|
nif:isString
|
-
Prior to commencement, we established the reliability of the clinical interpretation of digitally acquired images by performing a pilot study assessing the ability of a clinical nurse specialist (CNS) in wound care to assess a digital image. This sudy was conducted over the course of 6 weeks at the wound care clinic with 35 patients studied. Each patient had their relevant wound digitally photographed using a 5 megapixel digital camera. The image was immediately uploaded to a high-resolution monitor. This image was assessed by the CNS using a standard wound care assessment sheet constructed to individually assess 7 features of the wound. Immediately following this the CNS physically assessed the patients wound and again scored the wound using the same scoring system. The scores were recorded and statistically assessed at the end of the study. The result demonstrated that a clinical assessment can be reliably made based on digital images with an overall concordance of 96% between phyiscal and digital images.
Having established consistency between digital images and clinical assessment, an iPhone application (app) was developed, entitled ReMIT Client. The ReMIT Client app was designed to be used by medical professionals without specialist training. The app presents a simple interface in which the user can select an image, either by capturing from the camera or selecting an existing image. The image along with a patient identifier and any notes are sent to the remote server when the user selects the “Send” button, or the user can save the image for later use by selecting the “Save” button (all illustrated in Figure 1). The user is then informed if the transfer to the server is successful.
Figure data removed from full text. Figure identifier and caption: 10.1371/journal.pone.0078786.g001 Images are captured on the iPhone as shown (A).The user then chooses the option to “send” in the lower left corner of the screen and is presented with the opportunity to add free-text notes prior to selecting the patient’s name from the list stored on the “app” (B). Once the correct name is chosen, the user presses “send” again in the lower left corner and the image and accompanying notes are sent to the tertiary centre database.
The ReMIT project is built around the dcm4che collection of open source applications, in particular its DICOM Image Manager/Image Archive server, dcm4chee. The dcm4chee server coupled with the image processing application OsiriX, implements a picture archiving and communications system (PACS). The client iPhone application (ReMITclient) is integrated with the PACS through the use of a web-based interface. The workflow between the ReMIT Client app, the web-based interface and the PACS server is shown in Figure 2.
Figure data removed from full text. Figure identifier and caption: 10.1371/journal.pone.0078786.g002 Workflow in the ReMIT system. In the ReMIT project we created a DICOM study and series for each patient. The web-based interface, combines the patient details, dynamically generated content, such as the time and date, and the image data (baseline JPEG format) into a DICOM image. This image is transferred to the PACS as an image in the DICOM series for the patient. If the transfer is not successful, usually due to network problems or by the user cancelling the transfer, the sequence is not updated and this information is reported back to the ReMIT Client, so that the user knows that they need to transfer the image again. The consultant’s review workstation is a Macintosh computer running the medical imaging software OsiriX. Using the extensible architecture of OsiriX we developed a plugin (called REMIT) to enable the consultant access uploaded images from a PACS server. The user can examine, manipulate and annotate the images, and can review the images individually or as a chronological series of images of individual cases. The software is written as a native plugin in Objective-C and is integrated within the mixed C/C++/Objective-C environs of OsiriX. The user can examine the selected images, perform various transformations of the images including colour correction and white balancing to compensate for poor lighting and colour anomalies in the original image. The user can also access various measurement and annotation tools in the plugin toolbar directly above the image. Across the bottom of the window is a text entry field where the consultant can make comments on the particular image or image set. When the review is completed the changes and annotations are merged into a new version of the image(s), thus preserving the original images. Using this approach the consultant is able to review the case as a longitudinal study of images.
Following the initial pilot study and application development, 8 patients attending a University teaching hospital with chronic ulcers for more than sixteen weeks were recruited, along with their five PHNs, in a geographical area extending to 120 km from the specialist centre. PHNs in a range of geographical areas, with various levels of experience and different patient demographics were chosen to achieve a maximum variation sample. Unselected PHNs with patients regularly attending the vascular clinic were approached to consider participation and no nurse declined participation. Data were collected regarding the underlying disease process, duration of ulcer treatment, ankle-brachial index (ABI) measurements and co-morbidities. These patients had digital images of their ulcer taken in the community on a regular basis by their PHN using an iPhone 4 (Apple, Cupertino, CA, USA) mobile Smartphone. The digital images were of the ulcer, with more than one view taken if required. These images were sent, along with information about the patient’s current dressings, directly to a secure encrypted computer database containing the patient’s medical history at the tertiary hospital. This was performed using the specifically created iPhone (Apple) application, ReMIT. Photos were then reviewed on the specifically designed IT interface accessed through a designated terminal (Apple), by a consultant vascular surgeon or registrar (minimum postgraduate year 4 doctor). This image display software allowed the reviewing doctor to make an ulcer assessment using a standardized proforma based on the transmitted images(s). Patients continued to attend the dressing clinic at their usual intervals and the same standardized proforma assessment of their ulcer was made at their clinical assessment, again by the consultant or registrar. Ulcer assessments for each patient were not necessarily performed by the same person but were assessed immediately by an available senior doctor in line with day-to-day practice in the vascular clinic. An assessment of the image and a clinic visit assessment were made within one week of each other. Same day assessments were not possible due to the long round-trip travel to be undertaken by patients. Therefore PHNs were asked to transmit a photograph taken at their closest home assessment either immediately pre- or post-clinic assessment. The proforma recorded ulcer location, size, wound bed, colour, degree of exudate and surrounding skin condition. The proforma required the assessor to select the best of four or five options to describe the ulcer under each heading. Concordance of the assessment based on observation of the photograph versus viewing the ulcer in person was recorded; concordance was measured as agreement between both of the assessors as to which of the options best fit for each of the individual characteristics of the ulcer. Ethical Approval for this study was granted by the Cork Teaching Hospitals Research Ethics Committee. Written informed consent was required from all patients, on the ethics committee approved consent form.
Qualitative data were collected from the PHN’s using a combination of a focus group and semi structured interviews, where attitudes towards, satisfaction and difficulties with, and suggestions for improvement of the service were explored. Data was collected from PHNs until theoretical saturation, by virtue of recurring themes, was reached. Discussions were digitally recorded and transcribed for analysis. Thematic content analysis used to explore the data generated by the participants’ narratives.
|
![[This page as RDF]](http://data.gesis.org/somesci/static/rdf-icon.gif){kind=icon}