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Teleradiology in Europe
Davide Caramella a,*, Jarmo Reponen b, Fabrizio Fabbrini c, Carlo Bartolozzi a
a
Department of Radiology, Diagnostic and Inter6entional Radiology, Uni6ersity of Pisa, Via Roma 67, 56100 Pisa, Italy
b
Department of Radiology, Uni6ersity of Oulu, Oulu, Finland
c
Istituto di Elaborazione dellInformazione, CNR, Pisa, Italy
Received 21 July 1999; accepted 22 July 1999
Abstract
The new concept of teleradiology is centered on the consideration that it involves management of medical information rather
than the simple transmission of diagnostic images from one location to another. Teleradiology must therefore be able to
contribute to the seamless integration of the digital environment in which medical data are managed throughout and beyond the
hospital, generating value added services for the patients as well as prospective economical benefits for the institution. In this
perspective the evolution of telecommunication with the spectacular success of mobile telephony and Internet will play and
increasingly important role, by allowing further development in the exchange of multimedia medical information on a regional as
well as international level. However, new responsibilities are being given to the radiologists, who must take all necessary technical
and organizational actions in order to avoid that the digital management of data may endanger the confidentiality and the
integrity of patients data. 2000 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Teleradiology; Images transmission; Internet; Computers multimedia
1. Introduction
Teleradiology is evolving from the present capability
of moving images from one place to the other to the
capability of managing medical information within an
integrated environment stretching from the hospital
towards affiliated institutions and medical partners distributed in large geographical areas [1,2].
The consolidation of many health institutions is an
ongoing process in most European countries. This is
mainly due to the need to reduce costs by making more
efficient use of human as well as technological
resources.
Also the approach to PACS implementation has been
influenced by this process: it is now well understood by
the industry and the users alike that PACS can not be
modeled after the paradigm of office automation. The
aim of replacing the traditional film-based system by
deploying technologically advanced equipment for the
display, archiving, and transmission of diagnostic im-
0720-048X/99/$ - see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 7 2 0 - 0 4 8 X ( 9 9 ) 0 0 1 0 4 - 7
2. Clinical applications
3. Mobile teleradiology
A new field of teleradiology applications is currently
being experimented in Finland, where mobile telephone
technology has been used in parallel to terrestrial lines
[17,18]. In 1993 at the Oulu University Hospital a
laptop computer was connected to a Nokia DC 560
portable NMT-450 (Nordic Mobile Telephone) cellular
system car phone with a modem adapter. This system
was connected to an image server at the University
Hospital, where digitized and JPEG compressed CT
images were available. The transfer speed was as slow
as 2400 bit/s and the system weighed over 9 kg. The
laptop computer used as a remote terminal could only
show 16 grey levels on the screen. Despite its limitations, the system could be used for image reception all
over Scandinavia and showed the potentialities of mobile teleradiology.
Since 1994 a smaller NMT-900 standard handheld
cellular phone and a compatible NMT PCMCIA data
card were tested. A more advanced laptop computer
was capable of showing 256 colors. Packed in a suitcase, this system weighed less than 5 kg, and could
serve as a portable terminal. The limitations were short
operation time and slow effective speed due to transmission errors in the analogue transmission.
After the development of GSM digital networks the
problems in establishing a secure and stable transmission have largely been solved. This new technology
enabled a clinical trial. A neuroradiologist was supplied
with a portable terminal which was capable of receiving
and viewing images. The terminal consisted of a notebook computer whose display had 640 480 pixel resolution and 256 colors. The notebook computer was
equipped with a PCMCIA digital cellular data card,
4. Security issues
The transmission of radiological data over open networks inherently put at risk the confidentiality and the
integrity of alphanumeric data and images sent during a
teleradiology session.
Therefore, well defined policies need to be established
to reduce the risk that information exchanged during a
teleradiology session might be used for purposes that
may harm (physically, emotionally or economically) the
patient [19]. As a result, data protection measures are
to be taken to safeguard the confidentiality as well as
the completeness, accuracy and correctness of
information.
Interconnectivity of imaging equipments, archives
and information systems, although desirable from a
clinical and managerial point of view, adds new complexity to data protection initiatives. In fact, the in-
5. Security management
Teleradiology systems have the contradictory task of
both protecting the transmitted radiological information and of making it accessible by a number of users
[20]. Security management should provide an enabling
mechanism for information sharing, while ensuring the
protection of data and computing assets, rejecting every
access that does not result in accordance with the
established security scheme.
A variety of mechanisms exist for protecting electronic information [21]. These include both technical
actions for improving computer and network security
as well as organizational actions for ensuring that all
co-workers understand their responsibility to protect
information and realize that security processes are in
place for detecting and reporting violations.
From a technical point of view, the security elements
needed to meet the desired protection level and to
realize the defined sharing scheme may be implemented
by means of two main tools. The first tool is the
identification of the user, that is any mechanism able to
verify the identity of a user requesting information in a
computing environment. Identification of the user may
be implemented:
(1) by location, that identifies the user on the basis of
where the user is located (e.g. a terminal connected by
hardwired line, a phone number used in a callback
scheme, a network address). To prevent illegal access,
security precautions have often to be taken (such as
surveillance personnel, locked doors, passwords) in order to guarantee the physical security of the terminal as
well as the communication line.
(2) by characteristics, that is based on the identification of something that the user has (a key, a magnetic
card, etc.) or something related to who the user is
(signature, fingerprints, voiceprints, etc.).
(3) by knowledge, that is based on the use of something the user knows (a password, a personal ID number? etc).
The degree of success of all these methods depends,
of course, on users willingness not to share the key,
information or characteristic that allows to uniquely
identify them. The classical method for identification in
computing environments is to assign each user a unique
identifier and to associate a secret personal password
with it. Nevertheless, the realization of a protecting
Mechanism based on the use of IDs and passwords
presents many weak points, fundamentally related to
the vulnerability of the handling process (selection,
assignment, conservation).
The second security tool to help secure exchange of
information is encryption, that is coding information
into unintelligible data. Cryptography is a technique
that has been used for centuries, however in the computer era it has reached new levels of complexity and
sophistication [22,23]. The basic encryption process encodes text material, converting it into scrambled data
that must be decoded to be understood. The process is
based on algorithms able to translate the original information into a data stream absolutely incomprehensible
to the person who does not know the decoding
algorithm.
Encryption is used most often for sensitive data that
is transmitted over networks or public communication
systems. When the encrypted material reaches its desti-
6. Organizational issues
7. Conclusions
Teleradiology greatly influences the way radiologists
do their work. The changes are seen at an organizational level and also in how primary image interpretation is performed [27].
A typical teleradiology scenario is the one in which
is a remote site sends images for second opinion. The
straightforward output of this service is the opinion
given by the subspecialist to the requesting physician.
However, the process of giving this information is
rather complex, and involves a requesting physician, a
technician digitizing the images, a radiologist interpreting the images, a secretary typing the report, and
once again the original physician reading the answer.
There are two kinds of supporting work or articulation work to enable this process: articulation work
of cooperation and articulation work of individual
tasks. The first group of supporting work makes
workflow possible by delivering information to the
next performer and the latter group of supporting
work prepares and organizes materials for each task.
In practice, each step has great influence to the quality and to the speed of the service. For instance the
order and quality how a technician at the remote site
digitized images influences the performance of the radiologist. Also the information in the written request
Teleradiology is rapidly evolving: remote consultations may become a reality in the near future for
many radiologists. Since a few years Internet has already been enabling professionals to update their
knowledge by means of on-line publications and image databases.
However, security issues and workflow adjustments
still have to be fully analyzed in order to avoid that
the potential advantages for the organization may
bring unacceptable damage to both patients and radiologists. In particular, the protection of electronic information transmitted from a radiological department
requires a combination of technical and organizational practices, whose selection involves trade-offs
among cost, complexity, and degree of privacy provided. Organizational practices are at least as important as technical practices: although technical
mechanisms can be used to validate the identity of
computer users, establish controls on the information
they can access, and encrypt information transmitted
between locations, organizational policies have to establish the objectives of technical measures, determining who is allowed access to information and how
tightly the access will be controlled.
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