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. email@example.com). 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
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:
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
*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
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
Netherlands. michael:lbmi2.hobby.nl). 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;
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.
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
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.
pnfl:le.ac.uk). 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
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;
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
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
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;
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
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;
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
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;
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
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
*II 3, *III 6 B
1. Okumura, A.; Suzuki, J.; Furukawa, I.; Ono, S., and Ashihara, T. (NTT Optical Network Systems
Laboratories, Kanagawa, Japan. mura:exa.onlab.ntt.co.jp). 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
*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:
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
*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.
*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. dsweinberg:bics.bwh.harvard.edu). How is telepathology being used to
improve patient care?. [Review] [20 refs]. Clinical Chemistry. 1996 May; 42(5). CODEN: 831-5;
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
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. U.Engelmann:DKFZ-Heidelberg.de). 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. orphanou:ics.forth.gr). 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.
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;
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
*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:
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.
1. Mun, S. K.; Levine, B.; Cleary, K., and Dai, H. (ISIS Center, Department of Radiology, Georgetown
University Medical Center, Washington, DC 20007, USA. firstname.lastname@example.org).
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.
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
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. email@example.com). 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
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.
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;
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;
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
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.
firstname.lastname@example.org). 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. email@example.com). 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
8. Hayward, T. and Mitchell, J. (Women's and Children's Hospital, Adelaide, Australia.
firstname.lastname@example.org). 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
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.
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.
email@example.com). [Comments on separate consultations for second opinions (comment)
(see comments)]. [Review] [3 refs] [Dutch]. Nederlands Tijdschrift Voor Geneeskunde. 1999 Dec 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. firstname.lastname@example.org). Patient reactions to specialist
telemedicine consultations--a sociological approach. Journal of Telemedicine & Telecare. 1998;
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. email@example.com). 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