Intra and Inter-Observer Reliability of Mobile Tablet PACS Viewer System vs. Standard PACS Viewing Station-Diagnosis of Acute Central Nervous System Events


Background and Purpose: The display resolution of the Apple iPad? is 1024 × 768 pixels, which is greater than that required for generating the typical CT or MRI images. The purpose of this study is to determine if specific CT and MR sequences can be interpreted accurately on mobile device/PACS software platforms when compared to a traditional stationary high resolution monitor/PACS radiological workstation. If so, this allows radiologists to provide comparable interpretation as if they were onsite at an imaging center or hospital. Materials and Methods: This study is an investigator initiated, single site, retrospective, nonrandomized, IRB approved study. Five radiologists were included in this study. Each independently interpreted specific CT and MR sequences on traditional high-resolution LCD monitors via eFilm? software as well as an iPad? mobile device using Osirix? software program. Repeat interpretations were performed, with 4 weeks minimum interval between interpretations of each patient. This investigation included: 50 patients with CTA perfusion imaging, 50 patients with MRI of the brain, and 50 patients with MRI of the spine, which were image study orders generated through emergency room requests. Subsequently, interpretive results of each radiologist for each patient were statistically compared to evaluate for intra-observer and inter-observer reliability. Results: The parameters set within the CTA perfusion brain studies demonstrated excellent intra-observer variability. All of the parameters within the MRI brain studies demonstrated excellent intra-observer variability with a Cohen’s kappa value > 0.75. The Cohen’s kappa values for the board certified neuroradiologist demonstrated excellent variability for all parameters; the resident radiologists had good variability, with a majority of kappa values near 0.75. Conclusions: The data and statistical analysis demonstrated that portable mobile devices such as the Apple iPad? can display adequate resolution of CT and MRI sequences to accurately diagnose acute central nervous system injuries and other non-acute pathology.

Share and Cite:

A. Bhatia, S. Patel, G. Pantol, Y. Wu, M. Plitnikas and C. Hancock, "Intra and Inter-Observer Reliability of Mobile Tablet PACS Viewer System vs. Standard PACS Viewing Station-Diagnosis of Acute Central Nervous System Events," Open Journal of Radiology, Vol. 3 No. 2, 2013, pp. 91-98. doi: 10.4236/ojrad.2013.32014.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] S. John, A. C. Poh, T. C. Lim, E. H. Chan and L. R. Chong, “The iPad Tablet Computer for Mobile On-Call Radiology Diagnosis? Auditing Discrepancy in CT and MRI Reporting,” Journal of Digital Imaging, Vol. 25, No. 5, 2012, pp. 628-634. doi:10.1007/s10278-012-9485-3
[2] F. Volonté F, J. H. Robert, O. Ratib and F. Triponez, “A lung Segmentectomy Performed with 3D Reconstruction Images Available on the Operating Table with an iPad,” Interactive CardioVasc Thoracic Surgery, Vol. 12, No. 6, 2011, pp. 1066-1068. doi:10.1510/icvts.2010.261073
[3] D. Yeager, “Images on the Move,” Radiology Today, Vol. 12, No. 7, 2011. pp. 12-15.
[4] A. F. Choudhri and M. G. Radvany, “Initial Experience with a Handheld Device Digital Imaging and Communi cations in Medicine Viewer: OsiriX Mobile on the iPhone,” Journal of Digital Imaging, Vol. 24, No. 2, 2011, pp. 184-189. doi:10.1007/s10278-010-9312-7
[5] G. Shih, P. Lakhani and P. Nagy, “Is android or iPhone the Platform for Innovation in Imaging Informatics,” Journal of Digital Imaging, Vol. 23, No. 1, 2010, pp. 2-7. doi:10.1007/s10278-009-9242-4
[6] S. Lee, T. Lee, G. Jin and J. Hong, “An Implementation of Wireless Medical Image Transmission System on Mo bile Devices,” Journal of Medical Systems, Vol. 32, No. 6, 2008, pp. 471-480. doi:10.1007/s10916-008-9153-9
[7] M. Yamada, H. Watarai, T. Andou and N. Sakai, “Emer gency Image Transfer System through a Mobile Tele phone in Japan: Technical Note,” Neurosurgery, Vol. 52, No. 4, 2003, pp. 986-988. doi:10.1227/01.NEU.0000053152.45258.74
[8] P. Georgiadis, D. Cavouras, A. Daskalakis, K. Sifaki, M. Malamas, G. Nikiforidis and E. Solomou, “PDA-Based System with Teleradiology and Image Analysis Capabili ties,” Annual International Conference of the IEEE Engineering in Medicine and Biology Society, Lyon, 22-26 August 2007, pp. 3090-3093. doi:10.1109/IEMBS.2007.4352981
[9] D. K. Kim, E. Y. Kim, K. H. Yang, C. K. Lee and S. K. Yoo, “A Mobile Tele-Radiology Imaging System with JPEG2000 for an Emergency Care,” Journal of Digital Imaging, Vol. 24, No. 4, 2011, pp. 709-718. doi:10.1007/s10278-010-9335-0
[10] A. J. Doyle, J. Le Fevre, and G. D. Anderson, “Personal Computer versus Workstation Display: Observer Performance in Detection of Wrist Fractures on Digital Radiographs,” Radiology, Vol. 237, No. 3, 2005, pp. 872-877. doi:10.1148/radiol.2373041439
[11] R. J. Toomey, J. T. Ryan, M. F. McEntee, M. G. Evanoff, D. P. Chakraborty, J. P. McNulty, D. J. Manning, E. M. Thomas and P. C. Brennan, “Diagnostic Efficacy of Hand-Held Devices for Emergency Radiological Consultation,” American Journal of Roentgenology, Vol. 194, No. 2, 2010, pp. 469-474. doi:10.2214/AJR.09.3418
[12] M. F. McEntee, J. Lowe, M. L. Butler, M. Pietrzyk, M. G. Evanoff, J. Ryan, P. C. Brennan and L. A. Rainford, “iPads and LCDs Show Similar Performance in the Detection of Pulmonary Nodules,” Proceedings of the Society of Photo-Optical Instrumentation, Vol. 8318, 2012, Article ID: 83180C.
[13] P. Mc Laughlin, S. O. Neill, N. Fanning, A. M. Mc Garrigle, O. J. Connor, G. Wyse and M. M. Maher, “Emergency CT Brain: Preliminary Interpretation with a Tablet Device: Image Quality and Diagnostic Performance of the Apple iPad,” Emergency Radiology, Vol. 19, No. 2, 2012, pp. 127-133. doi:10.1007/s10140-011-1011-2
[14] J. A. Mitchell, “Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke,” Journal of Medical Internet Research, Vol. 13, No. 2, 2011, Article ID: e31. doi:10.2196/jmir.1732
[15] F. H. Tang, M. Y. Law, A. C. Lee and L. W. Chan, “A Mobile Phone Integrated Health Care Delivery System of Medical Images,” Journal of Digital Imaging, Vol. 17, No. 3, 2004, pp. 217-225. doi:10.1007/s10278-004-1015-5
[16] S. Tachakra, K. A. Banitsas and F. Tachakra, “Performance of a Wireless Telemedicine System in a Hospital Accident and Emergency Department,” Journal of Tele medicine and Telecare, Vol. 12, No. 6, 2006, pp. 298-302. doi:10.1258/135763306778558169
[17] K. Phabphal and S. Hirunpatch, “The Effectiveness of Low-Cost Teleconsultation for Emergency Head Computer Tomography in Patients with Suspected Stroke,” Journal of Telemedicine and Telecare, Vol. 14, No. 8. 2008, pp. 439-442. doi:10.1258/jtt.2008.080603
[18] B. K. Patel, C. G. Chapman, N. Luo, J. N. Woodruff and V. M. Arora, “Impact of Mobile Tablet Computers on Internal Medicine Resident Efficiency,” Archives of Internal Medicine, Vol. 172, No. 5, 2012, pp. 436-438. doi:10.1001/archinternmed.2012.45
[19] P. T. Johnson, S. L. Zimmerman, D. Heath, J. Eng, K. M. Horton, W. W. Scott and E. K. Fishman, “The iPad as a Mobile Device for CT Display and Interpretation: Diagnostic Accuracy for Identification of puLmonary Embolism,” Emergency Radiology, Vol. 19, No. 4, 2012, pp. 323-327. doi:10.1007/s10140-012-1037-0
[20] D. Schulze and M. Heiland, “Diagnostic Advantages and Possibilities for Secondary Reconstruction of NewTom 9000 Data Sets Using eFilm,” International Journal of Computerized Dentistry, Vol. 7, No. 1, 2004, pp. 61-66.
[21] L. C. Ebert, W. Ptacek, M. Fürst, S. Ross, M. J. Thali and G. Hatch, “Minimally Invasive Postmortem Telebiopsy,” Journal of Forensic Sciences, Vol. 57, No. 2, 2012, pp. 528-530. doi:10.1111/j.1556-4029.2011.01990.x
[22] H. A. Gratama van Andel, H. W. Venema, C. B. Majoie, G. J. Den Heeten, C. A. Grimbergen and G. J. Streekstra, “Intracranial CT Angiography Obtained from a Cerebral CT Perfusion Examination,” Medical Physics, Vol. 36, No. 4, 2009, pp. 1074-1085. doi:10.1118/1.3078043
[23] F. H. Xu, W. J. Chen, Y. J. Yang, Y. X. Duan and F. L. Fu, “Evaluation of Multislice Computed Tomographic Perfusion Imaging and Computed Tomographic Angiography on Traumatic Cerebral Infarction,” Chinese Journal of Traumatology, Vol. 11, No. 3, 2008, pp. 186-189. doi:10.1016/S1008-1275(08)60039-5
[24] M. A. Ezzeddine, M. H. Lev, C. T. McDonald, G. Rordorf, J. Oliveira-Filho, F. G. Aksoy, J. Farkas, A. Z. Segal, L. H. Schwamm, R. G. Gonzalez and W. J. Koroshetz, “CT Angiography with Whole Brain Perfused Blood Volume Imaging: Added Clinical Value in the Assess ment of Acute Stroke,” Stroke, Vol. 33, No. 4, 2002, pp. 959-966. doi:10.1161/hs0402.105388
[25] A. Xyda, U. Haberland, E. Klotz, K. Jung, H. C. Bock, R. Schramm, M. Knauth and P. Schramm, “Diagnostic Performance of Whole Brain Volume Perfusion CT in Intra-Axial Brain Tumors: Preoperative Classification Ac curacy and Histopathologic Correlation,” European Journal of Radiology, Vol. 81, No. 12, 2012, pp. 4105-4111. doi:10.1016/j.ejrad.2012.08.005
[26] P. F. Judy and R. G. Swensson, “Display Thresholding of Images and Observer Detection Performance,” Journal of the Optical Society of America A, Vol. 4, No. 5, 1987, pp. 954-965. doi:10.1364/JOSAA.4.000954
[27] K. Bacher, P. Smeets, A. De Hauwere, T. Voet, P. Duyck, K. Verstraete and H. Thierens, “Image Quality Performance of Liquid Crystal Display Systems: Influence of Display Resolution, Magnification and Window Settings on Contrast-Detail Detection,” European Journal of Radiology, Vol. 58, No. 3, 2006, pp. 471-479. doi:10.1016/j.ejrad.2005.12.016
[28] M. Sasaki, M. Ida, K. Yamada, Y. Watanabe and M. Matsui, “Standardizing Display Conditions of Diffusion Weighted Images Using Concurrent b0 Images: A Multi vendor Multi-Institutional Study,” Magnetic Resonance in Medical Sciences, Vol. 6, No. 3, 2007, pp. 133-137. doi:10.2463/mrms.6.133
[29] U. E. Anwer, “Essential Investigations of Patients with Suspected TIAs,” European Neurology Vol. 39, No. 1, 1998, pp. 17-20. doi:10.1159/000052065
[30] S. Ruchholtz, C. Waydhas, T. Schroeder, K. Piepenbrink, H. Kühl and D. Nast-Kolb, “The Value of Computed To mography in the Early Treatment of Seriously Injured Pa tients,” Neurochirurgie, Vol. 73, No. 10, 2002, pp. 1005-1012. doi:10.1007/s00104-002-0429-1
[31] J. W. Van Goethem, M. Maes, O. Ozsarlak, L. van den Hauwe and P. M. Parizel, “Imaging in Spinal Trauma,” European Radiolog, Vol. 15, No. 3, 2005, pp. 582-590. doi:10.1007/s00330-004-2625-5
[32] H. G. Deen, Jr., “Diagnosis and Management of Lumbar Disk Disease,” Mayo Clinic Proceeding, Vol. 71, No. 3, 1996, pp. 283-287. doi:10.4065/71.3.283
[33] S. M. Papadopoulos, N. R. Selden, D. J. Quint, N. Patel, B. Gillespie and S. Grube, “Immediate Spinal Cord De compression for Cervical Spinal Cord Injury: Feasibility and Outcome,” Journal of Trauma, Vol. 52, No. 2, 2002, pp. 323-332. doi:10.1097/00005373-200202000-00019
[34] M. A. Haider, “Extending PowerPoint with DICOM image support,” Radiographics, Vol. 23, No. 6, 2003, pp. 1683-1687. doi:10.1148/rg.236035074
[35] T. Gillespy and A. H. Rowberg, “Dual Lookup Table Algorithm: An Enhanced Method of Displaying 16-Bit Gray-Scale Images on 8-Bit RGB Graphic Systems,” Journal of Digital Imaging, Vol. 7, No. 1, 1994, pp. 13 17. doi:10.1007/BF03168474
[36] L. C. Ebert, G. Hatch, G. Ampanozi, M. J. Thali and S. Ross, “You Can’t Touch This: Touch-Free Navigation through Radiological Images,” Surgical Innovation, Vol. 19, No. 3, 2012, pp. 301-307. doi:10.1177/1553350611425508
[37] A. F. Choudhri, T. M. Carr III, C. P. Ho, J. R. Stone, S. B. Gay and D. L. Lambert, “Handheld Device Review of Abdominal CT for the Evaluation of Acute Appendicitis,” Journal of Digital Imaging, Vol. 25, No. 4, 2012, pp. 492-496. doi:10.1007/s10278-011-9431-9
[38] F. Nicoli, Y. Lefur, B. Denis, J. P. Ranjeva, S. Confort-Gouny and P. J. Cozzone, “Metabolic Counterpart of Decreased Apparent Diffusion Coefficient during Hyperacute Ischemic Stroke: A Brain Proton Magnetic Resonance Spectroscopic Imaging Study,” Stroke, Vol. 34, No. 7, 2003, pp. e82-87. doi:10.1161/01.STR.0000078659.43423.0A
[39] C. H. Sotak, “The Role of Diffusion Tensor Imaging in the Evaluation of Ischemic Brain Injury—A Review,” NMR in Biomedicine, Vol. 15, No. 7-8, 2002. pp. 561-569. doi:10.1002/nbm.786
[40] B. K. Kang, D. G. Na, J. W. Ryoo, H. S. Byun, H. G. Roh and Y. S. Pyeun, “Diffusion-Weighted MR Imaging of Intracerebral Hemorrhage,” Korean Journal of Radiology Vol. 2, No. 4, 2001, pp. 183-191. doi:10.3348/kjr.2001.2.4.183
[41] R. A. Zimmerman, “Pediatric Cerebrovascular Disease,” JBR-BTR, Vol. 83, No. 5, 2000, pp. 245-252.
[42] G. C. Zheng, L. Tieqiang and T. Hindmarsh, “Diffusion MRI Studies of Experimental Animal Models and Patients with Stroke,” Chinese Medical Journal, Vol. 112, No. 2, 1999, pp. 176-181.
[43] B. C. Chu and K. Miyasaka, “The Clinical Application of Diffusion Weighted Magnetic Resonance Imaging to Acute Cerebrovascular Disorders,” No To Shinkei, Vol. 50, No. 9, 1998, pp. 787-795.
[44] A. Korge, C. J. Siepe, F. Heider and H. M. Mayer, “Total Cervical Disk Replacement-Implant-Specific Approaches: Keel Implant (Prodisc-C Intervertebral Disk Prosthesis),” Oper Orthop Traumatol, Vol. 22, No. 5-6, 2010, pp. 480 494.
[45] R. W. Katzberg, P. F. Benedetti, C. M. Drake, M. Ivanovic, R. A. Levine, C. S. Beatty, W. R. Nemzek, R. A. McFall, F. K. Ontell, D. M. Bishop, V. C. Poirier and B. W. Chong, “Acute Cervical Spine Injuries: Prospective MR Imaging Assessment at a Level 1 Trauma Center,” Radiology, Vol. 213, No. 1, 1999, pp. 203-212.
[46] B. B. Forster and R. A. Koopmans, “Magnetic Resonance Imaging of Acute Trauma of the Cervical Spine: Spectrum of Findings,” Canadian Association of Radiologists Journal, Vol. 46, No. 3, 1995, pp. 168-173.
[47] S. J. Davis, L. M. Teresi, W. G. Bradley Jr., M. A. Ziemba and A. E. Bloze, “Cervical Spine Hyperextension Injuries: MR Findings,” Radiology, Vol. 180, No. 1, 1991, pp. 245-251.
[48] S. C. Saur, H. Alkadhi, P. Stolzmann, S. Baumüller, S. Leschka, H. Scheffel, L. Desbiolles, T. J. Fuchs, G. Székely and P. C. Cattin, “Effect of Reader Experience on Variability, Evaluation Time and Accuracy of Coronary Plaque Detection with Computed Tomography Coronary Angiography,” European Journal of Radiology, Vol. 20, No. 7, 2010, pp. 1599-606. doi:10.1007/s00330-009-1709-7
[49] E. C. van Straaten, P. Scheltens, D. L. Knol, M. A. van Buchem, E. J. van Dijk, P. A. Hofman, G. Karas, O. Kjartansson, F. E. de Leeuw, N. D. Prins, R. Schmidt, M. C. Visser, H. C. Weinstein and F. Barkhof, “Operational Definitions for the NINDS-AIREN Criteria for Vascular Dementia: An Interobserver Study,” Stroke, Vol. 34, No. 8, 2003, pp. 1907-1912. doi:10.1161/01.STR.0000083050.44441.10
[50] M. Keberle, W. Kenn, H. Müller and D. Hahn, “Interob server Variability in CT of oro and Hypopharyngeal Carcinomas,” Rofo, Vol. 173, No. 7, 2001, pp. 583-590. doi:10.1055/s-2001-15833
[51] P. T. de Souza Figueiredo, A. F. Leite, F. R. Barra, R. F. Dos Anjos, A. C. Freitas, L. A. Nascimento, N. S. Melo and E. N. Guerra, “Contrast-Enhanced CT and MRI for Detecting Neck Metastasis of Oral Cancer: Comparison between Analyses Performed by Oral and Medical Radiologists,” Dentomaxillofacial Radiology, Vol. 41, No. 5, 2012, pp. 396-404. doi:10.1259/dmfr/57281042
[52] Q. Y. Lee, G. S. Chan, S. J. Redmond, P. M. Middleton, E. Steel, P. Malouf, C. Critoph, G. Flynn, E. O’Lone and N. H. Lovell, “Multivariate Classification of Systemic Vascular Resistance Using Photoplethysmography,” Physiological Measurement, Vol. 32, No. 8, 2011, pp. 1117 1132. doi:10.1088/0967-3334/32/8/008
[53] A. Ozcan, Y. Karslioglu, B. Kurt, O. Onguru and O. Gunhan, “Quantitative Evaluation of Immunohistochemical Staining in Gastrointestinal Stromal Tumors,” Analytical & Quantitative Cytology & Histology, Vol. 29, No. 3, 2007, pp. 159-165.
[54] R. Cannings, K. Hawthorne, K. Hood and H. Houston, “Putting Double Marking to the Test: A Framework to Assess If It Is Worth the Trouble,” Medical Education, Vol. 39, No. 3, 2005, pp. 299-308. doi:10.1111/j.1365-2929.2005.02093.x
[55] U. Garske, A. Haack, O. Beltrán, L. F. Flores-Suárez, J. P. Bremer, P. Lamprecht, J. Hedderich, J. Quetz, W. L. Gross, P. Ambrosch and M. Laudien, “Intra and Inter-Rater Reliability of Endonasal Activity Estimation in Granulomatosis with Polyangiitis (Wegener’s),” Clinical and Experimental Rheumatology, Vol. 30, Suppl. 70, 2012, pp. 22-28.
[56] I. Fletcher, M. Mazzi and M. Nuebling, “When Coders are Reliable: The Application of Three Measures to Assess Inter-Rater Reliability/Agreement with Doctor-Patient Communication Data Coded with the VR-CoDES,” Patient Education and Counseling, Vol. 82, No. 3, 2011, pp. 341-345. doi:10.1016/j.pec.2011.01.004
[57] A. B. Patel, A. Amin, S. Z. Sortey, A. Athawale and H. Kulkarni, “Impact of Training on Observer Variation in Chest Radiographs of Children with Severe Pneumonia,” Indian Pediatrics, Vol. 44, No. 9, 2007, pp. 675-681.
[58] J. L. Fleiss, “Statistical Methods for Rates and Proportions,” 2nd Edition, John Wiley, New York, 1981, pp 38-46.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.