Digitized radiographs in skeletal trauma: a performance comparison between a digital workstation and the original film images

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.

Digitization of medicine: how radiology can take advantage of the digital revolution

In the era of medical cost containment, radiologists must continually maintain their actual and perceived value to patients, payers, and referring providers. Exploitation of current and future digital technologies may be the key to defining and promoting radiology's "brand" and assure our continued relevance in providing predictive, preventive, personalized, and participatory medicine. The Association of University of Radiologists Radiology Research Alliance Digitization of Medicine Task Force was formed to explore the opportunities and challenges of the digitization of medicine that are relevant to radiologists, which include the reporting paradigm, computational biology, and imaging informatics. In addition to discussing these opportunities and challenges, we consider how change occurs in medicine, and how change may be effected in medical imaging community. This review article is a summary of the research of the task force and hopefully can be used as a stimulus for further discussions and development of action plans by radiology leaders.

Digital camera resolution and proximal caries detection

OBJECTIVES

To evaluate the diagnostic accuracy of proximal caries detection from digitized film images captured by a digital camera at different resolution settings.

METHODS

Twenty-five periapical radiographs of 50 premolar and 25 molar teeth were photographed using a digital camera, Sony Cyber-shot, DSC-S75 at three different resolution settings: 640 x 480, 1280 x 960 and 1600 x 1200. Seventy-five digital images were transferred to a computer, saved and opened using ACDSee software. In addition, a PowerPoint slide was made from each digital image. Five observers scored three groups of images (the films, the displayed 1:1 digital images on the ACDSee software, and the PowerPoint slides) for the existence of proximal caries using a 5-point confidence scale, and the depth of caries on a 4-point scale. Ground sections of the teeth were used as the gold standard. Az values under the receiver operating characteristic (ROC) curve of each group of images and at different resolutions were compared using the Friedman and Wilcoxon signed rank tests. Mean different values between the lesions' depth interpreted by the observers and that of the gold standard were analysed.

RESULTS

Films showed the highest Az values. Only the 1280 x 960 images on the ACDSee software showed no significant difference of the Az value from the films (P=0.28). The digital images from three resolution settings on the PowerPoint slides showed no significant differences, either among each other or between them and the films. For caries depth, the 1280 x 960 images showed lower values of mean difference in enamel lesions compared with the other two resolution groups.

CONCLUSIONS

This study showed that in order to digitize conventional films, it was not necessary to use the highest camera resolution setting to achieve high diagnostic accuracy for proximal caries detection. The 1280 x 960 resolution setting of the digital camera demonstrated comparable diagnostic accuracy with film and was adequate for digitizing radiographs for caries detection.

Teleradiology in orthopaedics

Teleradiology is a means of electronically transmitting radiographic image files from one location to another. Technologic advances in digital imaging, telecommunications, digital storage, and viewing technologies have made teleradiology readily available and reasonably affordable. The five components of a teleradiology system include: a sending station, a transmission network, a storage device, a viewing station and, a software package. The advantage of teleradiology is the mobility of digital images. In contrast to plain radiographs that only can be seen in one location at a time, multiple persons who are at different locations can view digital images simultaneously. When applied to orthopaedic trauma applications, when the consulting orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, disposition planning of patients from emergency departments or outlying hospitals, and planning of surgical procedures. These systems also improve the comfort level of consulting orthopaedic surgeons and potentially limit the risk of litigation for incorrect diagnosis. The quality, convenience, and effectiveness of teleradiology systems should improve as the technologies continue to mature. Having radiographic images available on handheld devices, such as cell phones, is likely to be a reality in the near future.

Comparison of radiographic assessments of the tibial plateau slope in dogs

OBJECTIVES

To evaluate the accuracy of 2 radiographic methods used to assess tibial plateau slope (TPS) in dogs and evaluate effects of film digitization and radiographic beam placement on TPS measurements.

SAMPLE POPULATION

16 hind limbs from dog cadavers weighing > 20 kg.

PROCEDURES

Radiographs of tibiae were made with the radiographic beam centered over the stifle joint and midshaft of the tibia. Tibiae were collected, the femorotibial contact area was determined, and slope of the medial tibial condyle in relation to the tibial shaft was measured. Radiographs were digitized. Slope of the medial tibial condyle was measured on printed and digitized radiographs read in random order by 6 examiners unaware of anatomic measurements. Three examiners used a conventional measuring technique, and 3 examiners used an alternative measuring technique.

RESULTS

Anatomic measurements were significantly higher than radiographic measurements made by use of the conventional interpretation method but did not differ from radiographic measurements made by use of the alternate method. Measurements from printed radiographs were lower than measurements from digitized radiographs for the 4 most experienced examiners.

CONCLUSIONS AND CLINICAL RELEVANCE

Measurements made by use of a line tangential to the cranial, linear portion of the medial tibial condyle at the femorotibial contact point were accurate measurements of the anatomic TPS. Measurements made by use of the conventional TPS measurement method underestimated the anatomic TPS. Measurements made on digitized radiographs were typically more accurate than measurements made on printed radiographs.

Report on a new type of trauma full-body digital X-ray machine

The purpose of this study was to evaluate the diagnostic equivalence, radiation dose, clinical usefulness and radiographic aspects of a low-dose, full-body digital X-ray machine in a busy trauma unit. A digital trauma X-ray machine known as "LODOX" was compared with conventional radiography between June 1999 and November 2001 in the Groote Schuur Hospital Trauma Unit, Cape Town. Digital images of a variety of body regions commonly imaged in trauma were compared for diagnostic image quality in a number of categories with equivalent conventional radiographs. A seven-point equivalence scoring system ranging from much inferior (-3) through equivalent (0) to much superior (+3) was used in each category. Radiation dose was recorded and compared with that in conventional measurements. Turnaround times of patients undergoing digital and conventional X-rays were evaluated. Clinical and radiographic issues were assessed by staff feedback. The digital images when compared with conventional film had an overall mean equivalence score of -0.429, with a standard deviation (SD) of 0.77. The best digital performance was in the mediastinum (mean 0.346, SD 0.49) and the weakest was for bony detail (mean -0.654, SD 0.81). Relative digital radiation dose compared to conventional varied from 72% (chest) to 2% (pelvis), with a simple average of 6%. Radiographic points included full-body imaging capability and differing positioning, penetration, workflow and practicality considerations. The digital images required overall patient times of 5-6 min, compared with 8-48 min for conventional X-rays. New installations are under way, and computed tomography and angiography applications are being explored. FDA approval is awaited. Projected cost is similar to that of flat-panel digital units. This digital unit was felt to be diagnostically substantially equivalent to conventional radiographs, with low-dose full-body imaging, improved workflow, digital technology and long-term cost benefits as potentially favourable contributions to trauma imaging.

Digital radiography in the diagnosis of Toddler's fracture

BACKGROUND

The objective of this study was to evaluate the accuracy of digital imaging in the diagnosis of toddler's fractures.

METHODS

Medical records for a 9.4-year period were reviewed to locate children whose initial radiographs were interpreted as normal by a pediatric radiologist and whose subsequent bone scans or follow-up radiographs showed toddler's fractures. Radiographs from these children (ie, positive controls) and from children without toddler's fractures (ie, negative controls) were digitized to create a film bank that was reviewed by a panel of 14 physicians with various medical backgrounds. Medical records were reviewed for demographic information, findings on history and physical examination, and radiographic and laboratory tests.

RESULTS

Pediatric radiology physicians correctly diagnosed 73.2 +/- 5.4% of the digitized images, as compared with pediatric emergency physicians, 66.7 +/- 6.5% and residents/fellows, 57.1 +/- 6.9%.

CONCLUSION

Digitized images may be helpful in evaluating limping children with suspected toddler's fractures, possibly eliminating the need for further diagnostic studies.

Digital radiographs in the assessment of distal radius fracture parameters

The purpose of the current study was to assess the reliability of measurement of distal radius fracture parameters using digital radiographs. Digital radiographs and corresponding plain radiographs of the wrists of 20 patients with intraarticular distal radius fractures were used to measure radial inclination, palmar tilt, radial height, and articular step-off. The plain radiographs and digital images were evaluated independently by three examiners in two sessions. The plain radiographs were assessed using a standard goniometer (manual measurements) whereas the digitized radiographs were evaluated using imaging software to do the computer-assisted measurements. The interobserver and intraobserver reliability were measured using repeated measures analysis of variance and weighted kappa statistics. Measurement of the digital images improved the interobserver reliability of measurement of palmar tilt from substantial to excellent, radial height from moderate to substantial, and articular step-off from fair to moderate. Similarly, intraobserver reliability increased from moderate to substantial when measuring radial height. In no instance (between or within observers) did the level of reliability decrease when using digital images for fracture evaluation. The current data suggest that the reliability of measurements of angular and linear fracture parameters of distal radius fractures is similar between plain and digital radiographs.

Teleradiology in orthopaedic surgery: impact on clinical decision making for acute fracture management

OBJECTIVE

To determine whether teleradiology improved clinical decision making for the treatment of patients with acute fractures.

DESIGN

Prospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

One-hundred eight consecutive patients with 123 acute fractures who visited our Level 1 trauma center, when the first author was the attending orthopedic surgeon on call, and had orthopaedic consultations were included.

MAIN OUTCOME MEASURES

In each case, an orthopaedic junior resident performed the emergency department consultation. Radiographs were digitized and electronically transmitted to the attending orthopaedist. Treatment plans were formulated and recorded by the attending surgeon at three different times. The original plan was defined after traditional verbal communication of physical and radiographic findings. A revised plan was defined after the radiographic images were reviewed by the attending surgeon, and the final plan was defined after review of the original radiographs. Two different types of deviations from the original plan were distinguished. Changes in the acute management were defined as any emergency department procedures, emergent operative procedures, or dispositions that were not part of the original plan. Changes in the ultimate management were defined as changes to the original plan that did not affect emergency department treatment, emergent operative procedures, or the disposition of the patient.

RESULTS

In twenty-six of the 123 fractures (21 percent), the additional information provided by viewing electronically transmitted images of radiographs changed the acute management or the ultimate management. In none of the 123 cases did subsequent review of original radiographs result in any further changes to the treatment plan.

CONCLUSIONS

The routine use of electronically transmitted digitized radiographic images has the potential to improve clinical decision making for the care of patients with acute fractures.

Fracture interpretation using electronic presentation: a comparison

The purposes of this study were to determine whether (1) fractures are interpreted differently after digitization and electronic presentation; (2) there are differences in accuracy between screen radiographs and electronic presentation; (3) differences in interpretation are a function of monitor resolution; and (4) differences in interpretation between radiographs and electronic images relate to radiological subspecialty. Forty cases with fractures of varying degrees of subtlety and 35 cases without fractures were interpreted. Radiographs were digitized with 2 different systems and displayed on 3 monitors of different spatial resolution. Four radiologists, with varying experience, were asked to decide whether fractures were present, absent, or they were uncertain. Accuracy of interpretation increased with improved electronic image presentation and monitor resolution. The sensitivity, specificity, and accuracy of fracture detection on System A were 63%, 98%, and 78%, respectively. The results were 72%, 98%, and 84% with System B. System C results were 81%, 97%, and 88% with Lumiscan 75, and 82%, 96%, and 88% with Lumiscan 150. Sensitivity, specificity, and accuracy results of the original radiograph interpretation were 89%, 95%, and 92%. Results were significantly different for System A. No significant differences were found for the other systems compared with film radiographs. System A did not have adequate monitors for interpretation of subtle fractures. Systems B and C were capable of displaying even subtle fractures. Our initial results indicate that interpretation with high-quality 1K x 1K monitors is substantially similar to radiograph interpretation.

Rural trauma: the challenge for the next decade

Improving the care of trauma patients in a rural environment requires that several important issues be addressed. First, a universal definition of what constitutes "rural" must be established. We propose that a combined effort of the Federal Government and the Committee on Trauma of the American College of Surgeons develop this definition. Second, data on rural trauma demographics and outcome must be collected in a national database. We propose that this database be incorporated in the "TRACS" database of the Committee on Trauma of the American College of Surgeons. Such a database will allow a "needs assessment analysis of existing care in rural environments and facilitate planning and implementation of efficient systems of care. Funding for the rural database should come from the federal government. Finally, increased public awareness of problems unique to rural trauma care is necessary. The rural trauma subcommittee of the ACSCOT should go from an ad hoc committee to a standing committee with the American College of Surgeons Committee on Trauma. We propose a national conference on rural trauma care hosted by the federal government for the purpose of addressing these issues and simultaneously increasing public awareness.

The use of teleradiology in an emergency setting with speculation on the near future

None of these models will automatically come to pass but all are possible today. Radiologists have to realize that the teleimaging era for emergency patients is here to stay. Successful utilization for good and gain may no longer be accomplished by a reliance on old or outmoded practice assumptions. The virtual turf, prepared by the rapidity of the remote transmission of electronically generated pictures, is a real phenomenon for which radiology has and will play a major role. The practice opportunities may not be vast in scope, but on a regional basis the imaging landscape is still green and up for grabs.

Emerging technology: remote analysis of traumatic musculoskeletal radiographs transmitted by electronic mail

OBJECTIVES

To determine whether remote analysis of radiographs via electronic mail (e-mail) had an impact on treatment decision-making.

DESIGN

Prospective.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-five cases randomly selected from previous emergency room consultation.

INTERVENTION

Textual descriptions obtained from emergency medicine physicians were compared with computer-digitized images of radiographs sent via e-mail and with the actual radiographs. Four board-certified orthopaedic surgeons reviewed all three forms of data to determine fracture diagnosis and treatment plans. MAIN OUTCOME ASSESSMENT: Diagnosis and treatment plans were obtained via written questionnaire after review of each group of data (textual, digitized image, and actual radiograph). Results were then compared across groups to determine whether digitized images were better than textual descriptions and equivalent to actual radiographs.

RESULTS

Statistical analysis revealed a significant improvement in the frequency of correct diagnosis and treatment planning when digitized images were used (91 percent) compared with textual descriptions alone (48 percent) (p < 0.001). The difference in correct diagnosis and treatment plans between digitized images and actual radiographs was not statistically significant (p = 0.27).

CONCLUSION

Digitized radiographs sent via e-mail can significantly improve accuracy of diagnosis and treatment compared with a simple verbal description.

Skeletal surveys for child abuse: comparison of interpretation using digitized images and screen-film radiographs

OBJECTIVE

The objective of our study was to compare child abuse detection using screen-film radiographs and their digitized images displayed on a computer workstation.

MATERIALS AND METHODS

Skeletal surveys of 20 consecutive child abuse patients whose abuse was clinically proven by a combination of history, physical and radiographic findings, and social work history, and 20 consecutive control subjects were evaluated. Three radiologists rated both the screen-film radiographs (400-speed, double-emulsion film) and their digitized images displayed on a workstation (2K x 2K resolution) using a six-point ordinal scale for suspicion of child abuse, fracture detection, and image quality. The rating response was analyzed using multiobserver-multicase receiver operating characteristic analysis of variance. The McNemar test was used to evaluate differences between imaging techniques and between diagnoses made using each imaging technique and clinically proven child abuse.

RESULTS

The area under the receiver operating characteristic curve for screen-film radiographs was 0.934+/-0.025 and for digitized images was 0.922+/-0.013. This difference was not significant (p = .658); however, two observers significantly underestimated the child abuse diagnosis with digitized images (p = .02). In a review of the false-negative child abuse diagnoses, observers failed to recognize characteristic metaphyseal fractures (10 observations) and rib fractures (five observations) on digitized images that had been recognized on screen-film radiographs. Mean image quality was rated significantly lower (p < .0001) and interpretation time was significantly longer (75 sec; p < .001) for the digitized images than for screen-film radiographs.

CONCLUSION

The characteristic types of fractures that were not identified on the digitized images, lower image quality, and longer interpretation time raise concern that digitized images may not be adequate for interpretation of suspected child abuse.

Telemedicine in practice

Telemedicine is defined as the "delivery of health care and sharing of medical knowledge over a distance using telecommunication systems." The concept of telemedicine is not new. Beyond the use of the telephone, there were numerous attempts to develop telemedicine programs in the 1960s mostly based on interactive television. The early experience was conceptionally encouraging but suffered inadequate technology. With a few notable exceptions such as the telemetry of medical data in the space program, there was very little advancement of telemedicine in the 1970s and 1980s. Interest in telemedicine has exploded in the 1990s with the development of medical devices suited to capturing images and other data in digital electronic form and the development and installation of high speed, high bandwidth telecommunication systems around the world. Clinical applications of telemedicine are now found in virtually every specialty. Teleradiology is the most common application followed by cardiology, dermatology, psychiatry, emergency medicine, home health care, pathology, and oncology. The technological basis and the practical issues are highly variable from one clinical application to another. Teleradiology, including telenuclear medicine, is one of the more well-defined telemedicine services. Techniques have been developed for the acquisition and digitization of images, image compression, image transmission, and image interpretation. The American College of Radiology has promulgated standards for teleradiology, including the requirement for the use of high resolution 2000 x 2000 pixel workstations for the interpretation of plain films. Other elements of the standard address image annotation, patient confidentiality, workstation functionality, cathode ray tube brightness, and image compression. Teleradiology systems are now widely deployed in clinical practice. Applications include providing service from larger to smaller institutions, coverage of outpatient clinics, imaging centers, and nursing homes. Teleradiology is also being used in international applications. Unresolved issues in telemedicine include licensure, the development of standards, reimbursement for services, patient confidentiality, and telecommunications infrastructure and cost. A number of states and medical boards have instituted policies and regulations to prevent physicians who are not licensed in the respective state to provide telemedicine services. This is a major impediment to the delivery of telemedicine between states. Telemedicine, including teleradiology, is here to stay and is changing the practice of medicine dramatically. National and international communications networks are being created that enable the sharing of information and knowledge at a distance. Technological barriers are being overcome leaving organizational, legal, financial, and special interest issues as the major impediments to the further development of telemedicine and realization of its benefits.

Digital radiology in skeletal trauma: assessment of casualty officers' performance

Radiographic images can now be produced without the requirement of film processing and development, and can be displayed rapidly on a computer monitor. We assessed junior doctors' performance in interpreting images from 25 patients being investigated for possible fracture and also compared the diagnostic abilities of casualty officers with those of radiology specialist registrars. For interpretation of images viewed at a workstation or as filmed laser images, respectively, sensitivities were 75% and 78%, and specificities were 65% and 76%. These differences were not significant. There was a tendency for radiology specialist registrars to be less specific when reviewing images at a workstation. The demonstration that there is no loss in diagnostic quality when casualty officers interpret fracture images in a purely digitally acquired and viewed format forms a robust basis for economic evaluation of the technology.

Comparative assessment of digital and analog radiography: diagnostic accuracy, cost analysis and quality of care

OBJECTIVE

The aim of this study was to compare digital and conventional radiography for diagnostic accuracy, direct costs, and quality of care.

MATERIALS AND METHODS

Diagnostic accuracy was assessed by a critical review of the literature on sensitivity, specificity and ROC analysis of these imaging techniques and by a survey with a panel of radiologists. Direct costs and quality of care were evaluated with a before/after study of the implementation of digital radiography in a Department of Radiology in 'Hospices Civils de Lyon' (France). We included 292 patients and measured duration of examinations and direct costs of equipment, films, maintenance and depreciation. To evaluate any changes in working conditions and patient management, a questionnaire was filled out by the staff of the department.

RESULTS

Diagnostic accuracy with digital radiography was equivalent to that of conventional radiography but there were wide variations depending on the type of examination. In 1993, although digital radiography resulted in savings of FF 18,000 including tax (US$ 3600) on film consumption for 1 year of examinations, there was a global additional cost of FF 253,000 (US$ 50,600) for maintenance and depreciation. Results showed a nonsignificant tendency to reduced procedure times for all examinations. Working conditions improved, including greater availability for the patient, improved safety, and increased job interest.

CONCLUSION

Digital radiography can be introduced into a large hospital to improve patient and staff conditions, at a higher cost than analog radiography, and depending on the type of examinations performed by the radiology department.

Comparison of conventional and computed radiography: assessment of image quality and reader performance in skeletal extremity trauma

RATIONALE AND OBJECTIVES

Reader performance and image quality wee assessed for standard film, computed film, and computer monitor radiography viewing formats in the evaluation of skeletal extremity trauma.

MATERIALS AND METHODS

Three radiologists and three orthopedic surgeons interpreted 27 skeletal radiographs obtained with equivalent technical parameters. Readers evaluated standard film, computed film, and computer monitor formats randomly for fracture and soft-tissue abnormalities. Sessions were videotaped, and eye motion was recorded.

RESULTS

No statistically significant differences were found between image formats for true-positive or false-positive findings of trauma indicators. Findings were classified as false-negative based on eye position fixation times. Search errors (lesion not fixated) accounted for 21.7%, 20.6% and 17.1% of false-negative errors with the computer monitor, computed film, and standard film formats, respectively. Combined recognition errors and decision errors were 78.3%, 79.4%, and 82.9%, respectively. Viewing times were longest for the computer monitor images (P < .001). Image quality, contrast, and sharpness were rated highest for computed radiographs (P = .001). Radiologists had a higher true-positive decision rate than orthopedic surgeons (P = .03).

CONCLUSION

No statistically significant differences were seen in reader performance among viewing formats. The computed film format received the highest quality rating, and workstation viewing times were longest.

Teleradiology: state of the art in clinical environment

Teleradiology may even be a tautology since communication is an essential part of radiology. The value of a radiological report is strictly dependent on how fast and clearly it is transmitted to the referring physician. The radiologist has therefore learnt to combine imaging expertise with communicator's skills. However, the term teleradiology is usually reserved to define the instances in which computers and digital networks help to reduce the limitations imposed by the physical distance between radiologists and between radiologist and referring physician. In this paper the main clinical applications of teleradiology will be presented, distinguishing between intra-institutional teleradiology (that involves more units belonging to the same department or to the same hospital) and inter-institutional teleradiology (more classically aimed at primary interpretation and subspecialty consultation). Finally a brief mention will be made concerning the potential for Internet to provide radiologists with new professional and educational opportunities.