Does teleradiology improve inter-hospital management of head-injury?

Telehealth practice in surgery: Ethical and medico-legal considerations

There was rapid growth of telehealth practice during the COVID-19 outbreak in 2020. In surgery, there were beneficial effects in terms of saving time and avoiding physical contact between healthcare professionals and patients when using telehealth in the delivery of perioperative care. As telehealth is gaining momentum, the evolving ethical and medico-legal challenges arising from this alternative mode of doctor-patient interaction cannot be underestimated. With reference to the "Ethical Guidelines on Practice of Telemedicine" issued by the Medical Council of Hong Kong and some published court and disciplinary cases from other common law jurisdictions, this article discusses relevant ethical and medico-legal issues in telehealth practice with emphasis on the following areas: duty of care; communication and contingency; patient-centred care and informed consent; limitations and standard of care; keeping medical records, privacy, and confidentiality; and cross-territory practice. Whilst existing ethical and legal obligations of practicing medicine are not changed when telehealth is used as opposed to in-person care, telehealth practitioners are advised to familiarize themselves with the ethical guidelines, to keep abreast of the medico-legal developments in this area, and to observe the licensure requirements and regulatory regimes of both the jurisdiction where they practice and where their patients are located.

Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond

BACKGROUND

Evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the COVID-19 era.

OBJECTIVE

To conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. Additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience.

METHODS

A systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. We reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty.

RESULTS

A total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. A total of 13 studies were conducted in the United States and 39 in foreign countries. Patient management was successful via telemedicine in 99.6% of cases. Telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. A total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. From 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). About 94.3% of telemedicine visits were billed using face-to-face procedural codes.

CONCLUSION

Neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics.

Italian guidelines on the assessment and management of pediatric head injury in the emergency department

OBJECTIVE

We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

METHODS

These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

CONCLUSIONS

Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.

Telestroke Imaging: A Review

The use of telecommunications technology to provide the healthcare services, telemedicine, has been in use since the 1860s. The use of technology has ranged from providing medical care to far-off places during wartimes to monitoring physiological measurements of astronauts in space. Since the 1990s, reports have been published on diagnoses of neurological diseases with the use of video links. Studies confirm that the neurological examinations, including the National Institutes of Health Stroke Scale, performed during teleneurology are dependable. The transfer of stroke patients in rural hospitals to bigger medical centers delays treatment while there exists current and projected shortage of neurologists. Telestroke provides the solution. Patients suspected of acute stroke need a noncontrast computerized tomography (CT) scan for tissue plasminogen activator administration. Vascular imaging such as CT angiography, magnetic resonance angiography, and digital subtraction angiography can help show large-vessel occlusion or critical stenosis responsive to endovascular therapy. A standard protocol can be followed to decide a vascular modality of choice, considering advantages and disadvantages of each imaging modality. Telestroke solves the problems of distance and of shortage of neurologists. Neuroimaging plays a vital role in the delivery of telestroke, and the telestroke doctor should be comfortable with making a decision on selecting an appropriate vascular imaging modality.

Image-based medical expert teleconsultation in acute care of injuries. A systematic review of effects on information accuracy, diagnostic validity, clinical outcome, and user satisfaction

Objective

To systematically review the literature on image-based telemedicine for medical expert consultation in acute care of injuries, considering system, user, and clinical aspects.

Design

Systematic review of peer-reviewed journal articles.

Data sources

Searches of five databases and in eligible articles, relevant reviews, and specialized peer-reviewed journals.

Eligibility criteria

Studies were included that covered teleconsultation systems based on image capture and transfer with the objective of seeking medical expertise for the diagnostic and treatment of acute injury care and that presented the evaluation of one or several aspects of the system based on empirical data. Studies of systems not under routine practice or including real-time interactive video conferencing were excluded.

Method

The procedures used in this review followed the PRISMA Statement. Predefined criteria were used for the assessment of the risk of bias. The DeLone and McLean Information System Success Model was used as a framework to synthesise the results according to system quality, user satisfaction, information quality and net benefits. All data extractions were done by at least two reviewers independently.

Results

Out of 331 articles, 24 were found eligible. Diagnostic validity and management outcomes were often studied; fewer studies focused on system quality and user satisfaction. Most systems were evaluated at a feasibility stage or during small-scale pilot testing. Although the results of the evaluations were generally positive, biases in the methodology of evaluation were concerning selection, performance and exclusion. Gold standards and statistical tests were not always used when assessing diagnostic validity and patient management.

Conclusions

Image-based telemedicine systems for injury emergency care tend to support valid diagnosis and influence patient management. The evidence relates to a few clinical fields, and has substantial methodological shortcomings. As in the case of telemedicine in general, user and system quality aspects are poorly documented, both of which affect scale up of such programs.

Transfer patient imaging: current status, review of the literature, and the Harborview experience

Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.

Great hospitals of Asia: neurosurgery at Prince of Wales Hospital

Prince of Wales Hospital, a 1400-bed regional referral center, was established in 1984 as the primary teaching hospital of the second medical school in Hong Kong at the Chinese University of Hong Kong. The Academic Division of Neurosurgery was given an autonomous status, the support of 40 acute beds, and a well-equipped and well-staffed intensive care unit (ICU), in developing neurosurgery as a distinct surgical specialty. Over this short 26-year history, we have gone through the difficult time of one-man-band neurosurgery, excelled in emergency neurosurgery, and evolved to an era of organized neurosurgical practice, where clinical services, teaching of undergraduate and postgraduate students, and clinical and translational research have been brought up to international standards.

The impact of a telehealth web-based solution on neurosurgery triage and consultation

INTRODUCTION

To enhance the quality of neurosurgery consultations, triage, and transport decisions between a Level I trauma service neurosurgery program at the University of New Mexico Hospital and referring hospitals, a secure Health Insurance Portability and Accountability Act (HIPAA)-compliant Web-based system was developed, to which digital neurological images could be sent for review by a neurosurgeon for consultation or patient transfer. Based upon prior experience of neurosurgery, it was predicted that 25% of transfer requests would be avoided if the neurosurgeons reviewed the computerized tomography scans at the time of a transfer request. In addition, it was predicted in 25% of the case that changes in management recommendations would take place independent of the transfer decision.

METHODS

The program was designed to allow referring hospitals to transmit digital images to the Web site, providing consulting doctors with additional patient information. This project analyzed the neurosurgeons' responses to questions designed to determine if transport or management decisions were altered when using this telehealth program in response to a request for consultation or transfer from a rural facility.

RESULTS

Analysis of the responses of the consulting neurosurgeons revealed that, after viewing the images, 44% of the potential transfers were avoided and 44% of consulted cases resulted in management recommendation changes independent of the transfer decision.

CONCLUSIONS

Use of the system resulted in improved triage and changes in transfer or management recommendations. A significant number of potential transfers were avoided, resulting in transport cost avoidance, more effective use of resources, and more appropriate use of the neurosurgery service as well as improved patient preparation.

Teleradiology in neurosurgery: experience in 1024 cases

Between June 1995 and June 2000 teleradiology was performed in 1024 neurosurgical cases (945 patients). An analogue image transfer system was used for presentation of computed tomography (CT) and magnetic resonance imaging (MRI) scans from seven referring hospitals in southern Germany. The system used a 19,200 baud modem connection via the ordinary telephone network. The diagnoses on presentation were intracerebral haematoma (50%), trauma (27%), subarachnoid haemorrhage (4%), stroke (5%) and others (14%). Retrospective analysis showed that in 67% of cases admission and therefore ground-based transportation of the patients to our neurosurgical centre was not necessary for different reasons (moribund status, no surgical intervention required or no neurosurgical problem at all). If each patient had been transferred, then the potential savings for ground transportation were euro339.93 per case (with accompanying physician of the affiliated hospital) or euro373.96 per case (with accompanying experienced ICU physician), respectively (euro1 is US$1.4). The total cost of the image transfer system for all eight hospitals was euro96,000; this was amortised after 282 teleconsultations, which occurred after 15 months of usage. A simple teleradiology system in neurosurgery enables rapid and reliable telephone consultations, mainly on patients with trauma, stroke and intracerebral haematoma at low cost.

Quand faut-il décider d'un transfert en milieu neurochirurgical spécialisé?

The annual incidence of severe head injury lies between 9 and 25/100000 inhabitants, depending on the criteria used for its definition. In most countries, the shortage in neurosurgical ICU beds makes it impossible to take in charge all patients with a severe brain injury. But the beneficial effect of a specialized neurosurgical ICU on outcome after brain injury has been demonstrated in several retrospective studies. Ideally, the best strategy is to admit the patients with a severe head injury directly in a neurosurgical centre. When this is not possible, the appropriate decision of a secondary transfer relies on the quality of the relationships between physicians in the community and the neurosurgical hospitals. Teleradiology is the best method to avoid unnecessary transportation or deleterious delays before transfer. In an era of decreasing medical budgets, technical improvements to enhance medical cooperation should be encouraged.

Telemedicine and neurosciences

It is well known that in most countries there is a perennial shortage of specialists in neurosciences. The available neurologists and neurosurgeons are clustered in the metropolitan, urban areas. Those living in suburban and rural areas may have limited or no access to neurological care. Concurrently, there has been an unprecedented growth in information and communication technology (ICT). In this article, the author will demonstrate how the practice of neurosciences will change, with increasing use of telemedicine and ICT. In addition to presenting the author's personal experience, the literature on telemedicine in neurosciences is reviewed.

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.

Swiss teleradiology survey: present situation and future trends

The purpose of this study was to obtain a survey about the present situation including the usage pattern, technical characteristics and the anticipated future of teleradiology in Switzerland. An internet-based questionnaire was made available to all members of the Swiss Society of Radiology. Questions concerning current teleradiology usage, the type of transmitted modalities, the technology employed, security, billing issues and the anticipated future of teleradiology were addressed. One hundred and two (22.67%) of 450 radiologists responded to the survey. Of the total, 41.2% (42) were teleradiology users, 35.3% (36) planned to use teleradiology in the near future and 24.5% (25) did not use or plan to use teleradiology. The mean number of examinations transmitted per month was 198 (range 1-2,000) and the mean distance was 33 km (range 1,250 km). An emergency service was considered the most important purpose (mean score 6.90; minimum 1, maximum 10) for the use of teleradiology, followed by image distribution (mean 6.74) and expert consultation (mean 6.61). The most commonly transmitted modality was computed tomography (mean 8.80), followed by conventional X-rays (8.40) and magnetic resonance imaging (8.32). The most commonly transmitted format was Digital Imaging and Communications in Medicine (DICOM) (66.7%), followed by bitmap/Joint Photographic Experts Group (jpg) (38.1%), using the DICOM send/receive protocol (52.4%), followed by the hypertext transfer protocol (26.2%) and e-mail (21.4%). For security a secure connection (54.8%) followed by encryption (14.3%) and anonymization (9.5%) was used. For the future, image distribution was rated the most important aspect of teleradiology (7.88), followed by emergency (7.22) and expert consultation (6.53). Development of legal regulations is considered most important (8.17), followed by data security guidelines (8.15). Most radiologists believe that insurance companies should pay for the costs of teleradiology (37.3%), followed by the radiologist (33.3%). In conclusion, in Switzerland a wide spectrum of teleradiology applications and technologies is in use. Guidelines and reimbursement issues remain to be solved.

[The value of teleradiology in the management of neuroradiologic emergencies]

First, to summarize the results of teleradiology programs on neurosurgical emergency care in France. Second, to compare French data with the international literature. Third, to discuss the likely developments and future of teleneuroradiology and teleneurosurgery. Data on French use of telemedicine applications in neuroradiology come from a survey of telemedicine applications in France, which has been conducted in year 2003 at the request of the French ministry of the Research. Teleradiology clearly has a positive impact on emergency neurosurgical care by reducing the time to correct diagnosis and initiation of treatment of patients who need to be transferred and avoid unnecessary transfers. However, present teleradiology applications have organizational limitations that are summarized and discussed with reference to the literature. Further developments in information and communications technology have the potential to revolutionise neurosurgical emergency care and contribute to improve the training of neuroradiology and neurosurgery staff.

Rapid wireless transmission of head CT images to a personal digital assistant for remote consultation

RATIONALE AND OBJECTIVES

We describe a simple technique for transmission of a complete set of cranial computed tomography (CT) images to a commercially available wireless personal digital assistant (PDA) for remote teleradiology consultation.

MATERIALS AND METHODS

A complete set of images from the head CT of a trauma patient with subdural hematoma (19 images) was captured from a picture archiving and communication system and transmitted wirelessly as an e-mail attachment after being compressed. The images were retrieved, decompressed, and reviewed using commercially available software and a PDA with cellular phone capability.

RESULTS

A complete head CT was transmitted to a remote radiologist's wireless PDA for consultation. The entire procedure (including image capture, transmission, and review) took approximately 11.5 minutes.

CONCLUSION

Using the technique described in this article the wireless PDA may function as a robust medium for facilitating care of brain trauma patients by allowing rapid access to trauma radiologists or neurosurgeons.

A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients

OBJECTIVES

To find out the effect of early neurological consultation using a real time video link on the care of patients with neurological symptoms admitted to hospitals without neurologists on site.

METHODS

A cohort study was performed in two small rural hospitals: Tyrone County Hospital (TCH), Omagh, and Erne Hospital, Enniskillen. All patients over 12 years of age who had been admitted because of neurological symptoms, over a 24 week period, to either hospital were studied. Patients admitted to TCH, in addition to receiving usual care, were offered a neurological consultation with a neurologist 120 km away at the Neurology Department of the Royal Victoria Hospital, Belfast, using a real time video link. The main outcome measure was length of hospital stay; change of diagnosis, mortality at 3 months, inpatient investigation, and transfer rate and use of healthcare resources within 3 months of admission were also studied.

RESULTS

Hospital stay was significantly shorter for those admitted to TCH (hazard ratio 1.13; approximate 95% CI 1.003 to 1.282; p = 0.045). No patients diagnosed by the neurologist using the video link subsequently had their diagnosis changed at follow up. There was no difference in overall mortality between the groups. There were no differences in the use of inpatient hospital resources and medical services in the follow up period between TCH and Erne patients.

CONCLUSIONS

Early neurological assessment reduces hospital stay for patients with neurological conditions outside of neurological centres. This can be achieved safely at a distance using a real time video link.

Clinical outcomes resulting from telemedicine interventions: a systematic review

BACKGROUND

The use of telemedicine is growing, but its efficacy for achieving comparable or improved clinical outcomes has not been established in many medical specialties. The objective of this systematic review was to evaluate the efficacy of telemedicine interventions for health outcomes in two classes of application: home-based and office/hospital-based.

METHODS

Data sources for the study included deports of studies from the MEDLINE, EMBASE, CINAHL, and HealthSTAR databases; searching of bibliographies of review and other articles; and consultation of printed resources as well as investigators in the field. We included studies that were relevant to at least one of the two classes of telemedicine and addressed the assessment of efficacy for clinical outcomes with data of reported results. We excluded studies where the service did not historically require face-to-face encounters (e.g., radiology or pathology diagnosis). All included articles were abstracted and graded for quality and direction of the evidence.

RESULTS

A total of 25 articles met inclusion criteria and were assessed. The strongest evidence for the efficacy of telemedicine in clinical outcomes comes from home-based telemedicine in the areas of chronic disease management, hypertension, and AIDS. The value of home glucose monitoring in diabetes mellitus is conflicting. There is also reasonable evidence that telemedicine is comparable to face-to-face care in emergency medicine and is beneficial in surgical and neonatal intensive care units as well as patient transfer in neurosurgery.

CONCLUSIONS

Despite the widespread use of telemedicine in virtually all major areas of health care, evidence concerning the benefits of its use exists in only a small number of them. Further randomized controlled trials must be done to determine where its use is most effective.

Telemedicine

Telemedicine began from the humble beginnings of the first telephone call from Alexander Graham Bell to his associate, Watson. These systems already have been used for educational programs, consultative care, image transfer, second opinions, and direct acute patient care. Most of the original programs failed because of several reasons, primarily because of lack of funding when a grant ended. The major lesson of these programs is that a solid business plan is needed initially for long-term survival. The reliability of telemedical examinations has been demonstrated superficially, but more conclusive work in this area is needed. Studies that evaluate clinical, financial, and satisfaction outcomes are required simultaneously. Further integration of medical informatics into telemedicine systems is needed before these systems can achieve more acceptance. Twenty years ago, few people predicted this technologic revolution. Innovations arise almost daily. The future seems promising for telemedical systems, but much work is required. Partnerships with industry must move beyond niche projects, and regulatory and medicolegal issues must be resolved. Anesthesiologists can expect their practice to be affected directly by technology, and should embrace it, evaluate it, and help lead its use in this millennium.

Technique for neurosurgically relevant CT image transfers using inexpensive video digital technology

OBJECTIVE

To examine and document neurosurgically relevant CT image transfers using inexpensive video digital technology.

METHODS

Thirty abnormal CT scans were evaluated on a personal computer monitor following their digital image creation and transfer by electronic mail (e-mail). These were compared with the radiologist's interpretation of a hard copy of the CT scan originals. Any change in diagnosis based on the CT scan or e-mail image was assessed after completion of the comparison.

RESULTS

A total of 30 CT scans were successfully transferred and reviewed. On only one image was there disagreement between the neurosurgeon's and the radiologist's interpretations of the image. This resulted in a change in the radiologist's diagnosis after digital image transfer occurred and the neurosurgeon diagnosed an isodense subdural hematoma, which was later confirmed at the time of surgical decompression.

CONCLUSIONS

A hand-held, inexpensive digital camera may serve neurosurgeons as a helpful alternative to expensive, labor-intensive teleradiology systems. It should be considered as an adjunctive option for small community-based hospitals unable to financially support more sophisticated teleradiology techniques, which have been shown to provide a significant benefit in the management and outcome of head trauma patients.

Digital still image recording during video endoscopy

With the advances in telemedicine and virtual consultation services comes the need for state-of-the-art endoscopic imaging techniques and equipment. Concomitant with current day concerns of cost containment, the ability to utilize the aforementioned tools in a cost-effective fashion that lowers operating expenses, accurately depicts procedures, and expedites chart documentation is paramount. We report on a fast and efficient way to obtain and store images during endoscopic procedures, which can be stored on standard 3.5-inch floppy disks using an innovative digital image recorder. These images are stored as high-resolution (640x480x24) JPEG files, which can be placed in electronic medical records, imported into Internet Web pages, incorporated into slide presentations, and, most importantly, stored in easily accessed archives.

Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals

BACKGROUND

Teleradiology is one form of telemedicine that would allow the transmission of radiographs before the transfer of acutely traumatized patients between referring and receiving hospitals. The purpose of this study was to evaluate the potential impact of a prehospital teleradiology system on trauma patient management and transfer.

METHODS

Forty-four injured adults referred to a trauma center were included. The history, physical examination, and radiographic findings reported by the referring physician to the receiving physician were documented. The plain radiographs of the chest, pelvis, and cervical spine taken at the referring hospital were obtained after patient transfer. For each case, two reviewers blinded to the case (surgeon [S] and emergency department physician [E]) and one reviewer not blinded to the case were individually presented with the referring physician's report and the radiographs. The reviewers were surveyed as to the implications of viewing the plain radiographs taken at the referring hospital before patient transfer.

RESULTS

Overall, the blinded reviewers felt that viewing the radiographs before transfer would have influenced care in 40% and 38% of cases as judged by (S) and (E), respectively, with a crude agreement of 67.5% (kappa level, 0.32). The blinded reviewers (S and E) commonly noted the following four changes in management as a result of viewing the referred radiographs: requested further clinical history (S, 18%; E, 23%), suggested further pretransfer interventions (S, 38%; E, 30%), suggested further pretransfer diagnostic tests (S, 25%; E, 13%), and emphasized precautions during transfer (S, 28%; E, 30%). The nonblinded reviewer suggested potential influence in the management of at least 65% of the cases.

CONCLUSION

This study suggests that viewing the radiographs of acutely injured trauma patients has the potential to influence many aspects of the management of interhospital transfer.

Secure transmission of urologic images and records over the Internet

PURPOSE

Telemedicine has become a common method for the transmission of images and patient data across long distances. Our goal was to assess the efficiency and accuracy of Photomailer MD software, a store-and-forward telemedicine system, in the urologic setting.

METHODS

Photomailer MD software was loaded on two computers in the host institution, one with a T1 connection to the Internet and the other with a dial-up modem connection (24,000 bits/second), and computers at three remote sites. A total of 14 clinical cases, comprised of digitized histories and radiographic images, were sent to the remote institutions four separate times using the four transmission modes available: nonencrypted, 56-bit encryption, 128-bit encryption, and 128-bit encryption with password. The following data points were recorded: file size before and after encryption, file transmission times, and diagnostic accuracy of the remote urologists. One-way ANOVA was used to compare mean values statistically, while the z-test was used to compare diagnostic accuracies.

RESULTS

Encryption increased the file size by a mean of 37.8%, with the three encryption modes increasing file sizes by the same number of kilobytes. When a dial-up modem was used, encrypted files required a significantly longer transmission time (P < 0.05) than the unencrypted files. The same trend was seen with the T1 connection, although the differences often were not significant. When T1 transmission times were compared with modem times with other variables held constant, modem times were significantly longer (P < 0.05). Diagnostic accuracies for each of the three remote centers ranged from 85.7% to 100%. Differences in accuracy rates between attending physicians and residents were not significant.

CONCLUSIONS

Photomailer MD provides a secure, convenient, and affordable method of transmitting patient images and records via the Internet. Transmission speed was significantly greater when using a T1 line and also tended to be faster when files were not encrypted. There was no significant difference in transmission time among the three encryption modes; therefore, 128-bit encryption with a password should be used to maximize security. Diagnostic accuracies were comparable to those in the literature. In general, 640 x 480-pixel resolution was adequate for urologic diagnoses, although higher-resolution images may improve accuracy.

Telemedicine in the NHS for the millennium and beyond

This article defines telemedicine, discusses evidence of its effectiveness, looks at its advantages and disadvantages (and barriers to implementation), and considers its role in the NHS for the millennium and beyond.