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PubMed1998

Comparative evaluation of a commercial system for identification of gram-positive cocci.

The performance of a new commercial system for the identification of different groups of gram-positive cocci [BBL Crystal Gram-Positive (GP) Identification System; Becton Dickinson Microbiology Systems, Germany] was evaluated in comparison with two currently used commercial systems, the API Staph and the API Strep (bioMérieux Diagnostic, Germany). A total of 191 strains from seven different gram-positive genera comprising 32 different species were tested. For the BBL Crystal GP system, the correct identification rate without additional tests was 89.5% at the species level and 97.9% at the genus level. The findings suggest that the newly introduced BBL Crystal GP ID system provides an accurate method for the identification of gram-positive cocci, with an overall rate of correct species identification of about 90%, similar to that of the established API systems. Its major advantage is the extended spectrum of taxa included in a single test panel in contrast to the two different API test kits. Furthermore, the simplicity of use and the safe and rapid handling in a closed system conveniently accommodate existing laboratory workflow.

Bacteriological Techniques↗

PubMed1999

Comparison of two automated systems for the isolation of mycobacteria from clinical specimens.

The Bactec MGIT 960 (Becton-Dickinson, UK) automated mycobacterial liquid culture system was compared with the Bactec 9000 MB (Becton-Dickinson) in order to assess ease of use, diagnostic reliability and safety features. One thousand twenty-nine clinical specimens were cultured in parallel, yielding a total of 125 (12.1%) mycobacterial isolates, including 71 Mycobacterium tuberculosis and 18 Mycobacterium avium. The Bactec MGIT 960 demonstrated a mycobacterial recovery rate and speed of detection equivalent to that of the Bactec 9000 MB for clinically important isolates. The Bactec MGIT 960 integrates smoothly into laboratory workflow, does not require needle inoculation and has a much larger capacity than the Bactec 9000 MB.

Bacteriological Techniques↗

PubMed2026

Comparative genomics reveals genotype-phenotype concordance and cryptic resistomes in clinical Pseudomonas aeruginosa.

BACKGROUND: Pseudomonas aeruginosa (P. aeruginosa) is a major pathogen because of its adaptability. It shows rapid evolution of multidrug resistance (MDR). Phenotype-based diagnostics often fail to detect silent resistance determinants and early adaptive changes. This study integrates phenotypic profiling with whole-genome sequencing (WGS) to examine resistance architecture in clinical isolates from eastern India. METHODS: From 1295 culture-positive P. aeruginosa specimens collected at a tertiary care hospital in eastern India. Using predefined criteria, representative MDR and non-MDR isolates were selected, including distinct resistance phenotypes, specimen-source diversity, and hospital and community-acquired settings; multivariate analysis of resistance profiles illustrated phenotypic diversity. Antimicrobial susceptibility assessed using VITEK-2 and Kirby-Bauer disk diffusion, species identity confirmed by 16 S rRNA sequencing, and genomic analysis processed through a reference-guided workflow. Antimicrobial Resistance (AMR) determinants were identified through CARD, and phylogenetic tree constructed from 454 publicly available P. aeruginosa genomes. RESULTS: MDR exhibited greater sequence divergence relative to PA14 (~ 69,000 variants) than the non-MDR isolate (~ 58,700 variants), with > 92% coverage at ≥ 30X depth. Strong genotype-phenotype concordance observed in MDR isolates across five antibiotic classes, associated with β-lactamase variants (PDC-67, OXA-396) and regulatory adaptations (ArmR, cprS). The non-MDR isolate harboured gyrA (T83I) resistance-associated mutations, PDC-1, and OXA-847 without phenotypic expression, indicating silent resistome. Phylogenetically, MDR isolates clustered tightly within the phylogeny, while the non-MDR isolate formed a distinct lineage. CONCLUSION: Observed genomic differences align with adaptation under antimicrobial selection, though confirmation requires larger collections. The non-MDR isolate retained a silent resistome. Findings highlight limitations of phenotype-only diagnostics, support genomic data integration, and emphasize transcriptomics for hidden resistance expression and regulatory dynamics.

Pseudomonas aeruginosa↗

PubMed2006

Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images?

Feasibility of diagnosing small bowel obstruction on multidetector-row computed tomography (MDCT) using coronal reformations alone is evaluated. Three radiologists with subspecialty training in abdominal imaging reviewed abdominopelvic CT of 67 patients in consensus. Thirty-four patients had surgically proven small bowel obstruction. The remaining 33 patients had CT for other reasons and had no intestinal obstruction. The images were displayed in either axial or coronal planes and were reviewed on separate days . Each CT was evaluated for the presence of small bowel obstruction and its etiology when applicable. Thirty-three (100%) of 33 patients were correctly diagnosed not to have intestinal obstruction on coronal images. Thirty-four (100%) of 34 patients were correctly diagnosed to have small bowel obstruction on both forms of image display. There were five patients where the final surgical diagnosis for the etiology of small bowel obstruction did not agree with the interpretation of either the coronal or axial images; however, in all five patients, the interpretations of axial and coronal images were similar. In only one patient, the etiology of small bowel obstruction based on the coronal images did not agree with that of axial images and the surgical result; however, the site of small bowel obstruction was correctly diagnosed. There were approximately 20% fewer images in the coronal reformation data set, and the radiologists found review of these images to be easier for localizing the zone of transition in small bowel obstruction. Very high diagnostic accuracy can be achieved based on coronal reformations alone, and this form of image display may potentially be substituted for the conventional axial images. Since there are fewer images to review when the studies are displayed in coronal plane, this may positively impact radiologist workflow.

Artificial Intelligence↗

PubMed2001

Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital.

Many large urban hospitals converting to filmless radiography use a phased approach for digital imaging implementation. In fact, this strategy often is recommended by picture archival communication systems (PACS) experts and vendors alike for large, busy hospitals installing PACS in existing physical facilities. The concern is that comprehensive conversion from film-based to digital imaging may be too overwhelming an adjustment in operations for a medical staff to effectively handle without serious disruption of workflow for patient treatment and care. Elmhurst Hospital Center is a 543-bed hospital located in the Borough of Queens in New York City. Owned by the New York City Health and Hospitals Corporation, this municipal teaching hospital provides services to a patient mix that is 38% indigent with no insurance, 50% covered by Medicaid or Medicare, and 12% affiliated with HMOs. Most inpatients are admitted through the emergency department. Forty-five percent of all radiology procedures conducted are for emergency patients. Historically, up to 25% of all diagnostic imaging examinations were never reported formally by radiologists. Report turnaround time for the remaining 75% was unacceptable, with only 3% of all imaging examinations reported within a 12-hour period in 1996. Both situations existed in great part because physicians and residents who felt they needed access to films simply took them. Many were never located or returned days after they were taken. In 1998, Elmhurst Hospital Center replaced its RIS and added voice recognition dictation capabilities in January 1999. A hospitalwide PACS was deployed 10 months later. With the exception of mammography, the hospital converted to filmless radiography within 60 days. The critical objectives to maintain control of films and radically improve the reporting process were achieved immediately. Over 99% of all examinations now are formally reviewed and reported. Only 7% of all reports take 1 or more days to generate. This report describes Elmhurst Hospital's efforts to make improvements in the delivery of radiology services and the reasons attributed to its rapid conversion to becoming a filmless (mammography excluded) medical center. The impact of the PACS on radiology department operations and service is discussed.

Hospital Bed Capacity, 500 and over↗

PubMed2002

Impact of tightly coupled PACS/speech recognition on report turnaround time in the radiology department.

As medical reimbursements decline in real dollars, solid evidence of potential cost savings and improved service is needed to justify purchasing new health care equipment. Many picture archiving and communication systems (PACS) and speech recognition studies have examined the cost savings implied by their adoption, and some studies have investigated service improvement as defined by shortened report turnaround times (RTT). However, it is not clear what synergy is possible with adoption of tightly coupled PACS/speech recognition and how that would impact RTT. A survey of more than 40 North American sites was undertaken to quantify the manpower and RTT efficacy of four possible workflows: film with transcription, film with speech recognition, PACS with transcription, and PACS with speech recognition (as distinct applications or tightly coupled). Twenty-five percent of sites completed the full survey.

Data Collection↗

PubMed2002

Enterprise-wide worklist management.

Radiologists in multi-facility health care delivery networks must serve not only their own departments but also departments of associated clinical facilities. We describe our experience with a picture archiving and communication system (PACS) implementation that provides a dynamic view of relevant radiological workload across multiple facilities. We implemented a distributed query system that permits management of enterprise worklists based on modality, body part, exam status, and other criteria that span multiple compatible PACSs. Dynamic worklists, with lesser flexibility, can be constructed if the incompatible PACSs support specific DICOM functionality. Enterprise-wide worklists were implemented across Generations Plus/Northern Manhattan Health Network, linking radiology departments of three hospitals (Harlem, Lincoln, and Metropolitan) with 1465 beds and 4260 ambulatory patients per day. Enterprise-wide, dynamic worklist management improves utilization of radiologists and enhances the quality of care across large multi-facility health care delivery organizations. Integration of other workflow-related components remain a significant challenge.

Community Networks↗

PubMed2002

The electronic imaging technology specialist: the role of a new radiology subspecialty for the 21st century.

Modern radiology departments need radiologists who understand subjects not thoroughly addressed during residency training: picture archiving and communication system (PACS) technology and administration, usability and acceptance testing, workflow analysis, digital image acquisition, compression, and quality control. A structured Electronic Imaging and Technology (EIT) fellowship program focusing on practical, technical, and administrative aspects of electronic imaging, teleradiology, and PACS was formed at the Mayo Clinic, Rochester, Minnesota. We review the rationale for dedicated EIT training, define its core curriculum, and discuss the purpose of an EIT specialist. Resources necessary to optimize this fellowship are discussed. Scheduling and coordination with clinical training is presented. The responsibilities and deliverables expected of an EIT fellow are examined. We differentiate the EIT fellowship from an Informatics fellowship and explore the role an EIT specialist within a department. An EIT fellowship provides practical and valuable skills, and can be compared to the added expertise gained through established fellowship training programs.

Curriculum↗

PubMed2002

Radiology workstation design for the medical intensive care unit.

The "one-size-fits-all" approach for radiology workstation design is not good enough anymore. While most of the picture archiving and communication system (PACS) vendors are racing to add more features to the radiology workstation, there is little interest in addressing the specific needs of other hospital departments. Significant delays in the availability of radiology reports are often caused by the fact there is not enough Intensive Care Unit (ICU) volume to justify a full time radiologist. Consequently, the radiologist assigned to cover the ICU exams, most likely working from a different building, will read the ICU exams only at certain times, depending on the limitations for remote image availability. This paper addresses the main objectives in designing a digital radiology workstation for use in the medical ICU (MICU), requiring enhancements to current PACS systems. Our suggestions for PACS improvement follow the ICU digital workflow starting with the transfer of the images from the modality, continuing with the presentation of the radiology examination to different types of users (radiologists or ICU staff), up to the creation and distribution of the reports.

Computer Systems↗

PubMed2002

RIS minus PACS equals film.

Web-based integration methods can be used to resolve a fundamental issue in the transition from film to a picture archiving and communication system (PACS): the identification of relevant prior studies only available on film. Even in the most ambitious conversions from a film-based environment to PACS, there are issues regarding prior studies not on PACS. Failure to compare with prior exams is one of the known risk factors for malpractice in radiology. While most commercial PACS systems today have some degree of RIS integration, knowledge of prior studies is usually limited to an awareness of studies in the PACS. On the other hand, most RIS systems today do not or cannot distinguish between studies on film and those in PACS. We made the observation, from a set theory perspective, that in general: Therefore we sought to create a system that would query both the RIS and PACS and reconcile the results using the above set operation. The query is initiated from a display station via the invocation of a Web browser installed on that station. The process of starting the browser is implemented using a scripting language provided by the workstation vendor, though the use of other mechanisms, such as the CCOW (Clinical Context Object Workgroup) or IHE (RSNA Integrated Healthcare Enterprise) interfaces, can be supported by this architecture. The medical record number, which identifies the current patient and is the primary parameter of the query, is passed as part of the URL (Universal Resource Locator) used to launch the browser. Once running, the browser connects to a Web server that hosts a JSP (Java Server Page) page that performs a DICOM query of the PACS and an HL7 query of the RIS, and then collates the results using the set operation described above. Both the DICOM and HL7 functionality are provided by Java-based toolkits developed in house. The results are returned to the client's browser as a standard HTML page with a tabular format detailing which studies are on PACS and which are available only on film. The responsiveness of the system in terms of time required to complete the two queries and display the results was measured. In addition, the number of diagnostic reports, whose retrieval was triggered by the results of the queries, was monitored to determine the overall performance and use of the system. This project demonstrates that, with minimal modification of commercial software, Web-based integration methods exist to enable patient-context sensitive queries from the diagnostic workstation that identify relevant prior studies that exist only on film and are unknown to the PACS. As a result radiologist workflow is enhanced by the elimination of the need to consult a physically separate system for this type of information. In addition, quality of service is improved by providing more accurate and easier identification of relevant prior studies.

Information Storage and Retrieval↗

PubMed2002

Filmless in New Jersey: the New Jersey Medical School PACS Project.

Transitioning to a filmless department is no easy task, especially at a large academic medical center. At the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, a phased modality integration schedule was implemented to allow the technical and clinical staff to gradually absorb all of the changes to workflow. One-on-one training sessions were designed to prepare radiologists and referring clinicians to access and navigate the in-house picture archiving and communication system (PACS) workstations as well as to view images over the Internet via the PACS Web server. An interdepartmental steering committee was formed to plan deployment of the in-house workstations. A planning committee met on a weekly basis to outline placement of workstations within the Radiology Department, and to redesign the reading room. A user group was created to discuss specific user problems. Of particular interest was the challenge of outfitting a dozen conference rooms with projection systems capable of displaying radiologic images. We distinguished between regular and working conferences. At regular conferences only a few cases are reviewed over the course of an hour and only after the diagnosis has been made at a PACS workstation. In contrast, the surgical and medical intensive care units conduct daily working conferences. At those sessions the images of 20 to 30 patients are reviewed, many of them for the first time, and for each case a definitive diagnosis is expected. During the implementation process, a range of issues came up that limited access of certain studies to radiologists and referring clinicians alike. Even after the initial PACS installation, many studies went unread because of a lack of worklists. Other problems included image ordering for head computed tomography and magnetic resonance imaging. A few of our modalities were not DICOM compliant and needed image capture devices in order to be integrated with the PACS. To our dismay, this was also true of one of our modalities that was supposed to be DICOM compliant. These problems, and the solutions we discovered, are discussed in this paper.

Academic Medical Centers↗

PubMed2002

The strategy to be "paperless" via a cost-effective filmless plan.

The group of folks assigned to the project were identified, and on April 23, 2001, an Request For Information (RFI) was released to 11 preidentified Picture Archiving Communication System (PACS) vendors. Our project was unique in 2 respects. First, there was an aggressive timeline. Second there was specific outpatient environment requirements. There was a need to move images and other patient-related data between several sites while depending heavily on the Wide Area Network (WAN) design rather than the typical Local Area Network (LAN) configuration. We learned quickly that there was not one live site, at which we could visit to observe our vision in action, nor had any solution been built to accomplish our specific objectives. The months of May, June, and July consisted of vendor meetings, RFI response reviews and, clinical and corporate visits ending on August 9, 2001 when our prime vendor of choice was selected. During this process, we identified deal breakers outlining specific needs for "go live," which is targeted for Q2 (2nd Quarter) 2002. The biggest workflow opportunity is to be paperless as well as filmless. By this we not only mean traditional RIS information but also patient documents (insurance information, physician script) as well as modality-patient-specific information. All of this information needs to be available electronically to accomplish) any patient record, any place, any time! The month of August was filled with WAN and LAN solution investigations. The solution of choice will be both cost effective and challenged to achieve 99.9% reliability. A cost-benefit analysis was performed and reviewed to better understand our return on investment. The months of September and October have been dedicated to Computerized Radiography (CR) technology. The TEAM reviewed 3 solutions, which consisted of both sit-down sessions as well as clinical site assessments. Again, "deal breaker" criteria were summarized and a solution chosen. Contract negotiations will soon conclude, and an aggressive implementation will begin!

Ambulatory Care Facilities↗

PubMed2002

Defining the role of a PACS technologist.

As hospitals convert from conventional image processing to picture archiving and communication systems (PACS) technology, new job opportunities arose for PACS analysts, PACS system administrators, PACS operators, and PACS trainers. To support a PACS, these positions require education in computer information systems and work experience in information technology. At Texas Children's Hospital, new roles for radiologic technologists (RT) in supporting the operation of PACS were not recognized until after implementation of the filmless system. A new position entitled PACS technologis was created, but roles and responsibilities largely were undefined. The inadequate job description contributed to problems with appropriate utilization of the PACS technologist. The primary role of the technologist was nebulous, and the priority of tasks was undefined. There was an excessive volume of information and technology to be mastered. The role represented a new paradigm, so no template for the job description was available that encompassed the array of functions to be performed. The result was a "morph" of the RT and PACS analyst job descriptions that was contrived and unworkable. The role of the PACS technologist is vital to the operation of the radiology department that uses PACS. There is a well-established need for cross training of RTs in PACS. PACS technology is not taught in RT training programs. There are recurrent communications problems between RT and Information Technology (IT) personnel. The PACS technologist can participate in a number of activities that improve the overall level of proficiency in the imaging operation, such as specialized PACS training for RTs, collection and analysis of quality control data, and planning for installations of PACS acquisition modalities. RTs have acquired knowledge of medical terminology and human anatomy, imaging modalities, and workflow. These qualifications constitute a common basis for communication with other RTs, physicians, and other health care providers. In addition the appropriate candidate for PACS technologist should have computer software and hardware knowledge, interpersonal skills, oral and written communications skills, and analytical skills to troubleshoot issues. This report will describe the evolution of a more accurate job description for the PACS technologist, the relationship between the PACS technologist and the RT supervisor, and specific tasks are appropriate for the PACS technologist to perform.

Allied Health Personnel↗

PubMed2004

PACS training modules at Texas Children's Hospital.

In 1999, the Performance Improvement Committee of the Diagnostic Imaging Services of Texas Children's Hospital identified the need for smoother integration of the picture archiving and communications system (PACS) technology into the workflow of the rest of the department. An effort was then launched to document prevalent issues, as well as to define the processes needed to implement a department-wide program to acquaint the staff with this new technology. The department's application trainer, with the guidance of the Performance Improvement Committee, spearheaded the design and implementation of the PACS training program and has continued to develop it during the past 2 years. This article describes the format and components of the PACS training modules now in use, and details some of the positive effects of this effort.

Hospitals, Pediatric↗

PubMed2004

Evolution of the digital revolution: a radiologist perspective.

The transformation from film-based to filmless operation has become more and more challenging, as imaging studies expand in size and complexity. To adapt to these changes, radiologists must proactively develop new workflow strategies to compensate for increasing work demands and the existing workforce shortage. This article addresses the evolutionary changes underway in the radiology interpretation process and reviews changes that have occurred in the past decade. These include a number of developments in soft-copy interpretation, which is migrating from a relatively static process, duplicating film-based interpretation, to a dynamic process, using multi-planar reconstructions, volumetric navigation, and electronic decision support tools. The result is optimization of the human-computer interface with improved productivity, diagnostic confidence, and interpretation accuracy.

Humans↗

PubMed2004

Interactive image enhancement of CR and DR images.

There is continual pressure on the radiology department to increase its productivity. Two important links to productivity in the computed/digital radiography (CR/DR) workflow chain are the postprocessing step by technologists and the primary diagnosis step by radiologists, who may apply additional image enhancements to aid them in diagnosis. With the large matrix size of CR and DR images and the computational complexity of these algorithms, it has been challenging to provide interactive image enhancement, particularly on full-resolution images. We have used a new programmable processor as the main computing engine of enhancement algorithms for CR or DR images. We have mapped these algorithms to the processor, maximally utilizing its architecture. On a 12-bit 2688 x 2688 image, we have achieved the execution time of 465A ms for adaptive unsharp masking, window/level, image rotate, and lookup table operations using a single processor, which represents at least an order of magnitude improvement compared to the response time of current systems. This kind of performance facilitates rapid computation with preset parameter values and/or enables truly interactive QA processing on radiographs by technologists. The fast response time of these algorithms would be especially useful in a real-time radiology setting, where the radiologist's waiting time in performing image enhancements before making diagnosis can be greatly reduced. We believe that the use of these processors for fast CR/DR image computing coupled with the seamless flow of images and patient data will enable the radiology department to achieve higher productivity.

Algorithms↗

PubMed2004

Multidimensional analysis: a management tool for monitoring HIPAA compliance and departmental performance.

Most RIS and PACS systems include extensive auditing capabilities as part of their security model, but inspecting those audit logs to obtain useful information can be a daunting task. Manual analysis of audit trails, though cumbersome, is often resorted to because of the difficulty to construct queries to extract complex information from the audit logs. The approach proposed by the authors uses standard off-the-shelf multidimensional analysis software tools to assist the PACS/RIS administrator and/or security officer in analyzing those audit logs to identify and scrutinize suspicious events. Large amounts of data can be quickly reviewed and graphical analysis tools help explore system utilization. While additional efforts are required to fully satisfy the demands of the ever-increasing security and confidentiality pressures, multidimensional analysis tools are a practical step toward actually using the information that is already being captured in the systems' audit logs. In addition, once the work is performed to capture and manipulate the audit logs into a viable format for the multidimensional analysis tool, it is relatively easy to extend the system to incorporate other pertinent data, thereby enabling the ongoing analysis of other aspects of the department's workflow.

Computer Security↗

PubMed2004

Addressing the coming radiology crisis-the Society for Computer Applications in Radiology transforming the radiological interpretation process (TRIP) initiative.

The Society for Computer Applications in Radiology (SCAR) Transforming the Radiological Interpretation Process (TRIP) Initiative aims to spearhead research, education, and discovery of innovative solutions to address the problem of information and image data overload. The initiative will foster interdisciplinary research on technological, environmental and human factors to better manage and exploit the massive amounts of data. TRIP will focus on the following basic objectives: improving the efficiency of interpretation of large data sets, improving the timeliness and effectiveness of communication, and decreasing medical errors. The ultimate goal of the initiative is to improve the quality and safety of patient care. Interdisciplinary research into several broad areas will be necessary to make progress in managing the ever-increasing volume of data. The six concepts involved are human perception, image processing and computer-aided detection (CAD), visualization, navigation and usability, databases and integration, and evaluation and validation of methods and performance. The result of this transformation will affect several key processes in radiology, including image interpretation; communication of imaging results; workflow and efficiency within the health care enterprise; diagnostic accuracy and a reduction in medical errors; and, ultimately, the overall quality of care.

Humans↗