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PubMed2001

Digital radiography and film scanners: automating the transition to filmless radiology.

To facilitate the integration of digital radiography (DR) and legacy film/screen technology, we have devised a methodology for film digitization that optimizes workflow and integrates well with the picture archiving and communication system (PACS). This work was performed at Mercy Medical Center (Cedar Rapids, IA) using a film digitizer with built-in Digital Imaging and Communications in Medicine (DICOM) communication. The radiology department at Mercy has one DR system and three separate film/screen systems. The DR system software suite features DICOM Modality Worklist capability to provide complete radiology information system (RIS) integration functionality. This provides for patient demographic information to be automatically downloaded from the RIS worklist to populate the DICOM image header. Likewise, we have taken advantage of the film scanner's DICOM capability to develop software linking it with the hospital RIS. This capability provides a worklist downloading functionality equivalent to that of the DR. Patient demographics can then be rapidly downloaded as each film is digitized. The worklist capability of the scanner is essential in several respects. First, it guarantees that patient demographic information is completely accurate and, therefore, that the digitized x-ray image will be merged with the correct patient file in the PACS. Additionally, high film scanner throughput is achieved, guaranteeing that all inpatient-digitized films are as readily available on the PACS as their DR image counterparts. The digitized images have proven to be of diagnostic quality on the typical 1K by 1K PACS workstation. Also, as patients are admitted to the hospital, prior films from the radiology archive are digitized to form a readily available patient history for in-house physicians. Over time, we are building archival patient histories of soft-copy images that will enable increased availability of patient x-rays to both in-hospital and outside referring physicians, especially as more internet-viewing software becomes available to the out-of-hospital medical community. Finally, the results of this study show that high-throughput RIS integration of film scanning equipment is a key component to making a graceful transition to the filmless hospital as more DR systems are installed.

Humans↗

PubMed2001

Combining speech recognition software with Digital Imaging and Communications in Medicine (DICOM) workstation software on a Microsoft Windows platform.

This presentation describes our experience in combining speech recognition software, clinical review software, and other software products on a single computer. Different processor speeds, random access memory (RAM), and computer costs were evaluated. We found that combining continuous speech recognition software with Digital Imaging and Communications in Medicine (DICOM) workstation software on the same platform is feasible and can lead to substantial savings of hardware cost. This combination optimizes use of limited workspace and can improve radiology workflow.

Humans↗

PubMed2004

[Use of computer applications to support clinical processes. An electronic letter of discharge as resource for DRG-relevant coding].

Not long ago forensic aspects where the major driving force to complete and correct medical documentation. Diagnosis related groups becoming basic data for billing of hospital treatment in Germany now extremely extend the need for complex administrative documentation over-ruling all medical documentary needs. Due to unchanged personnel resources in hospitals and due to a lack of comfortable tools supporting these documentary needs medical personnel in most hospitals is confronted with an annoying effort to fulfill these needs. As a result innumerable hours of working time have to be shifted from patient focused to administrative work. This paper introduces a computer system based on a hospital-wide documentation concept and clinical workflow allowing to derive administrative data straight from medical documents so that redundant documentation and discrepancies between medical and administrative documentation can be avoided.

Computer Systems↗

PubMed2005

The development of quality assurance programs for radiotherapy within the German Hodgkin Study Group (GHSG). Introduction, continuing work, and results of the radiotherapy reference panel.

BACKGROUND AND PURPOSE: The German Hodgkin Study Group (GHSG), including more than 500 participating centers, established a central radiotherapy (RT) reference center to improve quality of treatment, starting with the first study generation in 1978. More than 11,000 patients with Hodgkin's lymphoma (HL) have been enrolled into these trials. Extensive continuing quality assurance programs (QAPs) during the study generations have been performed. The purpose of the present article is to summarize the experiences and results of the performed and ongoing QAPs. MATERIAL AND METHODS: A panel of expert radiation oncologists (second study generation HD4-6, 1988-1994, and third study generation HD7-9, 1993-1998) retrospectively evaluated the adequacy of treatment fields, applied radiation doses, treatment time, and technical parameters. Furthermore, a detailed analysis of relapses in correlation with the performed RT was conducted. For the fourth study generation (HD10-12, 1998-2002), the RT reference center changed from Munich to Cologne. New RT QAPs were initiated according to the demands of the new trials and former programs were enhanced: (1) central prospective radiation oncologic review of cross-sectional imaging (HD10, HD11) to create the individual radiation treatment plan; (2) retrospective analysis of the adequacy of the performed involved-field (IF) RT (HD10, HD11); (3) the multidisciplinary HD12 panel (radiation oncologists, medical oncologists, diagnostic radiologists); (4) initiation and integration of a teleradiotherapy network into the GHSG trials. RESULTS: A strong achievement of these activities in the era of extended-field RT was to show that major deviations of radiation treatment portals and radiation dose from prospective treatment prescriptions revealed to be unfavorable prognostic factors for patients with early-stage HL (HD4). The central prospective radiation oncological review of all diagnostic imaging (HD10, HD11) showed that corrections of disease involvement in 49% of patients (593/1,214) with early stages (HD10) and in 67% of patients (936/1,397) with intermediate stages (HD11) were necessary. These procedures had a significant impact on the correctness of stage definition, allocation to treatment groups and on the extension of the IF treatment volume. Until now, 1,080 patients in HD10 and HD11 have been evaluated retrospectively with regard to the adequacy of the performed IF-RT. Although the participating institutions got a precise RT prescription, interim results reveal deviations in a significant number of cases. In the HD12 trial (advanced stages), a multidisciplinary panel of radiation oncologists, radiologists and medical oncologists reviewed all the diagnostic imaging from diagnosis throughout the treatment in comparison to the documentation forms. For patients with poor response to chemotherapy, the panel recommended RT independent of the randomization. This procedure ensured that patients with a poor response to chemotherapy received additional RT. 1,080 of 1,594 randomized patients (68%) could be analyzed. After chemotherapy, 599 patients (56%) showed residual disease (> 1.5 cm), and in 145/1,080 patients (13.5%) the panel recommended additional RT independent of the randomization arm. The introduction of electronic image transfer optimized and simplified the workflow of the QAPs. Rapid online consultation and real-time teleconferences regarding disease involvement, patient management and communication of the RT prescription with connected hospitals proved to be extremely helpful. CONCLUSION: Today, radiation oncologists in the GHSG perform a continuous and efficient QAP to improve treatment quality of study patients. For early favorable and unfavorable HL a central prospective review of all diagnostic imaging is performed by expert radiation oncologists to control the disease extension and to define the IF treatment volume. Retrospective analysis of RT portals by an expert panel detects faults in the applied irradiation. Participants are trained on the definition of IF-RT by workshops on the occasion of annual GHSG meetings and on the annual meetings of the German Society of Therapeutic Radiation Oncology (DEGRO). For the advanced stages a multidisciplinary panel evaluates the treatment response to chemotherapy. Patients with a poor response receive additional RT due to the panel's recommendation. The introduction of teleradiotherapy into the GHSG trials improves the dialogue between the central RT reference center and study participants and thus contributes to high RT quality for study patients.

Disease-Free Survival↗

PubMed2002

[Efficient OP management. Suggestions for optimisation of organisation and administration as a basis for establishing statutes for operating theatres].

Economic aspects have gained increasing importance in recent years. The operating room (OR) is the most cost-intensive sector and determines the turnover process of a surgical patient within the hospital. Thus, optimisation of workflow processes is of particular interest for health care providers. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated analogously to a manufacturing process. All steps involved in producing the end-result can and should be analysed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide to manage this process is important and leads to the introduction of a specialised "OR manager". This position must have the authority to issue directives to all other members of the OR team. An OR management subordinates directly to the administration of the hospital. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. This paper gives a short introduction into the difficulties of organising an OR. Some suggestions are made to overcome common shortcomings in the daily practise. A proposal for an "OR statute" is presented that should be a basis for discussion within the OR team. It must be modified according to individual needs and prerequisites in every hospital. The single best opportunity for dramatic improvement in effective resource use in surgical services lies in the perioperative process. The management strategy must focus on process measurement using information technology and feed-back implementing modern quality management tools.However, no short-term effects can be expected from these changes. Improvements take about a year and continuous feed-back of all measures must accompany the reorganisation process.

Appointments and Schedules↗

PubMed2005

[Multimedia preoperative patient information].

Due to heavy workloads and shortage of staff, doctors often find it difficult to explain operations to their patients with the legally required detail and timing (in Germany, 24 h preop). This is however mandatory for obtaining informed consent. We developed a computer program that generates films explaining 24 common orthopedic operations and blood transfusion. They explain the operation, early postoperative phase, and benefits and risks to the patient. At our clinic, this program is used in daily routine and precedes the actual doctor-patient conversation for informed consent. We asked 300 patients about their satisfaction with the newly developed program. The multimedia presentation gives the patient more time, enough detail and clarity, and the chance to repeat parts of the film. For the doctor, it saves time. The time gap required in Germany between explanation and operation is thus easily adhered to. In case of legal problems, the film can be used for evidence. The use of this multimedia presentation to help in getting informed consent is improving workflow considerably.

Computer-Assisted Instruction↗

PubMed2004

[The anterosigmoidal approach. A function-preserving surgical method for petroclival tumors].

BACKGROUND AND OBJECTIVE: The antero- or persigmoid approach preserves all functional structures of the petrous bone and, therefore, is an alternative to the classic laterobasal approaches for exploring the petroclival region. As high morbidity is assumed and it is a time consuming procedure, this approach is not well known. METHODS AND PATIENTS: Initially, a cadaver study using computer assisted surgery was used to determine the surgical workflow before we optimized our surgical procedures. RESULTS: In a series of 7 patients with benign tumors growing from the petrous apex to the petroclival region, we were able to resect all tumors completely via the anterosigmoidal surgical corridor using computer assisted surgery. CONCLUSIONS: The navigation-guided anterosigmoidal approach is an excellent method, allowing a good overview of the petroclival region. In patients suffering from complex petroclival tumors, it offers a real chance to achieve complete microsurgical tumor resection without functional defects by an interdisciplinary neuro-oto-surgical session.

Adolescent↗

PubMed2006

[Clinical pathways--practical aid for the physician? Example: clarification of the suspicion of tuberculosis].

Guidelines, clinical pathways and clinical algorithms are popular instruments nowadays to ensure quality as well as the economic efficiency of medical work. These terms themselves, however, are frequently defined only in a diffuse way. Thus, medical standard procedures often complicate clinical workflows more than to facilitate decision making in everyday life. In our department, feasible standardized approaches have been generated in the form of structured text documents, which on the one hand can aid clinical decision making at the bedside and on the other hand serve as medical sketches for the generation of operational treatment paths on an interdisciplinary level. Structure and content of such an instructional text are exemplified here using our standardized document for the diagnostic approach when tuberculosis is suspected.

Critical Pathways↗

PubMed2002

[Time optimized modern shock room management using digital techniques].

Emergency room management means time management. A time and four color based algorithm is described to improve workflow, follow up of diagnostic procedures and initial treatment. As a result introducing the time based interdisciplinary emergency algorithm within 60 minutes all necessary treatment and diagnostic procedures were completed. This algorithm is an effective tool to improve emergency room treatment.

Algorithms↗

PubMed2007

Power matters in closing the phenotyping gap.

Much of our understanding of physiology and metabolism is derived from investigating mouse mutants and transgenic mice, and open-access platforms for standardized mouse phenotyping such as the German Mouse Clinic (GMC) are currently viewed as one powerful tool for identifying novel gene-function relationships. Phenotyping or phenotypic screening involves the comparison of wild-type control mice with their mutant or transgenic littermates. In our study, we explored the extent to which standardized phenotyping will succeed in detecting biologically relevant phenotypic differences in mice generated and provided by different collaborators. We analyzed quantitative metabolic data (body mass, energy intake, and energy metabolized) collected at the GMC under the current workflow, and used them for statistical power considerations. Our results demonstrate that there is substantial variability in these parameters among lines of wild-type C57BL/6 (B6) mice from different sources. Given this variable background noise in mice that serve as controls, subtle phenotypes in mutant or transgenic littermates may be overlooked. Furthermore, a phenotype observed in one cohort of a mutant line may not be reproducible (to the same extent) in mice coming from a different environment or supplier. In the light of these constraints, we encourage researchers to incorporate information on intrastrain variability into future study planning, or to perform advanced hierarchical analyses. Both will ultimately improve the detectability of novel phenotypes by phenotypic screening.

Animals↗

PubMed2003

[Flat-panel detectors in X-ray systems].

For all application segments X-ray systems with flat-panel detectors increasingly enter the market. In digital radiography,mammography and cardiologic angiography flat-panel detectors are already well established while they are made ready for market introduction in general angiography and fluoroscopy. Two flat-panel detector technologies are available. One technology is based on an indirect conversion process of X-rays while the other one uses a direct conversion method. For radiography and dynamic applications the indirect method provides substantial advantages, while the direct method has some benefits for mammography. In radiography and mammography flat-panel detectors lead to clear improvements with respect to workflow, image quality and dose reduction potentials. These improvements are fostered by the immediate availability of the image, the large dynamic range and the high sensitivity to X-rays. New applications and the use of complex image processing algorithms have the potential to enlarge the present diagnostic range of applications. Up to now, image intensifiers are still the well-established technology for angiography and fluoroscopy. Nevertheless flat-panel detectors begin to enter this field, especially in cardiologic angiography. Characteristics of flat-panel detectors such as the availability of distortion-free images, the excellent contrast resolution, the large dynamic range, the high sensitivity to X-rays and the usability in magnetic fields provide the basis for improved and new diagnostic and interventional methods.

Angiography↗

PubMed2003

[New computed radiography technologies in digital radiography].

Digital radiography (DR) has become integral to modern diagnostic radiology. One of the earliest forms of DR, computed radiography (CR) using storage phosphors, has established itself as the mainstay of DR-based diagnostic imaging over the past 20 years. More recently, flat-panel DR systems based on solid state X-ray detectors with integrated, large-area, active-matrix readout electronics are promising further improvements in clinical workflow and image quality. Despite CR's longevity, innovations continue to be made. New developments in CR screen technologies, like structured (needle) screens, and new scanner concepts based on line-at-a-time reading promise major improvements in image quality (comparable to that of flat-panel systems), system through-put and physical size, at a cost comparable to that of today's systems. Thus, despite the advent of flat-panel acquisition systems, there will still be an important role for CR in the foreseeable future. After a brief review of the current state of CR technology, this paper will explore several of these new CR developments and present some examples of their potential clinical impact.

Artifacts↗

PubMed2003

[The use of flat-panel detectors for CT imaging].

Clinical CT has reached a very high performance level by now. The introduction of spiral scanning and of multirow detectors have allowed to image even large body sections in very short time and with isotropic, high spatial resolution of better than 1 mm. For further improvements with respect to detector technology the use of flat-panel detectors (FPD), which have been developed for radiographic applications, is currently under investigation. In this article we discuss the general demands on CT detectors and specifically the suitability of FPDs with respect to CT imaging. FPDs offer excellent performance for the imaging of high-contrast structures with high spatial resolution.Low-contrast resolution and dose efficiency, however, do not yet reach the level of performance of dedicated CT detectors; temporal resolution is also limited. FPDs appear primarily suited for special applications in CT as for example 3D angiography or intraoperative imaging which also allows for improvements in workflow. For standard diagnostic CT they are not to be recommended at present, last but not least for dose reasons. The respective technical developments will have to be reassessed constantly in the future. The development of detector systems which are equally suited for radiography and CT constitutes an attractive goal.

Angiography↗

PubMed2005

[KIS-RIS-PACS integration: the Marburg approach].

When describing the development of data processing at the Department of Radiology at the Philipps University of Marburg, three phases can be identified covering the areas of patient care, education, and research as well as administrative and organizational aspects. The first phase (1987-1995) was centered on radiology and characterized by the early implementation of the radiology information system (RIS) and installation of a picture archiving and communication system (PACS). The experiences gained during this phase led to intensive discussion on application-oriented information processing. The second phase (1996-2000) describes the changes in the general framework brought by Internet technology and international standards. The course was set for the future of data processing in the hospital setting. The phase ended with implementation of a clinical workplace system (KAS) as the basis for a comprehensive electronic patient record and the switch in radiology to an integrated RIS solution. The third phase (2001-2006) addressed further implementation and development of clinical data management in which both regular documentation of patient data and information processing not related to patients are optimized by making use of Intranet/Internet technology. It includes the hospital wide implementation of PACS and the forthcoming phase of information processing increasingly shaped by workflow and decision support.

Database Management Systems↗

PubMed1997

[Advantages and cost-benefit analysis of various teleradiology scenarios].

With the increasing number of users and technical improvements, there are several application scenarios of teleradiology. To perform a cost-benefit analysis, an approach is presented, which focuses on both monetary and qualitative aspects. Process-related, qualitative and quantitative evaluations are described. The prestudy compares the radiological workflow before and after the introduction of a teleradiology system. A scoring model is part of the qualitative evaluation. The quantitative study focuses on costs and savings. Amortisation and a net present value of savings versus costs can be derived using dynamic investment methods. Savings can be achieved after a short time under ideal conditions, but there is no guarantee for a reimbursement for all systems.

Computer Systems↗

PubMed1999

[Wish and reality in installation of a clinic-wide system for image and documentation access].

PROBLEM: This report describes the problems that can occur in the representation of the radiological workplace in a digital environment. On one hand the radiologist can sometimes access good equipment in "stand-alone" surroundings (CT, laser printer, workstations,...); on the other hand, the existing insufficient communication between different components is only rarely qualified to support the radiological workflow. This unsatisfactory framework handicaps the required clinic-wide distribution of radiological information. METHODS: From the beginning we defined user groups requiring different radiological data closely associated with specific hard- and software: The radiological workstation in the department for reporting and image processing. The demonstration workstation in wards/outpatient departments for clinicians involved in treatment. Standard PCs with access to the digital medical document for clinicians involved in treatment. At all workstations the medical as well as the legal unity of digital radiological images and the corresponding report is ensured. RESULTS: Only the first two user groups have unrestricted access to the RIS database and to the PACS archive. We have decided that the RIS should be the master of the RIS/PACS-System. For an effective master/slave relationship between RIS and PACS archive and PACS workstations we suggest to mark images and/or series of images. CONCLUSION: The third user group depends on the information exported by the radiologist from PACS. After the report is written and signed by the radiologist, the digital report is transferred from the RIS to the HIS. The report is automatically attached to these images. Authorized personnel at the wards and outpatient are able to read the combination of validated report and exported radiological images as part of the digital medical record with an intranet browser on standard PCs.

Computer Systems↗

PubMed1999

[Aspects of electronic patient records in radiology].

PURPOSE: The computerized patient record must provide patient- and problem-oriented access to all relevant patient data for health care professionals. The aspects of such systems will be analyzed in the light of the radiologist's needs. METHODS: Integration of the computerized patient record in a hospital communication network allows automated data exchange with the ancillary systems. Accessibility of electronic textbooks supports case-based learning during routine work. RESULTS: The computerized patient record not only supports routine clinical tasks but also training, education and research. The workflow in a hospital can be supported by the computerized patient record. Studying the tasks of a radiology department shows that both clinicians and radiologists will benefit from such a system. DISCUSSION: Current implementations of clinical computerized workstations offer only a fraction of these features. Advances in technology and increasing demands at the point of care will promote the development of new information systems of this kind.

Computer Systems↗

PubMed2000

[Internet technology for clinical applications in a digital radiography department].

PROBLEM: To provide an overview and to assess the clinical feasibility of Internet technology-based systems for hospital-wide image and report distribution as well as for video conferencing. METHODS: The paper describes the theoretical concept behind, the various technical approaches and the experience gained from different systems. RESULTS: Image and report distribution: Advantages include the universal availability of images and reports inside and outside hospitals; ease of use; security features; image and report integration; cost savings by reducing support and training efforts and by optimising available hardware. The main critical issues are performance and workflow integration with RIS and PACS. Video conferencing: main advantages are the standardised, software-based approach and the low investments for hard- and software. Depending on the desired usage the communication performance can be seen as inappropriate. CONCLUSION: Today, Internet technology-based systems appear to satisfy the main clinical needs in radiology. The mentioned drawbacks could be eliminated by means of modified software implementation and focused standardisation efforts. Considering the numerous advantages of these systems a further distribution can be expected for the future.

Communication↗