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Smartphones Facilitate Teleradiology—But Should Be Used with Caution

Key findings

  • Interobserver agreement about distal radius fracture classification was similar for surgeons who viewed radiographs on a smartphone or used a DICOM viewer
  • Likewise, interobserver agreement about recommendation for surgery was similar in the two groups of observers
  • Rates of recommendation for surgery were significantly higher in the smartphone group than in the DICOM viewer group
  • Rates of confidence in the recommendation for surgery were also significantly higher in the smartphone group

Several recent studies have documented that physicians often use smartphones to teleconsult a colleague for assistance in assessing a radiograph. This practice has implications for formal telemedicine programs. Potential limitations are that mobile picture messaging does not offer the scaling, windowing and leveling options available with a DICOM (Digital Imaging and Communications in Medicine) viewer.

In a randomized study reported in Archives of Bone and Joint Surgery, researchers at Massachusetts General Hospital found that interobserver reliability was not significantly different between a group of orthopedic surgeons who used a mobile messenger application and a group that used a DICOM viewer. However, teleconsultation via smartphones resulted in more recommendations for surgery.

Interim Chief of the Hand & Arm Center, Neal C. Chen, MD, and colleagues randomly assigned 20 orthopedic surgeons to view 10 radiographs of distal radius fractures on either an iPhone 6 using the WhatsApp Messenger application or a laptop computer using a DICOM viewer.

Each surgeon was asked to answer three questions for each radiograph:

  • What is the fracture type according to the AO classification?
  • Would you recommend operative treatment for this fracture?
  • How confident are you about this decision on a scale of zero to 10?

The surgeons did not receive any patient-specific information to guide their recommendation.

Interobserver reliability for Aclassification was fair (κ = 0.34) in the DICOM viewer group and moderate (κ = 0.43) in the mobile messenger group. That difference was not statistically significant. Neither was there any significant difference between groups regarding interobserver reliability for recommendation of surgery (κ = 0.53 and κ = 0.60, respectively).

The rate of recommendation for surgery was significantly higher in the smartphone group than in the DICOM viewer group (89% vs 78%; = .02). Confidence about that treatment decision rate was also significantly higher in the smartphone group (8.9 vs 7.9, = .03).

The authors conclude that, although teleconsultation via smartphones seems useful, it should be approached cautiously. The choice of assessment modality appears to influence clinical reasoning, so teleconsultation might result in unnecessary surgeries.

Furthermore, the authors note, WhatsApp Messenger is owned by Facebook, which raises concerns about the privacy of patient data. The application is designed to offer end-to-end encryption, but recent tests have shown that encryption is not properly executed in all devices.

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