Most neurosurgeons recognize the value of the commonplace consultation based on imaging studies and a written clinical history. In the past, consultations were rendered in person, by mail or by phone; today they can be accomplished through the Internet.
Neurosurgery: Ideally Suited for Image-Based Telemedicine
Internet technology has enabled international communication and collaboration between the estimated 23,000 neurosurgeons practicing in the world today, up to one third of whom operate in regions of limited medical and educational resources, with many practicing in isolated regions without access to neurosurgical colleagues, up-to-date textbooks, or journals. While “telemedicine” will never replace face-to-face patient consultations, neurosurgery is ideally suited for image-based telemedicine because most interventions are based on radiographic confirmation of clinical findings.
The Doctor to Doctor Web site at https://www .doctortodoctor.org is a multilingual online consultation and educational resource featuring image-based case discussion forums, real-time online chat room discussions, and a curated database of submitted neurosurgical cases searchable by keyword or author. It was designed to simulate international interaction through the traditional grand rounds model of neurosurgical education, integrating clinical and radiological data, neurosurgical expertise and experience, and cultural and social aspects of treatment recommendations based on local conditions. Launched in 2001 by nonprofit Neurosurgery International, which sponsors and maintains it, the site is fast, free, easy-to-use, and readily accessible on low bandwidth Internet in most regions that support operative neurosurgery.
How It Works
Access to Doctor to Doctor is restricted to neurosurgeons, who are required to register before they can access the site; credentials are confirmed within 24 hours by e-mail. Once registered, a neurosurgeon can submit a case, including commentary and digital images in JPEG format; detailed instructions on the site are available to registered users. A senior editor of an editorial board consisting of neurosurgeons, neuroradiologists and neuropathologists from the United States and the United Kingdom reviews each case within 24 hours and edits comments as necessary before the case is posted.
To ensure patient privacy all identifying information is removed from the case or codified, and the patient’s written consent is obtained; proof of informed consent must be e-mailed to Doctor to Doctor before the case is posted. In addition, the site is encrypted and protected by a firewall.
The online chat room is a popular resource for “real-time” case discussions. Every Friday a case discussion is translated into Russian and English. Regular participants include neurosurgeons from the United States, United Kingdom, Azerbaijan, Russia and India.
Equipment Basics
Equipment for Doctor to Doctor includes a personal computer, telephone modem, and digital desktop scanner or camera, but participants have scanned images at local Internet cafes and travel agencies. The Web site itself utilizes Oracle 8i database management software, which permits a bulletin board format while accommodating text and high-resolution images. All case images and discussions are archived and searchable by user-defined keywords. The site is translated into Chinese and Russian and mirrored on dual processor Linux-based servers in the United States, Egypt and China to increase download speeds and accessibility.
How It’s Being Used
In the nine months following the site’s inception, neurosurgeons from Albania, Azerbaijan, Bosnia-Herzegovina, China, India, Pakistan, Russia, Ukraine, the United Kingdom, and the United States posted 200 neurosurgical cases, of which 66 percent were intracranial, and 34 percent spinal. Average time for case revieww and reply was less than 24 hours. The majority of cases (82 percent) involved the diagnosis and treatment of brain and spinal cord tumors, while pediatric cases constituted 28 percent of all cases discussed. Case discussions resulted in a significant change in diagnosis or management in 23 percent of cases. Neuroradiologists and neuropathologists consulted on 15 percent and 4 percent of cases respectively, and neurosurgery trainees from 26 different countries accessed the site 947 times for educational purposes. Because magnetic resonance imaging is still new in many developing countries, radiographic interpretation of MRI scans was and remains a frequent request.
Several benefits of Doctor to Doctor have emerged beyond the immediate benefit of improved patient care. The site has fostered continued education; partnerships with regional peers; research and fellowship opportunities for neurosurgeons; collaborative research efforts; and documentation of patient follow-up and outcome assessment in developing regions. The site shows how a Web-based collaboration provides an opportunity for all neurosurgeons to communicate across geographic and political boundaries, creating a more equitable distribution of knowledge and a foundation for improved neurosurgical care around the world.
Gregory D. Foltz, MD, a resident at the Department of Neurological Surgery, University of Washington, is a founder of Doctor to Doctor and Neurosurgery International. He coauthored a study on the Doctor to Doctor Web site that was presented at the AANS Annual Meeting in April 2002.