU using a storage phosphor system. Laser-printed images were interpreted and the data set for each radiograph was then irreversibly compressed by a 10 : 1 ratio. Four radiologists with extensive PACS 43
    • experience used a five-point grading system to score laser-printed hard copy images for the visibility of six parameters of anatomic landmarks and interventional devices in the chest. Compressed soft copy images displayed on 2K PACS workstation were subsequently scored using the same approach. Statistical manipulation demonstrated no loss of anatomic detail in five of the six parameters scored, with minimal difference in one landmark, the retrocardiac lung assessment. While further study is required to assess the clinical impact of the variance noted when evaluating lung parameters, the preservation or improvement of information in the remaining parameters following irreversible compression and soft copy interpretation is promising for the potential use of teleradiology in this population. *III 6 B, *II 3, II B 1. Della Mea, V.; Forti, S.; Puglisi, F.; Bellutta, P.; Finato, N.; Dalla Palma, P.; Mauri, F., and Beltrami, C. A. (Department of Anatomic Pathology, University of Udine, Italy. Telepathology using Internet multimedia electronic mail: remote consultation on gastrointestinal pathology. Journal of Telemedicine & Telecare. 1996; 2(1). CODEN: 28-34; ISSN: 1357-633X. Call Number: *III 6 B, *II 3, II B Abstract: The feasibility of using the Internet for remote pathology consultation was examined. We assessed the diagnostic agreement between two groups of pathologists who independently evaluated histopathological cases exchanged by Internet electronic mail. The exchange was between two different workstations using readily available software not specifically developed for telemedicine. Data and images from 76 cases were transmitted to four pathologists. An average of 4.5 images per case were transmitted at compression ratios of between 6:1 and 40:1, corresponding to 250 kByte of data per case. In two cases the remote pathologists could not make a diagnosis. Agreement was reached in 63 of the other 74 (kappa = 0.79). In 11 cases (15%) there was a misdiagnosis. However, the results are encouraging and suggest that Internet electronic mail can be used successfully for remote consultation in pathology. 2. Eusebi, V.; Foschini, L.; Erde, S., and Rosai, J. (Section of Anatomic Pathology, Marcello Malpighi, University of Bologna, Italy.). Transcontinental consults in surgical pathology via the Internet [see comments]. Human Pathology. 1997 Jan; 28(1). CODEN: 13-6; ISSN: 0046-8177. Call Number: *III 6 B, *II 3, II B Abstract: An efficient and inexpensive electronic system to submit surgical pathology cases in consultation via the Internet is presented. A transcontinental pilot study showed a high degree of concordance between the diagnosis provided by the consultant on the basis of the pathology images and that given after examining the corresponding microscopic slides. *III 6 B, *II 5 1. Bertazzoni, G.; Genuini, I., and Aguglia, F. (Medical Emergency Department, La Sapienza University, Rome, Italy.). Telecar: an Italian telecardiology project. [Review] [1 refs]. Journal of Telemedicine & Telecare. 1996; 2(3). CODEN: 132-5; ISSN: 1357-633X. Call Number: *III 6 B, *II 5 Abstract: The Telecar (tele-assistance cardiology) project was an example of tele-assistance between health centres of the Regione Lazio in Italy. The project was approved by the Ministry of Health, financed with 500,000,000 lire and carried out by an operative station within 'La Sapienza' University (Rome). About 40 of the health centres in Lazio that did not have cardiologists or electrocardiography (ECG) equipment were provided with telematic instruments (Cardiophone and fax). With this equipment, they were able to transmit ECG signals and receive copies of ECG reports. The 40 health centres included first-aid clinics, 'guardia medica' surgeries and community centres. The project was carried out between 1989 and 1992. During these three years the health centres transmitted a total of 4807 ECGs, 2057 (43%) of which were routine, the remaining 2750 (57%) being suspected emergencies. Of the suspected emergencies, 681 cases (25%) had a confirmed abnormality. We can confirm that telematic aids are very important for an operative station, where all kinds of emergencies must be dealt with. [References: 1] 44
    • 2. Johnson, M. A.; Davis, P.; McEwan, A. J.; Jhangri, G. S.; Warshawski, R.; Gargum, A.; Ethier, J., and Anderson, W. W. (Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, and Medical Imaging Consultants, Edmonton, Alberta, Canada). Preliminary findings from a teleultrasound study in Alberta. Telemedicine Journal. 1998 Fall; 4(3):267-76. Call Number: *III 6B, *II 5 Abstract: BACKGROUND AND OBJECTIVES: Ultrasound practice in Alberta requires direct supervision by an ultrasound-accredited specialist physician (sonologist). This requirement limits access to ultrasound examinations in many rural communities. A prospective study was performed to evaluate the adequacy of teleultrasound service in High Level, Alberta, with remote sonologist supervision from Edmonton, Alberta. METHODS: A total of 146 patients were evaluated in two groups. Group A (72 patients) was evaluated by both an on-site radiologist in High Level and a remote supervising radiologist in Edmonton. Group B (74 patients) was evaluated only by the remote supervising radiologist in Edmonton. The teleultrasound service included digital store-and- forward capabilities using a commercially available teleradiology system, with videoconferencing review for real-time scanning. RESULTS: The teleultrasound service was helpful to the referring physician. It made transfer unnecessary in 42% of patients, and the results of the ultrasound assessment influenced management in 59% of patients. The sonographer on site and the remote radiologists agreed on the quality of the images. The information required for diagnosis was available from the sonographer's study in the majority of cases, with second-look scanning by the on-site radiologist or videoconferencing by the remote radiologist providing a major new diagnosis in only 1% of patients. CONCLUSION: Teleultrasound service to High Level could be provided reliably with remote supervision, comparable to direct on-site supervision 3. Weisz-Carrington, P.; Blount, M.; Kipreos, B.; Mohanty, L.; Lippman, R.; Todd, W. M., and Trent, B. (Department of Pathology and Laboratory Medicine, Hunter Holmes McGuire VAMC, Richmond, Virginia). Telepathology between Richmond and Beckley Veterans Affairs Hospitals: report on the first 1000 cases. Telemedicine Journal. 1999 Winter; 5(4):367-73. Call Number: *III 6B *II 5 Abstract: OBJECTIVE: A telepathology connection between Richmond VAMC and Beckley VAMC using dynamic robotic telepathology to provide pathology services remotely was established. MATERIALS AND METHODS: This study reports a 14-month experience using telepathology to diagnose surgical specimens obtained from patients at the Beckley VA Medical Center and viewed in Richmond 250 miles away. Over 14 months, 2325 slides representing 1000 cases were viewed. RESULTS: Discrepancies were observed in 20 of 2325 slides, or 0.86% of the total. None of the patients, where a discrepancy was found, were adversely affected by the preliminary report given. CONCLUSIONS: This study demonstrates that telepathology is a reliable and cost-effective alternative to on-site pathology services and reviews advantages and disadvantages of the system *III 6 B, *III 6 A, *II 3 1. Phillips, C. M.; Burke, W. A.; Shechter, A.; Stone, D.; Balch, D., and Gustke, S. (Section of Dermatology, East Carolina University, School of Medicine, Greenville, NC 27858-4354, USA.). Reliability of dermatology teleconsultations with the use of teleconferencing technology. Journal of the American Academy of Dermatology. 1997 Sep; 37(3 Pt 1). CODEN: 398-402; ISSN: 0190-9622. Call Number: *III 6 B, *III 6 A, *II 3 Abstract: BACKGROUND: Recent advances in telecommunications technology allow physicians to consult on patients at a distance via an interactive video format. Few data exist as to the reliability of this form of consultation. OBJECTIVE: Our purpose was to measure the degree of concordance between a dermatologist seeing a patient in a clinic and another dermatologist seeing the same patient over a commercially available videoconferencing system. METHODS: Patients referred to a general dermatology clinic were seen by both a "live" dermatologist and a "teledermatologist" via a T1 connection. Diagnosis and recommendations were recorded by both physicians and compared. The physicians were also asked to rate the degree of confidence they had in their diagnosis. RESULTS: Seventy-nine diagnoses were made on 60 patients. The two physicians were in absolute agreement on 61 of the diagnoses (77.2%). Race or sex of the patient, nature of the skin problems, or which of the two physicians was the teledermatologist did not statistically correlate with the 45
    • concordance of the two physicians. CONCLUSION: There was a reasonable degree of agreement between the two examining physicians. Despite the relatively high degree of concordance the teledermatologist had a significantly lower degree of confidence in his diagnoses. *III 6 B, *IV, *III 9 1. Corr, P. (Department of Radiology, University of Natal, Durban.). Teleradiology in KwaZulu-Natal. A pilot project. South African Medical Journal. 1998 Jan; 88(1). CODEN: 48-9; ISSN: 0038-2469. Call Number: *III 6 B, *IV, *III 9 Abstract: OBJECTIVE: This was a pilot teleradiology project connecting two secondary KwaZulu- Natal hospitals' radiography departments to a central Durban teaching hospital. The purpose of the study was to assess the usefulness of same-day teleradiology reports to the medical staff and whether such a service changed patient management. DESIGN: After 1 month's service at each hospital, the first 200 teleradiology reports, original radiographs and patients' case notes were reviewed to determine whether any errors in interpretation of the radiographs had been made and whether the reports had changed patient management. RESULTS: The service changed patient management in 10% of cases. Undetected pathology was recognised by the radiologist in 20 patients--pulmonary tuberculosis in 10, spinal tuberculosis in 3, miliary tuberculosis in 2 and fractures in 5. Problems were encountered with transmission of data using the current telephone network, loss of data at the receiving station and the increased workload of the radiographer transmitting the data. CONCLUSIONS: Teleradiology services do make a positive impact on patient management in rural hospitals. However, there are many technical pitfalls that must be avoided in order to establish an effective service. *III 6 B (JAPANESE) 1. Shimada, M.; Akaishi, M.; Asakura, K.; Baba, A.; Iwanaga, S.; Asakura, Y.; Miyazaki, T.; Mitamura, H., and Ogawa, S. (Department of Internal Medicine and Laboratory Medicine, Keio University School of Medicine, Tokyo.). [Usefulness of the newly developed transtelephonic electrocardiogram and computer-supported response system]. [Japanese]. Journal of Cardiology. 1996 Apr; 27(4). CODEN: 211-7; ISSN: 0914-5087. Call Number: *III 6 B (JAPANESE) Abstract: The "Cardiophone System" is a system designed to expand the relationship between patients and medical services using a transtelephonic electrocardiogram and computer-assisted answering system. The transtelephonic electrocardiogram, or so-called "Cardiophone", developed by Nihon Kohden, Inc., allows the patients to carry a "Cardiophone" to record electrocardiograms during paroxysmal occurrences of palpitation, chest pain, and other symptoms. The Cardiophone may function as a terminal of the host computer at the hospital, which stores the electrocardiogram and print it as soon as the computer receives the electrocardiogram over the phone. Cardiologists can examine the electrocardiogram immediately after it is printed. Cardiologists and operators are on duty 24 hours a day. Judgments based on the electrocardiogram are made by the cardiologist on duty, and stored in the computer by the operator. The patients may listen to the judgment over the phone within 30 min of sending the electrocardiogram. In the case of potentially lethal findings on the electrocardiogram, the cardiologist on duty calls the patient directly to give a medical advice. We studied 184 outpatients who were enrolled in the Cardiophone System of our hospital. The average number of transtelephonic electrocardiograms was 10 per day. Abnormal electrocardiographic changes were observed in 42 patients, and the diagnoses were as follows: paroxysmal supraventricular tachycardia in 18 patients, paroxysmal atrial fibrillation in 17, ventricular tachycardia in 3, and angina in 7. Among seven patients in whom ST changes were documented by Cardiophone, six were diagnosed as variant angina. In several patients with diagnoses already made by Holter monitoring, the Cardiophone was used to monitor the drug effects and the correlations between symptoms and arrhythmic events. We conclude that the Cardiophone System is useful for diagnosing the causes of paroxysmal cardiac symptoms in some patients and for improving home medical services. 46
    • III 6 B* (SPANISH) 1. Villarroel, H.; Pereira, D.; Rivas, G.; Morataya, R. M.; Morales, D.; Caceros, S.; Marroquin, M.; Suarez Arana, R.; Espinola Zavaleta, N., and Ben Haim, I. (CARDIOTEL de Centroamerica, Ciudad Merliot, La Libertad E.S. San Salvador.). [Epidemiologic profile of transtelephonic electrocardiography in El Salvador during 1994]. [Spanish]. Archivos Del Instituto De Cardiologia De Mexico. 1997 Nov-1997 Dec 31; 67(6). CODEN: 469-74; ISSN: 0020-3785. Call Number: III 6 B* (SPANISH) Abstract: A total of 3,787 electrocardiograms were obtained with transtelephonic monitors (TT- ECG) during 1994 in CardioTel of Central America, Nueva San Salvador, El Salvador. Each case was evaluated in terms of patient's risk and classified as high or low risk on basis of its clinical profile. There were 3,441 traces of low risk patients and 346 of high risk one. Female patients accounts for 64.7% of cases, with 35.3% corresponding to males. Of all the TT-ECG's a 52.3% were normal. Subjects older than 60 years (independently of risk had a greater probability of an abnormal TT-ECG; in the same way there was an statistically significative increase in the incidence of abnormal TT-ECG in high risk subjects compared with low risk ones. In respect to specific TT-ECG abnormalities against cardiovascular risk, a high risk condition implied a greater incidence of bundle branch blocks, signs of myocardial lesion/necrosis, left ventricular hypertrophy, sinus tachycardia and bradycardia, atrial fibrillation and premature ventricular and supraventricular complexes, with a p value of 0.05 of 0.001. Conclusions: TT-ECG is useful in the search of cardiovascular disease, regardless the presence or absence of symptoms. Age greater than 60 years and high cardiovascular risk implies a greater probability of abnormal TT-ECG. *III 6 B, *V 1. Bowers, G. H.; Steiner, E., and Kalman, M. (American Radiology Services, Inc., Baltimore, MD 21208, USA.). Implementing teleradiology in a private radiology practice: lessons learned. [Review] [0 refs]. Journal of Digital Imaging. 1998 Aug; 11(3 Suppl 1). CODEN: 96-8; ISSN: 0897-1889. Call Number: *III 6 B, *V Abstract: The private practice of radiology deals with the delivery of high quality, timely service to referring physicians. Technology offers the promise of supporting this objective through faster reading of studies through electronic imaging and the delivery of results in a fast, efficient manner. In order to be successful, the practice must clearly define its objectives, understand its fundamental business processes and select a technology solution that is proven to meet those objectives. [References: 0] 2. Della Mea, V. and Beltrami, C. A. (Department of Pathology, University of Udine, Italy). Telepathology applications of the Internet multimedia electronic mail. Medical Informatics. 1998 Jul-1998 Sep 30; 23(3):237-44. Call Number: *III 6 B, *V Abstract: Telepathology is based on the sharing of medical images coming from the microscope, and comprises different applications: intra-operative telediagnosis, second opinion teleconsultation, reference case archives, remote data and image processing, quality assessment. Since the Internet is available worldwide, it can be of interest to define which of these tasks can be performed by means of some telepathology method based on it. This paper focuses particularly on the use of Internet multimedia electronic mail for exchanging multimedia cases. To test the validity of the proposed approach for transmission of multimedia cases, the first step is to evaluate its diagnostic accuracy. Trials involving the transmission of 299 cases have been carried out between two departments of Pathology in Italy (at the University of Udine and at the City Hospital of Trento, respectively) in order to evaluate the diagnostic accuracy as well as the time needed for acquisition and transmission. First results show that good diagnostic agreement can be reached, but the time needed for transmission, generally low, is not sufficiently affordable to be adopted in those cases where time is important. In particular, telepathology through multimedia e-mail can be adopted for second opinion consultation, remote image processing, quality assessment and continuing education possibly by means of software that integrates acquisition and delivery of cases with HIS functionalities 47
    • 3. Kayser, K. and Kayser, G. (Department of Pathology, Thoraxklinik, Heidelberg, Germany). Basic aspects of and recent developments in telepathology in Europe, with specific emphasis on quality assurance. [Review] [29 refs]. Analytical & Quantitative Cytology & Histology. 1999 Aug; 21(4):319-28. Call Number: *III 6 B, *V Abstract: Telepathology is the diagnostic work of a pathologist from a distance and includes all specific fields of diagnostic pathology, such as frozen section services, expert consultation, cytometric and histometric measurement, and continuous education. For about 15 years experience has been collected at several universities in the United States and Europe based upon analog telephone lines (9.2 kbaud), digitized lines (ISDN, 64 kbaud), broad band connections (1.5 Mbaud) and the World Wide Web (28 kbaud). Potential use can be expected in the application of telepresentation, remote slide preparation, remote central diagnostics and telediscussion. The transfer of still images is well developed; that of live images is used in only a few institutions for frozen section services. The image quality and spatial resolution as well as the transfer speed are sufficient for expert consultations, morphometric measurements, quality assurance and education. All applications focus on discontinuous work flow. Although the European Community focuses on user needs and standardization aspects of telepathology by sponsoring a widespread telepathology project (Europath), implementation of telepathology into routine application in the continuous work flow has still to be developed. The technical equipment has still to be adjusted to the labor flow charts in routine pathologic diagnostic procedures. Telepathology seems to be the appropriate technique to offer both improvement in diagnostic quality and inclusion of the "control institution" into diagnostic responsibility. [References: 29] *III 6 B, VI B 1. Baigent, M. F.; Lloyd, C. J.; Kavanagh, S. J.; Ben-Tovim, D. I.; Yellowlees, P. M.; Kalucy, R. S., and Bond, M. J. (Department of Psychiatry, Flinders Medical Centre, South Australia, North Adelaide. Telepsychiatry: 'tele' yes, but what about the 'psychiatry'?. Journal of Telemedicine & Telecare 1997;3 Suppl 1:3-5. ISSN: 1357-633X. Call Number: *III 6 B, VI B Abstract: To investigate what is lost or gained in a psychiatric evaluation when it takes place via telepsychiatry we compared the interrater reliability between two psychiatrists interviewing 63 subjects in an observer/interviewer split configuration in telepsychiatry and same-room settings. The measures used were the BPRS and interviewer ratings from a semi-structured interview. Patients also rated their experience. There were some clear differences between the telepsychiatry and same- room evaluations. Despite these variations, diagnoses were as reliably made by telepsychiatry. Patient acceptance of telepsychiatry was high. 2. Duffy, J. R.; Werven, G. W., and Aronson, A. E. (Division of Speech Pathology, Mayo Clinic Rochester, MN 55905, USA.). Telemedicine and the diagnosis of speech and language disorders. Mayo Clinic Proceedings. 1997 Dec; 72(12). CODEN: 1116-22; ISSN: 0025-6196. Call Number: *III 6 B, VI B Abstract: OBJECTIVE: To summarize results of telemedicine evaluations of speech and language disorders in patients in a small, rural hospital and in large multidisciplinary medical practices. MATERIALS AND METHODS: Eight patients underwent assessment as part of experiments with the National Aeronautics and Space Administration-launched Advanced Communications Technology Satellite. A second clinician was on-site with patients to assess the reliability of satellite observations. Twenty-four previously videotaped samples of speech disorders were also transmitted to assess agreement with original face-to-face clinical diagnoses. In addition, results of 150 telemedicine evaluations among Mayo Clinic practices in Minnesota, Arizona, and Florida were examined retrospectively. RESULTS: Evaluations were reliable, and patient satisfaction was good. Diagnoses were consistent with lesion localization and medical diagnosis when they were known, and they frequently had implications for lesion localization and medical diagnosis and management when they were previously unknown. The frequency of uncertain diagnosis (13%) for evaluation among the Mayo practices was only slightly higher than that encountered in face-to-face practice. Face-to-face evaluations were considered necessary for only 6 of the 150 patients (4%). CONCLUSION: Telemedicine evaluations can be reliable, beneficial, and acceptable to patients 48
    • with a variety of acquired speech and language disorders, both in rural settings and within large multidisciplinary medical settings. *III6B 1. Knudsen, P.; Ryther, A. J.; Nesheim, J. A.; Abeler, V. M.; Nesland, J. M., and Danielsen, H. E. (Avdeling for Patologi Det Norske Radiumhospital, Oslo). [Telepathology at the Norwegian Radium Hospital]. [Norwegian]. Tidsskrift for Den Norske Laegeforening. 2000 Aug 10; 120(18):2170-3. Call Number: *III6B Abstract: BACKGROUND: The article gives an overview of the telepathology activity at the Norwegian Radium Hospital from the service was launched in 1994 and up until today. We show the development during these years and discuss telepathology in general terms. We also discuss those aspects that determine how well a telepathology service functions. MATERIAL AND METHODS: 74 frozen section slides were diagnosed by two different telepathology systems. One of these systems was used for examining its appropriateness as a tool for second opinion in pathology. A new Internet-based system was developed that provided additional functionality. RESULTS: A telepathology system with a digital camera outperforms one with an analog camera with respect to diagnostic accuracy. INTERPRETATION: Image quality determines the precision of a telepathology service. Telepathology is a feasible tool for second opinion in pathology 2. Pickering, T. G.; Gerin, W., and Holland, J. K. (LifeLink Monitoring, Inc., PO Box 152, Bearsville, NY, 12409, USA). Home blood pressure teletransmission for better diagnosis and treatment. Current Hypertension Reports. 1999 Dec; 1(6):489-94. Call Number: *III6B Abstract: The rate of control of high blood pressure is disappointing, and noncompliance is one factor that contributes to this. The reasons for poor compliance are complex and include factors related to the patient, the healthcare provider, and the medical system. In general, the lack of regular communication between the patient and the physician, as occurs in the traditional model of clinic- based care, predicts a low rate of blood pressure control. In addition, clinic-based blood pressure rates are notoriously unreliable. A solution to this dilemma is teletransmission of self- measured blood pressure readings, which offers the dual advantages of more reliable measurements, and the establishment of regular telephone communication between the patient and the healthcare provider. Preliminary evidence with this type of system suggests that blood pressure control can be improved substantially 49