This document summarizes the introduction and evaluation of a telemedicine system for plastic surgery referrals in the UK. [1] A store-and-forward telemedicine system was implemented to allow referring hospitals to send digital images of injuries along with referrals. [2] An evaluation of over 900 referrals found the system was used for 42% of cases and helped overcome initial resistance from clinicians. [3] A prospective study of nearly 1000 patients found telemedicine referrals were 10% more likely to be directly booked for day surgery and there was a decrease in patients that could not be accepted due to lack of capacity.
From testing to spread: Sharing the knowledge and learning from organisations...NHS Improvement
From testing to spread:Sharing the knowledge and learning from organisations spreading the Winning Principles - case studies
The spread case studies illustrate many of these factors and provide an opportunity for sharing ‘working’ knowledge and learning experiences with the intention to promote further spread, adoption and action of good practice across the country and benefit more patients (Published July 2010).
Providing access to interventional
radiology services, seven days a week
Interventional radiology procedures are low volume and have a number of complex challenges. The service configuration at each Trust differs and is dependent on the number and the skill mix of interventional radiology consultants in the Trust. It is a service that supports a wide range of clinical pathways.
Based on the work of the NHS England Seven Day Services Forum and NHS Improving Quality’s Seven Day Services Improvement Programme (SDSIP), the focus for the 2013/14 interventional radiology programme has been to develop networks to deliver seven day access for nephrostomy, embolisation for haemorrhage and embolisation for post-partum haemorrhage.
Nephrostomy is a core interventional radiology service required for patients with a potential to deteriorate and require urgent intervention. Embolisation for haemorrhage usually, but not exclusively, is performed as an emergency/urgent intervention.Embolisation for post-partum haemorrhage may involve predelivery planning and be performed as an emergency/urgent intervention.
The Complementary Roles of Computer-Aided Diagnosis and Quantitative Image A...Carestream
This presentation from RSNA explains how their similarities and differences have an impact on assessment, quality assurance and training in radiography. Read the blog at http://www.carestream.com/blog/2016/06/07/differences-between-computer-aided-diagnosis-and-quantitative-image-analysis/
Towards best practice in interventional radiologyNHS Improvement
Towards best practice in interventional radiology draws together the findings from visits to interventional radiology (IR) services at proposed major trauma centres in England during 2011/12. This record of their major findings provides a definitive read for trust chief executives and commissioners to help better inform IR service reviews. (June 2012)
The Value of Multimedia-Enhanced Radiology ReportingCarestream
Statistics from the American College of Radiology study,“Traditional Text-Only Versus Multimedia-Enhanced Radiology Reporting: Referring Physicians’ Perceptions of Value," explains how valuable referring physicians believe multimedia radiology report to be.
Imran Sarwar Bajwa, [2010], "Virtual Telemedicine Using Natural Language Processing", International Journal of Information Technology and Web Engineering IJITWE 5(1):43-55, January 2010
Review of Image Watermarking Technique for MediIJARIIT
In this article, we focus on the complementary role of watermarking with respect to medical information security (integrity, authenticity …) and management. We review sample cases where watermarking has been deployed. We conclude that watermarking has found a niche role in healthcare systems, as an instrument for protection of medical information, for secure sharing and handling of medical images. The concern of medical experts on the preservation of documents diagnostic integrity remains paramount. Medical image watermarking is an appropriate method used for enhancing security and authentication of medical data, which is crucial and used for further diagnosis and reference. This paper discusses the available medical image watermarking methods for protecting and authenticating medical data. The paper focuses on algorithms for application of watermarking technique on Region of Non Interest (RONI) of the medical image preserving Region of Interest (ROI).
From testing to spread: Sharing the knowledge and learning from organisations...NHS Improvement
From testing to spread:Sharing the knowledge and learning from organisations spreading the Winning Principles - case studies
The spread case studies illustrate many of these factors and provide an opportunity for sharing ‘working’ knowledge and learning experiences with the intention to promote further spread, adoption and action of good practice across the country and benefit more patients (Published July 2010).
Providing access to interventional
radiology services, seven days a week
Interventional radiology procedures are low volume and have a number of complex challenges. The service configuration at each Trust differs and is dependent on the number and the skill mix of interventional radiology consultants in the Trust. It is a service that supports a wide range of clinical pathways.
Based on the work of the NHS England Seven Day Services Forum and NHS Improving Quality’s Seven Day Services Improvement Programme (SDSIP), the focus for the 2013/14 interventional radiology programme has been to develop networks to deliver seven day access for nephrostomy, embolisation for haemorrhage and embolisation for post-partum haemorrhage.
Nephrostomy is a core interventional radiology service required for patients with a potential to deteriorate and require urgent intervention. Embolisation for haemorrhage usually, but not exclusively, is performed as an emergency/urgent intervention.Embolisation for post-partum haemorrhage may involve predelivery planning and be performed as an emergency/urgent intervention.
The Complementary Roles of Computer-Aided Diagnosis and Quantitative Image A...Carestream
This presentation from RSNA explains how their similarities and differences have an impact on assessment, quality assurance and training in radiography. Read the blog at http://www.carestream.com/blog/2016/06/07/differences-between-computer-aided-diagnosis-and-quantitative-image-analysis/
Towards best practice in interventional radiologyNHS Improvement
Towards best practice in interventional radiology draws together the findings from visits to interventional radiology (IR) services at proposed major trauma centres in England during 2011/12. This record of their major findings provides a definitive read for trust chief executives and commissioners to help better inform IR service reviews. (June 2012)
The Value of Multimedia-Enhanced Radiology ReportingCarestream
Statistics from the American College of Radiology study,“Traditional Text-Only Versus Multimedia-Enhanced Radiology Reporting: Referring Physicians’ Perceptions of Value," explains how valuable referring physicians believe multimedia radiology report to be.
Imran Sarwar Bajwa, [2010], "Virtual Telemedicine Using Natural Language Processing", International Journal of Information Technology and Web Engineering IJITWE 5(1):43-55, January 2010
Review of Image Watermarking Technique for MediIJARIIT
In this article, we focus on the complementary role of watermarking with respect to medical information security (integrity, authenticity …) and management. We review sample cases where watermarking has been deployed. We conclude that watermarking has found a niche role in healthcare systems, as an instrument for protection of medical information, for secure sharing and handling of medical images. The concern of medical experts on the preservation of documents diagnostic integrity remains paramount. Medical image watermarking is an appropriate method used for enhancing security and authentication of medical data, which is crucial and used for further diagnosis and reference. This paper discusses the available medical image watermarking methods for protecting and authenticating medical data. The paper focuses on algorithms for application of watermarking technique on Region of Non Interest (RONI) of the medical image preserving Region of Interest (ROI).
An Assessment of Problems and Preferences in Medical Imaging of Pediatric Pat...ijtsrd
Medical Imaging is extremely valuable as a diagnostic tool in the pediatric population, but it comes with a number of distinct challenges as compared to the imaging of adults. This is because of the following: It requires dedicated imaging protocols to acquire the images, there is need for sedation or general anesthesia for longer procedures such as MRI, specific training is required for the healthcare personnel involved, thorough knowledge and expertise should be applied for evaluating the images, and most importantly, it requires consideration for radiation exposure if ionizing radiation is being used. One of the challenges for clinical care personnel is to gain the childs trust and co-operation before and throughout the duration of an examination, which can prove to be difficult in children who may be ill and have pain. This is important to acquire quality images and prevent repeat examinations. Even with a quality examination, the accurate interpretation of images requires a thorough knowledge of the intricate and dynamic face of anatomy and specific pathological presentations in children. The increased radiation sensitivity of growing organs and childrens longer expected life spans make them more susceptible to the harmful effects of radiation. Imaging pediatric patients in a dedicated pediatric imaging department with dedicated pediatric CT technologists may result in greater compliance with pediatric protocols and significantly reduced patient dose. In order to prevent the harmful effects of ionizing radiation, As Low As Reasonably Achievable (ALARA) principle should be strictly followed. This article seeks to draw attention to various challenges of pediatric imaging and the ways to overcome them Tamijeselvan S"An Assessment of Problems and Preferences in Medical Imaging of Pediatric Patients" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-2 | Issue-3 , April 2018, URL: http://www.ijtsrd.com/papers/ijtsrd11012.pdf http://www.ijtsrd.com/medicine/radiology/11012/an-assessment-of-problems-and-preferences-in-medical-imaging-of-pediatric-patients/tamijeselvan-s
The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient.
In our study the efficacy of external beam irradiation in the palliation of bone metastasis-related symptoms is confirmed by this study, even with short treatments and single-dose administrations. This is important for both patient expectations and the necessity for improved resource allocation with reference to the territorial distribution and waiting lists of radiotherapy centers. The issue of their efficacy in combination with antiblastic drugs (Bisphosphonates drugs such as Zoledronic acid) and/or external beam irradiation(EBRT) remains open and will be clarified only with further randomized clinical trials.
The Effects of Sleep Deprivation, Caffeine, and Alcohol on Simulated Neurosur...Crimsonpublisherssmoaj
Objectives: We hypothesized that sleep deprivation, caffeine intake, and alcohol consumption the night prior to simulated microneurosurgery may impact performance on a virtual reality neurosurgical simulator.Patients and Methods: After IRB approval, trainees practiced a simulated bimanual arachnoid dissection microsurgical task on the NeuroTouch Neurosurgical simulator (National Research Council, Canada) until it was mastered. For each participant, the task was repeated several times following sleep deprivation, caffeine intake and the morning after a social gathering where blood alcohol content (BAC) was measured. Each time the task was performed, the participants documented variables on a questionnaire. Performance metrics included: task duration, left or right hand excessive force, number of incorrect or correct fibers cut, and overall score based on several measurements.
Craig lipset, Director of Clinical Research
at Pfi zer, leads a panel discussion on the
current state of clinical trials and the use
of technology to capture the voice of the
patient. Th e panelists, coming from various
backgrounds, lend their diff ering viewpoints
on the current and future trends in
this space
Cancer of Right Breast with Single-Liver MetastasisSimultaneous Treatment of ...Kanhu Charan
Cancer of Right Breast with Single-Liver Metastasis Simultaneous Treatment of Chest Wall with Radiotherapy for Carcinoma Breast and SBRT for Liver Lesion: Procedural
Details of the Complex Procedure
An Assessment of Problems and Preferences in Medical Imaging of Pediatric Pat...ijtsrd
Medical Imaging is extremely valuable as a diagnostic tool in the pediatric population, but it comes with a number of distinct challenges as compared to the imaging of adults. This is because of the following: It requires dedicated imaging protocols to acquire the images, there is need for sedation or general anesthesia for longer procedures such as MRI, specific training is required for the healthcare personnel involved, thorough knowledge and expertise should be applied for evaluating the images, and most importantly, it requires consideration for radiation exposure if ionizing radiation is being used. One of the challenges for clinical care personnel is to gain the childs trust and co-operation before and throughout the duration of an examination, which can prove to be difficult in children who may be ill and have pain. This is important to acquire quality images and prevent repeat examinations. Even with a quality examination, the accurate interpretation of images requires a thorough knowledge of the intricate and dynamic face of anatomy and specific pathological presentations in children. The increased radiation sensitivity of growing organs and childrens longer expected life spans make them more susceptible to the harmful effects of radiation. Imaging pediatric patients in a dedicated pediatric imaging department with dedicated pediatric CT technologists may result in greater compliance with pediatric protocols and significantly reduced patient dose. In order to prevent the harmful effects of ionizing radiation, As Low As Reasonably Achievable (ALARA) principle should be strictly followed. This article seeks to draw attention to various challenges of pediatric imaging and the ways to overcome them Tamijeselvan S"An Assessment of Problems and Preferences in Medical Imaging of Pediatric Patients" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-2 | Issue-3 , April 2018, URL: http://www.ijtsrd.com/papers/ijtsrd11012.pdf http://www.ijtsrd.com/medicine/radiology/11012/an-assessment-of-problems-and-preferences-in-medical-imaging-of-pediatric-patients/tamijeselvan-s
The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient.
In our study the efficacy of external beam irradiation in the palliation of bone metastasis-related symptoms is confirmed by this study, even with short treatments and single-dose administrations. This is important for both patient expectations and the necessity for improved resource allocation with reference to the territorial distribution and waiting lists of radiotherapy centers. The issue of their efficacy in combination with antiblastic drugs (Bisphosphonates drugs such as Zoledronic acid) and/or external beam irradiation(EBRT) remains open and will be clarified only with further randomized clinical trials.
The Effects of Sleep Deprivation, Caffeine, and Alcohol on Simulated Neurosur...Crimsonpublisherssmoaj
Objectives: We hypothesized that sleep deprivation, caffeine intake, and alcohol consumption the night prior to simulated microneurosurgery may impact performance on a virtual reality neurosurgical simulator.Patients and Methods: After IRB approval, trainees practiced a simulated bimanual arachnoid dissection microsurgical task on the NeuroTouch Neurosurgical simulator (National Research Council, Canada) until it was mastered. For each participant, the task was repeated several times following sleep deprivation, caffeine intake and the morning after a social gathering where blood alcohol content (BAC) was measured. Each time the task was performed, the participants documented variables on a questionnaire. Performance metrics included: task duration, left or right hand excessive force, number of incorrect or correct fibers cut, and overall score based on several measurements.
Craig lipset, Director of Clinical Research
at Pfi zer, leads a panel discussion on the
current state of clinical trials and the use
of technology to capture the voice of the
patient. Th e panelists, coming from various
backgrounds, lend their diff ering viewpoints
on the current and future trends in
this space
Cancer of Right Breast with Single-Liver MetastasisSimultaneous Treatment of ...Kanhu Charan
Cancer of Right Breast with Single-Liver Metastasis Simultaneous Treatment of Chest Wall with Radiotherapy for Carcinoma Breast and SBRT for Liver Lesion: Procedural
Details of the Complex Procedure
ASTUTE: Acute Stroke Telemedicine: Utility Training and Evaluation
Implementing Telemedicine in Acute Stroke and the development of a Standardised Telemedicine Tookit
Lancashire Teaching Hsopitals NHS Foundation Trust
Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013
More information about this event can be found at
http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx
Teleradiology is a branch of telemedicine in which telecommunication systems are used to transmit radiological images from one location to another. Interpretation of all noninvasive imaging studies, such as digitized x-rays, CT, MRI, ultrasound, and nuclear medicine studies, can be carried out in such a manner.
The first steps in teleradiology date back to 1929 when a medical image was transmitted via telegraph to a distant location
Based on the recommendations of a committee set up by the Government of India, this document briefly present a set of guidelines of standard practice in Telemedicine in India.
This month's community call is part two in a series on Clinical Transformation. The presentations will highlight how Clinical Transformation affects outcomes AND the bottom-line of health care organizations. The presentation will provide a proof point on how Clinical Transformation has a direct Return on Investment (ROI) for both the patient and the provider organization.
This topic is both clinical and administrative in nature and will likely be useful to physicians, nurses and others interested in outcomes, as well as health care CIOs, CFOs and administrators.
Please feel free to forward this invitation to any colleagues or associates who you believe would find this topic of interest or would like to participate in the discussion.
What: Clinical Transformation (Part II)
- Clinical Transformation
- a Blueprint
- in Practice
- Transformation Working Group Update
- Review of status
- Framework for Planning
- Discussion
- Open Project Updates
- OpenVista/GT.M Integration
- CCD/CCR collaboration
- Medsphere.org: Tip of the month
When: March 26, 12:30 - 2pm Pacific
Where: Dial-in: (888) 346-3950 // Participant Code: 1302465
Web conference: http://www.medsphere.com/infinite/
===
The community calls are listed on the Medsphere.org event calendar (http://medsphere.org/community-events/) and we will update each month's call as the agenda is solidified.
Details and Recording available here: http://medsphere.org/blogs/events/2009/03/26/community-call-march-2009
Tele-ophthalmology: the new normal in current timesObaidur Rehman
Covers telehealth and telemedicine in general. Tele-ophthalmology development in India. Practice and patterns as defined by concerned authorities. Guidelines as set up Govt of India. Current tele-ophthalmology projects in India
deep learning applications in medical image analysis brain tumorVenkat Projects
The tremendous success of machine learning algorithms at image recognition tasks in recent years intersects with a time of dramatically increased use of electronic medical records and diagnostic imaging. This review introduces the machine learning algorithms as applied to medical image analysis, focusing on convolutional neural networks, and emphasizing clinical aspects of the _eld. The advantage of machine learning in an era of medical big data is that signi_cant hierarchal relationships within the data can be discovered algorithmically without laborious hand-crafting of features. We cover key research areas and applications of medical image classi_cation, localization, detection, segmentation, and registration. We conclude by discussing research obstacles, emerging trends, and possible future directions.
Heavily based on a presentation I gave for the CMS 2020 National Quality Forum. Emphasis is on dialysis (particularly home dialysis). Discusses regulatory framework, medical devices used to render the services and outcomes of studies performed to day
Care expert assistant for Medicare system using Machine learning
Articulo de telemedicina en urgencia
1. Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 31e36
Telemedicine for acute plastic surgical
trauma and burns
D.L. Wallace a,b,d, S.M. Jones a,c,e, C. Milroy a, M.A. Pickford a,*
a
Plastic Surgery Department, Queen Victoria Hospital, Holtye Road,
East Grinstead, West Sussex RH19 3DZ, UK
Received 20 December 2005; accepted 17 March 2006
KEYWORDS Summary Visual images can enhance communication over a distance. In the UK,
Telemedicine; plastic surgery provides services over large distances by a ‘hub and spoke’ model.
Store-and-forward; Telemedicine could help to increase the efficiency of service for plastic surgery pa-
Digital; tients. Telemedicine, along with the impending Electronic Patient Record system
Trauma; could combine to improve communication, patient triage, record keeping, audit
Triage and could lead to a better quality of clinical care. Another benefit could be signif-
icant cost savings.
We report our experience of the introduction of telemedicine to a Regional Plas-
tic Surgery Service. Our first study compared assessments from images and patient
examinations, which gave us confidence in the use of images [Jones SM, Milroy C,
Pickford MA. Telemedicine in acute plastic surgical trauma and burns. Ann R Coll
Surg Engl 2004;86:239e42]. We proceeded to a 10-week evaluation of all 973 refer-
rals to our unit. We found that the system was used for a wide variety of injuries
and for 42% of the 452 patients where the system was available. Initial resistance
was overcome by the ease of use of the system, with both receiving and referring
clinicians reporting benefits. The third phase was a 12-week prospective cohort
study of 996 patients comparing the referrals with and without the telemedicine
system. The system was available for 389 patients, and used for 243 patients
(63%). The groups were analysed by a chi squared test and confidence interval cal-
culation. We demonstrated a significant difference in the initial management of pa-
tients, with 10% more being booked directly to our Day Surgery Unit. There was
a decrease in number of occasions when we were unable to accept a patient due
* Corresponding author. Tel.: þ44 1342 414035; fax: þ44 1342 414121.
E-mail addresses: davidandvix@aol.com (D.L. Wallace), mark.pickford@qvh.nhs.uk (M.A. Pickford).
b
DL Wallace presented a part of the submission at the 3rd Annual International Conference of Telecare and Telehealth in Brisbane,
Australia, August 2003.
c
SM Jones presented a part of the submission at the British Association of Plastic Surgeons Winter Meeting, December 2001.
d
Present address: 21 Huddesford Drive, Balsall Common, Coventry CV7 7RR, UK
e
Present address: Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire SP2 8BJ, UK
1748-6815/$ - see front matter ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2006.03.045
2. 32 D.L. Wallace et al.
to a lack of capacity. We found no change in the patients being managed with tele-
phone only advice.
We found that telemedicine is a valuable method of providing useful preliminary
information in the referral process for injured patients and often significantly mod-
ifies their treatment and/or management plan. This has implications for the use of
Information Technology resources and potentially the delivery of healthcare in
relation to the management of injured patients.
ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Published by Elsevier Ltd. All rights reserved.
The simplest definition of telemedicine is ‘the Information Technology experts, Consultants and
practise of medicine at a distance’.2 There are Junior Staff of the surgical specialties based at the
two main types of visual telemedicine; store-and- QVH (Plastic Surgery and Maxillofacial Surgery).
forward or real-time videoconferencing systems. Specialist software was commissioned (DISTAR
Videoconferencing allows synchronous consulta- Telemedicine, Digital Image ST-orage And Re-
tions that report high patient and clinician satis- trieval, and TM Clientª) to provide secure and
faction rates,3 and is successfully used in many technically simple data acquisition and transfer.
Minor Injury Units to provide a real-time link to The software consists of five simple steps for im-
a larger Accident and Emergency Department.4 age location, selection of the correct images with
However, real-time technology can be expensive a small preview check, demographic data entry,
to install and maintain, the quality may be vari- recording the level of consent and transmission
able, the software is complex and often restric- of the encrypted email. The average file size was
tive, and the clinician requires technical skills 700 KB, for 24-bit colour images at a resolution of
and usually a designated room. Store-and-forward 1600 Â 1200 pixels. This was manageable for the
systems provide high resolution images but are hospital networks and allowed rapid transmission
asynchronous; they have been used for many years over the Internet. The encrypted email could be
in specialties such as Dermatology and Radiology. sent from other hospital sites (external) or net-
The agreement in diagnosis between face-to-face worked computers within the QVH (internal).
consultations and real-time is 51e80% and for Upon arrival at the QVH server (Pentium 4 256MB
store-and-forward systems 70e95%.5 RAM and RAID-1 mirrored 14 GB disks) emails
The Queen Victoria Hospital (QVH) provides were decrypted and were available for viewing at
plastic surgical services to the South East of England any networked computer. The hospital computers
(population 4.5 million). Approximately 450 trauma operated Windows NT and were a minimum of Pen-
referrals are received each month from 24 different tium II, 64 RAM; but most commonly used were
NHS Trusts in the region. Audit in our department Pentium III, 128 RAM. Images were viewed on
has shown that referrals have doubled over the last a screen resolution of 800 Â 600 pixels and re-
five years and are still increasing. Capacity to treat corded onto a database, which was backed up
hand injuries in our geographical region is under daily.
considerable strain with 17% of units being unable to The referring clinicians obtained consent for
accept referrals.6 We were keen to assess the po- photographs from their patients and emailed
tential of telemedicine to improve the triage and digital images via the NHS intranet, in addition to
management of trauma referrals to our unit. the usual telephone referral. A plastic surgery
The choice of telemedicine system is best made trainee (SMJ) was employed to drive the project
by the clinical users.7 We chose a store-and-for- in the early stages. Over a six-month period the
ward system because high resolution images could system was introduced to 10 hospitals that
be easily and cheaply accessed at any networked regularly referred injuries to QVH. During this six-
hospital computer, even in theatre while surgeons month period we undertook a 10-week retrospec-
are scrubbed. tive evaluation study. The Telemedicine team
reviewed the initial results, and the installation
of the telemedicine software and education
Methods and materials programme in referring units was continued.
A subsequent prospective 12-week trial was
A Telemedicine team was created consisting of carried out to investigate changes in patient
nursing staff, medical illustrators, audit personnel, management from the telemedicine assisted
3. Telemedicine for acute plastic surgical trauma and burns 33
referrals compared to telephone only referrals.
From 01 March 2003 to 23 May 2003 the receiving
clinician recorded the demographic and clinical
details of all trauma referrals. Statistical analysis
was performed with the chi squared test and
confidence interval calculation.
Results
Ten-week retrospective evaluation of the
telemedicine system
We received 973 referrals over 10 weeks from 53
different sites. There were 644 male and 329 Figure 2 Radiograph of a crushed finger fracture.
female patients; 730 adults and 174 children. A
wide variety of injuries were assessed (Figs. 1e7).
Use of the system was seen to steadily increase A significant difference was noted (P ¼ 0.004) in
over the initial six-month period (Fig. 8). From the management of patients with and without the
the sites with the telemedicine installed there availability of the telemedicine system (Table 1).
were 452 patients referred; telemedicine was Significantly fewer patients needed to come for
used for 42% of these patients. After initial resis- further assessment or review and more patients
tance, referring clinicians were generally pleased could be directly booked for definitive care on an
with the introduction of the system, finding it operating list in our Day Surgery Unit (10.5%)
easy to use and helpful in the referral process. Re- when the telemedicine system was available. We
ceiving clinicians also expressed an improvement also observed a decrease in number of occasions
in the clarity of the information. when the QVH was unable to accept a referral
due to a lack of capacity. There was no increase
Twelve-week prospective cohort study or decrease in patients being managed with only
telephone advice, nor for patients admitted to
Over 12 weeks 996 referrals were received from their local hospital to await transfer to the QVH
over 60 different sites. There were 607 male and (outlier).
389 female referrals; 725 were adults and 271
were children. The telemedicine system was avail-
able for 389 referrals, and used for 243 referrals Discussion
(63%). Analysis was undertaken of telemedicine
system availability, not only when used, to mini- Telemedicine is a rapidly growing tool in modern
mise bias from the referring clinician’s choice. medicine, giving the promise of efficiency and
250
With Telemedicine
200 Without Telemedicine
Number of referrals
150
100
50
0
ry ury s ip rn n
tur
e n
nju inj los ert Bu ec
tio tio
ni d kin ing Inf Fr
ac
lanta
lea n ate e/s d/F ep
C
mi su ilb
e R
nta Tis Na
Co
Injury Type
Figure 1 The distribution of injuries and the use of
telemedicine during the 10-week evaluation study. Figure 3 Clinical image of finger in Fig. 2.
4. 34 D.L. Wallace et al.
Figure 4 Flame burn to fingers.
better communication between clinicians.8 Tele-
medicine systems have proved useful in reducing
unnecessary transfers in Neurosurgical emergen-
cies,9 and in reducing mortality, complications
and costs in Intensive Care.10 In the UK the na-
tional telemedicine database has 260 projects cur-
rently listed,11 though only a minority have been
reported moving into routine or mainstream use,
even with successful pilots. There are numerous
Figure 6 Paediatric mixed depth burn.
barriers to the implementation of telemedicine
including limited financial support or reimburse-
ment,12,13 legal uncertainties14 and an inadequate adequate, technical difficulties in the viewing of
evidence base.15 images led us to commission specialist software.
Image resolution in telemedicine is crucial. On This facilitated the ease of loading, sending, re-
viewing a series of images of different resolutions viewing, record keeping and security of images.
clinicians can lose confidence in their diagnosis There have been feasibility studies assessing the
before they realise that the image resolution has role of telemedicine for wound assessment,19 burn
changed.16 Our initial assessment demonstrated injuries,18,20 fractures21 and replantations.22
that 800 Â 600 pixels provided good enough resolu- There are no previous studies demonstrating supe-
tion for diagnosis,1 confirming a resolution level riority to the traditional telephone referral for
shown to be effective for dermatology17 and burn acute plastic surgery, nor reporting the routine
injuries.18 Although this image resolution was
Figure 5 Flank and buttock post-debridement of
necrotising fascitis. Figure 7 Pre-tibial laceration.
5. Telemedicine for acute plastic surgical trauma and burns 35
180
160
140
120
100
80
60
40
20
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
January 2002 to July 2003
Figure 8 The use of telemedicine at the Queen Victoria Hospital since the introduction of the specialist software TM
Clientª in January 2002.
use of telemedicine in the usual referral process. the receiving clinician with greater confidence in
Our initial results confirmed the feasibility of the planning the delivery of the surgical service, e.g.
telemedicine system for assessing all types of to book directly to an urgent day case appoint-
acute plastic surgical referrals, with both referring ment, a next day clinic review or organise an
and receiving clinicians reporting benefits.1 immediate transfer.
Our results demonstrated significant differences In addition to the improved clarity of commu-
in the management of referrals when the tele- nication we also observed improved access, earlier
medicine system was used (Table 1). Triage of and more frequent senior clinician involvement.
referrals was improved with greater use of day sur- We believe this is because the telemedicine
gery and a decreased need for face-to-face system images provide enough information to
assessment. An audit of London region Hand sur- make some clinical decisions immediately and
gery units (including the QVH) showed that nine involve senior clinicians prior to the face-to-face
departments are working so near to maximum consultation.
capacity that on 17% of occasions they are unable The evidence for direct cost savings to the
to accept referrals.6 We observed a decrease in providers of telemedicine is poor.23 Only in a few
the frequency with which patients were not prison and military populations where the patient
accepted at the QVH with the use of telemedicine. transportation costs are high is there evidence of
The changes observed could be because the cost savings.24 We found no evidence of cost sav-
telemedicine image provided more objective in- ings for the QVH trust, and only anecdotal patient
formation to the receiving clinician compared to cost savings. The capital outlay was significant
telephone referrals alone. This may have allowed (£70K) for the installation of the computer
Table 1 Difference in the management of referrals with and without telemedicine availability
Telemedicine assisted referral Telephone only referral
% (n ¼ 389) Confidence intervals % (n ¼ 607) Confidence intervals
Admit 29.6 (25.2e34.3) 28.3 (24.9e32.0)
Review 15.4 (12.2e19.3) 22.1 (19.0e25.5)
Dressing clinic 0.5 (0.1e1.9) 1.2 (0.6e2.4)
Day surgery 27.5 (23.3e32.1) 17 (14.2e20.2)
Full e unable 8.7 (6.3e12.0) 12.5 (10.1e15.4)
to accept
Outpatients 7.7 (5.5e10.8) 8.1 (6.2e10.5)
Outlier 4.6 (2.9e7.2) 4.4 (3.1e6.4)
Telephone advice 5.7 (3.8e8.4) 5.9 (4.3e8.1)
Inappropriate referral 0.3 (0.0e1.4) 0.5 (0.2e1.4)
Total 100 100
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We would like to thank S. Reynolds of Godalming
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Computer Products for the development of the ulcers. Ostomy Wound Manage 2000;46:20e30.
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