Videos, photographs, and patient consent
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7171.1522 (Published 28 November 1998) Cite this as: BMJ 1998;317:1522All rapid responses
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Medical images can be transferred by email.
Editor - I read with interest the recent articles1,2 regarding the
transference of medical images via the Internet. I agree that successful
simple telemedicine is possible using email. I organise an international
email discussion group on ophthalmic pathology3. Due to the specialised
nature of our work, there are a relatively few ophthalmic pathologists
worldwide, and most work in isolation with large distances between
colleagues4. This email group allows rapid access to members, some of whom
are the most prominent experts in the world. Most communication is by
text messages, but some involve mailing digitised photomicrographs. Such
digital files can be produced indirectly by electronic scanning of
photo(micro)graphs or photographic transparencies; directly using a
microscope-mounted digital camera; or, directly by digitising video images
via relatively inexpensive digital conversion hardware linked to a
personal computer (e.g. Snappy Video Snapshot, Play Incorporated, Rancho
Cordova, California, USA). The latter method should be virtually
universally available, as most departments possess a microscope-mounted
video camera for teaching or clinical meetings and the additional hardware
required is inexpensive and easily applied. We recommend MIME encoded JPEG
images as the most efficient format. Since most computers use screen
resolutions of 640x480 or 800X600 pixels, we ask members to send images of
800x600 JPEG (60-100Kb), to allow even the simplest browser software to
display an image filling the entire screen without zooming. The
disadvantage, however, is that any enlargement of the image will be
pixellated and of poor quality. However, if higher magnifications are
required, additional images highlighting the detail are also mailed. To
submit a series of images, these are sent as attachments to a message to
the group "owner's" address (eyepathology-request@mailbase.ac.uk). They
are then placed in the central message archive and all members notified of
their existence and how to access them. Access is possible via email
downloads from the server or, more simply, by direct access to the group's
web site3. This indirect method of mailing to the group is preferred to
avoid the potential to clog the mail systems of individual members.
We concur with the Buxton et al.2 that the exciting possibilities for
this simple technology should be viewed with some caution. For example,
electronic diagnostic consultations raise potentially problematical issues
involving sampling errors and the temptation to offer an expert opinion on
a poor pictorial image. Who is responsible for these errors? Does
professional liability insurance cover this type of consultation? These
issues are important, but they should not inhibit the intelligent use of
electronic communication networks in medicine5 as, to some extent, they
only highlight the difficulties intrinsic to the process of seeking a
second expert opinion on diagnostic material by any method.
BJ Clark Consultant Pathologist
Institute of Ophthalmology, University College London and Moorfields Eye
Hospital, Bath Street, London, EC1V 9EL.
Tel: +44 171 608 6808
Fax: +44 171 608 6862
Email:brian.clark@ucl.ac.uk
1. Johnson DS, Goel RP, Birtwistle P, Hirst P. Transferring medical
images on the worldwide web for emergency clinical management: a case
report. BMJ 1998; 316: 988 - 9.
2. Vasallo DJ, Buxton PJ, Kilbey JH, Trasler M. Defence medical services
telemedicine. J R Army Med Serv (in press).
3. http://www.mailbase.ac.uk/lists/eyepathology/
4. Clark BJ, Parsons MA. Ophthalmic pathology in the electronic age. Eye.
1998; 12:611-614.
5. Clark BJ. Information technology in ophthalmology. Brit J Ophthalmol
1998;82:984-986.
Competing interests: No competing interests
The perceptive reader will have noticed that the letter published in
mine and Nick's name does not make sense as it stands. In particular, the
penultimate paragraph, beginning "One could argue..." states that we have
used images without consent, when there is no previous mention of the use
of patient-derived images.
This unhappy circumstance has arisen because the BMJ has edited the
letter and then, as a matter of policy I suspect, not seen fit to let us
see the proofs.
The following sentences were present at the start of the penultimate
paragraph in the letter that we actually submitted:
"Next we attempted to create a fictional image of a melanoma. We morphed
together two melanoma images that we obtained from the Internet, then
placed the composite image on to an image of the arm of one of the authors
(MJP). We then used Photoshop's clone tool to alter the shape and textural
surface of the lesion (Figure)."
When these are included the discussion that follows then makes sense.
For the complete version of what we actually submitted see:
http://www.medmicro.mds.qmw.ac.uk/~mpallen/bmjletter/bmjlett.html
Competing interests: No competing interests
Transmission of images by e-mail is not necessarily the best method
Buxton et al make some interesting and valid comments[1] in reply to
our article concerning transfer of images across the Internet.[2] We agree
that image quality and maintaining patient confidentiality are of
paramount importance.
They state that e-mail is the most suitable method of transmission of
images. This method has been described previously[3] and was considered
prior to development of our system. There are, however, some drawbacks to
the use of e-mail. Firstly, transfer times are not necessarily
instantaneous, with Internet servers causing delays of anything from a few
seconds to several hours. Secondly, confidentiality is difficult to
maintain with e-mail unless additional encryption techniques are used.
Thirdly, accessibility to e-mail is restricted to individual users and
requires more training to use the software. Finally, there are wider moves
to improve electronic record keeping and communication, as indicated in a
recent Government White Paper.[4] We feel strongly that the way forward
for this technology is Web based[5] and our case was aimed at testing one
small component of such a system.
DS Johnson, Orthopaedic Specialist Registrar
P Birtwistle, Computer Systems and Research Officer
P Hirst, Orthopaedic Consultant Surgeon
Department of Orthopaedics, Manchester Royal Infirmary, Manchester M13 9WL
[1] Buxton PJ, Vasallo DJ, Kilbey JH. Medical images can be
transferred by email. BMJ 1998;317:1523.
[2] Johnson DS, Goel RP, Birtwistle P, Hirst P. Transferring medical
images on the world wide web for emergency clinical management: a case
report. BMJ 1998;316:988-9.
[3] Yamamoto LG, Elliott PR, Herman MI, Abramo TJ. Telemedicine using the
Internet. American Journal of Emergency Medicine 1996;14:416-420.
[4] Burns F. Information for Health. Leeds: NHS Executive, 1998
[5] Johnson DS. A new strategy using old technology?
http://www.bmj.com/cgi/eletters/317/7163/900
Competing interests: No competing interests