Teleradiology in orthopaedics

What Is the Best Way for Patients to Take Photographs of Medical Images (Radiographs, CT, and MRI) Using a Smartphone?

BACKGROUND

Teleradiology has become one of the most important approaches to virtual clinical diagnosis; its importance has only grown during the coronavirus 2019 pandemic. In developing countries, asking patients to take photographs of their images using a smartphone can facilitate the process and help keep its costs down. However, the images taken by patients with smartphones often are of poor quality, and there is no regulation or standard instruction about how to use smartphones to take photographs of medical examination images effectively. These problems limit the use of smartphones in remote diagnosis and treatment.

QUESTIONS/PURPOSES

To formulate a set of guidelines for the most appropriate and effective use of smartphones to capture images (radiographs, CT images, and MR images), and to determine whether these guidelines are more effectively adopted by patients of differing ages and genders.

METHODS

In this prospective study, a set of step-by-step instructions was created with the goal of helping patients take better smartphone photographs of orthopaedic diagnostic images for transfer to telemedicine services. Following the advice of surgeons, experts in smartphone technology, imaging experts, and suggestions from patients, the instructions were modified based on clinical experience and finalized with the goals of simplicity, clarity, and convenience. Potentially eligible patients were older than 18 years, had no cognitive impairment, and used smart phones. Based on that, 256 participants (patients or their relatives and friends) who visited the orthopaedic department of our hospital from June to October 2020 potentially qualified for this study. A total of 11% (29) declined to participate, leaving 89% (227) for analysis here. Their mean age was 36 ± 11 years, 50% were women (113 of 227), and the patient himself/herself represented in 34% (78 of 227) of participants while relatives or friends of patients made up 66% (149 of 227) of the group. In this study, the diagnoses included spinal stenosis (47% [107 of 227]), disc herniation without spinal stenosis (31% [71 of 227]), vertebral fractures (14% [32 of 227]), and other (7% [17 of 227]). Each study participant first took photographs of their original medical images based on their own knowledge of how to use the smartphone camera function; each participant then took pictures of their original images again after receiving our instructional guidance. Three senior spine surgeons (YZ, TQL, TCM) in our hospital analyzed, in a blinded manner, the instructed and uninstructed imaging files based on image clarity (the content of the image is complete, the text information in the image is clearly visible, there is neither reflection nor shadow in the image) and image position (it is not tilted, curled, inverted, or reversed). If either of these conditions was not satisfied, the picture quality was deemed unacceptable; two of three judges' votes determined the outcome. Interobserver reliability with kappa values for the three judges were 0.89 (YZ versus TQL), 0.92 (YZ versus TCM), and 0.90 (TQL versus TCM).

RESULTS

In this study, the overall proportion of smartphone medical images deemed satisfactory increased from 40% (91 of 227) for uninstructed participants to 86% (196 of 227) for instructed participants (risk ratio 2.15 [95% CI 1.82 to 2.55]; p<0.001). The proportion of acceptable-quality images in different age groups improved after instruction, except for in patients aged 51 years or older (3 of 17 uninstructed participants versus 8 of 17 instructed participants; RR 2.67 [95% CI 0.85 to 8.37]; p = 0.07). The proportion of acceptable-quality images in both genders improved after instruction, but there was no difference between the genders.

CONCLUSION

We believe our guidelines for patients who wish to take smartphone photographs of their medical images will decrease image transmission cost and facilitate orthopaedic telemedicine consultations. However, it appears that patients older than 50 years are more likely to have difficulty with this approach, and if so, they may benefit from more hands-on assistance from clinic staff or younger relatives or friends. The degree to which our findings are culture-specific should be verified by other studies in other settings, but on the face of it, there is little reason to believe our findings would not generalize to a reasonable degree. Other studies in more heterogeneous populations should also evaluate factors related to levels of educational attainment and wealth differences, but in the meantime, our findings can give clinical teams an idea of which patients may need a little extra assistance.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Tablets for Image Review and Communication in Daily Routine of Orthopedic Surgeons-An Evaluation Study

Medical images are essential in modern traumatology and orthopedic surgery. Access to images is often cumbersome due to a limited number of workstations. Moreover, due to the tremendous increase of data, the time to review or to communicate images has also become limited. One approach to overcome these problems is to make use of modern mobile devices, like tablet computers, to facilitate image access and associated workflows. Ten orthopedic surgeons were equipped with an Apple iPad mini 2 and specialized viewing software for medical images. The surgeons were able to send images from a workstation onto the tablets or to search for patient images directly. The software enabled the physicians to share images, annotated key slices, and messages instantly with their colleagues. The surgeons carried the tablets within or in the periphery of the hospital. The participants evaluated the software by means of daily questionnaires. Data was collected for a period of 9 months. Nearly 25 images were viewed in total by the surgeons per day. The tablet viewer was used for accessing approximately 30% of these images. On average, the surgeons were asked 1.7 times per day by a colleague for a second opinion. They used the tablets in approximately 29% of these cases. Furthermore, the mean time for accessing images was significantly lower using mobile software compared to conventional methods. Tablet computers can play a vital role for image access and communication in the daily routine of an orthopedic surgeon. Mobile image access is an important aspect for surgeons, especially in larger facilities, to facilitate and accelerate the clinical workflows.

The value of WhatsApp communication in paediatric burn care

BACKGROUND

Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels.

METHODS

A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service.

RESULTS

838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution.

DISCUSSION

Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.

Mapping telemedicine efforts: surveying regional initiatives in Denmark

OBJECTIVES

The aim of this study is to survey telemedicine services currently in operation across Denmark. The study specifically seeks to answer the following questions: What initiatives are deployed within the different regions? What are the motivations behind the projects? What technologies are being utilized? What medical disciplines are being supported using telemedicine systems?

MATERIALS AND METHODS

All data were surveyed from the Telemedicinsk Landkort, a newly created database designed to provide a comprehensive and systematic overview of all telemedicine technologies in Denmark.

RESULTS

The results of this study suggest that a growing numbers of telemedicine initiatives are currently in operation across Denmark but that considerable variations exist in terms of regional efforts as the number of operational telemedicine projects varied from region to region.

CONCLUSIONS

The results of this study provide a timely picture of the factors that are shaping the telemedicine landscape of Denmark and suggest potential strategies to help policymakers increase and improve national telemedicine deployment.

Validity of Cobb angle measurements using digitally photographed radiographs

BACKGROUND CONTEXT

Advances in technology are influencing the way that medical information is archived and shared. Considering that an estimated two-thirds of the world has little or no orthopedic care, high demand exists for adequate consultation regarding diagnostic images in orthopedic specialties.

PURPOSE

To validate the use of photographed scoliosis films for the accurate interpretation of Cobb angles.

STUDY DESIGN

Retrospective review.

PATIENT SAMPLE

Thirty scoliosis radiographs.

OUTCOME MEASURE

Cobb angle.

METHODS

Thirty scoliosis radiographs were photographed using a digital camera from a straight and a 45° angle position. Cobb angles were then measured on the digital images using standard measurement software. Comparison was made between two types of curves: convex and concave, relative to the left side (side for the angled position).

RESULTS

There was excellent reproducibility between the measurements of the conventional radiographs and the photographs taken from a straight on position, p value of .97 for convex curves and p value of .98 for concave curves. Photographs taken from a 45° angle significantly increased the magnitude of the curve convex to the angle (p=.001).

CONCLUSION

Sharing photographs of scoliosis radiographs can be done with reliability if the image is taken directly in front of the viewbox rather than at an oblique angle; pictures taken at oblique angles are prone to misinterpretation of curve magnitude.

Telesurveillance of circular frame pin sites: one year's experience at a specialist unit

Circular frame treatment for limb reconstruction involves repeated follow-up visits, and a substantial number of these appointments are for pin site review only. We have encouraged our frame patients to take photographs of their pin sites when they carry out their weekly dressing changes. The photographs are taken with mobile phones or digital cameras by the patients themselves, and the images sent to us by email. We reply within 24 hours, with either reassurance or appropriate instructions as indicated. In the past 12 months, five patients have had their pin sites reviewed remotely using this method, and have expressed a high level of satisfaction. These early results are encouraging.

Electronic collaboration: using technology to solve old problems of quality care

The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand.

Consultation of orthopaedics cases using multimedia messaging services

Background:

Frequently, radiological data is transferred verbally between the Emergency Department (ED) and orthopaedic registrar. Given the different language skills and medical experience of health staff, there is often a limit to the adequacy of the verbal description that could lead to suboptimal patient care. This study proposes that concurrent review of MMS teleradiology with traditional verbal reporting results in a significant therapeutic benefit.

Methods:

Case notes of 40 patients who presented to ED were reviewed. Images were captured and sent to an Orthopaedic registrar along with a brief clinical synopsis. Information was collected on the diagnosis of the MMS radiograph, need for urgent admission and management plan outlined to ED.

Results:

Correct diagnosis was made in 27 of 40 cases. Using the latest technology available, MMS teleradiology had 79% sensitivity, 83% specificity and an accuracy of 80%. 50% of paediatric fractures and 60% of undisplaced fractures were diagnosed successfully.

Conclusion:

MMS teleradiology is not suitable by itself as a remote diagnostic tool. However, when combined with existing clinical practice, it is effective in screening patients, enhances confidence in decision making and communication between doctors.

Teleradiology and emergency neurosurgery-presence in a small asian city state and need in a large canadian province

Teleradiology involving the transfer of vital patient information such as scan images is an important technology to facilitate effective and efficient provision of neurosurgical care in the setting of scarce resources and geographic isolation. We review the implementation of teleradiology initiatives in the small city state of Singapore and its potential and need in the large province of Ontario and draw parallels in their strategic implementation. Although it may seem intuitive that teleradiology has greater applications in regions of vast geographical size, the technology has universal usefulness if applied appropriately in any neurosurgical or health care system.

National Organ Retrieval Imaging System: results of the pilot study

Efficient utilization of marginal liver grafts is dependant on the accurate assessment and relay of graft-related information to recipient units in an organ-sharing network. Currently, information is conveyed by the recovery team over the telephone and can sometimes be inconclusive or incomplete. We have developed a web-based instrument called the National Organ Retrieval Imaging System (NORIS) to improve this assessment process. The aim of this pilot study was to assess the feasibility of real-time data upload and the reliability of web-based remote assessment in identifying donor livers with significant macro-steatosis. Data from 153 donor livers uploaded to the website were analysed. Completeness of graft data uploads, accuracy of on-site and two separate remote assessments using a semi-objective graft score in identifying grafts with moderate or severe macro-vesicular steatosis were analysed. Uploads were complete in all recoveries. Liver grafts with moderate or severe macro-vesicular steatosis had a higher incidence of initial poor function (7/10 vs. 26/86, P = 0.029). Organ scores for steatotic grafts were significantly higher than nonsteatotic grafts in all three assessments (P < 0.001). Accuracy of the two remote assessors was similar to the actual on-site assessment. There was a substantial degree of inter-observer agreement between the assessments (kappa statistics = 0.658, 0.597, 0.698). Feasibility of real-time data upload and reliability of remote graft assessment have been confirmed.

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.

The state of teleradiology in 2003 and changes since 1999

OBJECTIVE

The purpose of our study is to describe in detail the use of teleradiology in 2003 and to report on changes since 1999 in this rapidly evolving field.

MATERIALS AND METHODS

We analyze non-individually identified data from the American College of Radiology's 2003 Survey of Radiologists, a stratified random sample mail survey that achieved a response rate of 63%, and data from the American College of Radiology's 1999 Survey of Practices. Responses were weighted to represent the distribution of individual radiologists and radiology practices nationwide. We present descriptive statistics and multivariable regression analysis results on the prevalence and uses of teleradiology in 2003 and comparisons with 1999.

RESULTS

Overall, 67% of all radiology practices in the United States, which included 78% of all U.S. radiologists, reported using teleradiology. A significant increase (p < 0.05) was seen in the prevalence of teleradiology or PACS, from 58% of practices in 1999 to 73% in 2003. Regression results indicate that, other practice characteristics being equal, in 2003, primarily academic practices were less likely to use teleradiology than private radiology practices, and medium-sized practices (5-14 radiologists) were more likely to have teleradiology than larger ones. In practices using teleradiology, home was the most frequent receiving site in both 1999 (81%) and 2003 (75%), the percentages being not significantly different.

CONCLUSION

Already a fixture of radiology practice in 1999, teleradiology increased in prevalence substantially by 2003. The primary use of teleradiology, transmission of images to home, did not change, suggesting that easing the burden of call remains the main use of teleradiology.

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.

Entrusting patients with their own plain radiographs increases their availability in fracture clinic

Missing radiographs are a common cause of frustration in many fracture clinics. This can lead to unjustified delays and unnecessary radiation exposure. Patients were entrusted with their own radiographs and asked to bring them back to subsequent clinic consultations. We audited a 14-day-period and compared it with a similar period before implementation of this new protocol. The results showed a significant reduction in the number of missing radiographs by entrusting them with patients.

A comprehensive portrait of teleradiology in radiology practices: results from the American College of Radiology's 1999 Survey

OBJECTIVE

This article presents a comprehensive portrait of the characteristics of teleradiology systems of radiology practices as of 1999. Our purposes are to help profile a rapidly evolving area of radiology that has been underexamined to date and to provide a baseline with which future findings can be compared.

MATERIALS AND METHODS

In 1999, the American College of Radiology surveyed 970 practices by mail. A response rate of 66% was achieved. Responses were weighted to represent all radiology practices in the United States. Data from nine questions specifically designed to profile the use of teleradiology were analyzed using descriptive statistical methods and multivariate regression analyses.

RESULTS

Seventy-one percent of multiradiologist practices had teleradiology systems in place, using them to interpret 5% of their studies. For solo practices, corresponding statistics were 30% and 14%. Ninety-two percent of multiradiologist practices with teleradiology systems used them for preliminary on-call interpretation. Other major uses included consultation with other radiologists (20%) and primary interpretation of studies (18%). Ninety-five percent of multiradiologist practices with teleradiology systems used them to interpret CT, 84% used them for sonography, 69% for nuclear medicine, 47% for MRI, and 43% for conventional radiographs.

CONCLUSION

Teleradiology had already become a fixture in most practices by 1999, though it was used for only a small fraction of image interpretations. Its widespread presence positioned teleradiology to become a key element of radiology practice nationwide.