title: Secure transmission of urologic images and records over the Internet.
abstract: OBJECTIVE
  Telemedicine has become a common method for the transmission of images and patient data across long distances. Our goal was to assess the efficiency and accuracy of Photomailer MD software, a store-and-forward telemedicine system, in the urologic setting.
  
  
  METHODS
  Photomailer MD software was loaded on two computers in the host institution, one with a T1 connection to the Internet and the other with a dial-up modem connection (24,000 bits/second), and computers at three remote sites. A total of 14 clinical cases, comprised of digitized histories and radiographic images, were sent to the remote institutions four separate times using the four transmission modes available: nonencrypted, 56-bit encryption, 128-bit encryption, and 128-bit encryption with password. The following data points were recorded: file size before and after encryption, file transmission times, and diagnostic accuracy of the remote urologists. One-way ANOVA was used to compare mean values statistically, while the z-test was used to compare diagnostic accuracies.
  
  
  RESULTS
  Encryption increased the file size by a mean of 37.8%, with the three encryption modes increasing file sizes by the same number of kilobytes. When a dial-up modem was used, encrypted files required a significantly longer transmission time (P < 0.05) than the unencrypted files. The same trend was seen with the T1 connection, although the differences often were not significant. When T1 transmission times were compared with modem times with other variables held constant, modem times were significantly longer (P < 0.05). Diagnostic accuracies for each of the three remote centers ranged from 85.7% to 100%. Differences in accuracy rates between attending physicians and residents were not significant.
  
  
  CONCLUSIONS
  Photomailer MD provides a secure, convenient, and affordable method of transmitting patient images and records via the Internet. Transmission speed was significantly greater when using a T1 line and also tended to be faster when files were not encrypted. There was no significant difference in transmission time among the three encryption modes; therefore, 128-bit encryption with a password should be used to maximize security. Diagnostic accuracies were comparable to those in the literature. In general, 640 x 480-pixel resolution was adequate for urologic diagnoses, although higher-resolution images may improve accuracy.
authors.affiliation: Comprehensive Kidney Stone Center, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Kuo
authors.forename: P
authors.initials: P
authors.lastname: Aslan
authors.forename: C Z
authors.initials: CZ
authors.lastname: Dinlenc
authors.forename: B R
authors.initials: BR
authors.lastname: Lee
authors.forename: D
authors.initials: D
authors.lastname: Screnci
authors.forename: R K
authors.initials: RK
authors.lastname: Babayan
authors.forename: L R
authors.initials: LR
authors.lastname: Kavoussi
authors.forename: G M
authors.initials: GM
authors.lastname: Preminger
mesh_terms: D000704:Analysis of Variance; D001315:Australia; D016494:Computer Security; D006801:Humans; D020407:Internet; D008499:Medical Records; D008838:Microcomputers; D011856:Radiographic Image Enhancement; D015203:Reproducibility of Results; D012984:Software; D017216:Telemedicine; D014481:United States; D014572:Urology / Q000379:methods*