Referral patterns in a global store-and-forward telemedicine system

We examined the nature of the referral patterns in the email telemedicine network operated by the Swinfen Charitable Trust with a view to informing long-term resource planning. Over the first six years of operation, 62 hospitals from 19 countries registered with the Trust in order to be able to refer cases for specialist advice; 55 of these hospitals (89%) actually referred cases during this period. During the first six years of operation, nearly 1000 referrals were submitted and answered, from a wide range of specialty areas. Between July 2002 and March 2005 the referral rate rose from 127 to 318 cases per year. The median length of time required to provide a specialist's response was 2.3 days during the first 12 months and 1.8 days during the last 12 months. Five hospitals submitted cases for more than four years (together sending a total of 493 cases). Their activity data showed a trend to declining referral rates over the four-year period, which may represent successful knowledge transfer. There is some evidence that over the last three years the growth in demand has been exponential, while the growth in resources available (i.e. specialists) has been linear, a situation which cannot continue for very long before demand outstrips supply.

Realtime telemedicine

Telemedicine conducted via prerecorded interaction is more convenient than that using realtime interaction. On the other hand, a realtime consultation allows an immediate result to be obtained and there is likely to be a strong educational component for the remote practitioner. The use of the telephone is under-rated in telemedicine. Telephones have been used in outpatient follow-up, mental health, help lines and support groups. Telephones (fixed and mobile) have also been used for data transfer (e.g. for transmission of electrocardiograms). Realtime transfer of still images has been used in telepathology for many years, and more recently for rapid assessment of injuries. Realtime transfer of video images has been widely explored, perhaps most successfully in telepsychiatry. Some realtime telemedicine applications have been taken up with enthusiasm, even if formal evidence of cost-effectiveness may be lacking. Teleradiology and telepsychiatry are two examples where widespread adoption is beginning to occur. Other forms of realtime telemedicine represent 'niche' applications. That is, they appear to be both successful and sustainable in the centres where they were pioneered, but have not been adopted elsewhere. Teledialysis and teleoncology are examples of this type. The patchy diffusion of telemedicine is something that is not yet well understood.

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).

A bibliographic snapshot of the telemedicine citation literature

There appear to have been no previous literature-based or literature-oriented studies in telemedicine which have analysed raw citation data. Using a simple search strategy, the Web of Science was analysed up to the end of 2005 to give a snapshot of the field, and to identify matters which would need to be considered in larger scale bibliometric studies. Of the 3673 telemedicine documents retrieved, 2213 (60%) had been cited. Of 56,875 citation records, 32,460 unique citation formats were found. The most-cited paper, and the paper with the greatest annual citation rate, was Perednia and Allen's review article in JAMA, 1995. The two specialist telemedicine journals published 40% of all papers retrieved. In the general literature (i.e. excluding the two specialist journals) there were 1556 citations to their 1374 'citable' articles, apportioned in the ratio 76:24, almost exactly in accordance with the distribution of the articles themselves. However, each of the two specialist telemedicine journals cited itself in a proportion higher than its share of original articles, with an 'excess' of self-citations of 14% in the journal of Telemedicine and Telecare, and 19% in the Telemedicine journal and E-Health. Despite certain technical difficulties, there is considerable scope for bibliometric research in telemedicine.