Evaluation of aDigital Camera for
Acquiring Teleradiology Images
Elizabeth A. Krupinski, PhDUniversity of ArizonaDepartment of RadiologyArizona Telemedicine Program
Ronald S. Weinstein, MDUniversity of ArizonaDepartment of PathologyArizona Telemedicine Program
Carlos Gonzales, MD Michael GonzalesPatagonia Family Health Center
This work was supported by:
1) US Dept. Agriculture, Rural Utilities Service Distance Learning and Telemedicine Grant2) US Dept. Commerce, National Telecommunications and Information Administration TIIAP Grant3) Office of Rural Health Policy, HRSA Dept. Health & Human Services Rural Telemedicine Grant Program4) The State of Arizona
Goal To determine if a commercially available
digital camera can be used to acquire photographs of radiologic images to transmit them via store-forward technology over a telemedicine network.
ATP Telemedicine SitesTuba City
Kingman
Cottonwood
Ganado
Payson Springerville
Whiteriver
DOC - Phoenix
DOC - Yuma
NogalesPatagonia
Douglas
AHSCKinoTucson VA
AHSC Hub
Telemedicine
Telepathology
Teleradiology
Flagstaff
NARBHA Net
Arizona Rural Telemedicine Network (ARTN) ATM based network based on high-speed T1 carriers 3 ATM switches located in Northern (Flagstaff),
Central (Phoenix) & Southern (Tucson) regions of the state
Tandberg CANVAS Health Care Unit for real-time interactive teleconsults
MedVision for store-forward teleconsults CompuRAD/Lumisys for teleradiology
Case Volume Telemedicine
020406080
100120140160180
Num
ber
of C
ases
2ndQtr97
3rdQtr97
4thQtr97
1stQtr98
2ndQtr98
3rdQtr98
4thQtr98
1stQtr99
Teleradiology Network 3 of the sites (Kino Community
Hospital in Tucson, Springerville & White River) are connected to the University Medical Center via the high-speed (T1) Arizona Rural Telemedicine Network (ARTN)
1 site (Tucson VA) uses dial-up service
Case Volume Teleradiology
0
50
100
150
200
250
300
350N
umb
er o
f ca
ses
2ndQtr97
3rdQtr97
4thQtr97
1stQtr98
2ndQtr98
3rdQtr98
4thQtr98
1stQtr99
Sub-Specialties CoveredCardiology Ophthalmology Peds. Orthopedics
Dental Orthoped. Surg. Peds. Psychiatry
Dermatology Orthopedics Peds. Pulmonology
Endocrinology Otorhinology Peds. Rheumatology
Fam. & Comm. Med. Pain Clinic Peds. Urology
Gastroenterology Pathology Psychiatry
Genetics Peds. Cardiology Radiology
Hematology/OncologyPeds. Dermatology Reprod/Infertility
Infectious Disease Peds. Endocrinology Rheumatology
Internal Medicine Peds. Gastroenterology Surgery
Medicine Peds. Hem/Onc Surgical Oncology
Nephrology Peds. Infec. Disease Toxicology
Neurology Peds. Nephrology Urology
Ob/Gyn Peds. Neurology Vascular
Types of Service
Routine Diagnostic Consult
38%
Second Opinion18%
Medication Check19%
Psych Therapy15%
Other1%
Psych Evaluation6%
Manage Chronic Condition
2%
Manage Acute Condition
1%
Patient Information
Lab Reports51%
Written*10%
Still Photos23%
Other4%
EKG/EEG/EMG2%
Radiographs10%
Rationale Teleradiology is an important part of an
increasing number of Radiology & Telemedicine programs
Saves time and feedback to referring clinician is faster than with other methods (e.g., courier) - 85% of our teleradiology cases have a “wet read” report generated within 6 hours
Rationale
It can, however, be expensive! For digital modalities a merge box is needed For plain film a digitizer or video capture system
is required Some sites just cannot afford these options A low-cost alternative had to be explored
Rationale The Patagonia Family Health Center needs
consults especially in orthopedics & bone radiology
Have no x-ray facilities so send patients to Nogales’ Mariposa Clinic, the report & films are sent over either with patients or later
Problem - Mariposa only has a general radiologist so sub-specialty consults are often required
The Camera
Canon PowerShot600CCD image sensor832 x 608 pixels24-bit color resolutionf/2.5 lensBuilt-in flash150 kB file size
The Cases 40 bone trauma cases (e.g., fracture, subluxation,
soft tissue damage) from the Patagonia Family Health Clinic
Cases that required a consult in the past & were representative of the types of cases they would be sending for teleconsults in the future - typically subtle lesions
The Photographs Film images were placed on standard viewbox
with extraneous light blocked out The physician identified region(s) of interest
based on clinical history and nature of problem At least one global and one close up shot were
acquired for each image using the Canon PowerShot camera
Display
Images sent over ARTN to the MedVision workstation
Color monitor, 1024 x 768 pixels Window/level, zoom/pan available for use during
viewing Film images displayed on standard viewbox
Protocol 2 orthopedic surgeons & 2 bone radiologists
reviewed the 40 cases on film & using the digital photographs displayed on the monitor
Film reading 6 months after monitor reading Reported:
• Diagnosis• Decision confidence using 6-level scale• Image quality using 4-level scale
Results - Image Quality
0
1020
3040
50P
ER
CE
NT
Film Photo
Excellent
Good
Fair
Poor
Results - Image Quality 2 = 20.32, df = 9, p = 0.02 9 of the photo cases were rated poor
4 film cases were rated poor Of the 9 photo cases, 4 (45%) were rated as poor
because the region-of-interest was not captured sufficiently
Some views (film & photo) were not what the readers were used to - different technologists
Results - Diagnoses* Reader Agreement (Kappa)
1 0.89
2 0.92
3 0.94
4 0.88
* Truth was determined by 2 radiologists not participating in the study from the film images
Results - Confidence
0
20
40
60
PE
RC
EN
T
FILM vs PHOTOCONFIDENCE
Same*
One*
Two*
* How many categories film & monitor confidences differ by
Conclusions A digital still camera can be used effectively to
capture images of bone trauma radiographs for store-forward telemedicine consults
Well-framed close-up shots of the region-of-interest are essential
Good quality original films are essential
Other Applications? Other non-screening applications where a specific
suspicious region-of-interest can be identified for close-up photographs
Unless the lesion is fairly gross, the global shots are not adequate for consultation - close-up shots are required in the majority of cases