- Email: [email protected]
The Internet as a research tool in radiography
TH LLEG E OF RA E / R A P H E R S Radiography(1998) 4, 107-114
The Internet as a research tool in radiography Stephen Brealey The University of York, Department of Health Sciencesand Clinical Evaluation, Alcuin College, Heslington, York, YOI 5DD, U.K (Received 8 November I996; accepted 4 November 1997)
Keywords: research infrastructure; computerization; communication; collaboraLion; multimedia; ctissernina{ion of information.
The radiography profession is experiencing a transition, where the medium for displaying images that are used to aid the diagnosis of a patient is changing from an emulsion base to a digital interface. In conjunction with this development, the change to an all-graduate entry to the profession has had an impact on the establishment of the research infrastructure, which is attempting to ameliorate the acceptance of radiography research on a national and international scale. The Internet offers the potential to synergize the progressive computerization of Imaging Departments and the development of a research foundation within the profession. The objective of this paper is to promote the Internet as an effective research tool in the field of radiography, whilst taking into consideration some of the legal and security implications of using the Internet.
Introduction The digitization of X-ray imaging and the construction of a research infrastructure constitute two fundamental developments within the profession of radiography. Radiographic film has served the medical community well for a century, but there is a growing interest in replacing it by digital imaging technology. In a pre-emptive attempt to exploit the potential of digital imaging services and eliminate film, picture archival and communication systems (PACS) are being established [1]. Similarly, there has been an increase in the interest of research in radiography which has moved from almost non-existence to a state of heightened sensitivity, by many radiographers, to the need for practice-related research in all specialties of the profession [2]. At a time of advances in computer technology of unprecedented scale and speed, the Internet can potentially provide a wealth of multi-media digital information resources within the clinical and academic environment. With its global reach, it could help to establish the acceptance of radiography research within the national and international health and scientific community, as well as providing a vast and diverse knowledge base and 1078-8174/98/020107+08 $18.00•0
opportunity to interact with people and institutions with similar interests. At this nascent stage of the development of research within the profession an open and enquiring mind is imperative. The progressive computerization of the Imaging Department offers an ideal opportunity for providing a platform for the introduction and implementation of the lnternet. The objective of this paper, therefore, is to promote the Internet as a useful research tool in radiography whilst taking into consideration legal and security implications. This will involve a description of each facility and reference to the potential of the different applications.
What is the Internet? The Internet 'is a medium for effectively communicating with others and acts as a research support and information retrieval mechanism' [3]. The 'information superhighway', as it has been colloquially phrased, is a global network of computing networks, linking together millions of machines from the mightiest mainframe to the humblest home computer. Any two computers connected to this ubiquitous network can exchange information © 1998 The College of Radiographers
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as easily as if they were linked together directly. For the user, this means that you can send messages, retrieve files, visit Internet sites and inspect the information they hold anywhere in the world. However, the one major fault of the Web is its lack of organization. This stems from the nature of the Internet itself; no one owns or controls it, and so there is no central index of what is available. This can be off-putting to newcomers, although this is being overcome by the introduction of vast searchable databases [4]. Even though the Internet itself may be an amorphous entity, the benefits which flow from it are not. Every day, more and more information is being placed in publicly accessible directories. This represents an unparalleled opening up of a world's store of knowledge. While it is true that the coverage is so far rather patchy and circucnspect, with no guarantee that a particular subject is covered in the depth you want, the sheer quantity of information to be discovered on the Internet, and the diversity of the people and institutions which are making it available, means it is becoming easier and easier to find data in any given field [5]. At present, a high speed computer network is under development to connect all NHS hospitals, and Internet access may be one benefit from this. Anyone with a modem and a personal computer (PC) which will provide the relevant software, can connect to the Internet from their workplace or home today for the price of a local phone call and a small fee (typically £ I 5 per month) via a number of Internet service providers {4]. Therefore, there is the potential for utilizing the Internet both in the Imaging Department and at home. The specific applications of the Internet as a research tool in radiography will now be discussed.
Electronic mail and mailing lists 'Electronic :mail is both the simplest and the most widely-used of Internet tools' [6]. It is also one of the most powerful, allowing a surprisingly wide range of activities to be carried out with the minimum of resources and effort. Because of the way the Internet works, it is possible to send messages to anyone else in the Internet world in just a few seconds. Data may be displayed in the form of documents, spread sheets and illustrations. As well as receiving personal electronic mail, it is also possible to sign up for electronic mailing lists. A mailing list is for people with a special area of
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interest [7] for example, evidence-based health care. Mailing lists exploit electronic mails' broadcast capabilities to send copies of important messages periodically or sporadically [8]. There are thousands of these lists on just about every Subject imaginable and allow anyone to keep abreast of specialized areas, or perhaps exchange information with others who have similar interests. Mailing lists offer one of the most powerful and convenient ways of obtaining information automatically on the Internet. By sending a simple electronic mail message a file can be obtained with details of mailing lists relevant to the subject chosen. Furthermore, mailing lists are a very convenient way of receiving updates on a particular field, not least because they deliver information directly, rather than leaving users to find the information themselves. It is possible, however, to be more proactive if necessary by making use of an option to search through archives of mailing lists. This is a very valuable adjunct as the archives can form rich sources of further information. This facility allows for the search to be made between specific dates, other words to be found and words which must not be present. Mailing lists are generally very controlled, both in how they run and how they are used. Since there is someone usually in charge of the mailing list software, this means that there can be a central authority which is able to make decisions about who should and should not be allowed to join and what should and should not appear. In summary, electronic mail and mailing lists can serve as an autonomous communication tool among members of special interest groups and between collaborators. Several studies have already stressed the beneficial effects of communication by electronic mail in medical, nursing and other settings [9-131 cited by Pallen [14]. Together they promise to be a potential method of exchanging information and views between researchers and radiographers with similar interests. However, the security implications in the use of e-mail and the transfer of private material must be taken into account. This will be discussed in more detail in a later section.
Usenet This application of the Internet is similar to the function of mailing lists, in that it helps to aggregate the dissemination of information on the
The Internet in Radiography
Internet by bringing people with common interests together. However, whereas mailing lists are generally very well controlled, the Usenet news groups are anarchy personified. These news groups are like bulletin boards that circulate over the Internet, gathering messages and comments on particular subjects as they go. There are now~ well over 10 000 separate subject areas, or news groups, with more being created by the day. The range of Usenet news groups is extraordinary. Some are highly technical discussion groups; others cover completely trivial areas; and in between, many are of a more specialized nature probably of interest to a few thousand people around the world, who would otherwise have no way of communicating so efficiently [15]. In comparison to mailing lists, news groups adopt a more egalitarian approach with an unstructured format for discussing research interests and positing ideas for future study. A news group could be analogous to a progressive 'think tank' whereas mailing lists are concerned with channelling energies towards present and established projects. News groups are a valid tool for research in that they provide an alternative method of collating data and collaborating with other specialists.
Finding things Despite the plethora of resources available on the Internet, the perennial question is, how do you find them? In an attempt to provide the answer, a number of special services have been developed to help users discover the different kinds of pervasive information. For example, suppose you want to download a particular file: how do you find which site holds it? The answer is to use Archie, whose name comes from the fact that it has to do with Archives. Archie holds a kind of global index of files that can be downloaded from various sites. It is simple to use, the name of the appropriate file is inputted and a list of possible locations is returned. Archie is the place to start if searching for programs, data, or text files. Sometimes it is preferable to search for general information rather than a particular file, but the problem may be that too many sites hold too much information. For guidance through this maze the Gopher tool was developed. The name comes from its ability to 'go for' things. It is structured in the form of on-screen menus offering various options, each of which may lead to another menu. The idea
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is to give direction to the required data, and then to connect to the site where it is held. Gophers usually come with an extra feature called Veronica which is a search system that looks through all the Gopher menus and entries it knows about. When a search term is entered it returns a list of matches from its records. Veronica does not search the information resources themselves, just their titles. However, there is another application able to do precisely this called WAIS (Wide Area Information Servers). This simply means that the data is held not centrally on one computer, but dispersed all over the world on hundreds of them. The WAIS service allows text searches to be carried out on the final documents themselves and is a tool for working with collections of data, or databases. Conversely, the action at a distance that the Internet offers is not limited to downloading files. It is possible to operate a computer located thousands of miles away as if connected to it directly. This feature is called Telnet and is 'a powerful tool in resource sharing' [I6]. For example, using Telnet it is possible to log into the world's largest library, at the Library of Congress in Washington, and search the 20 million items held in catalogue in a matter of seconds. This diverse spectrum of applications illustrates the attempts that have been made to enhance the efficacy of assessing relevant information on the Internet, thus making it a useful research tool in any profession.
World Wide Web The World Wide Web (WWW) is a medium for exchanging information in the form of documents over the Internet, according to defined protocols. These documents are stored on computers around the world and are linked together to form what is called, hypertext. The idea is that instead of reading text in a linear fashion, from beginning to end, there are certain points, often called hot spots, that allow for jumping to other documents. All this is quite seamless, and is performed without the user intervening or ever needing to know where the linked documents are held. The simplicity of the Web has resulted in the widespread adoption of this medium. This has been fuelled by the availability of 'server' software for providing documents on demand from server computers anywhere on the Internet, and 'client' software for user workstations that understand the Web protocol
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110 Table 1. Useful and interesting Web sites World-Wide Web site
Internet address (Uniform Resource Locator)
RadiographyrelatedWeb pages List of radiography sites Medical imaging Medical imaging journals Radiation science Radiology teaching files The whole brain Atlas RSNA Electronic Journal
http;llsearch.yahoo.comlbinlsearch?p = radiography http;//www.yahoo.com/Health/Medicine/MedicalImaging/
http:llwww.yahoo.comlHealthlMedicinelMedical
ImaginglJournalsl
http://www-chne.unm.edulchne/hlthphys/SUBJECTS.HTM
http:llwww.rad.washington.edul http:llwww.med.harvard.edulAANLIBlhome.html http:llej.rsna.orgl
HealthJournals The British Medical Journal Journal of the American Medical Association New England Journal Annals of Internal Medicine
http://www.bmj.com/bmj/
http://www.ama-assn.orglpublicljournalsljamaljamahome.htm http://www.nejm.org/ http:Hwww.acponline.org/index.html
Health organizations The Royal College of Radiologists The British Institute of Radiology Health Services/Technology Assessment The U.K. Cochrane Centre Centre for Evidence-Based Medicine
http:Hwww.r cr.ac.uk/enquiries
http://www.bir.org.uk/index.html
http:l[text.nlm.nih.gov/ftrs/gateway?collect = cps&dbk = 2&ftrsk = 35 751 http:llhiru.mcmaster.ca/cochrane/centres/UK/ http://cebm.jr2.ox.ac.ukJ
and are able to display the documents, otherwise known as Web pages. It is the client software, often called 'browsers', such as Netscape Navigator, Internet Explorer and Mosaic, that allow portions of documents to link to other documents so that these links between documents can be readily followed. Each of these documents may be accessed by a Web browser through a basic Internet address called a Uniform Resource Locator (URL). This takes the form http:llwww.bmj.comlbmjl where http://refers to the HyperText Transport Protocol which underlies the WWW. This URL would access the British Medical Journal Web site. To access this site using Netscape, you use the open button in the button bar, and enter the URL in the resulting dialogue box. Pressing the return key instructs Netscape to locate this site and then to try to make contact with it in order to retrieve the relevant Web page [i7]. Table i provides a list of appropriate and interesting Web pages which can be found through the use of URLs. A feature of the W W W which allows the user to find different types of references to a specific topic of interest, is called a search engine. This tool searches databases of information collected from the Internet on a regular basis. The search engines are known as crawlers, worms, spiders or robots as
they access the addresses to different documents, or Web pages, and find links to other pages. The software is then compiled into the database where it is indexed into categories. The original search engines were Lycos, Webcrawler and the WWW Worm which began as academic research projects. The new generation includes Open Text, Excite, Yahoo, Infoseek and Alta Vista, which are commercially orientated. Alta Vista proclaims to possess the largest Web index and offers compact or detailed searches through 8 billion words filling 30 million Web pages. It also provides a full-text index of more than 13 000 news groups. This database can be located at the following URL:
http:llwww.altavista.digital.coml Image access and display When viewed through a sophisticated graphical browser like Netscape Navigator, documents or Web pages can display colour graphics and photos, and can play sound, animation and video clips. Applied to radiography, the Web offers new opportunities, not only for research, but also for teaching, learning, communication and collaboration. All the applications discussed so far can be utilized through the client software or browser, in conjunction with the WWW interface.
The Internet in Radiography
Obviously, the potential of incorporating static and dynamic images in tangent with text is of immense relevance to the radiography profession. A popular application for downloading images so that they can be viewed through a browser is via File Transfer Protocol (FTP). This is a powerful feature which provides the ability to retrieve files from distant computers. File format is the specific format in which an image file is saved. The format is identified by the three letter extension at the end of the file name. Every format has its own characteristics, advantages and disadvantages. By defining the file format it may be possible to determine the number of bits per pixel and additional information such as the different quantities of colours. For example, an 8 bit pixel format is often used, which refers to an image with up to 256 colours. To incorporate the medical images into a Web page, they must first be digitized and then compressed because if the document is too large, downloading may be prohibitive. One of the two commonest graphic file formats has the extension .gif (Graphics Interchange Format). It produces very clear images of up to 256 colours. The other is .jpg (Joint Photographic Group). These .jpg files have the benefit of being more compact than .gif files, and can cope with up to i6 million colours, although a trade-off does exist between the image quality and the amount of compression. Colour images should only be used when colour is necessary to convey essential information and should generally be in the .jpg format, especially if there are more than 256 colours. Therefore, in association with the increased computer power, graphical user interfaces [I8], and imaging software now available, which allow the manipulation of radiographic images on PCs, it is possible to download the resulting images on the Intemet. Radiographers could potentially display colour or grey-scale scintograms, sonograms, computed tomography scans, magnetic resonance images and plain radiographs on the Intemet juxtaposed with a text document research paper. Despite the increase in computer power, however, disadvantages of the Internet at present are those of speed and image quality. The popularity of the Internet causes transatlantic bottlenecks, and frequently the images are either small and of poor quality or unacceptably slow to arrive when accessed from Europe. The Internet is certainly not adequate for diagnostic quality teleradiology and PACS applications, and desktop PCs do not have the screen resolution of diagnostic workstations.
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However, for teaching purposes and publication of papers the technology is already sufficient to deliver quality images at a speed that is acceptable to most users, and this will improve as the infrastructure of the Internet develops [4]. Our American counterparts for example, the Radiological Society of North America (RSNA), have established a link with the WWW since i994. The purpose of the links that they have constructed is to promote and develop the high standards of radiology and related sciences through education and research. An electronic journal has also been distributed by the RSNA on the Interne{ to improve communication of scientific and clinical research in radiology and can be found at the following URL location: http:llej.rsna.orgl The immediacy of Internet publishing offers the opportunity to evolve the resource rapidly and to keep pace with changes in technology. By employing the multimedia capabilities of the Web, the RSNA have provided an environment for nurturing new approaches to teaching and the publication of research papers. This approach exemplifies the potential to disseminate information and to collaborate with developers who are geographically distant and yet are able to interact with other societies and affiliations in relation to research in radiography. Discussing the design of a strategy for regulating and monitoring the publishing of reputable radiography research and eliminating spurious sources on the Internet is beyond the scope of this paper. However, the implications of copyright law and security will now be considered./s32
Copyright law and security Desktop computer hardware and software provide many new accessible avenues for increased academic and research productivity, but some activities may have legal implications. The advent of technologies such as scanners, the increasing number of mailing lists and the development of the Internet affect the concept of copyright and require authors and publishers to reconsider their legal rights and obligations when they create or publish new works or modify existing ones. For example, with desktop scanners, almost any image, published or otherwise, can be copied, enhanced and multiplied. Moreover, health care professionals may have access to copyrighted digital radiological teaching file images, which are available on the
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Internet. Because 'downloading' a document or image is essentially making a copy of that document or image, copyright laws and the rights they afford to authors are involved. Theoretically, a copyright arises when the work is 'fixed' or set down on paper (once printed from the screen). To point out that the work is copyrighted, the author should include a notice in an easy-to-find place and should use the following format: © I997 Joe Bloggs. Before submitting a paper for publication, authors should make reasonable efforts to identify the source of copyrighted material that they wish to reproduce and to secure the written permission of the copyright owner before they publish an article or other work containing the protected material. To avoid charges of plagiarism and copyright infringement, credit should be given to the original source of the copied material [19]. One crucial issue in the use of the Internet is that of security. E-mail is a particular application for which the issue of security is important. Because of the nature of the Internet, it is theoretically possible for messages to be intercepted as they travel from point to point around the network. In this respect e-mail is more like a postcard than a letter. If confidential matters are being discussed in messages, privacy is obviously essential. The solution to this problem is to use encryption. The original text of the message is converted into a garbled form using an encryption key: only someone with a suitable key is able to decrypt the message, which can therefore be sent through the e-mail system quite safely. There is a very important program called Pretty Good Privacy (PGP), freely available on the Intemet, which provides a facility for using encryption [6]. There is a Web page which offers information on what PGP is, why you should use it and where you can obtain the latest version, at the following URL: http:llwww.algonet.sel ,-~hubbabub/pgp.html By far the weakest point of any security system is the password employed by legitimate users to gain entry to various services and locations; these should be chosen with care. Finally, another issue of importance is that of viruses. It is not impossible that a useful piece of software that you download may be infected with one of the many thousands of viruses now circulating (though only if they are executable programs: it is not possible to catch a virus from a data file such as simple documents, images or sounds) [20]. It is therefore important to take suitable precautions against them by using anti-virus soft-
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ware {5]. A good Web page on this topic can be located by using the following URL: http://
www.cse.bris.ac.uk/pcs/virus/virus.htm
Despite the legal implications of copying images and text files, as well as issues of security, these considerations should not detract the reader from utilizing the numerous applications offered by the Internet.
Conclusion Radiography is a technologically orientated profession. There has been an increase in the publication of papers either directly assessing technology or suggesting methods to assess the medical application of technology [21]. This tacits that radiographers should have the aptitude and ambition to discover how to use the Internet and also possess the ability to assess the impact on the profession in relation to research, its employment in the Imaging Department with reference towards the present trend in the digitization of X-ray imaging, and its possible contribution to education. One must not lose sight of the fact that a 'radiographer's spectrum of skills can be expressed as a mix of technological and psychological expertise' [22]. Even though the Internet would not diminish the physical distance between the patient and professional, its interactive capabilities could promote and improve communication between professional colleagues, albeit through an unconventional medium. In conclusion, when viewed through a sophisticated graphical browser, colour graphics and photos, sound, animation, video clips and text provide the opportunity for displaying static and dynamic images for their employment in research, education and within the hospital environment. Within the limits of legal and security implications, the use of various applications on the Internet, such as electronic mail, mailing lists, news groups, search engines and the myriad of resources offered to help find different sources of information, makes the Internet a valuable research tool in radiography.
Acknowledgement The author would like to acknowledgethe advice of Dr Peter Wright from the Department of Computer Sciences at York University.
The Internet in Radiography
References 1. Cowen AR. A review of digital support technologies for X-ray imaging. Part 1. Digital image communication and presentation. Imaging 1996; 8: 32-44. 2. Hammick M. Radiography research and the qualitative approach: a paradigm and a discourse. Radiography 1995; 1: 135-43. 3. Blanton K, Pike MA, Tolkhurst WA. The Internet: Infrastructure for the information age. In: Using the Internet. USA: Que Corporations, 1994: 7. 4. Downie AC. Teaching radiology on the Internet. Clin Radiol 1997; 52: 4-7. 5. Moody G. The Internet. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 1-2. 6. Moody G. E-mail. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 49. 7. Randall N. Getting the word out: Publishing a special interest magazine on the Internet. In: Teach Yourself the Internet. USA: Sachs Publishing, 1994: 384. 8. Snell N. An introduction to internet tools and resources. In: Navigating the Internet with Windows 95. USA: Sams Publishing, 1995: 65. 9. Sanda DZ, Safran C, Slack WV, Bleich HL. Use of electronic mail in a teaching hospital. Proc Annu Syrup Comput Appl A/led Care 1993; 17: 309-10. 10. Singarella T, Baxter J, Sandefur RR, Emery CC. The effects of electronic mail on communication in two health sciences institutions. J Med Syst 1993; 17: 69-86. 11. Sproull L, Kiesler S. Computers, networks and works. Scientific American I995; 6: 128-39. 12. Lyness AL, Raimond JA. Electronic communication to promote consensus-building skills: an innovative teaching strategy. J Nuts Edu 1992; 31: 331-4. 13. Staggers N. Electronic mail basics. J Nurs Adm 1989; 19: 31-5. 14. PaIlen M. Guide to the Internet: Electronic mail. BMIJ 1995; 311: 1487-90. 15. Moody G. The Internet. In: The lnternet with Windows. London: Butterworth Heinernann, 1996: 6. 16. Marine A, Kirkpatrick S, Neou V, Ward C. Applications. In: Internet: Getting Started. London: PTR Prentice Hall, 1994: 228. 17. Moody G. World-Wide Web. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 193. 18. Taylor G. Microcomputer-based graphics for radiology. A J Radiol 1986; 147: 1319-21. 19. Stern EJ, Westenberg L. Copyright law and academic radiology: Rights of authors and copyright owners and reproduction of information. A ] Radiol 1995; 164: 1083-88. 20. Moody G. FTP. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 124. 21. Prime NJ. Towards a model of technological development in radiology. Radiography 1996; 2: 43-52. 22. O'Connor G. Reflection on clinical practice: A means of fostering professional development. Radiography 1996; 2: 53-6.
Postscript Since the original article was initially written, the author believes that it is worthwhile discussing the
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potential of teleradiology to access and display images as Internet technology can now make more use of this application. Teleradiology allows radiographic images to be viewed at a site distant from the source if you have the appropriate software and hardware, such as a low-end UNIX workstation and scanner. One particular Web site offers the opportunity to make use of teleradiology and can be found at the following URL location: http'//
everest.radiology.uiowa.edu/ This site is particularly interested in the developing field of functional imaging, such as electron beam X-ray computed tomography (EBCT). EBCT allows for the capture of the beating heart's motion, the descent of the diaphragm, the passage of blood through tissues, and the distribution of a breath tagged with radiodense gas. The purpose of the Web site is to provide presentations of functional imaging such as EBCT in a format, which makes use of the advanced imaging technology available on the Internet to any site with the appropriate scanning facilities. The site has developed Web based tutorials for teaching specific applications of quantitative volumetric imaging. Once a patient has been scanned, image data can be viewed simultaneously by multiple distant sites, which allows for on-line consultation between radiologists and other clinicians. As any site which is in control alters the viewing parameters (slice location, zoom, pan, window/level), all sites see the same presentation. Any site can take control by clicking the appropriate button on their main panel, as the controlling site points at the image all sites see the cursor in the same location on their image. The International Standards Organization (ISO) Moving Pictures Expert Group (MPEG) developed the file format that is used to demonstrate volumetric images of data. This organization developed a video compression algorithm that is commonly referred to as .mpg and are responsible for generating the standards for digital video (sequences of images in time) and audio compression. The .mpg standard is in three parts, video, audio, and systems, where the last part gives the integration of the audio and video streams with the proper timestamping to allow synchronization of the two. MPEG-I, which refers to phase i of the development of the .mpg standard, is designed to produce VHS quality video at CD-ROM transfer rates, around 1.5 Megabits per second (Mbits/s), which is the data rate of (uncompressed) audio CDs. It operates with a resolution of 352 x 240 at 30
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frames per second and 30 fields and processes audio in 16-bit stereo at 44.1 kHz, the same rate as audio CD. MPEG-2, which refers to phase II, adheres to the standard of 720 × 486 and 60 fields, as opposed to 30 fields in MPEG-1 and defines a bits stream for video and audio coded at around 3 to iOMbits/s, as opposed to 1.5 Mbits/s in MPEG-I. In conclusion, this is one specific example of how the developing technology available for the Internet allows good diagnostic quality data to be accessible at multiple sites so that radiologists
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and other clinicians can view images and consult with each other simultaneously. There is therefore the potential to improve patient outcome as the expertise of several clinicians are available at the same time, which should help to reduce the delay between patient diagnosis and management. Furthermore, the same technology could be applied so that researchers from different specialities and institutions could communicate and collaborate with each other on both a national and international scale.
The Internet as a research tool in radiography Stephen Brealey The University of York, Department of Health Sciencesand Clinical Evaluation, Alcuin College, Heslington, York, YOI 5DD, U.K (Received 8 November I996; accepted 4 November 1997)
Keywords: research infrastructure; computerization; communication; collaboraLion; multimedia; ctissernina{ion of information.
The radiography profession is experiencing a transition, where the medium for displaying images that are used to aid the diagnosis of a patient is changing from an emulsion base to a digital interface. In conjunction with this development, the change to an all-graduate entry to the profession has had an impact on the establishment of the research infrastructure, which is attempting to ameliorate the acceptance of radiography research on a national and international scale. The Internet offers the potential to synergize the progressive computerization of Imaging Departments and the development of a research foundation within the profession. The objective of this paper is to promote the Internet as an effective research tool in the field of radiography, whilst taking into consideration some of the legal and security implications of using the Internet.
Introduction The digitization of X-ray imaging and the construction of a research infrastructure constitute two fundamental developments within the profession of radiography. Radiographic film has served the medical community well for a century, but there is a growing interest in replacing it by digital imaging technology. In a pre-emptive attempt to exploit the potential of digital imaging services and eliminate film, picture archival and communication systems (PACS) are being established [1]. Similarly, there has been an increase in the interest of research in radiography which has moved from almost non-existence to a state of heightened sensitivity, by many radiographers, to the need for practice-related research in all specialties of the profession [2]. At a time of advances in computer technology of unprecedented scale and speed, the Internet can potentially provide a wealth of multi-media digital information resources within the clinical and academic environment. With its global reach, it could help to establish the acceptance of radiography research within the national and international health and scientific community, as well as providing a vast and diverse knowledge base and 1078-8174/98/020107+08 $18.00•0
opportunity to interact with people and institutions with similar interests. At this nascent stage of the development of research within the profession an open and enquiring mind is imperative. The progressive computerization of the Imaging Department offers an ideal opportunity for providing a platform for the introduction and implementation of the lnternet. The objective of this paper, therefore, is to promote the Internet as a useful research tool in radiography whilst taking into consideration legal and security implications. This will involve a description of each facility and reference to the potential of the different applications.
What is the Internet? The Internet 'is a medium for effectively communicating with others and acts as a research support and information retrieval mechanism' [3]. The 'information superhighway', as it has been colloquially phrased, is a global network of computing networks, linking together millions of machines from the mightiest mainframe to the humblest home computer. Any two computers connected to this ubiquitous network can exchange information © 1998 The College of Radiographers
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as easily as if they were linked together directly. For the user, this means that you can send messages, retrieve files, visit Internet sites and inspect the information they hold anywhere in the world. However, the one major fault of the Web is its lack of organization. This stems from the nature of the Internet itself; no one owns or controls it, and so there is no central index of what is available. This can be off-putting to newcomers, although this is being overcome by the introduction of vast searchable databases [4]. Even though the Internet itself may be an amorphous entity, the benefits which flow from it are not. Every day, more and more information is being placed in publicly accessible directories. This represents an unparalleled opening up of a world's store of knowledge. While it is true that the coverage is so far rather patchy and circucnspect, with no guarantee that a particular subject is covered in the depth you want, the sheer quantity of information to be discovered on the Internet, and the diversity of the people and institutions which are making it available, means it is becoming easier and easier to find data in any given field [5]. At present, a high speed computer network is under development to connect all NHS hospitals, and Internet access may be one benefit from this. Anyone with a modem and a personal computer (PC) which will provide the relevant software, can connect to the Internet from their workplace or home today for the price of a local phone call and a small fee (typically £ I 5 per month) via a number of Internet service providers {4]. Therefore, there is the potential for utilizing the Internet both in the Imaging Department and at home. The specific applications of the Internet as a research tool in radiography will now be discussed.
Electronic mail and mailing lists 'Electronic :mail is both the simplest and the most widely-used of Internet tools' [6]. It is also one of the most powerful, allowing a surprisingly wide range of activities to be carried out with the minimum of resources and effort. Because of the way the Internet works, it is possible to send messages to anyone else in the Internet world in just a few seconds. Data may be displayed in the form of documents, spread sheets and illustrations. As well as receiving personal electronic mail, it is also possible to sign up for electronic mailing lists. A mailing list is for people with a special area of
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interest [7] for example, evidence-based health care. Mailing lists exploit electronic mails' broadcast capabilities to send copies of important messages periodically or sporadically [8]. There are thousands of these lists on just about every Subject imaginable and allow anyone to keep abreast of specialized areas, or perhaps exchange information with others who have similar interests. Mailing lists offer one of the most powerful and convenient ways of obtaining information automatically on the Internet. By sending a simple electronic mail message a file can be obtained with details of mailing lists relevant to the subject chosen. Furthermore, mailing lists are a very convenient way of receiving updates on a particular field, not least because they deliver information directly, rather than leaving users to find the information themselves. It is possible, however, to be more proactive if necessary by making use of an option to search through archives of mailing lists. This is a very valuable adjunct as the archives can form rich sources of further information. This facility allows for the search to be made between specific dates, other words to be found and words which must not be present. Mailing lists are generally very controlled, both in how they run and how they are used. Since there is someone usually in charge of the mailing list software, this means that there can be a central authority which is able to make decisions about who should and should not be allowed to join and what should and should not appear. In summary, electronic mail and mailing lists can serve as an autonomous communication tool among members of special interest groups and between collaborators. Several studies have already stressed the beneficial effects of communication by electronic mail in medical, nursing and other settings [9-131 cited by Pallen [14]. Together they promise to be a potential method of exchanging information and views between researchers and radiographers with similar interests. However, the security implications in the use of e-mail and the transfer of private material must be taken into account. This will be discussed in more detail in a later section.
Usenet This application of the Internet is similar to the function of mailing lists, in that it helps to aggregate the dissemination of information on the
The Internet in Radiography
Internet by bringing people with common interests together. However, whereas mailing lists are generally very well controlled, the Usenet news groups are anarchy personified. These news groups are like bulletin boards that circulate over the Internet, gathering messages and comments on particular subjects as they go. There are now~ well over 10 000 separate subject areas, or news groups, with more being created by the day. The range of Usenet news groups is extraordinary. Some are highly technical discussion groups; others cover completely trivial areas; and in between, many are of a more specialized nature probably of interest to a few thousand people around the world, who would otherwise have no way of communicating so efficiently [15]. In comparison to mailing lists, news groups adopt a more egalitarian approach with an unstructured format for discussing research interests and positing ideas for future study. A news group could be analogous to a progressive 'think tank' whereas mailing lists are concerned with channelling energies towards present and established projects. News groups are a valid tool for research in that they provide an alternative method of collating data and collaborating with other specialists.
Finding things Despite the plethora of resources available on the Internet, the perennial question is, how do you find them? In an attempt to provide the answer, a number of special services have been developed to help users discover the different kinds of pervasive information. For example, suppose you want to download a particular file: how do you find which site holds it? The answer is to use Archie, whose name comes from the fact that it has to do with Archives. Archie holds a kind of global index of files that can be downloaded from various sites. It is simple to use, the name of the appropriate file is inputted and a list of possible locations is returned. Archie is the place to start if searching for programs, data, or text files. Sometimes it is preferable to search for general information rather than a particular file, but the problem may be that too many sites hold too much information. For guidance through this maze the Gopher tool was developed. The name comes from its ability to 'go for' things. It is structured in the form of on-screen menus offering various options, each of which may lead to another menu. The idea
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is to give direction to the required data, and then to connect to the site where it is held. Gophers usually come with an extra feature called Veronica which is a search system that looks through all the Gopher menus and entries it knows about. When a search term is entered it returns a list of matches from its records. Veronica does not search the information resources themselves, just their titles. However, there is another application able to do precisely this called WAIS (Wide Area Information Servers). This simply means that the data is held not centrally on one computer, but dispersed all over the world on hundreds of them. The WAIS service allows text searches to be carried out on the final documents themselves and is a tool for working with collections of data, or databases. Conversely, the action at a distance that the Internet offers is not limited to downloading files. It is possible to operate a computer located thousands of miles away as if connected to it directly. This feature is called Telnet and is 'a powerful tool in resource sharing' [I6]. For example, using Telnet it is possible to log into the world's largest library, at the Library of Congress in Washington, and search the 20 million items held in catalogue in a matter of seconds. This diverse spectrum of applications illustrates the attempts that have been made to enhance the efficacy of assessing relevant information on the Internet, thus making it a useful research tool in any profession.
World Wide Web The World Wide Web (WWW) is a medium for exchanging information in the form of documents over the Internet, according to defined protocols. These documents are stored on computers around the world and are linked together to form what is called, hypertext. The idea is that instead of reading text in a linear fashion, from beginning to end, there are certain points, often called hot spots, that allow for jumping to other documents. All this is quite seamless, and is performed without the user intervening or ever needing to know where the linked documents are held. The simplicity of the Web has resulted in the widespread adoption of this medium. This has been fuelled by the availability of 'server' software for providing documents on demand from server computers anywhere on the Internet, and 'client' software for user workstations that understand the Web protocol
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110 Table 1. Useful and interesting Web sites World-Wide Web site
Internet address (Uniform Resource Locator)
RadiographyrelatedWeb pages List of radiography sites Medical imaging Medical imaging journals Radiation science Radiology teaching files The whole brain Atlas RSNA Electronic Journal
http;llsearch.yahoo.comlbinlsearch?p = radiography http;//www.yahoo.com/Health/Medicine/MedicalImaging/
http:llwww.yahoo.comlHealthlMedicinelMedical
ImaginglJournalsl
http://www-chne.unm.edulchne/hlthphys/SUBJECTS.HTM
http:llwww.rad.washington.edul http:llwww.med.harvard.edulAANLIBlhome.html http:llej.rsna.orgl
HealthJournals The British Medical Journal Journal of the American Medical Association New England Journal Annals of Internal Medicine
http://www.bmj.com/bmj/
http://www.ama-assn.orglpublicljournalsljamaljamahome.htm http://www.nejm.org/ http:Hwww.acponline.org/index.html
Health organizations The Royal College of Radiologists The British Institute of Radiology Health Services/Technology Assessment The U.K. Cochrane Centre Centre for Evidence-Based Medicine
http:Hwww.r cr.ac.uk/enquiries
http://www.bir.org.uk/index.html
http:l[text.nlm.nih.gov/ftrs/gateway?collect = cps&dbk = 2&ftrsk = 35 751 http:llhiru.mcmaster.ca/cochrane/centres/UK/ http://cebm.jr2.ox.ac.ukJ
and are able to display the documents, otherwise known as Web pages. It is the client software, often called 'browsers', such as Netscape Navigator, Internet Explorer and Mosaic, that allow portions of documents to link to other documents so that these links between documents can be readily followed. Each of these documents may be accessed by a Web browser through a basic Internet address called a Uniform Resource Locator (URL). This takes the form http:llwww.bmj.comlbmjl where http://refers to the HyperText Transport Protocol which underlies the WWW. This URL would access the British Medical Journal Web site. To access this site using Netscape, you use the open button in the button bar, and enter the URL in the resulting dialogue box. Pressing the return key instructs Netscape to locate this site and then to try to make contact with it in order to retrieve the relevant Web page [i7]. Table i provides a list of appropriate and interesting Web pages which can be found through the use of URLs. A feature of the W W W which allows the user to find different types of references to a specific topic of interest, is called a search engine. This tool searches databases of information collected from the Internet on a regular basis. The search engines are known as crawlers, worms, spiders or robots as
they access the addresses to different documents, or Web pages, and find links to other pages. The software is then compiled into the database where it is indexed into categories. The original search engines were Lycos, Webcrawler and the WWW Worm which began as academic research projects. The new generation includes Open Text, Excite, Yahoo, Infoseek and Alta Vista, which are commercially orientated. Alta Vista proclaims to possess the largest Web index and offers compact or detailed searches through 8 billion words filling 30 million Web pages. It also provides a full-text index of more than 13 000 news groups. This database can be located at the following URL:
http:llwww.altavista.digital.coml Image access and display When viewed through a sophisticated graphical browser like Netscape Navigator, documents or Web pages can display colour graphics and photos, and can play sound, animation and video clips. Applied to radiography, the Web offers new opportunities, not only for research, but also for teaching, learning, communication and collaboration. All the applications discussed so far can be utilized through the client software or browser, in conjunction with the WWW interface.
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Obviously, the potential of incorporating static and dynamic images in tangent with text is of immense relevance to the radiography profession. A popular application for downloading images so that they can be viewed through a browser is via File Transfer Protocol (FTP). This is a powerful feature which provides the ability to retrieve files from distant computers. File format is the specific format in which an image file is saved. The format is identified by the three letter extension at the end of the file name. Every format has its own characteristics, advantages and disadvantages. By defining the file format it may be possible to determine the number of bits per pixel and additional information such as the different quantities of colours. For example, an 8 bit pixel format is often used, which refers to an image with up to 256 colours. To incorporate the medical images into a Web page, they must first be digitized and then compressed because if the document is too large, downloading may be prohibitive. One of the two commonest graphic file formats has the extension .gif (Graphics Interchange Format). It produces very clear images of up to 256 colours. The other is .jpg (Joint Photographic Group). These .jpg files have the benefit of being more compact than .gif files, and can cope with up to i6 million colours, although a trade-off does exist between the image quality and the amount of compression. Colour images should only be used when colour is necessary to convey essential information and should generally be in the .jpg format, especially if there are more than 256 colours. Therefore, in association with the increased computer power, graphical user interfaces [I8], and imaging software now available, which allow the manipulation of radiographic images on PCs, it is possible to download the resulting images on the Intemet. Radiographers could potentially display colour or grey-scale scintograms, sonograms, computed tomography scans, magnetic resonance images and plain radiographs on the Intemet juxtaposed with a text document research paper. Despite the increase in computer power, however, disadvantages of the Internet at present are those of speed and image quality. The popularity of the Internet causes transatlantic bottlenecks, and frequently the images are either small and of poor quality or unacceptably slow to arrive when accessed from Europe. The Internet is certainly not adequate for diagnostic quality teleradiology and PACS applications, and desktop PCs do not have the screen resolution of diagnostic workstations.
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However, for teaching purposes and publication of papers the technology is already sufficient to deliver quality images at a speed that is acceptable to most users, and this will improve as the infrastructure of the Internet develops [4]. Our American counterparts for example, the Radiological Society of North America (RSNA), have established a link with the WWW since i994. The purpose of the links that they have constructed is to promote and develop the high standards of radiology and related sciences through education and research. An electronic journal has also been distributed by the RSNA on the Interne{ to improve communication of scientific and clinical research in radiology and can be found at the following URL location: http:llej.rsna.orgl The immediacy of Internet publishing offers the opportunity to evolve the resource rapidly and to keep pace with changes in technology. By employing the multimedia capabilities of the Web, the RSNA have provided an environment for nurturing new approaches to teaching and the publication of research papers. This approach exemplifies the potential to disseminate information and to collaborate with developers who are geographically distant and yet are able to interact with other societies and affiliations in relation to research in radiography. Discussing the design of a strategy for regulating and monitoring the publishing of reputable radiography research and eliminating spurious sources on the Internet is beyond the scope of this paper. However, the implications of copyright law and security will now be considered./s32
Copyright law and security Desktop computer hardware and software provide many new accessible avenues for increased academic and research productivity, but some activities may have legal implications. The advent of technologies such as scanners, the increasing number of mailing lists and the development of the Internet affect the concept of copyright and require authors and publishers to reconsider their legal rights and obligations when they create or publish new works or modify existing ones. For example, with desktop scanners, almost any image, published or otherwise, can be copied, enhanced and multiplied. Moreover, health care professionals may have access to copyrighted digital radiological teaching file images, which are available on the
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Internet. Because 'downloading' a document or image is essentially making a copy of that document or image, copyright laws and the rights they afford to authors are involved. Theoretically, a copyright arises when the work is 'fixed' or set down on paper (once printed from the screen). To point out that the work is copyrighted, the author should include a notice in an easy-to-find place and should use the following format: © I997 Joe Bloggs. Before submitting a paper for publication, authors should make reasonable efforts to identify the source of copyrighted material that they wish to reproduce and to secure the written permission of the copyright owner before they publish an article or other work containing the protected material. To avoid charges of plagiarism and copyright infringement, credit should be given to the original source of the copied material [19]. One crucial issue in the use of the Internet is that of security. E-mail is a particular application for which the issue of security is important. Because of the nature of the Internet, it is theoretically possible for messages to be intercepted as they travel from point to point around the network. In this respect e-mail is more like a postcard than a letter. If confidential matters are being discussed in messages, privacy is obviously essential. The solution to this problem is to use encryption. The original text of the message is converted into a garbled form using an encryption key: only someone with a suitable key is able to decrypt the message, which can therefore be sent through the e-mail system quite safely. There is a very important program called Pretty Good Privacy (PGP), freely available on the Intemet, which provides a facility for using encryption [6]. There is a Web page which offers information on what PGP is, why you should use it and where you can obtain the latest version, at the following URL: http:llwww.algonet.sel ,-~hubbabub/pgp.html By far the weakest point of any security system is the password employed by legitimate users to gain entry to various services and locations; these should be chosen with care. Finally, another issue of importance is that of viruses. It is not impossible that a useful piece of software that you download may be infected with one of the many thousands of viruses now circulating (though only if they are executable programs: it is not possible to catch a virus from a data file such as simple documents, images or sounds) [20]. It is therefore important to take suitable precautions against them by using anti-virus soft-
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ware {5]. A good Web page on this topic can be located by using the following URL: http://
www.cse.bris.ac.uk/pcs/virus/virus.htm
Despite the legal implications of copying images and text files, as well as issues of security, these considerations should not detract the reader from utilizing the numerous applications offered by the Internet.
Conclusion Radiography is a technologically orientated profession. There has been an increase in the publication of papers either directly assessing technology or suggesting methods to assess the medical application of technology [21]. This tacits that radiographers should have the aptitude and ambition to discover how to use the Internet and also possess the ability to assess the impact on the profession in relation to research, its employment in the Imaging Department with reference towards the present trend in the digitization of X-ray imaging, and its possible contribution to education. One must not lose sight of the fact that a 'radiographer's spectrum of skills can be expressed as a mix of technological and psychological expertise' [22]. Even though the Internet would not diminish the physical distance between the patient and professional, its interactive capabilities could promote and improve communication between professional colleagues, albeit through an unconventional medium. In conclusion, when viewed through a sophisticated graphical browser, colour graphics and photos, sound, animation, video clips and text provide the opportunity for displaying static and dynamic images for their employment in research, education and within the hospital environment. Within the limits of legal and security implications, the use of various applications on the Internet, such as electronic mail, mailing lists, news groups, search engines and the myriad of resources offered to help find different sources of information, makes the Internet a valuable research tool in radiography.
Acknowledgement The author would like to acknowledgethe advice of Dr Peter Wright from the Department of Computer Sciences at York University.
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References 1. Cowen AR. A review of digital support technologies for X-ray imaging. Part 1. Digital image communication and presentation. Imaging 1996; 8: 32-44. 2. Hammick M. Radiography research and the qualitative approach: a paradigm and a discourse. Radiography 1995; 1: 135-43. 3. Blanton K, Pike MA, Tolkhurst WA. The Internet: Infrastructure for the information age. In: Using the Internet. USA: Que Corporations, 1994: 7. 4. Downie AC. Teaching radiology on the Internet. Clin Radiol 1997; 52: 4-7. 5. Moody G. The Internet. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 1-2. 6. Moody G. E-mail. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 49. 7. Randall N. Getting the word out: Publishing a special interest magazine on the Internet. In: Teach Yourself the Internet. USA: Sachs Publishing, 1994: 384. 8. Snell N. An introduction to internet tools and resources. In: Navigating the Internet with Windows 95. USA: Sams Publishing, 1995: 65. 9. Sanda DZ, Safran C, Slack WV, Bleich HL. Use of electronic mail in a teaching hospital. Proc Annu Syrup Comput Appl A/led Care 1993; 17: 309-10. 10. Singarella T, Baxter J, Sandefur RR, Emery CC. The effects of electronic mail on communication in two health sciences institutions. J Med Syst 1993; 17: 69-86. 11. Sproull L, Kiesler S. Computers, networks and works. Scientific American I995; 6: 128-39. 12. Lyness AL, Raimond JA. Electronic communication to promote consensus-building skills: an innovative teaching strategy. J Nuts Edu 1992; 31: 331-4. 13. Staggers N. Electronic mail basics. J Nurs Adm 1989; 19: 31-5. 14. PaIlen M. Guide to the Internet: Electronic mail. BMIJ 1995; 311: 1487-90. 15. Moody G. The Internet. In: The lnternet with Windows. London: Butterworth Heinernann, 1996: 6. 16. Marine A, Kirkpatrick S, Neou V, Ward C. Applications. In: Internet: Getting Started. London: PTR Prentice Hall, 1994: 228. 17. Moody G. World-Wide Web. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 193. 18. Taylor G. Microcomputer-based graphics for radiology. A J Radiol 1986; 147: 1319-21. 19. Stern EJ, Westenberg L. Copyright law and academic radiology: Rights of authors and copyright owners and reproduction of information. A ] Radiol 1995; 164: 1083-88. 20. Moody G. FTP. In: The Internet with Windows. London: Butterworth Heinemann, 1996: 124. 21. Prime NJ. Towards a model of technological development in radiology. Radiography 1996; 2: 43-52. 22. O'Connor G. Reflection on clinical practice: A means of fostering professional development. Radiography 1996; 2: 53-6.
Postscript Since the original article was initially written, the author believes that it is worthwhile discussing the
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potential of teleradiology to access and display images as Internet technology can now make more use of this application. Teleradiology allows radiographic images to be viewed at a site distant from the source if you have the appropriate software and hardware, such as a low-end UNIX workstation and scanner. One particular Web site offers the opportunity to make use of teleradiology and can be found at the following URL location: http'//
everest.radiology.uiowa.edu/ This site is particularly interested in the developing field of functional imaging, such as electron beam X-ray computed tomography (EBCT). EBCT allows for the capture of the beating heart's motion, the descent of the diaphragm, the passage of blood through tissues, and the distribution of a breath tagged with radiodense gas. The purpose of the Web site is to provide presentations of functional imaging such as EBCT in a format, which makes use of the advanced imaging technology available on the Internet to any site with the appropriate scanning facilities. The site has developed Web based tutorials for teaching specific applications of quantitative volumetric imaging. Once a patient has been scanned, image data can be viewed simultaneously by multiple distant sites, which allows for on-line consultation between radiologists and other clinicians. As any site which is in control alters the viewing parameters (slice location, zoom, pan, window/level), all sites see the same presentation. Any site can take control by clicking the appropriate button on their main panel, as the controlling site points at the image all sites see the cursor in the same location on their image. The International Standards Organization (ISO) Moving Pictures Expert Group (MPEG) developed the file format that is used to demonstrate volumetric images of data. This organization developed a video compression algorithm that is commonly referred to as .mpg and are responsible for generating the standards for digital video (sequences of images in time) and audio compression. The .mpg standard is in three parts, video, audio, and systems, where the last part gives the integration of the audio and video streams with the proper timestamping to allow synchronization of the two. MPEG-I, which refers to phase i of the development of the .mpg standard, is designed to produce VHS quality video at CD-ROM transfer rates, around 1.5 Megabits per second (Mbits/s), which is the data rate of (uncompressed) audio CDs. It operates with a resolution of 352 x 240 at 30
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frames per second and 30 fields and processes audio in 16-bit stereo at 44.1 kHz, the same rate as audio CD. MPEG-2, which refers to phase II, adheres to the standard of 720 × 486 and 60 fields, as opposed to 30 fields in MPEG-1 and defines a bits stream for video and audio coded at around 3 to iOMbits/s, as opposed to 1.5 Mbits/s in MPEG-I. In conclusion, this is one specific example of how the developing technology available for the Internet allows good diagnostic quality data to be accessible at multiple sites so that radiologists
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and other clinicians can view images and consult with each other simultaneously. There is therefore the potential to improve patient outcome as the expertise of several clinicians are available at the same time, which should help to reduce the delay between patient diagnosis and management. Furthermore, the same technology could be applied so that researchers from different specialities and institutions could communicate and collaborate with each other on both a national and international scale.