Diagnostic accuracy of chest X-rays acquired using a digital camera for low-cost teleradiology

Evaluation of a chest radiograph reading and recording system for tuberculosis in a HIV-positive cohort

AIM

To assess the impact of introducing a chest radiograph reading and recording system (CRRS) with a short training session, on the accuracy and inter-reader variability of tuberculosis (TB) interpretation of chest radiographs (CXRs) by a group of non-expert readers in a human immunodeficiency virus (HIV)-positive cohort.

MATERIALS AND METHODS

A set of 139 CXRs was reviewed by a group of eight physicians pre- and post-intervention at two clinics in Shan State, Myanmar, providing HIV/TB diagnosis and treatment services. The results were compared against the consensus of expert radiologists for accuracy.

RESULTS

Overall accuracy was similar pre- and post-intervention for most physicians with an average area under the receiver operating characteristic curve difference of 0.02 (95% confidence interval: -0.03, 0.07). The overall agreement among physicians was poor pre- and post-intervention (Fleiss κ=0.35 and κ=0.29 respectively). The assessment of agreement for specific disease patterns associated with active TB in HIV-infected patients showed that for intrinsically subtle findings, the agreement was generally poor but better for the more intrinsically obvious disease patterns: pleural effusion (Cohen's kappa range = 0.37-0.67) and milliary nodular pattern (Cohen's kappa range = 0.25-0.52).

CONCLUSION

This study demonstrated limited impact of the introduction of a CRRS on CXR accuracy and agreement amongst non-expert readers. The role in which CXRs are used for TB diagnosis in a HIV-positive cohort in similar clinical contexts should be reviewed.

Comparison of diagnostic accuracy of plain film radiographs between original film and smartphone capture: a pilot study

The use of mobile devices for medical image capture has become increasingly popular given the widespread use of smartphone cameras. Prior studies have generally compared mobile phone capture images to digitized images. However, many underserved and rural areas without picture archiving and communication systems (PACS) still depend greatly on the use of film radiographs. Additionally, there is a scarcity of specialty-trained or formally licensed radiologists in many of these regions. Subsequently, there is great potential for the use of smartphone capture of plain radiograph films which would allow for increased access to economical and efficient consultation from board-certified radiologists abroad. The present study addresses the ability to diagnose a subset of radiographic findings identified on both the original film radiograph and the captured camera phone image.

"Evaluation of a very low-cost and simple teleradiology technique"

This paper describes and analyzes a proposed solution of fundamental limitative factor of teleradiology to overcome the teleradiology usages problems in underdeveloped and developing countries. The goal is to achieve a very simple and cost-efficient way to take advantage of teleradiology in anywhere even in remote and rural areas. To meet the goal of this study, the following methodology which is consists of two main procedures was done: (1) Using a digital camera in order to provide a digital image from radiographs. (2) Using an image compression tool in order to compress digital images. The results showed that there is no significant difference between digital images (non-compress and compress images) and radiographic films. Also, there was a logic relationship between the diagnostic quality and diagnostic accuracy. Since the maximum percent of diagnostic accuracy can be seen among "Good" quality images and the minimum to was related "Poor". The results of our study indicate that a digital camera could be utilized to capture digital images from radiographic films of chest x-ray. To reduce the size of digital images, a lossy compression technique could be applied at compression percent of 50 or less without any significant differences. The compressed images can be sent easily by email to other places for consultation and also they can be stored with a smaller size.

A national teleradiology programme in Mali: implementation and results

We reviewed the national teleradiology programme in Mali to establish whether it improved diagnosis for patients and improved the referring doctor's ability to give an accurate diagnosis. The teleradiology programme connected the University Hospital in Bamako to all seven regional hospitals in Mali and one private health clinic. The pilot phase began in 2005 in three hospitals. Initially the implementation involved connections via broadband, but subsequently satellite antennae were provided at three remote hospitals in the north. Between 2005 and 2013, X-ray and mammogram images from 5628 patients were read by teleradiology. Radiologists provided the sole diagnosis for 29% of cases (i.e. the referrer did not make a diagnosis) and altered the regional doctor's diagnosis in 12% of cases. The proportion of cases for which the regional doctor gave no diagnosis decreased from 93% to 24% over the same period, indicating an increase in the doctors' confidence and incentive to test their own diagnosis. The percentage of cases for which regional doctors made an inaccurate diagnosis decreased to 3% in 2013. Use of the teleradiology service varied widely between hospitals. Successful implementation depended on local ownership of a network, which was developed in close collaboration with hospital leadership, national radiologists and other healthcare personnel.

Teleradiology usage and user satisfaction with the telemedicine system operated by médecins sans frontières

Médecins Sans Frontières (MSF) began a pilot trial of store-and-forward telemedicine in 2010, initially operating separate networks in English, French, and Spanish; these were merged into a single, multilingual platform in 2013. We reviewed the pattern of teleradiology usage on the MSF telemedicine platform in the 4-year period from April 2010. In total, 564 teleradiology cases were submitted from 22 different countries. A total of 1114 files were uploaded with the 564 cases, the majority being of type JPEG (n = 1081, 97%). The median file size was 938 kb (interquartile range, IQR 163–1659). A panel of 14 radiologists was available to report cases, but most (90%) were reported by only 4 radiologists. The median radiologist response time was 6.1 h (IQR 3.0–20). A user satisfaction survey was sent to 29 users in the last 6 months of the study. There was a 28% response rate. Most respondents found the radiologist’s advice helpful and all of them stated that the advice assisted in clarification of a diagnosis. Although some MSF sites made substantial use of the system for teleradiology, there is considerable potential for expansion. More promotion of telemedicine may be needed at different levels of the organization to increase engagement of staff.

Diagnostic accuracy of digitized chest X-rays using consumer-grade color displays for low-cost teleradiology services: a multireader-multicase comparison

INTRODUCTION

In teleradiology services and in hospitals, the extensive use of visualization displays requires affordable devices. The purpose of this study was to compare three differently priced displays (a medical-grade grayscale display and two consumer-grade color displays) for image visualization of digitized chest X-rays.

MATERIALS AND METHODS

The evaluated conditions were interstitial opacities, pneumothorax, and nodules using computed tomography as the gold standard. The comparison was accomplished in terms of receiver operating characteristic (ROC) curves, the diagnostic power measured as the area under ROC curves, accuracy in conditions classification, and main factors affecting accuracy, in a factorial study with 76 cases and six radiologists.

RESULTS

The ROC curves for all of the displays and pathologies had similar shapes and no differences in diagnostic power. The proportion of cases correctly classified for each display was greater than 71.9%. The correctness proportions of the three displays were different (p<0.05) only for interstitial opacities. The evaluation of the main factors affecting these proportions revealed that the display factor was not significant for either nodule size or pneumothorax size (p>0.05).

CONCLUSIONS

Although the image quality variables showed differences in the radiologists' perceptions of the image quality of the three displays, significant differences in the accuracy did not occur. The main effect on the variability of the proportions of correctly classified cases did not come from the display factor. This study confirms previous findings that medical-grade displays could be replaced by consumer-grade color displays with the same image quality.

Quality assessment of X-rays interpreted via teleradiology for Médecins Sans Frontières

Summary

Médecins Sans Frontières (MSF) is a humanitarian organisation which provides emergency medical aid in challenging settings; field staff often diagnose and treat patients using limited resources and without the expertise of specialists. Teleradiology is available for MSF sites which use digital computed radiography (CR) imaging or conventional film and chemistry. We conducted a retrospective study of the quality of X-rays utilised by MSF for teleradiology diagnosis over a one-year period. All plain X-ray examinations referred for interpretation using two MSF teleradiology platforms in 2012 were assessed against 15 image criteria and further evaluated as being either diagnostic or non-diagnostic. The sites studied sent an average of 115 images (range 10-452). Images were a mixture of chest, skeletal and abdominal radiographs. The majority of the images were CR (n = 597, 74%). Three sites were MSF/Epicentre installed and operated (Epicentre is a research facility affiliated with MSF); five sites were operated by the ministry of health, imaging patients referred by MSF. The sites performing poorest for quality were all facilities which used film and chemistry (53% non-diagnostic images). The sites performing better for quality were facilities which used CR digital imaging (12% non-diagnostic images), two of which had also undergone radiographer training. Our study suggests that transitioning to CR digital imaging has the potential to improve image quality compared to film and chemistry. Radiography training should be made a priority for all sites with X-ray services. The continued utilisation of X-ray services by MSF where images have proven to be consistently poor should be re-considered.

Digital radiology to improve the quality of care in countries with limited resources: a feasibility study from Angola

OBJECTIVE

Sub-standard quality in X-ray image acquisition and interpretation is common in low-resource countries, and can ultimately result in higher patient morbidity and mortality. This study aimed at evaluating; 1) feasibility of implementing a digital X-ray device in a second level hospital in Angola; 2) quality of digital X-ray images, when digital radiology was in the hands of local technicians; 3) feasibility of digital teleradiology and its potential impact on case management.

METHODS

We developed and tested at the Hospital Divina Providencia (HDP) in Luanda, Angola, a digital X-ray device and a telemedicine network to acquire and print digital X-ray images and send them as DICOM files for remote consultation.

RESULTS

20,564 digital X-ray images were made at HDP from November 2010 to December 2012, with no major technical problems and no need for on-site supervision. Digital radiology largely improved the number of X-ray images of good and very good quality (100% of images with digital radiology, compared to 15% of screen-film images, p<0.0001). Teleradiology using digital images was used in 7.6% of paediatric cases, and provided, in these cases, an important contribution to case management.

CONCLUSIONS

The implementation of a digital X-ray device is feasible in low resource settings with significant improvement in quality of X-ray images compared to standard screen film radiology.

The effect of a tuberculosis chest X-ray image reference set on non-expert reader performance

OBJECTIVES

In low-resource settings, limitations in diagnostic accuracy of chest X-rays (CXR) for pulmonary tuberculosis (PTB) relate partly to non-expert interpretation. We piloted a TB CXR Image Reference Set (TIRS) to improve non-expert performance in an operational setting in Malawi.

METHODS

Nineteen doctors and clinical officers read 60 CXR of patients with suspected PTB, at baseline and using TIRS. Two officers also used the CXR Reading and Recording System (CRRS). Correct treatment decisions were assessed against a "gold standard" of mycobacterial culture and expert performance.

RESULTS

TIRS significantly increased overall non-expert sensitivity from 67.6 (SD 14.9) to 75.5 (SD 11.1, P = 0.013), approaching expert values of 84.2 (SD 5.2). Among doctors, correct decisions increased from 60.7 % (SD 7.9) to 67.1 % (SD 8.0, P = 0.054). Clinical officers increased in sensitivity from 68.0 % (SD 15) to 77.4 % (SD 10.7, P = 0.056), but decreased in specificity from 55.0 % (SD 23.9) to 40.8 % (SD 10.4, P = 0.049). Two officers made correct treatment decisions with TIRS in 62.7 %. CRRS training increased this to 67.8 %.

CONCLUSION

Use of a CXR image reference set increased correct decisions by doctors to treat PTB. This tool may provide a low-cost intervention improving non-expert performance, translating into improved clinical care. Further evaluation is warranted.

KEY POINTS

• Tuberculosis treatment decisions are influenced by CXR findings, despite improved laboratory diagnostics. • In low-resource settings, CXR interpretation is performed largely by non-experts. • We piloted the effect of a simple reference training set of CXRs. • Use of the reference set increased the number of correct treatment decisions. This effect was more marked for doctors than clinical officers. • Further evaluation of this simple training tool is warranted.

A Low Cost Method of Digitizing Radiographs Using a Photo Light Box

We evaluated a low cost device for digitizing X-ray films. It consisted of a locally-made wooden box and a readily-available digital camera. Two experienced paediatric radiologists interpreted the original X-ray films (the reference standard) and the corresponding images obtained in the photo light box. Ninety paediatric chest X-ray films were used (30 were normal chest radiographs, 30 showed pneumonic-consolidation and 30 had interstitial infiltrates). The presence or absence of the three signs most frequently found in acute respiratory pathologies were evaluated: normal pulmonary transparency, pneumonic consolidation and interstitial infiltration. There was very good agreement between the X-ray films and the digitized images, with kappa values from 0.86 to 0.98. There was good agreement between the two observers, with kappa values from 0.67 to 0.90. The low-cost photo light box represents an accessible and low-cost approach to transmitting X-ray images, allowing findings or a second opinion from a specialist radiologist to be obtained from a distance.

Feasibility of using teleradiology to improve tuberculosis screening and case management in a district hospital in Malawi

PROBLEM

Malawi has one of the world's highest rates of human immunodeficiency virus (HIV) infection (10.6%), and southern Malawi, where Thyolo district is located, bears the highest burden in the country (14.5%). Tuberculosis, common among HIV-infected people, requires radiologic diagnosis, yet Malawi has no radiologists in public service. This hinders rapid and accurate diagnosis and increases morbidity and mortality.

APPROACH

Médecins Sans Frontières, in collaboration with Malawi's Ministry of Health, implemented teleradiology in Thyolo district to assist clinical staff in radiologic image interpretation and diagnosis.

LOCAL SETTING

Thyolo district's 600 000 inhabitants are mostly subsistence-level or migrant farmers living in extreme poverty. Health facilities include one public hospital and 38 primary health centres. Understaffing and the absence of a radiologist make the diagnosis of tuberculosis difficult in a population where this disease affects 66% of patients with HIV infection.

RELEVANT CHANGES

From September 2010-2011, 159 images (from 158 patients) were reviewed by teleradiology. Teleradiology changed patient management in 36 cases (23.5%). Two (1.3%) of them were cases of pulmonary tuberculosis not previously suspected by clinical staff. In addition, the radiologist's review corrected the misdiagnosis of tuberculosis and averted inappropriate treatment in 16 patients (10.5%).

LESSONS LEARNT

Teleradiology can improve tuberculosis diagnosis and case management, especially if criteria to identify the patients most suitable for referral are developed and the radiologist is conversant with local resources and health problems. Designating a clinical focal point for teleradiology ensures sustainability. Staff need time to adapt to a new teleradiology programme.

Comparison between different cost devices for digital capture of X-ray films: an image characteristics detection approach

A common teleradiology practice is digitizing films. The costs of specialized digitizers are very high, that is why there is a trend to use conventional scanners and digital cameras. Statistical clinical studies are required to determine the accuracy of these devices, which are very difficult to carry out. The purpose of this study was to compare three capture devices in terms of their capacity to detect several image characteristics. Spatial resolution, contrast, gray levels, and geometric deformation were compared for a specialized digitizer ICR (US$ 15,000), a conventional scanner UMAX (US$ 1,800), and a digital camera LUMIX (US$ 450, but require an additional support system and a light box for about US$ 400). Test patterns printed in films were used. The results detected gray levels lower than real values for all three devices; acceptable contrast and low geometric deformation with three devices. All three devices are appropriate solutions, but a digital camera requires more operator training and more settings.

Chest radiographic findings of pulmonary tuberculosis in severely immunocompromised patients with the human immunodeficiency virus

OBJECTIVE

We describe chest radiograph (CXR) findings in a population with a high prevalence of human immunodeficiency virus (HIV) and tuberculosis (TB) in order to identify radiological features associated with TB; to compare CXR features between HIV-seronegative and HIV-seropositive patients with TB; and to correlate CXR findings with CD4 T-cell count.

METHODS

Consecutive adult patients admitted to a national referral hospital with a cough of duration of 2 weeks or longer underwent diagnostic evaluation for TB and other pneumonias, including sputum examination and mycobacterial culture, bronchoscopy and CXR. Two radiologists blindly reviewed CXRs using a standardised interpretation form.

RESULTS

Smear or culture-positive TB was diagnosed in 214 of 403 (53%) patients. Median CD4+ T-cell count was 50 cells mm(-3) [interquartile range (IQR) 14-150]. TB patients were less likely than non-TB patients to have a normal CXR (12% vs 20%, p = 0.04), and more likely than non-TB patients to have a diffuse pattern of opacities (75% vs 60%, p = 0.003), reticulonodular opacities (45% vs 12%, p < 0.001), nodules (14% vs 6%, p = 0.008) or cavities (18% vs 7%, p = 0.001). HIV-seronegative TB patients more often had consolidation (70% vs 42%, p = 0.007) and cavities (48% vs 13%, p < 0.001) than HIV-seropositive TB patients. TB patients with a CD4+ T-cell count of ≤ 50 cells mm(-3) less often had consolidation (33% vs 54%, p = 0.006) and more often had hilar lymphadenopathy (30% vs 16%, p = 0.03) compared with patients with CD4 51-200 cells mm(-3).

CONCLUSION

Although different CXR patterns can be seen in TB and non-TB pneumonias there is considerable overlap in features, especially among HIV-seropositive and severely immunosuppressed patients. Providing clinical and immunological information to the radiologist might improve the accuracy of radiographic diagnosis of TB.

Expert interpretation compensates for reduced image quality of camera-digitized images referred to radiologists

We compared the accuracy of five veterinary radiologists when reading 20 radiographic cases on both analog film and in camera-digitized format. In addition, we compared the ability of five veterinary radiologists vs. 10 private practice veterinarians to interpret the analog images. Interpretation accuracy was compared using receiver operating characteristic curve analysis. Veterinary radiologists' accuracy did not significantly differ between analog vs. camera-digitized images (P = 0.13) although sensitivity was higher for analog images. Radiologists' interpretation of both digital and analog images was significantly better compared with the private veterinarians (P < 0.05).

Digitalização de filmes radiográficos com costura de imagens

OBJETIVO: Propor um método reprodutível, de fácil utilização e de baixo custo para a digitalização de filmes radiográficos de todos os tamanhos padrões, concentrando nossos esforços em filmes radiográficos de tórax. MATERIAIS E MÉTODOS: O objetivo de baixo custo ditou o uso de um escâner A4 com adaptador de transparência, bem como um software de costura de imagens otimizado, que tira proveito da geometria do escâner e área de captura constante, bem como o conhecimento das dimensões dos filmes radiográficos padrões. RESULTADOS: O resultado final do método proposto é uma imagem de alta resolução com bom contraste e sem artefatos de costura perceptíveis. CONCLUSÃO: O método de digitalização proposto usando um escâner A4 possibilita reprodutibilidade, excelente qualidade de imagem e alto grau de certeza na identificação de lesões.

Paediatric radiology seen from Africa. Part I: providing diagnostic imaging to a young population

Paediatric radiology requires dedicated equipment, specific precautions related to ionising radiation, and specialist knowledge. Developing countries face difficulties in providing adequate imaging services for children. In many African countries, children represent an increasing proportion of the population, and additional challenges follow from extreme living conditions, poverty, lack of parental care, and exposure to tuberculosis, HIV, pneumonia, diarrhoea and violent trauma. Imaging plays a critical role in the treatment of these children, but is expensive and difficult to provide. The World Health Organisation initiatives, of which the World Health Imaging System for Radiography (WHIS-RAD) unit is one result, needs to expand into other areas such as the provision of maintenance servicing. New initiatives by groups such as Rotary and the World Health Imaging Alliance to install WHIS-RAD units in developing countries and provide digital solutions, need support. Paediatric radiologists are needed to offer their services for reporting, consultation and quality assurance for free by way of teleradiology. Societies for paediatric radiology are needed to focus on providing a volunteer teleradiology reporting group, information on child safety for basic imaging, guidelines for investigations specific to the disease spectrum, and solutions for optimising imaging in children.

Paediatric radiology seen from Africa. Part II: recognising research advantages in a developing country

Radiologists in developing countries cite numerous reasons for poor research output including heavier workloads, poor remuneration (resulting in "brain drain"), poor infrastructure, language barriers, lack of modern imaging equipment, and a disease spectrum that may be of little interest to journals and readers in the developed world. On the other hand, large populations of patients suffering from distinctive diseases, cost-effective healthcare systems, and a set-up with highly centralised tertiary referral hospitals, may be seen as advantages to those willing to tap into this as a data source for research. The lack of resources may even stimulate cost-effective innovations relevant to the needs of poor communities. This paper challenges preconceived ideas and identifies advantages for radiologists in developing countries to producing good research and publications. It also cautions against "annexation of sites" by stakeholders from developed countries, and suggests simple solutions to maximise research output without a significant financial cost.

Comparison between differently priced devices for digital capture of X-ray films using computed tomography as a gold standard: a multireader-multicase receiver operating characteristic curve study

OBJECTIVE

Film digitizers are a specialized technology that is available for scanning X-ray radiographs; however, their cost makes them unaffordable for developing countries. Thus, less expensive alternatives are used. The purpose of this study was to compare three devices for digital capture of X-ray films: a film digitizer (US $15,000), a flatbed scanner (US $1800), and a 10-megapixel digital camera (US $450), in terms of diagnostic accuracy, defined as the area under the receiver operating characteristic curves and computed tomography as the gold standard.

MATERIALS AND METHODS

The sample included 136 chest X-ray cases with computed tomography confirmation of the presence or absence of pneumothorax, interstitial opacities, or nodules. The readers were six radiologists who made observations of eight variables for each digital capture of the X-ray films: three main variables to determine the accuracy in the detection of the above-mentioned pathologies, four secondary variables to categorize other pathological classifications, and one variable regarding digital image quality.

RESULTS

The receiver operating characteristic curves for each device and pathology were very similar. For the main variables, there was no significant statistical difference in diagnostic accuracy between the devices. For the secondary variables, >84% of cases were correctly classified, even those that were classified with the lowest image quality. High accuracy was determined for the three main variables (0.75 to 0.96), indicating good performance for all tested devices, despite their very different prices.

CONCLUSIONS

Choosing a device for a teleradiology service should involve additional factors, such as capture time, maintenance concerns, and training requirements.

Tuberculosis case-contact research in endemic tropical settings: design, conduct, and relevance to other infectious diseases

The study of the contacts of patients with tuberculosis has a long history. Where tuberculosis is endemic, regular recruitment of tuberculosis cases and their household contacts can be done for research and strategic intervention. This recruitment provides a platform whereby host, pathogen, and environmental factors related to tuberculosis can be investigated and new interventions can be assessed. We describe the types of study possible within a tuberculosis case-contact study platform and its essential components, including recruitment and follow-up of the patients with tuberculosis, their household contacts and community controls, assessments and sampling, and data management and processing. Sample handling and storage, local engagement, ethical challenges, and the strengths and weaknesses of study design are all important issues in case-contact research. A case-contact study platform is a powerful research tool to answer fundamental questions in tuberculosis and has relevance to the study of other major infectious diseases.

Virtual slide telepathology workstation of the future: lessons learned from teleradiology

The clinical reading environment for the 21st century pathologist looks very different than it did even a few short years ago. Glass slides are quickly being replaced by digital "virtual slides," and the traditional light microscope is being replaced by the computer display. There are numerous questions that arise however when deciding exactly what this new digital display viewing environment will be like. Choosing a workstation for daily use in the interpretation of digital pathology images can be a very daunting task. Radiology went digital nearly 20 years ago and faced many of the same challenges so there are lessons to be learned from these experiences. One major lesson is that there is no "one size fits all" workstation so users must consider a variety of factors when choosing a workstation. In this article, we summarize some of the potentially critical elements in a pathology workstation and the characteristics one should be aware of and look for in the selection of one. Issues pertaining to both hardware and software aspects of medical workstations will be reviewed particularly as they may impact the interpretation process.

Asynchronous telehealth: a scoping review of analytic studies

BACKGROUND

Asynchronous telehealth captures clinically important digital samples (e.g., still images, video, audio, text files) and relevant data in one location and subsequently transmits these files for interpretation at a remote site by health professionals without requiring the simultaneous presence of the patient involved and his or her health care provider. Its utility in the health care system, however, still remains poorly defined. We conducted this scoping review to determine the impact of asynchronous telehealth on health outcomes, process of care, access to health services, and health resources.

METHODS

A search was performed up to December 2006 of MEDLINE, CINAHL, HealthSTAR, the Database of Abstracts of Reviews of Effectiveness, and The Cochrane Library. Studies were included if they contained original data on the use of asynchronous telehealth and were published in English in a peer-reviewed journal. Two independent reviewers screened all articles and extracted data, reaching consensus on the articles and data identified. Data were extracted on general study characteristics, clinical domain, technology, setting, category of outcome, and results. Study quality (internal validity) was assessed using the Jadad scale for randomized controlled trials and the Downs and Black index for non-randomized studies. Summary data were categorized by medical specialty and presented qualitatively.

RESULTS

The scoping review included 52 original studies from 238 citations identified; of these 52, almost half focused on the use of telehealth in dermatology. Included studies were characterized by diverse designs, interventions, and outcomes. Only 16 studies were judged to be of high quality. Most studies showed beneficial effects in terms of diagnostic accuracy, wait times, referral management, and satisfaction with services. Evidence on the impact of asynchronous telehealth on resource use in dermatology suggests a reduction in the number of, or avoidance of, in-person visits. Reports from other clinical domains also described the avoidance of unnecessary transfer of patients.

CONCLUSIONS

A significant portion of the asynchronous telehealth literature involves its use in dermatology. Although the quality of many original studies remains poor, at least within dermatology, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or better) diagnostic accuracy when compared with face-to-face consultations. With the exception of a few studies in pediatric asthma, the impact of this intervention on individual health outcomes remains unknown.

Telemedicine technology assessment part I: setup and validation of a quality control system

The remarkable development of telemedicine applications has brought about the need for a telemedicine quality control system to prevent application failures and guarantee users. The aim of this paper was to report on the setup of a quality control system and validate it on a testing set of telemedicine products and services. The quality control system followed two main phases. Phase I was focused on data acquisition and preliminary evaluation of the telemedicine products and services. A classification form and an informative questionnaire were used to gather all the relevant information about the telemedicine application under test. Phase II was focused on evaluation and quality control of the telemedicine product. A Technical File and a Quality Assessment Checklist were used to assess the telemedicine product and service. The telemedicine quality control system was suitable for the efficient evaluation of telemedicine applications. A quality level was assigned to each product according to a threshold and an algorithm. All telemedicine products tested passed the test with a quality level higher than the threshold. The quality control system assured the definition of standardized quality levels for the telemedicine products and services. The study presented in this paper could be useful for promoting the use of standardized telemedicine applications, and therefore speeding up their integration process in the national health service.

Teleconsultation with digital camera images is useful for fracture care

Teleconsultation using digital camera images has not yet been proven useful in orthopaedic practice. We ascertained the validity and reliability of teleconsultation using digital camera images of 100 patients with nondisplaced or minimally displaced fractures and 50 healthy age-matched subjects. We used three sets of images from each patient: a digitized radiograph, digital clinical photographs of the injured site, and conventional analog radiographs. Assessments were made independently by three groups of assessors: four orthopaedic staff members, four senior residents, and four junior residents all of whom evaluated the digitized information via E-mail. Digitized radiographs, digitized radiographs supplemented with a clinical photograph, and conventional radiographs were assessed consecutively at 1-week intervals. We used clinical and radiographic followup data as a gold standard. The overall reliability (kappa), sensitivity, and specificity of digitized radiographs were 0.57, 83.2%, and 80.7%, respectively. Reliability, sensitivity, and specificity of the digitized radiographs were not decreased after transmitting via E-mail. The level of experience in radiographic interpretation was associated independently with fracture misdiagnosis. Teleconsultation using digital camera images was valid and reliable. We recommend sending clinical photographs with the digitized radiograph.

LEVEL OF EVIDENCE

Diagnostic study, level II. See the Guidelines for Authors for a complete description of levels of evidence.

Database application of digital medical X-rays and labs: computerization, storage, retrieval, interpretation, and distribution

Stenter lets the health care worker order an X-ray that is produced as a computer image rather than on flat film. The health care provider can be in any location with the correct equipment, and view the digital image. The dimensions of this discussion are extensive. The cost savings because of reduced media and storage cost is substantial. Health care quality can be improved because of the ability to obtain consultation via telemedicine and the enhanced ability to track medical problems over time via trends. The major downside is the limited cost imbursement system to pay for technology. Unfortunately, this may impact on the improved quality of care. In simple terms someone needs to pay for the technology and the quality of health care needs to be maintained or improved. The real cost to the health care systems needs to be correctly calculated and inappropriate charging kept to a minimum. Specific costs need to be kept in mind and the first is the cost for new staff or staff training. The number of health care providers that are able to read the X-ray can be enlarged remembering that only American Board Certified Radiologists are allowed to give the final recommendation. How do we view the cost of missing something? It could be argued that this risk will be reduced because of improved technology for obtaining the digital X-ray and improved enhancement software. One way to view this situation is to include technology, management, and organization. The cost and benefits occur through the interplay of all three dimensions. The development of digital imaging hardware and artificial intelligence software will demand change in the management and organization. The organization will require changes in its design to accommodate the technology as to support and resources. Management will evolve to include methods for control and monitoring this technology. Business processes and standard operating procedures will change to integrate the technology into the organization in the most effective and efficient manner.

Clinical outcomes associated with telemedicine/telehealth

This paper is a comprehensive review and synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. It starts out with a brief description of the findings reported by similar literature reviews already published. Subsequently, it proposes a conceptual model for assessing clinical outcomes based on Donabedian's formulation of the Medical Care Process. Accordingly, research findings are reported in terms of the relevant components of the medical care process, namely, diagnosis, clinical management, and clinical outcomes. Specific findings are organized according to the designated clinical and diagnostic application. This is followed by a general report of studies dealing with patient satisfaction.

Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations

BACKGROUND

Previous guidelines recommend doubling the daily dose of maintenance inhaled corticosteroid to treat or prevent progression of exacerbations of asthma.

METHODS

Over a 6 month period a cohort of patients were evaluated prospectively and randomised in a double blind controlled trial to treatment with either a continued maintenance dose (MD) of inhaled corticosteroid or doubling the dose (DD) at the time of an exacerbation.

RESULTS

A total of 290 patients were randomised (33% male) and 98 (DD, n = 46) experienced evaluable asthma exacerbations during the study period. Mean (SD) baseline characteristics at randomisation (age 33.5 (14.0) years; forced expiratory volume in 1 second (FEV(1)) 2.8 (0.7) l; peak expiratory flow (PEF) 422.9 (110.5) l/min) were similar in both groups. In the DD group 41% of patients were considered treatment failures because they either required systemic steroids (n = 12), had an unscheduled visit to a physician (n = 1), or their asthma did not return to baseline (n = 6). This did not differ from the MD group in which 40% were treatment failures (n = 9, 0, and 12, respectively; p = 0.94).

CONCLUSIONS

In patients who regularly take an inhaled corticosteroid, doubling the maintenance dose may not affect the pattern of the exacerbation.