1. Evaluation of a Digital Camera for Acquiring Teleradiology Images

2. Elizabeth A. Krupinski, PhD University of Arizona Department of Radiology Arizona Telemedicine Program Ronald S. Weinstein, MD University of Arizona Department of Pathology Arizona Telemedicine Program Carlos Gonzales, MD Michael Gonzales Patagonia Family Health Center

3. This work was supported by: 1) US Dept. Agriculture, Rural Utilities Service Distance Learning and Telemedicine Grant 2) US Dept. Commerce, National Telecommunications and Information Administration TIIAP Grant 3) Office of Rural Health Policy, HRSA Dept. Health & Human Services Rural Telemedicine Grant Program 4) The State of Arizona

4. Goal w 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.

5. ATP Telemedicine Sites Tuba City Kingman Cottonwood Ganado PaysonSpringerville Whiteriver DOC - Phoenix DOC - Yuma Nogales Patagonia Douglas AHSC Kino Tucson VA AHSC Hub Telemedicine Telepathology Teleradiology Flagstaff NARBHA Net

6. Arizona Rural Telemedicine Network (ARTN) w ATM based network based on high-speed T1 carriers w 3 ATM switches located in Northern (Flagstaff), Central (Phoenix) & Southern (Tucson) regions of the state w Tandberg CANVAS Health Care Unit for real-time interactive teleconsults w MedVision for store-forward teleconsults w CompuRAD/Lumisys for teleradiology

7. Case Volume Telemedicine

8. Teleradiology Network w 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) w 1 site (Tucson VA) uses dial-up service

9. Case Volume Teleradiology

10. Sub-Specialties Covered CardiologyOphthalmologyPeds. Orthopedics DentalOrthoped. Surg.Peds. Psychiatry DermatologyOrthopedicsPeds. Pulmonology EndocrinologyOtorhinologyPeds. Rheumatology Fam. & Comm. Med.Pain ClinicPeds. Urology GastroenterologyPathologyPsychiatry GeneticsPeds. CardiologyRadiology Hematology/OncologyPeds. DermatologyReprod/Infertility Infectious DiseasePeds. EndocrinologyRheumatology Internal MedicinePeds. GastroenterologySurgery MedicinePeds. Hem/OncSurgical Oncology NephrologyPeds. Infec. DiseaseToxicology NeurologyPeds. NephrologyUrology Ob/GynPeds. NeurologyVascular

11. Types of Service

12. Patient Information

13. Rationale w Teleradiology is an important part of an increasing number of Radiology & Telemedicine programs w 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

14. Rationale w It can, however, be expensive! w For digital modalities a merge box is needed w For plain film a digitizer or video capture system is required w Some sites just cannot afford these options w A low-cost alternative had to be explored

15. Rationale w The Patagonia Family Health Center needs consults especially in orthopedics & bone radiology w Have no x-ray facilities so send patients to Nogales’ Mariposa Clinic, the report & films are sent over either with patients or later w Problem - Mariposa only has a general radiologist so sub-specialty consults are often required

16. The Camera Canon PowerShot600 CCD image sensor 832 x 608 pixels 24-bit color resolution f/2.5 lens Built-in flash 150 kB file size

17. The Cases w 40 bone trauma cases (e.g., fracture, subluxation, soft tissue damage) from the Patagonia Family Health Clinic w 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

18. The Photographs w Film images were placed on standard viewbox with extraneous light blocked out w The physician identified region(s) of interest based on clinical history and nature of problem w At least one global and one close up shot were acquired for each image using the Canon PowerShot camera

19. Display w Images sent over ARTN to the MedVision workstation w Color monitor, 1024 x 768 pixels w Window/level, zoom/pan available for use during viewing w Film images displayed on standard viewbox

23. Protocol w 2 orthopedic surgeons & 2 bone radiologists reviewed the 40 cases on film & using the digital photographs displayed on the monitor w Film reading 6 months after monitor reading w Reported: Diagnosis Decision confidence using 6-level scale Image quality using 4-level scale

24. Results - Image Quality

25.   2 = 20.32, df = 9, p = 0.02 w 9 of the photo cases were rated poor 4 film cases were rated poor w Of the 9 photo cases, 4 (45%) were rated as poor because the region-of-interest was not captured sufficiently w Some views (film & photo) were not what the readers were used to - different technologists

26. Results - Diagnoses* ReaderAgreement (Kappa) 10.89 20.92 30.94 40.88 * Truth was determined by 2 radiologists not participating in the study from the film images

27. Results - Confidence * How many categories film & monitor confidences differ by

28. Conclusions w A digital still camera can be used effectively to capture images of bone trauma radiographs for store-forward telemedicine consults w Well-framed close-up shots of the region-of- interest are essential w Good quality original films are essential

29. Other Applications? w Other non-screening applications where a specific suspicious region-of-interest can be identified for close-up photographs w Unless the lesion is fairly gross, the global shots are not adequate for consultation - close-up shots are required in the majority of cases