Original article article Original article Image-based teleconsultation using smartphones or Image-based teleconsultation smartphones tablets: qualitative assessmentusing of medical experts or tablets: qualitative assessment of medical experts Constance Boissin,1 Lisa Blom,1 Lee Wallis,2 Lucie Laflamme1,3 ▸ Additional material is published online only To view ▸ Additional please visit thematerial journalisonline published online only To view (http://dx.doi.org/10.1136/ please visit the journal online emermed-2015-205258) (http://dx.doi.org/10.1136/ Department of Public Health emermed-2015-205258) Sciences, Karolinska Institutet, DepartmentSweden of Public Health Stockholm, Sciences, Karolinska Institutet, Division of Emergency Stockholm, Sweden Medicine, Faculty of Medicine Division of Sciences, Emergency and Health Medicine, Faculty of Medicine Stellenbosch University, and Health Sciences, Bellville, South Africa Stellenbosch University ofUniversity, South Africa, Bellville, Pretoria, South Africa University of South Africa, Pretoria, South Africato Correspondence Constance Boissin, Department Correspondence to of Public Health Sciences, Constance Boissin, Department Karolinska Institutet, of Public HealthHuset, Sciences, Widerströmska Karolinska Institutet, Tomtebodavägen 18 A, Widerströmska Stockholm 171 Huset, 77, Sweden; Tomtebodavägen 18 A, constance.boissin@ki.se Stockholm 171 77, Sweden; constance.boissin@ki.se Received 24 July 2015 Revised 15 June 2016 Received 24 2015 Accepted 17 July August 2016 Revised 15Online June 2016 Published First August 2016 5Accepted October17 2016 To cite: Boissin C, Blom L, Wallis L, et al Emerg Med J To cite: Boissin Blom L, Published Online C, First: To cite: Boissin C, Blom Wallis L,include et al Emerg MedL, J [please Day Month Wallis L, etOnline al Emerg Published First:Med J Year] doi:10.1136/emermed2017;34:95–99 [please include Day Month 2015-205258 Year] doi:10.1136/emermed2015-205258 Constance Boissin,1 Lisa Blom,1 Lee Wallis,2 Lucie Laflamme1,3 ABSTRACT Background Mobile health has promising potential in ABSTRACThealthcare delivery by facilitating access to improving Background Mobile health potential in expert advice Enabling expertshas to promising review images on their improving healthcare delivery by facilitating access to smartphone or tablet may save valuable time This study expertatadvice Enabling experts to review on their aims assessing whether images viewedimages by medical smartphone or tablet may save valuable time This study specialists on handheld devices such as smartphones aimstablets at assessing whethertoimages viewed by medical and are perceived be of comparable quality as specialists on on handheld devices such as smartphones when viewed a computer screen and tablets are perceived to be of comparable qualitytheas Methods This was a prospective study comparing when viewed on a computer screen perceived quality of 18 images on three different display Methods This was atablet prospective study comparing devices (smartphone, and computer) by 27 the perceived quality of 18 images on three different participants (4 burn surgeons and 23 emergency display devices (smartphone, tablet and computer) medicine specialists) The images, presentedbyin 27 random participants (4 burn surgeons and 23 emergency order, covered clinical (dermatological conditions, burns, medicine images, presented in random ECGs andspecialists) X-rays) andThe non-clinical subjects and their order, covered clinical (dermatological conditions, burns, perceived quality was assessed using a 7-point Likert ECGs and X-rays) and non-clinical subjects and their scale Differences in devices’ quality ratings were perceived using qualitylinear was regression assessed using a 7-point Likert analysed models for clustered scale.adjusting Differences devices’ ratings were data for inimage typequality and participants’ analysed using(age, lineargender regression models for clustered characteristics and medical specialty) data adjusting for image type and participants’ Results Overall, the images were rated good or very characteristics (age, gender good in most instances and and moremedical so for specialty) the smartphone Results mean Overall, the5.7) images goodmean or very5.5) (83.1%, score and were tabletrated (78.2%, good in most instances and more so for the smartphone than for a standard computer (70.6%, mean 5.2) Both (83.1%, mean score and tablethigher (78.2%, mean handheld devices had5.7) significantly ratings than5.5) than for a standard computer (70.6%, mean 5.2) Both the computer screen, even after controlling for image handheld devices had characteristics significantly higher ratings than type and participants’ Nearly all experts the computer even be after controllingusing for image expressed thatscreen, they would comfortable type and participants’ characteristics Nearly all experts smartphones (n=25) or tablets (n=26) for image-based expressed that they would be comfortable using teleconsultation smartphones (n=25) or tablets (n=26) for image-based Conclusion This study suggests that handheld devices teleconsultation could be a substitute for computer screens for Conclusion This suggests that handheld devices teleconsultation by study physicians working in emergency could be a substitute for computer screens for settings teleconsultation by physicians working in emergency settings Key messages Key messages What is already known on this subject? ▸ Studies from radiology and echocardiography What is already known this subject? show that experts can on accurately make a ▸ diagnosis Studies from radiology and echocardiography using images viewed on handheld show that experts can accurately make a devices diagnosisviewing using images viewed on handheld ▸ Experts radiological images on tablets devices perceive them as of comparable quality as ▸ when Expertsviewed viewing images on tablets onradiological computer screens perceive them as of comparable qualityare as ▸ Whether those favourable perceptions when viewed on computer screens specific to tablets as a handheld device or to ▸ the Whether those favourable perceptions particularity of those clinical fields are remains specific to tablets as a handheld device or to to be determined the particularity of those clinical fields remains What thisdetermined study adds to be ▸ Images viewed on handheld devices, on both What this studyand adds smartphones tablets, are perceived by ▸ medical Images viewed devices,than on both expertson as handheld of better quality when smartphones and tablets, are perceived by viewed on a computer screen medical experts of better quality than when ▸ Smartphones andastablets outperformed viewed on a computer screen standard, non-radiological computers for ECGs, ▸ X-rays, Smartphones tablets outperformed clinicaland photographs of dermatological standard, non-radiological computers for ECGs, conditions and burn wounds X-rays, clinical photographs of dermatological conditions and burn wounds and in conditions like ophthalmology,8 dermatology9 and burns,10 where pictures can be8 taken of a and in conditions like of ophthalmology, dermatolspecific body region concern However, to 10 ogy and burns, where pictures can be taken ensure effectiveness, the turnaround time has toofbea specific region This of concern However, kept to abody minimum may require experts to to ensure effectiveness, the turnaround time hassmartto be view the images received on their handheld kept minimum Thispotential may require to phonetoora tablet to avoid delaysexperts incurred view the images received on their handheld smartshould access to a computer screen be required phone or tablet avoid potential delays incurred Promisingly, in to radiology and echocardiography should access to a computer screen required where practice is in essence based onbeimage anaPromisingly, in radiology and echocardiography lysis, recent studies demonstrate that experts can where practice is inimages essence on11 image ana12 accurately diagnose onbased tablets Further, INTRODUCTION lysis, recent studies demonstrate that experts can field Mobile health (mHealth) is increasingly an additional study from the radiological accurately diagnose images on tablets.11 12 Further, INTRODUCTION acknowledged as a means to improve healthcare reveals that experts’ subjective evaluation of the an additional study from the radiological field Mobile globally health By(mHealth) delivery speeding upis andincreasingly facilitating quality of radiological images is as positive for reveals that experts’ subjective evaluation of the acknowledged as a means to improve healthcare access to expert 1advice, it contributes to effective tablets as for computer screens.13 quality of radiological images is as positive for delivery globally By speeding up and facilitating The evidence is promising regarding the usability treatment, reduced referral rates and ultimately 13 tablets as for computer screens access to expert advice, it contributes to effective reduced costs for both healthcare systems and of handheld devices (smartphones and tablets) for The evidence is promising regarding the usability treatment, reduced referral rates and ultimately patients In addition, increasing smartphone util- expert teleconsultation But it remains to be deterof handheld devices reduced costs for both healthcare systems and mined whether these(smartphones observations and are tablets) specific for to isation and rapidly growing internet access worldexpert teleconsultation But it remains to be deterpatients In addition, increasing smartphone utilwide make mHealth more widely available, radiological images or to the familiarity of the radimined whether observations specific to isation andin rapidly growingsettings internetThus, accessmHealth world- ologists—or any these expertise relevant are to emergency including resource-poor radiological images or to the familiarity of the radiwide make mHealth more widely available, may have a promising impact on the reduction of medicine—with the type of images presented ologists—or any expertise relevant to emergency including in resource-poor settings Thus, mHealth This study is concerned with acute conditions inequalities in access to healthcare the type of images presented may have a promising on theisreduction of medicine—with prevalent in resource-poor settings, specifically Image-based mHealthimpact in particular an area that This study is concerned with acute conditions inequalities in access to healthcare is developing rapidly, allowing clinicians at point of burns, and assesses whether images viewed on prevalent in resource-poor settings, specifically Image-based mHealth in particular is an area that care to take and transmit pictures to seek expert handheld devices are perceived by potential experts burns, and assesses whether images viewed on is developing rapidly, allowing clinicians at point of advice The practice is valuable for pictures as being comparable in quality as when viewed on handheld are perceived by potential experts care to take and transmit pictures to seek expert a standard,devices non-radiological computer screen taken of existing ECGs or radiological images advice.1 The practice is valuable for pictures as being comparable in quality as when viewed on 951 C, al et Emerg al Emerg Med J 2016;0:1–5 doi:10.1136/emermed-2015-205258 C, et Medor J 2017;34:95–99 doi:10.1136/emermed-2015-205258 taken Boissin ofBoissin existing ECGs radiological images6 a standard, non-radiological computer screen Original article Original METHODS Intervention In this prospective study, 18 images were viewed in a random order on three different display devices by 27 participants Three different display devices of types commonly used by physicians to view images were selected: a laptop computer screen (model Lenovo IdeaPad G5070 i3 1.9 GHz, Windows with a 15.600 HD LED screen of resolution 1366×768 pixels and a pixel density of 100 pixel/inch (PPI)) used as the reference, a tablet (model Samsung Galaxy Tab with a 10.100 screen of resolution 1280×800 pixels and a pixel density of 149.45 PPI) and a smartphone (model Apple iPhone 5S with a 400 screen of resolution 1136×640 pixels and a pixel density of 326 PPI) We used a selection of 18 images covering both clinical and non-clinical subjects (figure 1) The images were obtained from three different sources: two previous studies from our research group (n=4 and 6, respectively)10 14 and from an open access online medical database (n=8).15 The clinical images included dermatological conditions and burns captured with a camera as well as images of ECGs and standard plain film X-rays that represent results of examinations and are therefore not a direct photograph of a body part Participants A purposive sampling was used to recruit 27 participants based on two inclusion criteria First, participants reported being likely to be contacted in their professional life to give expert opinion on acute burn injuries Second, they reported having normal visual acuity and colour vision They were enlisted during two consecutive expert meetings that took place in April 2015 in Cape Town, South Africa; during a local meeting focusing on burn injuries and during an international emergency medicine conference A total of four South African burn surgeons and 23 emergency medicine specialists practicing in Sub-Saharan Africa or in the USA were enrolled All but one declared having at least moderate experience in acute burn care during the survey Survey A questionnaire was developed using the online software SurveyMonkey Each individual participant viewed the 18 images on each of the three devices and was asked to rate the overall quality of each image on a 7-point Likert scale (1=terrible to 7=excellent) Beforehand, the participants were instructed to focus on the quality of the images as such rather than on the ability to diagnose any particular condition The images were presented in a random order as defined automatically by the software Once participants had rated all the images on each device, two questions were asked concerning image quality and three regarding how frequently the participant used the specific type of device to look at images for personal, professional and teleconsultation purposes, the use of the device’s zoom feature during the survey and whether they would feel comfortable using the device for image-based remote Figure The 18 images presented in the survey 96 Boissin C, etC,al MedMed J 2017;34:95–99 Boissin etEmerg al Emerg J 2016;0:1–5 doi:10.1136/emermed-2015-205258 doi:10.1136/emermed-2015-205258 Original article article consultation Concerning quality, the participants were asked to rank order the importance of five image features:14 focus, resolution, contrast, colour and composition and then how they interpreted the word ‘quality’ when completing the survey Demographic data were collected at the very end Data collection procedure Each participant was tested individually and seated at a defined position where ambient lightning would be consistent and was presented with each device one at a time Although it was practically not feasible to hide what type of device they were presented with, each device was placed in a custom-designed cover to hide the brand or model All three were set to maximum luminance levels The order in which the participants were assigned to the devices was predetermined in accordance with the six possible permutations of the devices Data analysis A linear regression procedure for data clustered by participant was applied, where quality rating scores for the tablet and the smartphone were compared with those for the computer screen We then used a Wald-type test to assess the interaction between the type of device and, in turn, the type of image and medical specialty of the participants by adding their product terms in the model and jointly testing the regression coefficients of their product terms equal to zero The interaction between type of device and medical specialty was not significant (F=1.46; p=0.25) and medical specialty was not considered further By contrast, the interaction between type of device and type of image was significant (F=6.47; p