Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

This study investigates how the implementation of the means of communication and Archiving Images - Picture Archiving And Communication System (PACS) could be used as information technology and communication (ITC) in medical education online. Assessing trends and potential of this new field of study, one realizes that its applications and benefits may not be restricted to medical and hospital environment, but also the learning environments using radiological images. Medical care at a distance through telemedicine consultation favors a second opinion when the distance is a critical factor, and allows many calls from happening online, for example, implementation and testing of diagnostic imaging. For this reason, one of the areas of telemedicine that have benefited most from this modality was radiology. Often the exams at a distance is the responsibility of a resident oriented so online by a specialist, as the project POA_S@UDE Hospital Materno Infantil Presidente Vargas in Porto Alegre, in the care of pregnant patients Neighborhood Restinga taking the examinations ultrasound. This experiment was assessed from a perspective of distance education, whereas residents involved in the project are doctors in training who work in a mode online, through questionnaires to specialists and residents who work or have been engaged in the project. The formation aspects of medical teaching, especially to work in online environments, development of assessment methodologies, interaction between the individuals involved, were evaluated to consider the experience to be used in medical courses as a means of distance education using PACS. / Este estudo investiga como a implementação dos meios de Arquivamento e Comunicação de Imagens Picture Archiving And Communication System (PACS) poderiam ser utilizados como tecnologia de informação e comunicação (TIC) na formação médica online. Avaliando as tendências e as potencialidades deste novo campo de estudo, percebe-se que as suas aplicações e vantagens podem não se restringir apenas ao ambiente médico e hospitalar, mas também a ambientes de ensino utilizando imagens radiológicas. O atendimento médico à distância por meio da Telemedicina favorece a consulta de uma segunda opinião quando a distância é um fator crítico, bem como permite que muitos atendimentos aconteçam de forma online, como, por exemplo, na realização e exames de diagnóstico por imagem. Por esta razão, uma das áreas da Telemedicina que mais se beneficiaram desta modalidade foi a Radiologia. Muitas vezes a realização de exames à distância fica sob a responsabilidade de um residente orientado de forma online por um especialista, como acontece no projeto POA_S@UDE do Hospital Materno Infantil Presidente Vargas em Porto Alegre, no atendimento pacientes gestantes do Bairro Restinga que realizam exames de ultrassom. Esta experiência foi avaliada a partir de uma perspectiva de EAD, considerando que os residentes envolvidos no projeto são médicos em fase de formação que atuam em uma modalidade online, através de questionários aplicados com especialistas e residentes que atuam ou já atuaram no projeto. Os aspectos de formação docente dos médicos, especialmente para atuar em ambientes online, definição de metodologias de avaliação, interação entre os sujeitos envolvidos, foram avaliados para considerar a possibilidade de que a experiência fosse utilizada em cursos de Medicina como um meio de EAD utilizando PACS.

Abstract The possibilities of teleradiology to modify the radiological service process in a regional, international and mobile setting were investigated by building new types of technical connections and then by evaluating their feasibility. First a teleradiology link based on low-end technology was built for primary care and hospital settings. On evaluation, the total diagnostic agreement between the transmitted images and the original films was 98%. Then, a work practice-oriented approach was used to gain an understanding of the relationship between the emerging teleradiology work practice and the newly implemented technology. Ethnographically informed fieldwork and cooperative workshops were utilized. According to findings, articulation work that supports the key tasks is mostly conducted at the receiving site, and radiologists have to rely on much less information in image interpretation. The decisions made at the sending site influence the outcome. To study the idea of consultations between different countries, a connection utilizing the Internet was built between university hospitals in Oulu, Reykjavik and Tromsø. After 131 images, a suitable image compression ratio was selected. Image quality and transfer time of the 80 clinical case readings were found to be adequate for teleradiology. A wireless image consultation system for radiological sub-specialist consultations based on a portable computer and a mobile phone with secure access to the hospital network was set up and tested. The transmitted images of 68 patients were acceptable for final diagnosis in 72% of the cases. The wireless link saved the senior radiologist a hospital visit in 24% of the cases. A smartphone was then used to communicate computed tomography scans in a feasibility study of 21 patient cases of brain attacks. All transmitted image series were suitable for giving a preliminary consultation to the clinic, and in one case even a final report could be made. In a real life clinical setting of the study with neuroradiological and neurosurgical emergencies, two different smartphone platforms with electronic patient record integration were built in European research projects and evaluated with sets of 115 and 150 patient cases. They were good for final diagnosis in 38% and 40% of the cases, respectively. The concept was found to be ready for clinical use. Finally a survey was made showing the status and trends of the usage of eHealth applications in Finland. The results from all the public health care providers and a representative sample of private providers showed that in 2005, teleradiology services were used by 18/21 hospital districts and the usage of all eHealth applications has progressed throughout the entire health care delivery system. Teleradiology services have become an integrated part of eHealth.

Teleradiology has far-reaching implications for the health of remote and underserved populations. With coordination of radiographic evaluation and diagnosis from a distance, teleradiology has the potential to raise the standard of patient care throughout the world. Perhaps the safest and most cost-effective mode of teleradiology today is telesonography. The current research determined that telesonography improves the standard of care at a rural, government-run primary clinic within the Dominican Republic. The work reported herein is intended to compare the use of telesonography to the current standard of sonographic examination which is referral to government hospital 60km from the clinic. the following research questions were addressed: When compared to the standard of care, (1) To what extent does the use of asynchronous telesonography increase the percentage of received sonographic reports based on the total number of ultrasound referrals (sonographic reports / total number of referrals)? (2) To what extent does the use of asynchronous telesonography increase the rate of successful follow-up visits based on the total number of ultrasound referrals? (3) To what extent does the elapsed time between ultrasound referral and sonographic report delivery decrease with the use of asynchronous telesonography? (4) To what extent does the elapsed time between ultrasound referral and patient follow-up decrease with the use of asynchronous telesonography? Research methodology included randomly assigning 100 patients with clinical indications for sonographic examination into experimental and control groups during a 9-week implementation period. Findings from this study indicate that the implemented telesonography system, along with patient awareness of such a system, while not having an appreciable effect on the time to patient follow-up, provided a 4-fold increase in the proportion of patient follow-ups and a 6-fold increase in the proportion of returned radiological reports, and delivered those reports to the referring physician 6-times faster than in the control group. This study demonstrates the feasibility of utilizing a store-and forward telesonography system within this setting. Additional research focusing on the impact of telesonography on patient outcomes within this setting is recommended. / Ph. D.

Titel: Röntgensjuksköterskans upplevelse av att arbeta med externa granskare under jourtid Syfte: Att undersöka hur röntgensjuksköterskan upplever arbetet med externa granskare under jourtid. Material och metod: Sex stycken röntgensjuksköterskor från två olika sjukhus i mellansverige intervjuades under perioden januari till mars 2017. Inklusionskriterierna för studien var minst två års erfarenhet av yrket samt minst ett års erfarenhet av att arbeta med externa granskare under jourtid. Tillstånd från verksamhetschefer och samtycke från informanterna erhölls innan studien startade. Data samlades in genom en kvalitativ metod med semistrukturerade intervjuer bestående av öppna frågor. Den insamlade datan analyserades med kvalitativ innehållsanalys enligt Graneheim &amp; Lundman. Intervjuerna transkriberades och lästes igenom flera gånger. Därefter identifierades meningsbärande enheter och dessa kondenserades till koder. Genom koderna kunde kategorier och subkategorier identifieras. Resultat: I resultatet framkom fyra kategorier; Teleradiologi – tekniska aspekter, externa granskare jämfört med radiolog på plats, kommunikation och röntgensjuksköterskans kompetenser och egenskaper med tillhörande subkategorier. Konklusion: Informanterna upplever att det tar längre tid att kommunicera med externa granskare (EG) i jämförelse med att ha en radiolog på plats som kan ge svar direkt när röntgensjuksköterskan (RSS) är i behov av vägledning och snabba svar. I kommunikationen upplevs det också finnas språkbarriärer samt bristande kunskap, speciellt hos de sekreterare som tar emot samtal hos EG. Detta leder till frustration och blir ofta ett hinder i akuta situationer då RSS vill prata med en radiolog direkt. Under jourtid upplever RSS att denne får ta ett ökat ansvar samtidigt som förmågan att ta egna initiativ och beslut måste finnas. RSS upplever ingen förändring av bildkvalitén på de bilder som skickas i arbetet med EG. Informanterna upplevde i helhet att arbetet med EG fungerar bra och tillfredsställande under förutsättningarna att tekniken fungerar som den ska samtidigt som arbetsflödet inte ökar för mycket.

Choosing an authentication protocol or a digital signature algorithm becomes more challenging when performance constraints are of concern. In this thesis, we discuss the possible options in a top-down approach and propose viable alternatives for the efficiency criteria. Before all the technical discussions, we argue that identifying prerequisites, threats and risks on an organizational context has utmost importance so that effective solutions can be delivered at a reasonable cost. For instance, one approach to solve the performance problem is to relax the security requirements if it is allowable and use one-time passwords as the more efficient entity authentication protocol. SCOTP is the first protocol proposed in this study which improves the security and flexibility of one-time passwords. After requirements are set up, another high-efficiency solution is based on new designs of improved protocols. These new protocols might utilize the trade-offs between efficiency of distinct system parameters such as communication versus computational load. SAOTS is our new protocol designed to improve the performance and increase the round efficiency of server-assisted signature protocols. With an example in e-health, we also demonstrate that efficiency can be provided on the implementation level as well, the last step in the chain. EVEREST is the third proposal in this thesis which improves the real-time efficiency of digital signatures concerning the fact that the medical images are huge in size and to verify the signature a considerable amount of time is spent to compute the hash of the image file.

Titel: Röntgensjuksköterskans upplevelse av att arbeta med externa granskare under jourtid Syfte: Att undersöka hur röntgensjuksköterskan upplever arbetet med externa granskare under jourtid. Material och metod: Sex stycken röntgensjuksköterskor från två olika sjukhus i mellansverige intervjuades under perioden januari till mars 2017. Inklusionskriterierna för studien var minst två års erfarenhet av yrket samt minst ett års erfarenhet av att arbeta med externa granskare under jourtid. Tillstånd från verksamhetschefer och samtycke från informanterna erhölls innan studien startade. Data samlades in genom en kvalitativ metod med semistrukturerade intervjuer bestående av öppna frågor. Den insamlade datan analyserades med kvalitativ innehållsanalys enligt Graneheim &amp; Lundman. Intervjuerna transkriberades och lästes igenom flera gånger. Därefter identifierades meningsbärande enheter och dessa kondenserades till koder. Genom koderna kunde kategorier och subkategorier identifieras. Resultat: I resultatet framkom fyra kategorier; Teleradiologi – tekniska aspekter, externa granskare jämfört med radiolog på plats, kommunikation och röntgensjuksköterskans kompetenser och egenskaper med tillhörande subkategorier. Konklusion: Informanterna upplever att det tar längre tid att kommunicera med externa granskare (EG) i jämförelse med att ha en radiolog på plats som kan ge svar direkt när röntgensjuksköterskan (RSS) är i behov av vägledning och snabba svar. I kommunikationen upplevs det också finnas språkbarriärer samt bristande kunskap, speciellt hos de sekreterare som tar emot samtal hos EG. Detta leder till frustration och blir ofta ett hinder i akuta situationer då RSS vill prata med en radiolog direkt. Under jourtid upplever RSS att denne får ta ett ökat ansvar samtidigt som förmågan att ta egna initiativ och beslut måste finnas. RSS upplever ingen förändring av bildkvalitén på de bilder som skickas i arbetet med EG. Informanterna upplevde i helhet att arbetet med EG fungerar bra och tillfredsställande under förutsättningarna att tekniken fungerar som den ska samtidigt som arbetsflödet inte ökar för mycket.