Teleradiology System Research Articles

Teleradiology: results of a questionnaire of German radiologists.

A questionnaire was sent by mail to 4400 radiologists (i.e. to at least 1000 radiological institutions). The response rate was about 5%. The results showed that 47% of respondents felt well informed about teleradiology, 49% not enough and 3% not at all. Image and report transfer as well as interfaces to reference databases, educational applications, technical quality surveillance and product support (maintenance) were considered to be increasingly important areas. Smaller institutions (1-3 doctors) judged expert consultation as more important than bigger institutions. Standardization, system stability and data security were demanded as well as guidelines, for example concerning the linking of report and image, correct documentation and required image quality. Technically most demands can be fulfilled today but this technology is not yet commonly included in teleradiology systems.

Deployable teleradiology: Bosnia and beyond

The United States military has been an effective proponent of digital imaging and teleradiology for the past 15 years [1]. A digital imaging network that eliminates the use of x-ray film makes military medicine requirements simpler. X-ray film requirements include storage of new, unexposed films, storage and use of chemicals and water for processing, and disposal of chemicals. In some deployed situations, the chemical discharge needs to be collected and shipped out of the area. Therefore, the ability to implement electronic imaging and eliminate or greatly reduce the dependence on film, chemicals, and water are intrinsically important to military medicine. In December 1995, the United States government began deployment of 20,000 United States troops to Bosnia-Herzegovina as part of NATO's peacekeeping implementation force (IFOR) operation. A full complement of military medical support facilities was established in Bosnia. An army base in Hungary was the location from which the deployment was staged. The project to deploy telemedicine and teleradiology capabilities to the medical treatment facilities (MTF) in Bosnia and Hungary became known as PrimeTime III [2]. This paper deals with the deployable teleradiology (DEPRAD) system that was installed by the Imaging Science and Information Systems (ISIS) Center, Department of Radiology, Georgetown Medical Center, Washington, DC, at a number of facilities to implement filmless radiology and teleradiology services in support of PrimeTime III.

Teleradiology

According to the American College of Radiology, teleradiology is an electronic transmission of radiological images from one location to another for the purposes of interpretation or consultation. This article provides a historical perspective and discusses both solved and unsolved problems concerning the different elements of a teleradiology system (image acquisition, image transmission, image display, image compression). It concludes that teleradiology will in the future be a part of picture archiving and communication systems (PACS). Technical problems have for the most part been solved, with the exception of quality of gray-scale monitors. The characteristics of such a system depends on its goals.

The German teleradiology system MEDICUS system description and experiences in a German field test

MEDICUS is a teleradiology system which has been developed in a joint project of the German Cancer Research Center (Deutsches Krebsforschungszentrum) and the Transfer Center Medical Informatics (Steinbeis-Transferzentrum Medizinische Informatik) in Heidelberg, Germany. The system is designed to work on ISDN lines as well as in a local area network. Special attention has been given to the design of the user interface and data security, integrity, and authentication. The software is in use in 13 radiology departments in university clinics, small hospitals, private practices, and research institutes. More than 25 thousand images have been processed in 6 months. The system is in use in six different application scenarios. MEDICUS is running under the UNIX operating system. The connection of the modalities could in most cases not be realized with the DICOM protocol as older machines were not equipped with this standard protocol. Clinical experiences show that the MEDICUS system provides a very high degree of functionality. The system has an efficient and user friendly graphical user interface. The result of a comparison with other systems shows that MEDICUS is currently the best known teleradiology system. Cost reductions are already obvious, but additional research has to be performed in this field. An even more powerful commercial successor is currently under construction at the Steinbeis-Transferzentrum Medizinische Informatik in Heidelberg.

A Teleradiology System with Realtilne and E-mail-based Operating Modes

A Teleradiology System with Realtilne and E-mail-based Operating Modes

Accuracy of diagnosis of subtle chest disease and subtle fractures with a teleradiology system.

This study compared conventional thoracic and skeletal radiographs with 12-bit digitized images of the same radiographs in terms of subjective image quality and accuracy of diagnosis of subtle disease. Thirty-six chest radiographs with normal findings, 48 chest radiographs with abnormal findings, 29 skeletal radiographs with normal findings, and 26 skeletal radiographs with abnormal findings were included in this study. The images were chosen for the subtlety of their findings (nodules, pneumothoraces, interstitial lung disease, fractures). Each set of images was laser-digitized and viewed independently by three radiologists at a teleradiology workstation with a 1280 x 1024 pixel matrix monitor equipped with an eight-bit-per-pixel gray-scale display. All images were viewed at maximum resolution. After review of the digitized images for image quality and for the presence of abnormalities, each radiologist analyzed the analog images in a similar way. Sensitivities for detecting nodules, pneumothoraces, and interstitial lung disease on digitized chest radiographs were 58%, 75%, and 90%, respectively, compared with 62%, 79%, and 92%, respectively, on the original radiographs. Sensitivity for fracture detection on digitized bone radiographs was 87% compared with 88% on analog radiographs. None of these differences was statistically significant. Digitization of radiographs for primary diagnosis by teleradiology results in a slight decrease in sensitivity for detection of subtle abnormalities, provided that the images are viewed at maximum resolution.

Preliminary findings from a teleultrasound study in Alberta.

Ultrasound practice in Alberta requires direct supervision by an ultrasound-accredited specialist physician (sonologist). This requirement limits access to ultrasound examinations in many rural communities. A prospective study was performed to evaluate the adequacy of teleultrasound service in High Level, Alberta, with remote sonologist supervision from Edmonton, Alberta. A total of 146 patients were evaluated in two groups. Group A (72 patients) was evaluated by both an on-site radiologist in High Level and a remote supervising radiologist in Edmonton. Group B (74 patients) was evaluated only by the remote supervising radiologist in Edmonton. The teleultrasound service included digital store-and-forward capabilities using a commercially available teleradiology system, with videoconferencing review for real-time scanning. The teleultrasound service was helpful to the referring physician. It made transfer unnecessary in 42% of patients, and the results of the ultrasound assessment influenced management in 59% of patients. The sonographer on site and the remote radiologists agreed on the quality of the images. The information required for diagnosis was available from the sonographer's study in the majority of cases, with second-look scanning by the on-site radiologist or videoconferencing by the remote radiologist providing a major new diagnosis in only 1% of patients. Teleultrasound service to High Level could be provided reliably with remote supervision, comparable to direct on-site supervision.

Embedded Java in a web-based teleradiology system

Medinet is a Web-based solution for teleradiology currently undergoing clinical evaluation as part of the European Union's advanced communications technologies and services program. The system uses embedded Java applets to permit remote access to radiologic data and diagnostic services.

Experience implementing a DICOM 3.0 multivendor teleradiology network.

The ISIS Center at Georgetown University received a grant from the U.S. Army to act as systems integrator for a project to design, develop, and implement a commercial off-the-shelf teleradiology system to support the U.S. troops in Bosnia-Herzegovina. The goal of the project was to minimize troop movement while providing primary diagnosis to military personnel. This paper focuses on Digital Imaging Communications in Medicine (DICOM) 3.0 related issues that arose from this type of teleradiology implementation. The objective is to show that using the DICOM standard provides a good starting point for systems integration but is not a plug-and-play operation. Systems were purchased that were based on the DICOM 3.0 standard. The modalities implemented in this effort were computed radiography (CR), computed tomography (CT), film digitization (FD), and ultrasonography (US). Dry laser printing and multiple-display workstations were critical components of this network. The modalities and output devices were integrated using the DICOM 3.0 standard. All image acquisition from the modalities is directly to a workstation. The workstation distributes the images to other local and remote workstations, to the dry laser printer, and to other vendors' workstations using the DICOM 3.0 standard. All systems were integrated and tested prior to deployment or purchase. Local and wide area networking were also tested prior to implementation of the deployable radiology network. The results of the integration of the multivendor network were positive. Eventually, all vendors' systems did communicate. Software configuration and operational changes were made to many systems in order to facilitate this communication. Often, software fixes or patches were provided by a vendor to modify their DICOM 3.0 implementation to allow better communications with another vendor's system. All systems were commercially available, and any modifications or changes provided became part of the vendor's commercially available package. Seven DICOM interfaces were implemented for this project, and none was achieved without modification of configuration files, changes or patches in vendor software, or operational changes. Some of the problems encountered included missing or ignored required data elements, padding of data values, unique study identifiers (UID), and the use of application entity titles. The difficulties with multivendor connectivity lie in the understanding and interpretation of standards such as DICOM 3.0. The success of this network proves that these problems can be overcome and a clinically successful network implemented utilizing multiple vendors' systems.

TELERADIOLOGY IN UROLOGY: COMPARISON OF DIGITAL IMAGE QUALITY WITH ORIGINAL RADIOGRAPHIC FILMS TO DETECT URINARY CALCULI

Purpose Teleradiology systems are now being evaluated as a mechanism to provide rapid, accurate and cost-effective diagnostic radiographs to off-site physicians. Little data are available on the role and safety of teleradiology in urology. To address these issues a personal computer based system was developed to assess the diagnostic accuracy and ease of use of transmitted digital images when evaluating for urinary calculi. Materials and Methods A total of 100 plain abdominal scout films from excretory urograms performed during acute urological referrals was digitized on a laser scanner. The 10 megabyte files were transferred over public telephone lines and written to compact disks. The images were viewed on a 1280 × 1640 resolution monitor using "Imager-3D" software run on a 133 MHz. pentium personal computer with 32 megabytes of random access memory. Two faculty urologists and 2 urology fellows each looked at 50 original radiographs and 50 digital images. Diagnostic interpretations of the presence and location of calculi were recorded, and confidence in the diagnosis, assessment of image quality and diagnostic difficulty were scored using a numerical scale. Results The accuracy for all readers was 86.5% for plain radiographs and 81.5% for digital images (p >0.2). There was no statistical difference between faculty and fellows. Diagnostic accuracy did not differ between plain films and screen images when the results were assessed with respect to image quality, diagnostic difficulty or the reader confidence in the diagnosis (p >0.1). Compared to plain films, more screen images were classified as lower image quality (60 versus 40%) and the diagnostic confidence was lower (low and medium grade 50 versus 35%), although this did not interfere with diagnostic accuracy. Conclusions These data imply that a high quality affordable teleradiology system is effective and accurate compared to plain films for assessing urinary calculi.

Experiences with the German teleradiology system MEDICUS

This paper introduces the teleradiology system, MEDICUS, which has been developed at the Deutsches Krebsforschungszentrum (German Cancer Research Center) in Heidelberg, Germany. The system is designed to work on ISDN lines as well as in a local area network. The global software architecture is explained in the article. Special attention has been given to the design of the user interface and data security, integrity and authentication. The software has been evaluated in a German field test at 13 radiology departments in university clinics, small hospitals, private practices and research institutes. More than 30 thousand images have been transmitted using this system during a 9 month period. Realized application scenarios are: in-house communication, image and report delivery to referring hospitals, remote reporting, radiotherapy treatment planning and research cooperation. Experience has shown that the system is easy to use and saves time. It obviates the need for patient transport and reduces film costs. Experiences of individuals while using the system during the field test helped define the functionality of the second generation teleradiology system which is even more flexible and is also available as a commercial product.

A remote conference system for image diagnosis on the World-Wide Web.

The World-Wide Web on the Internet enables an exchange of multimedia information among remote desktop computers. Therefore, a teleradiology system using the Web would allow remote consultation with expert radiologists. Our objective was to establish a Web-based prototype system for image interpretation. Our system allows a physician to transmit clinically useful images to an expert radiologist at a different location, who can see them on a Web browser and discuss diagnoses with the physician.

Report of a national neurosurgical teleradiology system.

An emergency neurosurgical teleradiology system was initially installed in two referring hospitals in ireland to transmit images to the neurosurgical department in Cork. It was subsequently expanded to six major referring hospitals transmitting to both neurosurgical departments in ireland serving the entire population of 3.5 million people, effectively becoming a national teleradiology system. The system was based on PCs interconnected by leased data circuits and ISDN. The network was operational 24 hours a day. Over 750 emergency computerized tomography scans were transmitted and transmission failures occurred in only 6% of cases. We conclude that current PC technology can be used to form a peer-to-peer wide-area network upon which a robust emergency teleradiology system can be based.

Possible applications of the KAMEDIN teleradiology system with special reference to an economic analysis

Different concepts and applications of teleradiology systems have been realised. However, their cost-effectiveness is still questionable. Therefore, a cost-benefit analysis of three different scenarios of the new teleradiology system Kamedin (Kooperatives Arbeiten und rechnergestützte Medizinische Diagnostik auf innovativen Netzen der Deutschen Telekom) was performed. CT examinations were transmitted from an Advantage Windows (GE) workstation to a Kamedin workstation using DICOM 3 protocol. Afterwards a teleconference was established with a Kamedin workstation in the intensive care unit within the hospital via FDDI/Ethernet, with an external workstation in a radiology department 6 km away via ISDN and with a Kamedin PC located with radiologist on duty 22 km away via ISDN. On average, 36 CT slices per patient were transferred. A break-even analysis was performed with respect to costs of hardware, software, support, use of ISDN and staff, as well as benefits like the decrease in transportation or film documentation costs. Owing to the different reductions in transportation costs, two applications (intensive care unit and external PC) showed a break-even of 1817 and 528 teleconferences/year, respectively. Further optimisation of cost-effectiveness is possible on condition that existing hardware can be used and an automatic data transfer without staff control is available. When all optimisation factors were combined, the break-even decreased to a minimum of 167 and 77 teleconferences/ year, respectively. Teleconferences with high image quality can be set up between workstations and PCs using the Kamedin system. Depending on the possible decrease in transportation costs, teleconferencing is cost-effective under certain conditions. Teleradiology has additional advantages, such as the acceleration and optimisation of patient management.

Advantages and cost-benefit analysis of various teleradiology scenarios

With the increasing number of users and technical improvements, there are several application scenarios of teleradiology. To perform a cost-benefit analysis, an approach is presented, which focuses on both monetary and qualitative aspects. Process-related, qualitative and quantitative evaluations are described. The prestudy compares the radiological workflow before and after the introduction of a teleradiology system. A scoring model is part of the qualitative evaluation. The quantitative study focuses on costs and savings. Amortisation and a net present value of savings versus costs can be derived using dynamic investment methods. Savings can be achieved after a short time under ideal conditions, but there is no guarantee for a reimbursement for all systems.

Requirements for a teleradiology system. Experiences with the MEDICUS-2 field test

During the Medicus field test we gained experience using the teleradiology system for almost daily teleconferences between a radiology department and clinics for internal medicine, urology, and gynecology. The existing system has a high degree of functionality. The full 12-bit data format is available using the DICOM protocol. A data security concept is implemented, ensuring data integrity, privacy and authentication of communication partners. This concept covers the areas of organization, technique, user training, and software implementation. A future system should be a general purpose radiology workstation covering viewing functionality, image manipulation, and digital archive access. Dedicated teleradiology features have to be a part. Specialized evaluation software, e.g. for dynamic MRI, should be integratable in a modular way. For data exchange with other systems and for the synchronization of teleconference sessions, the protocols should be independent of the network standard used (ISDN, Ethernet, ATM) and based on the DICOM protocol. Extensions of the existing standard are therefore necessary. Besides future technical developments, reimbursement for teleradiology must be accomplished.

Commercial teleradiology systems in Germany

Teleradiologysystems can differ considerably in their features. The most important differences lie in the mode of image data acquisition, data transfer, data safety aspects and the possibilities of interaction between separate teleradiology units. A selection of commercially available teleradiologysystems is presented and compared.

How to deal with security issues in teleradiology

The use of teleradiological systems for medical image communication is increasing significantly. Digital images can be transferred over public telephone (e.g. ISDN) lines to colleagues for interpretation and/or consultation. Thus, a new quality is being introduced into the process of radiological diagnostics. However, technical implementation of such systems is accompanied by little consideration of legal, i.e. data protection and security, issues. In this paper we describe a concept for data protection in teleradiology which unites aspects of privacy and security as well as user aspects. After highlighting the legal situation in Germany we describe the methodology used for deriving the security profile for teleradiology in Germany. As a result the set of security measures which have to be employed with a teleradiology system is listed. A detailed description follows of how the software requirements are implemented in the teleradiology software MEDICUS.

A cost analysis of an emergency computerized tomography teleradiology system.

We carried out a cost analysis of a teleradiology system for emergency computerized tomography (CT) examinations. Teleradiology was implemented by connecting two spiral CT scanners in the University Hospital in Innsbruck and the Regional Hospital in Zwettl. It enabled the remote hospital in Zwettl to get fast and competent reports of emergency CT examinations when there was no specialist radiologist available. In 13 months' use for routine night and weekend service, the system proved fast and reliable. During the study period 121 emergency examinations of 116 patients were transmitted from Zwettl to Innsbruck. The fixed costs of teleradiology were for the ISDN connection and amounted to DM230 plus DM696/year rental. The average cost of one emergency CT examination by teleradiology was DM372 (range 308-453). One possible alternative, transporting the films by taxi for reporting elsewhere, was cheaper (estimated cost DM156), but would have been much slower. Another alternative, transporting the patient to the nearest central hospital for scanning, was much more expensive: DM524 by road or DM4667 by helicopter ambulance.

Telemedicine: Technology versus the business case

Summary. The implementation of telemedicine is spreading throughout the government and commercial sectors. Telemedicine is being implemented in an effort to contain costs and capture all medically related business in a given catchment area. Telemedicine and off-the-shelf DICOM teleradiology systems can allow for patient images and demographic data to be transmitted electronically over telecommunications lines from satellite clinics to medical centres. The technology allows virtual centres of excellence to be extended to the medical community which provide the expertise and training of physicians to remote sites, while realizing cost savings. The technology to implement telemedicine is available today but it can be very costly if the business case for the system is not carefully evaluated and executed. The decision to implement a telemedicine system must be based upon the business case which supports expenditures by realizing cost savings through prudent selection of technology and medical business practices.