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Page 1: An intranet‐based clinical imaging service

An intranet-based clinical imaging service

TREVOR HILL, SCOTT REYNOLDS AND TED BALK

This paper explains how the Photographic Departmentat The Queen Victoria Hospital, East Grinstead, has

transformed its clinical photography service throughthe use of digital technology. The Department nowplays a more proactive role in patient care, and itsintranet-based digital imaging system has been recog-nized as an area of best practice by The Department of

Health Information Policy Unit and by the Medicinesand Healthcare Products Regulatory Agency.

Introduction

The ‘digital revolution’ has rapidly transformed the

photographic industry, both technically and culturally,

to a level where it is now as much about visual

communication as about image-based recordings for

reference purposes (Figure 1). Digital technology has

allowed clinical photographers to raise the profile of

their profession by integrating their departments into the

clinical service delivery system, offering a service in which

the finished product is essentially a tool for the advance-

ment of health and surgical science, education, medico-

legal solutions, and, of course, patient care. This paper

explains how the Photographic Department at The Queen

Victoria Hospital (QVH), East Grinstead, has transformed

its core business, i.e., clinical photography, and how the

department now plays a more proactive role, which has led

to an improvement in patient care.

The Queen Victoria Hospital was established as a

reconstructive centre during the Second World War, when

Sir William Kelsey-Fry and Sir Archibald McIndoe set up

their respective maxillofacial and plastic surgery units on

the site of the present cottage hospital to treat injuries

sustained by servicemen.1 This regional specialty unit now

serves a population of over four million in the south-east

of England. Its specialties include burns, severe trauma

(often involving replantation), reconstructive plastic sur-

gery, maxillofacial surgery, oculoplastic and corneo-plastic

surgery, and orthodontics. The hospital is also a centre for

cleft-lip and palate repair, and craniofacial anomalies, and

has four consultants dedicated to hand surgery. There are

a number of smaller clinical areas requiring photography

and illustration services, and the department is always

busy with a case mix of emergency, urgent and elective

surgery (Figure 2).

Approximately 40,000 clinical images were produced in

2003. The Department also offers a wide range of digital

video services, including a modern editing suite, the usual

graphic services, and the provision of a teleconferencing

service, which is used as part of the Kent & Medway

Cancer Network, and as a ‘cross site’ teaching facility.

Scott Reynolds, Managing Director ‘GCP Software Systems Ltd’(GCP). Ted Balk, Head of Information Management and Technology,Queen Victoria Hospital.

Figure 1. Digital technology has raised the profile of theclinical photography profession.

Corresponding author: Trevor Hill, Manager, Medical IllustrationServices, Queen Victoria Hospital, Holtye Road, East Grinstead,West Sussex RH19 3RL, UK. E-mail: [email protected]

Figure 2. Breakdown of the use of clinical photographyservices according to speciality at QVH.

Journal of Audiovisual Media in Medicine, Vol. 27, No. 3, pp. 115–119

ISSN 0140-511X printed/ISSN 1465-3494 online/04/030115-05 # 2004 Institute of Medical Illustrators

DOI: 10.1080/01405110400010092

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Page 2: An intranet‐based clinical imaging service

Rationale for digital

For more than thirty years the department has supplied

clinical images in the form of colour transparencies, either

directly filed in patients’ case notes or cross-referenced into

a teaching slide library. With the advent of digital imaging,

its potential in health-care was immediately obvious.

Digital technology would also provide an opportunity to

address a number of outstanding issues: for example, over

several years patient numbers, and hence workload, had

steadily increased by approximately 8% per year, but with

the planned appointment of four additional consultants

there would be a sharper rise. Implemented correctly,

digital technology could provide a means of: (a) making

more efficient use of staff time, (b) controlling escalating

material costs, and (c) improving the speed of service.

To achieve these goals it was imperative that the change

to digital be complete; there would be no printed (hard)

copies because all images would be viewed electronically

(soft copies). It seemed pointless to originate electronically,

only to print and then laboriously file hard copies. Also,

there would have been considerable costs with the

production of large numbers of prints, which would

have compromised the improvement in financial efficiency.

In essence, the specification for the digital system was: that

it would manage and document images from the cameras

prior to uploading to a central server; that the images

would be immediately available for viewing at appropriate

locations across the site on terminals linked to the hospital

intranet; and that the images would be easy to retrieve by

staff with access privileges, fully documented, and securely

stored, whilst satisfying all requirements of patient

confidentiality.

Finance and Support

QVH is fortunate to have an enthusiastic Information

Technology (IT) Department, which was keen to run such

a system over the network. The Photographic Department

is managed within the Surgical Care Directorate and

represented at many forums, so it maintains a high profile,

and there is positive awareness within the hospital of its

work. Following a presentation to the Clinical Informa-

tion Advisory Group, and subsequently to the Trust

Board, the proposal was given unanimous approval. The

IT implications were considered, along with the initial set-

up costs; the presentation also indicated a conservative,

but immediate, saving of £13,000 per year on material

costs. It was also argued that non-implementation of the

proposal would require an increase in staffing in the

Department to accommodate the extra work following

the new consultant appointments.

With the support of the Trust Board a request for £25,000

was made to the QVH League of Friends, in order to

purchase four complete Nikon D1x systems, each comprising

a camera body, 105-, 60- and 35-mm lenses, two 64-MB

Compact Flash cards, an SB-29 flash unit, and a carry-bag.

Some computer hardware and software was also purchased,

including slide and flatbed scanners, and card readers. The

League had been looking for involvement in an active

project and the digital programme was considered ideal. It

was agreed the money should be ring-fenced, and could be

spent over a five-year period.

Software selection

Included in the initial set-up package was an off-the-shelf

image management software program, which, at the time,

was considered to be a suitable platform for the database.

However, subsequently there were problems linking this

software to the Patient Administration System (PAS), and

operating it through Internet Explorer for use over the

hospital intranet, so eventually it was abandoned.

At this time there was considerable interest at QVH for

telemedicine.2 The Plastic Surgery Department alone

receives approximately twenty acute referrals each day,

so consequently trauma services are under great pressure,

and a method of improving efficiency was sought.

Telemedicine seemed to be an ideal medium, whereby e-

mailed images from referral hospitals would help towards

better wound assessment, which, in turn, would lead to a

more appropriate transfer of patients. Therefore, God-

alming Computer Product Software Systems Ltd. (GCP)

designed and built a system to transmit images securely via

normal e-mail or NHS-Net, such that, when received at

the hospital, they become available for immediate review

using an ordinary web browser. This has meant that

consultants can give an instant opinion, even when in

theatre.

Having successfully designed the database and web

interface for the telemedicine project, GCP was

approached to see if it could assist the Photographic

Department with the digital project. During the develop-

ment of the management software, known as DISTAR

(Digital Image Storage And Retrieval), GCP also incor-

porated automatic patient data transfer via a direct link to

the PAS. As DISTAR evolved it was brought gradually on

line, whilst patients were photographed both on slide film

and digitally. However, many consultants were immedi-

ately content to receive images over the hospital intranet

and instructed the department not to bother with slides;

the department was shooting 90% of its work digitally

within six months, and 100% within a year.

Operation of the system

Following a photography session, the CompactFlash cards

are removed from the cameras and entered into a card

reader linked to one of four PCs loaded with DISTAR.

Accompanying the CompactFlash cards are the hospital’s

pink photographic request forms, which hold the relevant

patient details. From a desktop icon, the first screen to

appear gives the operator a choice of actions from the

digital image database: for uploading images ADD NEW

PINK SLIPS is selected (Figure 3). This displays a screen,

which is basically a copy of the pink request form

(Figure 4a). By clicking on GET NEW the operator is

116 T. Hill et al.

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Page 3: An intranet‐based clinical imaging service

asked for the patient’s HOSPITAL REGISTRATION

NUMBER; entering the number provides all the patient’s

details, which are automatically drawn from the PAS and

entered into the relevant boxes (Figure 4b). The operator

then tabs down and enters the relevant exposure details for

that particular patient, such as VIEWS, CLINICAL

CONDITION, LOCATION, PHOTOGRAPHER, and

LEVEL OF PATIENT CONSENT. A click on LOAD

IMAGE TRANSFER PROGRAMME lists the various

patients’ entries. Once the files have been selected, the

images on the CompactFlash card are displayed as

thumbnails. If necessary, images are rotated for correct

viewing, or flipped in the case of dental mirror views. They

are then highlighted for selection, and uploaded to the

hospital database (Figure 5).

At this stage the originals are stored on the Hospital’s

file-server, but simultaneously copies are made which have

a ‘text’ copyright message applied; these are the images

used for general viewing over the intranet. As soon as the

images are transferred to the server they are available for

viewing from the internal telemedicine website. The

clinician who requested the photography can view the

images elsewhere, and the case can then be discussed with

the patient or other clinicians. It should be noted that any

alteration of the original image is prohibited: the images

can be enlarged, rotated and panned, and aspects such as

brightness, contrast and sharpness can also be adjusted

(Figure 6); but any changes do not affect the original

images, which remain untouched and available for

retrieval by the Department in the event that they are

required for high-quality reproduction purposes.

Technical information

The file-server is installed with Windows NT4 operating

software and is a stand-alone unit with IIS4 (Internet

Information Service), which is used for publishing web

Figure 3. The first screen to appear when using theDISTAR system.

Figure 4. (a) The operator is prompted for the patient’shospital number; (b) the patient’s details are automati-cally entered from the PAS.

Figure 5. The images are viewed as thumbnails, thenselected and uploaded to the hospital database.

Figure 6. Viewers can manipulate the image to improveappearance without altering the original files.

An intranet-based clinical imaging service 117

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Page 4: An intranet‐based clinical imaging service

content. The system initially used a Pentium 4 rack-mount

server with 256 MB of RAM and dual (RAID-1) 14-GB

disks, but it has since had a second pair of RAID-1 disks

added for growth. The system will shortly be upgraded to

a Windows 2000 SQL server for exponential growth.

Original images are uploaded and stored on mirrored

hard-drives at the standard 8:1 JPEG compression

produced by the Nikon D1x cameras. During the

uploading process they are copyright branded, and resized

as smaller separate thumbnail JPEG files (to fit a 2006200

pixel square) before being stored on the server. The use of

pre-generated thumbnail files affords quick loading from

the server (and therefore less bandwidth use) when they

are required for viewing simultaneously on a web page.

Each evening the images are backed up on a secondary

server at a separate location on-site, and this is repeated

monthly as part of the normal IT Department backup

protocol. Hence the original images are effectively stored

four times.

During the development of the system, considerable

thought was given to the original file format before

adopting the D1x JPEG 8:1 medium setting, which gives

an approximate file size of 640 KB. This was chosen

because the image quality is more than fit for its intended

purpose, and larger file sizes were impractical because

approximately 40,000 pictures need to be stored each year.

Additionally, as the system is operated over the Trust

intranet, the JPEG file format is inherently supported by

the web browsers.

Digital management

In order to maintain strict management control, images

can only be uploaded to the database using the software

on PCs in the Photographic Department. Other functions

of this software include the ability to amend incorrect details,

transfer images, extract images, delete entries, and add images

to an existing session. This is ideal during long reconstructive

operations when surgical teams sometimes like to view the

earlier stages. In their administrative role the IT staff also

have full access to the system so that software maintenance

and system updates are straightforward.

Viewing page

Images from the Photographic Department and the

telemedicine service are stored on the same file server

and accessed via a common home page. Only authorized

staff with access privileges can access images, and PCs for

viewing are limited to ‘view only’; although, as noted

above, they are able to adjust, temporarily, the brightness

and contrast of the image, and to zoom into selected areas.

This function is particularly useful when viewing tele-

medicine referral images as the quality of pictures varies

considerably. Access privileges to enter the DISTAR

system are authorized on an individual basis by the

Human Resources Department, and issued by the IT

Department in its administration role.

The Burns Unit has particularly welcomed the digital

service, and a photographer attends all admissions and

dressing changes at key stages of treatment. It is not

always possible for some clinical members to be present at

these times, but they are able to see pictures at any viewing

terminal before the wound is dressed, and so make

informed decisions which improve clinical efficiency and

patient care. In such cases the wound need not be

disturbed for a second examination, correspondingly

reducing distress, pain and risk of infection. Morning

ward reports are also more meaningful when the notes

regarding a patient who has been admitted during the

night has pictures readily available for viewing (N.B. the

Photographic Department operates a 24-hour on-call

service).

Photographic and video recording policy

With images being uploaded from the telemedicine service

and the Photographic Department, it was clear that the

publication of a Trust Photographic and Video Recording

Policy was vital. In addition, many clinicians were using their

own digital cameras on site for personal reasons, so the Trust

has addressed these issues with a Policy Statement (Figure 7).

The DISTAR software has had to satisfy all aspects of this

policy and of issues detailed in the Data Protection Act, such

as the safe-keeping of information and the potential problems

of image alteration. A comprehensive policy should help to

control the problems associated with clinicians undertaking

their own photography for personal use.

Figure 7. A summary of the QVH Photographic andVideo Recording Policy.

118 T. Hill et al.

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Page 5: An intranet‐based clinical imaging service

Operational costs

The Department is now in its fourth year of digital

operation. Although it was clear that a substantial saving

on material costs would be achieved, 20% of the initial

cost per year was estimated to cover maintenance of the

equipment. So far, however, photographic equipment

repairs have cost £50, and additional software modifica-

tions, specifically requested by the hospital, and main-

tenance charges have cost approximately £2,000. An

estimated £45,000 has been saved on material costs over

the same period.

Support and Maintenance

First-level support for the system is provided by the IT

Department, including an element of out-of-hours cover.

Further support is provided by GCP under an ongoing

maintenance agreement with the Trust, with particular regard

to software support. Where appropriate, rapid intervention to

resolve any problem, including the installation of software

upgrades or hotfixes, is carried out by GCP via a secure

remote access connection. The maintenance agreement

incorporates the ongoing provision of updated versions of

the software in respect of both host software, based at the

Trust, and client software, based at remote A&E departments

and minor injuries units.

Future developments

There are increasing demands from consultants to view

images at home; this facilitates out-of-hours assessments

by on-call consultants at a junior doctor’s request.

DISTAR can send encrypted data over the internet to a

home e-mail address, where it is downloaded by a separate

DISTAR program, which decrypts and unpacks the

images and any accompanying demographic data. The

management aspect of the software will soon have

designated sections to accommodate images from the

Corneo-plastic Unit and the Clinical Research Depart-

ment, which have both discovered problems associated

with localized image management and storage.

QVH is scheduled to install a PACS DICOM digital

radiography system that will be networked to peripheral

hospitals via the QVH ‘hub-and-spoke’ scheme and the

Kent & Medway Cancer Network. It is planned to

incorporate all forms of clinical images within this

system, where they can be accessed via a common

platform: not only will communication between specialists

at disparate locations be greatly improved, but also all

clinical images of patients will be readily available to

health-care professionals at any networked site. This will

be a natural step toward achieving the aims of the

National Programme for Information Technology,

whereby each patient will have an electronic record.

Conclusion

In its four years, the intranet-based digital imaging system

has proven to be reliable and entirely successful for both

operators and users. In the Commission for Health

Improvement Report it is highlighted as an area of

improved patient care within the Hospital. The whole

concept has been recognized as an area of best practice by

the Department of Health Information Policy Unit and

by the Medicines and Healthcare Products Regulatory

Agency (Figure 8). Given the importance placed on the

photographic service at QVH, where it is an integral part

of the clinical support network, it is now difficult to

imagine how the department would have survived had

digital technology not been implemented.

Acknowledgements

Dr Nicolas Bowley, Consultant Radiologist, Queen

Victoria Hospital; Mr Derek Pocock, Chairman, League

of Friends, Queen Victoria Hospital; Mr Ian Chell, Senior

Medical Device Specialist, Medicines and Healthcare

Products Regulatory Agency.

References

1. Dennison EJ. A cottage hospital grown up. East Grinstead,1963.

2. Jones SM, Balk EJ, Hill TJ, Reynolds S. Setting up a store-and-forward telemedicine service for acute trauma in ahospital trust. J Audiovis Media Med 2004; 27(3): 107–14.

Figure 8. Trevor Hill demonstrates the DISTAR systemto the Princess Royal.

An intranet-based clinical imaging service 119

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