An analysis of the images attached to referral messages in an e-mail based telemedicine system for developing countries

Little is known about the quality of the images transmitted in email telemedicine systems. The present study was designed to survey the quality of images transmitted in the Swinfen Charitable Trust email referral system. Telemedicine cases were examined for a 3 month period in 2002 and a 3 month period in 2006. The number of cases with images attached increased from 8 (38%) to 37 (53%). There were four types of images (clinical photographs, microscope pictures, notes and X-ray images) and the proportion of radiology images increased from 27 to 48%. The cases in 2002 came from four different hospitals and were associated with seven different clinical specialties. In 2006, the cases came from 19 different hospitals and 20 different specialties. The 46 cases (from both study periods) had a total of 159 attached images. The quality of the images was assessed by awarding each image a score in four categories: focus, anatomical perspective, composition and lighting. The images were scored on a five-point scale (1 = very poor to 5 =very good) by a qualified medical photographer. In comparing image quality between the two study periods, there was some evidence that the quality had reduced, although the average size of the attached images had increased. The median score for all images in 2002 was 16 (interquartile range 14-19) and the median score in 2006 was 15 (13-16). The difference was significant (P < 0.001, Mann-Whitney test).