- Email: [email protected]
The comparative impact of video-consultation on neurosurgical health services
International Journal of Medical Informatics 62 (2001) 175– 180
www.elsevier.com/locate/ijmedinf
The comparative impact of video-consultation on neurosurgical health services W.S. Poon *, C.H.S. Leung, M.K. Lam, S. Wai, C.P. Ng, S. Kwok Di6ision of Neurosurgery, Prince of Wales Hospital and United Christian Hospital, The Chinese Uni6ersity of Hong Kong, Hong Kong, China
Abstract This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Telemedicine; Neurosurgical services; Video-consultation
1. Introduction In many developed countries, neurosurgical service is concentrated in regional centres. Traditionally, neurosurgical referrals made from peripheral hospitals were mainly done via telephone. With the advancement of tech-
* Corresponding author. Tel.: + 852-2632-2624; fax: +8522637-7974. E-mail address: [email protected] (W.S. Poon).
nology, nowadays, neurosurgeons can review radiological information from other hospitals via teleradiology systems. The usual teleradiology system only requires a normal domestic telephone line. The introduction of teleradiology in Neurosurgery had a significant impact on streamlining the process of neurosurgical referrals [1]. With the new improvements in telecommunication technology, it is now possible to communicate with our medical colleagues via a real-time video teleconferencing system. The potential advantage of this tech-
1386-5056/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 1 ) 0 0 1 6 1 - 7
176
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
nology is, in addition to clinical information and radiological images, that we can now assess the patients themselves in real-time. This study was conducted in a 1400-bedded teaching hospital and the regional neurosurgical centre serving a population of 2 million. We received referrals mainly from two peripheral hospitals; Alice Ho Mui Ling Hospital and the United Christian Hospital. A new audio-visual teleconferencing system was established between our unit and the United Christian Hospital in 1998 with the use of two Integrated Systems Digital Network (ISDN) lines. In order to evaluate the impact of telemedicine technology in neurosurgical service, we conducted a prospective randomized trial in comparing the efficacy between conventional telephone consultation, teleradiology and video-consultation (Audio-visual teleconferencing) systems. 2. System description
2.1. Teleradiology The teleradiology system that we use is called Multiview which is a commercially available Windows-based computer software. At the referral hospital there is a capture device installed to their CT scanners which is capable of acquiring and transmitting CT images to our unit via a normal telephone line. The acquisition of the image was done by analogue video frame-grabbing technology giving a resolution of 256× 256 matrix.
2.2. Audio-6isual teleconferencing The system consists of two cameras, one at each hospital, and a digital converter which converts images into digital signals which are then transmitted to the other side via two ISDN lines at a rate of 256 kilobits per second.
3. Patients and methods All patients requiring emergency neurosurgical consultation from the United Christian Hospital were recruited for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). The patients were stratified into three categories, Head injury (Group 1), Cerebrovascular accidents (Group 2) and Miscellaneous (Group 3). A standard proforma was created for recording the referred patients’ clinical details. This includes the patient’s demographic and clinical data, the time spent on setting up the system, and the time of the consultation process. The clinical details of the patient were also recorded which includes the Glasgow coma score (GCS), vital signs, pupil size and light reflexes, and any motor deficit at the time of presentation. Vital signs including oxygen saturation and blood pressure were measured every 5 min during the whole journey of patient transfer. Complications during transfer, such as hypoxia, hypotension and neurological deterioration were documented after the arrival at the neurosurgical centre. Outcome of patients were assessed according to the Glasgow outcome score [2] (GOS) at 1 month interval and the outcome was categorized as favorable (GOS 4 & 5) and unfavorable (GOS 1, 2 & 3). All consultations were received by the neurosurgeon on call for the day, and the patient would then be chosen for transfer or not. Once the patient was selected for transfer, he or she would be transferred to our hospital by ground ambulance with an escort from personnel of the referring hospital. The time taken for the system setup and the consultation time were studied separately in order to assess the practicality and efficacy respectively between the consultation modes.
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
If the consultation cannot be completed due to any kind of interruption (e.g. mechanical failure of consultation system), the case would be considered as failed and excluded from our analysis.
177
Table 2
Consultation mode
Consultation methods
A B
Telephone only 1.8 Teleradiology and 49.2 telephone Video-consultation 65.4
C
Time (min)
4. Results In a 10-month period (October 1998–July 1999), 327 patients were recruited. 125 patients (38%) required transfer to our neurosurgical centre. The male-to-female ratio was 2:1. The patients were categorized into three groups according to their diagnoses, which includes: (1) Head injury; (2) Cerebrovascular accident (intracerebral haemorrhage, subarachnoid haemorrhage); and (3) Miscellaneous (chronic subdural haematoma, subdural empyema, hydrocephalus, brain tumours). The number of patients in each group is summarized in Table 1. Once the on-call neurosurgeon received the referral, the time was noted as the referral time. When the decision on whether to transfer the patient was made, the time was noted as the decision made time. The time between referral and decision made (i.e. whole consultation) are summarized in Table 2. We found that the failure rate was particularly high in video-consultation (Mode C) as compared to the other two consultation modes. The failure rates are summarized in Table 3
As there was time spent on setting up the teleradiology and video-consultation system, the time when the neurosurgeon received the images was considered as the image recei6ed time. The time between referral and image recei6ed (i.e. system setup) were summarized in Table 4. The Time (actual consultation)=Time (whole consultation)−Time (system setup), the results are summarized in Table 5. One-month outcome assessment was performed in 269 patients, the 1 month outcome of the other 58 patients were not available at the time of analysis. The results are summarized in Table 6.
5. Discussion Neurosurgery depends heavily on the computerized digital imaging of the brain in order to diagnose intracranial space-occupying lesion. Early diagnosis and treatment is the Table 3
Table 1
Group Diagnoses
No. of patients
1 2 3
87 (26.6%) 159 (48.6%) 81 (24.8%)
Head injury Cerebrovascular accident Miscellaneous
Consultation mode
Consultation methods
A B
Telephone only 0 (0%) Teleradiology and 2 (1.2%) telephone Video-consultation 54 (53.4%)
C
Failure rate
178
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
Table 4
Consultation mode
Consultation methods
A B
Telephone only N/A Teleradiology and 36.0 telephone Video-consultation 55.0
C
Time (min)
key to success in managing emergency neurosurgical patients [3,4]. This was almost impossible to accomplish before the introduction of teleradiology. The accuracy of the information exchange over the telephone will depend on the experience of the referring physician. Unfortunately, more often the information was inaccurate and created a significant number of unnecessary transfers. Teleradiology did make an impact on the mentioned problem and brought down the number of unnecessary transfers. With more accurate information, neurosurgeons became more confident in their decision making on a patient referred from another hospital. Apart from radiological information, the neurological status of the patient is also a crucial element in the decision-making process. Whether the patient is fit for transfer or not quite often depends on their clinical state rather than the CT scan itself. Our experience told us that there were often discrepancies Table 5
Consultation mode
Consultation methods
A B
Telephone only 1.8 Teleradiology and 13.2 telephone Video-consultation 10.2
C
Time (min)
between the neurological status of the patients after arrival from the information received over the telephone. Of course this could be due to subsequent deterioration during transfer [5], but on the other hand this may be due to inaccurate neurological assessment in the first place. With the help of an audio-visual teleconferencing system, we can overcome the mentioned problem and assess the patient in real time. Therefore, making the neurosurgeon more confident in decision making. Our results showed that the video-consultation group seems to have a much higher failure rate than the other two consultation modes. There are two main reasons accountable for the high failure rate. First of all, there is only one video-consultation system located at the Accident & Emergency Department. It is a long way from the medical and surgical ward to the Accident & Emergency Department. Also it requires personnel to escort the patient down to the Accident & Emergency Department and switch on the video-consultation system to initiate the consultation. It is very difficult to spare personnel to perform a video-consultation since the peripheral hospital is one of the busiest hospitals in Hong Kong. More often they can only afford to consult us over the telephone with the films sent across to us via the teleradiology system. This situation was clearly shown on the difference in failure rate between teleradiology (1.2%) and video-consultation (53.4%). The second reason is that if the patient was unstable at the time of consultation, one could easily understand the difficulty in transporting such a patient to the Accident & Emergency Department for video-consultation. Unless the patient was referred from the Accident & Emergency Department, otherwise video-consultation is basically impossible for this group of patients.
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
179
Table 6
Consultation mode
Consultation methods
Favourable outcome
Unfavourable outcome
A B C
Telephone only Teleradiology and telephone Video-consultation
38.2% 30.8% 43.5%
61.8% 69.2% 56.5%
Despite of the difficulties we came across with video-consultation, the actual consultation time was in fact shorter than teleradiology. This may be due to the fact that video-consultation is just like telephone consultation that requires both parties’ presence at the same time. This was well reflected in the setup time which is much longer in the video-consultation mode (55 min) as compared with the teleradiology mode (36 min). This in turn makes the whole consultation in video-consultation much longer than the other two consultation modes. The outcome of patients in the video-consultation mode has a slightly more favourable outcome than the other two groups, this may be due to selection bias, since patients who were unstable were excluded from the analysis. But when we investigated those excluded patients, there were only a few patients who were labelled as too ill for the video-consultation. Therefore, the favourable outcome in the video-consultation group may be genuinely due to better patient assessment and subsequent management.
6. Conclusion From the result of our pilot study, there are several problems needing to be solved before we can further investigate the use of a video-consultation system in neurosurgery. The problems we faced include the requirement of manpower in escorting the patient
and operating the video-consultation system at the referring hospital. More than one video-consultation system may be needed in order to facilitate consultation from different wards. Also, we noted that there was a slight delay in radiological investigation on patients with suspected intracranial haemorrhage. Such a delay in diagnosis and/or referral has been shown to associate with poor prognoses [6]. In order to overcome the high failure rate in video-consultation, we employed an on-site research assistant to escort patients, perform randomization, and collect data regarding patients’ progress. This has brought down the failure rate of video-consultation to less than 5%. We also made an arrangement with the Radiology and Accident & Emergency Departments regarding early radiological investigation on patients with suspected intracranial haemorrhage at the Accident & Emergency Department level. This encourages early investigation, diagnosis and the most important of all, early neurosurgical referral. With the preliminary results from this pilot study, there might be a place for video-consultation in neurosurgical referrals. From our results there was an indication that videoconsultation provides a slightly better patient outcome as compared to the traditional telephone and teleradiology referral. Therefore, we believed that there is a need to further investigate the potential of video-consultation in neurosurgery provided we can rectify the problems mentioned above.
180
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
References [1] K.Y.C. Goh, C.K. Lam, W.S. Poon, The impact of teleradiology on the inter-hospital transfer of neurosurgical patients, Br. J. Neurosurg. 11 (1) (1997) 52–56. [2] B. Jennet, M. Bond, Assessment of outcome after severe brain damage. A practical scale, Lancet I (1975) 480 –484. [3] D. Gentleman, B. Jennett, Audit of transfer of unconscious head-injured patients to a neurosurgi-
cal unit, Lancet 335 (1990) 330 –334. [4] D. Gentleman, B. Jennett, R. MacMillan, Death in hospital after head injury without transfer to a neurosurgical unit: who, when, and why?, Injury 23 (1992) 471 – 474. [5] P.W. Barry, C. Ralston, Adverse events occurring during interhospital transfer of the critically ill, Arch. Dis. Childh. 71 (1994) 8 –11. [6] M. O’Sullivan, W.P. Gray, T.F. Buckely, Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on ‘delay’, Br. J. Surg. 77 (1990) 1391 – 1395.
.
www.elsevier.com/locate/ijmedinf
The comparative impact of video-consultation on neurosurgical health services W.S. Poon *, C.H.S. Leung, M.K. Lam, S. Wai, C.P. Ng, S. Kwok Di6ision of Neurosurgery, Prince of Wales Hospital and United Christian Hospital, The Chinese Uni6ersity of Hong Kong, Hong Kong, China
Abstract This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Telemedicine; Neurosurgical services; Video-consultation
1. Introduction In many developed countries, neurosurgical service is concentrated in regional centres. Traditionally, neurosurgical referrals made from peripheral hospitals were mainly done via telephone. With the advancement of tech-
* Corresponding author. Tel.: + 852-2632-2624; fax: +8522637-7974. E-mail address: [email protected] (W.S. Poon).
nology, nowadays, neurosurgeons can review radiological information from other hospitals via teleradiology systems. The usual teleradiology system only requires a normal domestic telephone line. The introduction of teleradiology in Neurosurgery had a significant impact on streamlining the process of neurosurgical referrals [1]. With the new improvements in telecommunication technology, it is now possible to communicate with our medical colleagues via a real-time video teleconferencing system. The potential advantage of this tech-
1386-5056/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 3 8 6 - 5 0 5 6 ( 0 1 ) 0 0 1 6 1 - 7
176
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
nology is, in addition to clinical information and radiological images, that we can now assess the patients themselves in real-time. This study was conducted in a 1400-bedded teaching hospital and the regional neurosurgical centre serving a population of 2 million. We received referrals mainly from two peripheral hospitals; Alice Ho Mui Ling Hospital and the United Christian Hospital. A new audio-visual teleconferencing system was established between our unit and the United Christian Hospital in 1998 with the use of two Integrated Systems Digital Network (ISDN) lines. In order to evaluate the impact of telemedicine technology in neurosurgical service, we conducted a prospective randomized trial in comparing the efficacy between conventional telephone consultation, teleradiology and video-consultation (Audio-visual teleconferencing) systems. 2. System description
2.1. Teleradiology The teleradiology system that we use is called Multiview which is a commercially available Windows-based computer software. At the referral hospital there is a capture device installed to their CT scanners which is capable of acquiring and transmitting CT images to our unit via a normal telephone line. The acquisition of the image was done by analogue video frame-grabbing technology giving a resolution of 256× 256 matrix.
2.2. Audio-6isual teleconferencing The system consists of two cameras, one at each hospital, and a digital converter which converts images into digital signals which are then transmitted to the other side via two ISDN lines at a rate of 256 kilobits per second.
3. Patients and methods All patients requiring emergency neurosurgical consultation from the United Christian Hospital were recruited for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). The patients were stratified into three categories, Head injury (Group 1), Cerebrovascular accidents (Group 2) and Miscellaneous (Group 3). A standard proforma was created for recording the referred patients’ clinical details. This includes the patient’s demographic and clinical data, the time spent on setting up the system, and the time of the consultation process. The clinical details of the patient were also recorded which includes the Glasgow coma score (GCS), vital signs, pupil size and light reflexes, and any motor deficit at the time of presentation. Vital signs including oxygen saturation and blood pressure were measured every 5 min during the whole journey of patient transfer. Complications during transfer, such as hypoxia, hypotension and neurological deterioration were documented after the arrival at the neurosurgical centre. Outcome of patients were assessed according to the Glasgow outcome score [2] (GOS) at 1 month interval and the outcome was categorized as favorable (GOS 4 & 5) and unfavorable (GOS 1, 2 & 3). All consultations were received by the neurosurgeon on call for the day, and the patient would then be chosen for transfer or not. Once the patient was selected for transfer, he or she would be transferred to our hospital by ground ambulance with an escort from personnel of the referring hospital. The time taken for the system setup and the consultation time were studied separately in order to assess the practicality and efficacy respectively between the consultation modes.
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
If the consultation cannot be completed due to any kind of interruption (e.g. mechanical failure of consultation system), the case would be considered as failed and excluded from our analysis.
177
Table 2
Consultation mode
Consultation methods
A B
Telephone only 1.8 Teleradiology and 49.2 telephone Video-consultation 65.4
C
Time (min)
4. Results In a 10-month period (October 1998–July 1999), 327 patients were recruited. 125 patients (38%) required transfer to our neurosurgical centre. The male-to-female ratio was 2:1. The patients were categorized into three groups according to their diagnoses, which includes: (1) Head injury; (2) Cerebrovascular accident (intracerebral haemorrhage, subarachnoid haemorrhage); and (3) Miscellaneous (chronic subdural haematoma, subdural empyema, hydrocephalus, brain tumours). The number of patients in each group is summarized in Table 1. Once the on-call neurosurgeon received the referral, the time was noted as the referral time. When the decision on whether to transfer the patient was made, the time was noted as the decision made time. The time between referral and decision made (i.e. whole consultation) are summarized in Table 2. We found that the failure rate was particularly high in video-consultation (Mode C) as compared to the other two consultation modes. The failure rates are summarized in Table 3
As there was time spent on setting up the teleradiology and video-consultation system, the time when the neurosurgeon received the images was considered as the image recei6ed time. The time between referral and image recei6ed (i.e. system setup) were summarized in Table 4. The Time (actual consultation)=Time (whole consultation)−Time (system setup), the results are summarized in Table 5. One-month outcome assessment was performed in 269 patients, the 1 month outcome of the other 58 patients were not available at the time of analysis. The results are summarized in Table 6.
5. Discussion Neurosurgery depends heavily on the computerized digital imaging of the brain in order to diagnose intracranial space-occupying lesion. Early diagnosis and treatment is the Table 3
Table 1
Group Diagnoses
No. of patients
1 2 3
87 (26.6%) 159 (48.6%) 81 (24.8%)
Head injury Cerebrovascular accident Miscellaneous
Consultation mode
Consultation methods
A B
Telephone only 0 (0%) Teleradiology and 2 (1.2%) telephone Video-consultation 54 (53.4%)
C
Failure rate
178
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
Table 4
Consultation mode
Consultation methods
A B
Telephone only N/A Teleradiology and 36.0 telephone Video-consultation 55.0
C
Time (min)
key to success in managing emergency neurosurgical patients [3,4]. This was almost impossible to accomplish before the introduction of teleradiology. The accuracy of the information exchange over the telephone will depend on the experience of the referring physician. Unfortunately, more often the information was inaccurate and created a significant number of unnecessary transfers. Teleradiology did make an impact on the mentioned problem and brought down the number of unnecessary transfers. With more accurate information, neurosurgeons became more confident in their decision making on a patient referred from another hospital. Apart from radiological information, the neurological status of the patient is also a crucial element in the decision-making process. Whether the patient is fit for transfer or not quite often depends on their clinical state rather than the CT scan itself. Our experience told us that there were often discrepancies Table 5
Consultation mode
Consultation methods
A B
Telephone only 1.8 Teleradiology and 13.2 telephone Video-consultation 10.2
C
Time (min)
between the neurological status of the patients after arrival from the information received over the telephone. Of course this could be due to subsequent deterioration during transfer [5], but on the other hand this may be due to inaccurate neurological assessment in the first place. With the help of an audio-visual teleconferencing system, we can overcome the mentioned problem and assess the patient in real time. Therefore, making the neurosurgeon more confident in decision making. Our results showed that the video-consultation group seems to have a much higher failure rate than the other two consultation modes. There are two main reasons accountable for the high failure rate. First of all, there is only one video-consultation system located at the Accident & Emergency Department. It is a long way from the medical and surgical ward to the Accident & Emergency Department. Also it requires personnel to escort the patient down to the Accident & Emergency Department and switch on the video-consultation system to initiate the consultation. It is very difficult to spare personnel to perform a video-consultation since the peripheral hospital is one of the busiest hospitals in Hong Kong. More often they can only afford to consult us over the telephone with the films sent across to us via the teleradiology system. This situation was clearly shown on the difference in failure rate between teleradiology (1.2%) and video-consultation (53.4%). The second reason is that if the patient was unstable at the time of consultation, one could easily understand the difficulty in transporting such a patient to the Accident & Emergency Department for video-consultation. Unless the patient was referred from the Accident & Emergency Department, otherwise video-consultation is basically impossible for this group of patients.
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
179
Table 6
Consultation mode
Consultation methods
Favourable outcome
Unfavourable outcome
A B C
Telephone only Teleradiology and telephone Video-consultation
38.2% 30.8% 43.5%
61.8% 69.2% 56.5%
Despite of the difficulties we came across with video-consultation, the actual consultation time was in fact shorter than teleradiology. This may be due to the fact that video-consultation is just like telephone consultation that requires both parties’ presence at the same time. This was well reflected in the setup time which is much longer in the video-consultation mode (55 min) as compared with the teleradiology mode (36 min). This in turn makes the whole consultation in video-consultation much longer than the other two consultation modes. The outcome of patients in the video-consultation mode has a slightly more favourable outcome than the other two groups, this may be due to selection bias, since patients who were unstable were excluded from the analysis. But when we investigated those excluded patients, there were only a few patients who were labelled as too ill for the video-consultation. Therefore, the favourable outcome in the video-consultation group may be genuinely due to better patient assessment and subsequent management.
6. Conclusion From the result of our pilot study, there are several problems needing to be solved before we can further investigate the use of a video-consultation system in neurosurgery. The problems we faced include the requirement of manpower in escorting the patient
and operating the video-consultation system at the referring hospital. More than one video-consultation system may be needed in order to facilitate consultation from different wards. Also, we noted that there was a slight delay in radiological investigation on patients with suspected intracranial haemorrhage. Such a delay in diagnosis and/or referral has been shown to associate with poor prognoses [6]. In order to overcome the high failure rate in video-consultation, we employed an on-site research assistant to escort patients, perform randomization, and collect data regarding patients’ progress. This has brought down the failure rate of video-consultation to less than 5%. We also made an arrangement with the Radiology and Accident & Emergency Departments regarding early radiological investigation on patients with suspected intracranial haemorrhage at the Accident & Emergency Department level. This encourages early investigation, diagnosis and the most important of all, early neurosurgical referral. With the preliminary results from this pilot study, there might be a place for video-consultation in neurosurgical referrals. From our results there was an indication that videoconsultation provides a slightly better patient outcome as compared to the traditional telephone and teleradiology referral. Therefore, we believed that there is a need to further investigate the potential of video-consultation in neurosurgery provided we can rectify the problems mentioned above.
180
W.S. Poon et al. / International Journal of Medical Informatics 62 (2001) 175–180
References [1] K.Y.C. Goh, C.K. Lam, W.S. Poon, The impact of teleradiology on the inter-hospital transfer of neurosurgical patients, Br. J. Neurosurg. 11 (1) (1997) 52–56. [2] B. Jennet, M. Bond, Assessment of outcome after severe brain damage. A practical scale, Lancet I (1975) 480 –484. [3] D. Gentleman, B. Jennett, Audit of transfer of unconscious head-injured patients to a neurosurgi-
cal unit, Lancet 335 (1990) 330 –334. [4] D. Gentleman, B. Jennett, R. MacMillan, Death in hospital after head injury without transfer to a neurosurgical unit: who, when, and why?, Injury 23 (1992) 471 – 474. [5] P.W. Barry, C. Ralston, Adverse events occurring during interhospital transfer of the critically ill, Arch. Dis. Childh. 71 (1994) 8 –11. [6] M. O’Sullivan, W.P. Gray, T.F. Buckely, Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on ‘delay’, Br. J. Surg. 77 (1990) 1391 – 1395.
.