Networking of Digital Images in the Academic Plastlc Surgery Program   James W. Fletcher, MD; Lee E. Edstrom, MD   The recent transition from standard kodachrome to digital images in plastic surgery has been dramatic. The advantages of digital photography including easier archiving, greatly reduced cost and greater versatility have been well documented. [ref] Recent developments in improved digital image quality and storage capabilities have allowed the plastic surgeon easy access to a variety of affordable options.   Solutions for capture, archiving and retrieval of images and the uses of these images vary greatly from surgeon to surgeon. Needs may be simple, such as the archiving and retrieval of images for documentation in the private office of a solo-practitioner. Requirements for an academic program may be more sophisficated, however. The tasks of capture, archiving and retrieval must be expanded to accommodate several physicians/nurses that may be caring for the same patient.   Ideally, the photographic record should be centralized so as to maximize completeness. Images of the patient should also be archived in a logical and systematic fashion to enhance easy retrieval of a great volume of patients and to permit easy access for teaching purposes. In addition, the plastic surgeon maintains the responsibility to ensure that the images are archived in a fashion preserve patient confidentiality. [1]   Our department has created a model of such a system to meet the needs of a training program that cares for multiple patients synchronously. We have developed the Local Area Network over a series of years during our own transition to digital photography.   The storage and movement of digital images is well accomplished.[2] Early descriptions in the literature related almost exclusively to the storage and retrieval of radiographic images on a central computer or via a limited local network. [3-7] Gradually the literature broadened to include the new capability to exchange images via existing communication networks, namely telemedicine. [8-12]. The novel ability of the digital image to enhance patient care via consultation provided the distant caregiver with access to remote pathologists, radiologists and other specialists. Until recently, the unique requirements of medical imaging including resolution necessitated larger files and consequently expensive equipment for archiving. New advances in technology have greatly reduced the cost and speed of these devices making them affordable solutions for a greater number of caregivers. Although the literature is replete with the evolution of digital image storage and communication, a review of Medline from 1966 to present reveals that the use of Local Area Networks for the use of a patient photographs us unique to our description. Most commonly, radiography or pathology applications populate the literature.   As our department converted to digital imaging, the impracticality of centralized archiving with one computer became apparent. Numerous residents caring for the same patients as the attending combined with several attendings in the department located in geographically distinct offices made the task of assimilating complete files difficult. The institution had an existing Local Area Network (LAN) in place, as most institutions, for standard file sharing and communication. Each of the computers in our department was already connected via an Ethernet 10/100 connection to a local hub with direct access to a central server. (FIGURE 1)
	All images were imported from a variety of digital cameras through numerous workstations. Residents would share a computer and a device for uploading images in a location discrete from the attendings. In addition, the capability for scanning 35mm color slides was added at one central location to be utilized by all faculty and residents. Each image was then imported into Mirror Image (Canfield Systems). The software allows for specification of storage location for all data and images. One may choose to save this data on the hard drive of the computer or on a volume of a server connected via a network. All data and images were saved to a server. Access to the server was arranged via the network support staff in our institution. Access to the volume where all images are to be stored is password protected utilizing commonly available software (Novell Client). From this central database, the images may be accessed from any workstation in the hospital that is connected to the network. In addition, the department purchased a laptop loaded with the Mirror Software allowing access from any conference room or clinic with a hard wire to the network.   This central storage and access allows for several important functions. The entire photographic archive of all residents and attendings is always readily available from any conference room or workstation at anytime. The ability to rapidly recall a myriad of clinical cases rapidly has added greatly to our conferences. (FIGURE 2)
	Additionally, each person with access to the network has file folders for the sharing of images to complete clinical series and add follow-up photographs. A user simply utilizes a simple export command from the software to the appropriate folder to share photos with other residents or attendings.   Additional benefits include the backup of all data is done nightly by the institution. This data is then sent to a remote location and archived in the event of a catastrophic loss of data or a system crash.   The issue of security and patient confidentiality with digital images has been debated.[1] This issue was addressed by several measures to prevent unauthorized access to the images. Mirror software utilized a proprietary format; this format may only be read and images displayed by workstations that possess the actual software and a security key physically attached to the computer. In addition, each user must log into the secure area of the server, exclusive to our department alone, with a specific user ID issued by the institutions network manager and password.   The network has also provided additional benefits. The standard use of file sharing by all members has greatly improved the ability to share call schedules, abstracts and other works in progress, presentations and any other files imaginable. Access to libraries of presentations means that carrying the information on a disk or on the hard drive of the laptop for presentation is unnecessary. We have also utilized the ability to access full text versions of common plastic surgery literature for real time online presentations in conference and at journal clubs. Journals available include Plastic and Reconstructive Surgery, Cleft Lip and Palate Journal and The Journal of Hand Surgery. All articles and diagrams are easily displayed via a digital projector in the conference room.   In summary, our department has found the utilization of the LAN an indispensable tool in the era of digital photography. The storage, retrieval and communication of images for patient care and for education have been vastly improved by the utilization of this common network. In addition, an added bonus of streamlined communication via file sharing and the access to digital projected journals has improved our conferences. The structure constructed by our department is secure, and may serve as a model for other departments utilizing digital photography.   References   1. Laske, C., Legal aspects of digital image management and communication. Medical Informatics, 1994.19(2): p. 189-96.   2. Noz, M.E., G.Q. Maguire, Jr., and W.A. Erdman, Local area networks in an imaging environment. Critical Reviews in Medical Informatics, 1986.1(1): p.81-133.   3. Aubry, F., et al., Design and implementation of a biomedical image database (BDIM). Medical Informatics, 1988.13(4): p.241-8.   4. Levine, B. and S.K. Mun, image management and communication systems: a new challenge in radiology. Medical Progress through Technology, 1989.15(3-4): p.199-216.   5. Anonymous, Delivering x-ray images on hospital computer networks. MD Computing, 1992.9(6): p.348,350.   6. Gillespy, T.d. and A.H. Row berg, Radiological images on personal computers: introduction and fundamental pnnciples of digital images. Journal of Digital Imaging, 1993.6(2): p.81-7.   7. Ratib, O., Y. Ligier, and J.R. Scherrer, Digital image management and communication in medicine. Computerized Medical Imaging & Graphics, 1994.18(2): p.73-84.   8. Dwyer, S.J.d., A.W. Templeton, and S. Batnitzky, Teleradiology: costs of hardware and communications. AJR. American Journal of Roentgenology, 1991.156(6): p.1279-82.   9. Mun, S.K., et al., Teleradiology/telepathology requirements and implementation. Journal of Medical Systems, 1995.19(2): p.153-64.   10. Osteaux, M., et al., Picture archiving and communication system (PACS): medical perspectives. Journal Belge de Radiologie, 1997.80(3): p.128-32.   11. Berry, R.F. and M.H. Barry, Evaluation ofa personal-computer-based teleradiology system serving an isolated Canadian community. Canadian Association of Radiologists Journal, 1998. 49(1): p.7-11.   12. Charvet-Protat, S. and F. Thoral, [Economic and organizational evaluation of an imaging network (PACS) (see comments)]. Journal de Radiologie, 1998.79(12): p.1453-9.