Intended for healthcare professionals

Information In Practice

Transferring medical images on the world wide web for emergency clinical management: a case report

BMJ 1998; 316 doi: (Published 28 March 1998) Cite this as: BMJ 1998;316:988
  1. David S Johnson (David.Johnson{at}, orthopaedic specialist registrar,
  2. Rajinder P Goel, orthopaedic specialist registrar,
  3. Paul Birtwistle, computer systems and research officer,
  4. Phil Hirst, orthopaedic consultant surgeon
  1. Department of Orthopaedics, Manchester Royal Infirmary, Manchester M13 9WL
  1. Correspondence to: Mr Johnson
  • Accepted 21 January 1998

Although the ability to transmit radiographs over the telephone has been feasible since 1929,1 more advanced systems have been slow in introduction. We describe a simple system for transmitting medical images across a system based on personal computers and the internet's world wide web.

Methods and results

A system for transfer of medical images was set up in our orthopaedic department (fig 1). Clinical photographs were taken with an Apple Quicktake 150 digital camera, and radiographs were scanned on an Epson GT9000 flat bed scanner. The resulting digital images were converted to Joint Photographic Experts Group (JPEG) format at maximum quality using Adobe Photoshop on an Apple Power Macintosh computer. The files were saved onto a password protected area of the departmental website, which is maintained on an IBM compatible Pentium computer running the Microsoft programs Windows NT Server 4.0 and Internet Information Server. The server is connected to the internet via the University of Manchester. The minimum requirement for viewing images is a computer able to display 640×480 pixels in 256 colours and which must be connected to the internet and have installed web browser software capable of displaying JPEG files.

Fig 1.
Fig 1.

System for transfer of medical images across the world wide web


A longer version of this article is available on our website

The system was tested when a 44 year old man presented with an isolated closed fracture of the right distal tibia and fibula (fig 2). The on call resident thought that urgent stabilisation was required but wished to perform this without compromising subsequent treatment. With the system described, two colour photographs of the patient's ankle and two scanned radiographs were placed on the departmental website. The JPEG files ranged in size from 640×480 pixels in 24 bit colour (clinical photographs) to 616×754 pixels in 8 bit grey scale (radiographs). The files took a total of 243 Kb (range 50-78 Kb) of disk space. The time taken to acquire and place the images on the website was 10 minutes.

The case was discussed with the consultant on call, who accessed the departmental website using a Power Macintosh computer with 28 800 bps modem via an internet service provider (CompuServe). The four images were downloaded over the internet in 70 seconds, after the password protection system had been cleared (fig 2). It was decided to apply calcaneal traction, and definitive fixation was performed several days later.


The ability to obtain advice from a non-resident senior doctor can be invaluable in an emergency situation. When clinical information is supplemented with medical images errors may be reduced. Although this method of consultation cannot replace direct patient contact, it can allow the correct treatment to be instituted more quickly.

Our system can be adapted for use by any specialty. Unlike other systems, no custom built equipment or software is required and learning to use it is easy. Although the internet has been used to transmit medical images,2 this is the first report of using the world wide web in an emergency that we are aware of.

Image quality is paramount to the success of such a system. Previous reports, of similar quality images, have indicated that interpretation of transmitted images is satisfactory.35 However, we recommend that any department adopting this approach to patient care should audit its use, as well as ensuring compliance with the Data Protection Act and its principles.

Fig 2.
Fig 2.

Lateral radiograph of patient's right ankle (left) and as viewed in a web browser (right)


Contributors: PB set up the computer system and software necessary for the project. DSJ and PH tested the system described. The paper was written jointly by DSJ, RPG, PB, and PH. DSJ is guarantor for the paper.

Funding: None.

Conflict of interest: None.


  1. 1.
  2. 2.
  3. 3.
  4. 4.
  5. 5.