1. hobbies and interests
2. arts and crafts
3. photography

Journal of Audiovisual Media in Medicine, Vol. 27, No. 3, pp. 115–119
An intranet-based clinical imaging service
TREVOR HILL, SCOTT REYNOLDS AND TED BALK
This paper explains how the Photographic Department
at The Queen Victoria Hospital, East Grinstead, has
transformed its clinical photography service through
the use of digital technology. The Department now
plays a more proactive role in patient care, and its
intranet-based digital imaging system 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.
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.
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 advancement of health and surgical science, education, medicolegal 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 surgery, 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
Corresponding author: Trevor Hill, Manager, Medical Illustration
Services, Queen Victoria Hospital, Holtye Road, East Grinstead,
West Sussex RH19 3RL, UK. E-mail: [email protected]
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 the
clinical photography profession.
Figure 2. Breakdown of the use of clinical photography
services according to speciality at QVH.
ISSN 0140-511X printed/ISSN 1465-3494 online/04/030115-05 # 2004 Institute of Medical Illustrators
DOI: 10.1080/01405110400010092
116
T. Hill et al.
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 Information Advisory Group, and subsequently to the Trust
Board, the proposal was given unanimous approval. The
IT implications were considered, along with the initial setup 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 emailed images from referral hospitals would help towards
better wound assessment, which, in turn, would lead to a
more appropriate transfer of patients. Therefore, Godalming 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 development of the management software, known as DISTAR
(Digital Image Storage And Retrieval), GCP also incorporated 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 immediately 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
An intranet-based clinical imaging service
117
Figure 3. The first screen to appear when using the
DISTAR system.
Figure 5. The images are viewed as thumbnails, then
selected and uploaded to the hospital database.
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 4. (a) The operator is prompted for the patient’s
hospital number; (b) the patient’s details are automatically entered from the PAS.
Figure 6. Viewers can manipulate the image to improve
appearance without altering the original files.
118
T. Hill et al.
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 telemedicine 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.
Figure 7. A summary of the QVH Photographic and
Video Recording Policy.
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.
An intranet-based clinical imaging service
119
Future developments
Figure 8. Trevor Hill demonstrates the DISTAR system
to the Princess Royal.
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 Department, 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
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 modifications, specifically requested by the hospital, and maintenance charges have cost approximately £2,000. An
estimated £45,000 has been saved on material costs over
the same period.
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.
Support and Maintenance
Acknowledgements
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.
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 storeand-forward telemedicine service for acute trauma in a
hospital trust. J Audiovis Media Med 2004; 27(3): 107–14.