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PubMed2002

Three-year experience in using total laboratory automation system.

We implemented a total laboratory automation (TLA) system, currently used in Chungnam National University Hospital (CNUH), designed around the A&T Corporation to perform the general and specific laboratory testing throughout the system in a timely and cost-effective manner. The system consists of two major lines: chemistry and hematology. The analyzers attached to the hematology line include one SE 9000 hematology analyzer (Sysmex Corporation, Kobe, Japan), one SP-100 slide maker (Sysmex), and one R9000 reticulocyte counter (Sysmex). The chemistry line consists of preanalytic system and linked analyzers. The analyzers attached to chemistry line are one Hitachi 747 chemistry analyzer (Hitachi, Ltd., Tokyo, Japan), one A&T 502X analyzer (A&T Corporation, Tokyo, Japan) and one Architect i2000 immunochemistry analyzer (Abbott Diagnostics Division, Santa Clara, USA). The preanaytic system including start stocker, centrifuge, de-cap unit and aliquoting unit were connected with analyzers. The turn around time (TAT) of all tests was shortened in comparison to manual systems. Consequently it makes feasible one-day care clinic and makes reduced inherent errors in sample identification, dispensing, and reporting. In addition, real-time re-run can make test quality more reliable. As many as 12 departments can be reduced to 7 departments. The subsidiary advantages of smaller size were incorporated into reduced working steps facilitating workflow. Overall, better qualified and quicker results can be provided to the clinicians, and proper cost-effectiveness and better quality services can be anticipated as a result of much easier system management and higher reliability. In conclusion, the TLA has been successful within our laboratory.

Automation↗

PubMed2002

[Flat-panel detector technology -State-of-the-art and future prospects-].

A flat-panel detector (FPD) is a long-awaited technology to implement the digital X-ray imaging technology into the radiological department. This paper describes the state-of-the-art technology and future prospects on the FPD technology. State-of-the-art technology was reviewed taking the CXDI series as an example. Several FPD-based systems have been introduced into the Japanese market since CXDI-11 opened it in November 1998. Accompanying CXDI-C2 for control, CXDI-22 for table position and CXDI-31 for portable, the CXDI series fulfills the requirement of the radiography room being a fully digitalized room. The FPD on the CXDI series is comprised of a scintillator (Gd(2)O(2)S:Tb(3+)) as a primary sensor in which the X-ray is captured and an amorphous silicon detector (LANMIT) as a secondary sensor in which the fluorescent light is detected. Since the scintillator is identical to that of the screen-film systems, it can be said as proven, durable and chemically stable and it is expected to produce the same image quality as the screen-film systems. CXDI-31, a portable FPD-based system, was developed targeting thinner dimensions, lightweight, durability and high spatial resolution. Thoroughly re-designing the mechanical structure and reducing the power consumption at the readout IC realized thinner dimensions. Introducing the portable note PC technologies successfully combined lightweight with durability. Improving the sensor process and re-designing the layout made the sensor high resolution without compromising the signal-to-noise ratio. Future prospects were overviewed in the aspect of technology and applications. Sensitivity, spatial resolution, frame rate and portability were described as the upcoming technology. Increasing gain and reducing noise will realize higher sensitivity, especially by adopting the PbI(2), HgI(2) or such photoconductor materials as the primary sensor. Pixelized amplifier will also achieve higher sensitivity. Layered sensor designed such that TFT layer and sensitive layer are constructed separately will decrease the pixel pitch lower than 100 microm. The FPD has been applied in radiography, mammography and angiography. It will expand the applications into low-dose fluoroscopy to replace the X-ray image intensifiers and into cone-beam computer tomography. What the FPD brought was mainly the efficient workflow of the X-ray technologist. However, diagnosis efficiency and patient benefit must be improved further more by combining FPD technology into computer-aided diagnosis, tele-radiography or other IT-based technologies. Such prospect may come true in the near future.

Fluoroscopy↗

PubMedDate not supplied

Strengthening your ties to referring physicians through RIS/PACS integration.

Many imaging centers are turning to technology solutions to increase refering physician satisfaction, implementing such enhancements as automated report distribution, picture archiving and communications system (PACS), radiology information systems (RIS), and web-based results access. However, without seamless integration, these technology investments don't address the challenge at its core: convenient and reliable, two-way communication and interaction with referring physicians. In an integrated RIS/PACS solution, patient tracking in the RIS and PACS study status are logged and available to users. The time of the patient's registration at the imaging center, the exam start and completion time, the patient's departure time from the imaging center, and results status are all tracked and logged. An integrated RIS/PACS solution provides additional support to the radiologist, a critical factor that can improve the turnaround time of results to referring physicians. The RIS/PACS enhances the interpretation by providing the patient's history, which gives the radiologist additional insight and decreases the likelihood of missing a diagnostic element. In a tightly integrated RIS/PACS solution, results information is more complete. Physicians can view reports with associated images selected by the radiologist. They will also have full order information and complete imaging history including prior reports and images. Referring physicians can access and view images and exam notes at the same time that the radiologist is interpreting the exam. Without the benefit of an integrated RIS/PACS system, the referring physician would have to wait for the signed transcription to be released. In a seamlessly integrated solution, film-tracking modules within the RIS are fused with digital imaging workflow in the PACS. Users can see at a glance if a historical exam is available on film and benefit when a complete study history--both film-based and digital--is presented with the current case. It is up to the imaging center to market the benefits of reduced errors, reduced turnaround times, and a higher level of service to referring physician community, and encourage them to take advantage of the convenience it provides. The savvy imaging center will also regard the integrated RIS/PACS as a valuable marketing tool for use in attracting radiologists.

Appointments and Schedules↗

PubMedDate not supplied

A tale of two CRs: hospital conducts side-by-side test.

While we elected to install a digital radiography system in the busiest exam room in emergency room (ER) suite at our 535-bed hospital, we selected computed radiography as the primary platform for digital capture throughout the facility because of its flexibility, productivity and cost-effectiveness. We now use CR systems to handle six exam rooms and portable exams conducted by the radiology department, as well as imaging studies conducted in two ER exam rooms. Before committing to a CR vendor, we conducted an eight-week, side-by-side pilot study with two vendors' systems. One CR system was located in the emergency room and the other unit was located in the main radiology department. Our staff received education and training from both vendors. I led an evaluation team that included representatives from the radiology group, the information services (IS) department, biomedical engineering, staff physicians, ER physicians, pulmonologists and orthopedic specialists. Our team met to design the trial and develop a list of factors that technologists would use to evaluate the two systems. The team met after installation and again after the trial was complete to provide verbal input on each vendor for each category and to review feedback from the technologists' survey. Categories included image quality, interactions with each vendor's sales and service staff, workflow, time studies, durability of cassettes and plates, entry of John Doe patients for ER, and other factors. After the trial, we chose a system by unanimous vote. We learned a lot about CR technology throughout this process. Overall we are extremely satisfied with the platform we selected and with this method of evaluating the two systems prior to making this important decision.

Decision Making, Organizational↗

PubMedDate not supplied

Success with voice recognition.

You need a compelling reason to implement voice recognition technology. At my institution, the compelling reason was a turnaround time for Radiology results of more than two days. Only 41 percent of our reports were transcribed and signed within 24 hours. In November 1998, a team from Lehigh Valley Hospital went to RSNA and reviewed every voice system on the market. The evaluation was done with the radiologist workflow in mind, and we came back from the meeting with the vendor selection completed. The next steps included developing a business plan, approval of funds, reference calls to more than 15 sites and contract negotiation, all of which took about six months. The department of Radiology at Lehigh Valley Hospital and Health Network (LVHHN) is a multi-site center that performs over 360,000 procedures annually. The department handles all modalities of radiology: general diagnosis, neuroradiology, ultrasound, CT Scan, MRI, interventional radiology, arthography, myelography, bone densitometry, nuclear medicine, PET imaging, vascular lab and other advanced procedures. The department consists of 200 FTEs and a medical staff of more than 40 radiologists. The budget is in the $10.3 million range. There are three hospital sites and four outpatient imaging center sites where services are provided. At Lehigh Valley Hospital, radiologists are not dedicated to one subspecialty, so implementing a voice system by modality was not an option. Because transcription was so far behind, we needed to eliminate that part of the process. As a result, we decided to deploy the system all at once and with the radiologists as editors. The planning and testing phase took about four months, and the implementation took two weeks. We deployed over 40 workstations and trained close to 50 physicians. The radiologists brought in an extra radiologist from our group for the two weeks of training. That allowed us to train without taking a radiologist out of the department. We trained three to six radiologists a day. I projected a savings of 5.0 FTEs over two years. The actual savings were 8.0 FTEs within three weeks for the first phase and an additional 4.3 FTEs within two weeks of the second phase. The transcription staff was retained to perform other types of transcription and not displaced. The goal was to reduce Medical Records' outsourcing expenses by $670,000 over three years. The actual savings are in excess of $900,000. The proposed payback period was 17 months, and the actual was less than 12 months. For two years prior to implementing the voice system, the turnaround time at Lehigh Valley was 41 percent within 24 hours. One week after implementation, the turnaround time was 78 percent within 24 hours. Today it ranges between 85 percent and 92 percent. Overall, the radiologists at Lehigh Valley Hospital did an excellent job with the cultural change to voice recognition. It has made a major impact on our ability to get reports to physicians in a timely manner so they can make treatment decisions.

Decision Making, Organizational↗

PubMed2003

Tools for discovery: gene expression enterprise solutions.

Expression profiling in drug discovery is a highly collaborative process requiring robust, centralized databases and exhaustive exploration of expanding libraries of expression experiments. In this review, state-of-the-art data analysis tools that identify relationships between gene expression and biological activities are described. Informatics workflow, system scalability and regulatory compliance issues are discussed in the context of expression data management.

Animals↗

PubMed2003

Beyond the genome--SMi Conference 27-28 January 2003, London, UK.

Over a decade of astonishing developments, genomics and proteomics have promised a fundamentally new approach to drug discovery. Although there has been an undeniable increase in the range of potential targets available, this has not led to an increased output of the drug discovery pipeline into the clinic. With tighter markets and increasing competition, the major pharmaceutical companies are under intense pressure to achieve rapid, concrete delivery of those early promises, but there remain acute problems in the genes-to-drugs pipeline. This meeting showcased a range of novel approaches from proteomics and bioinformatics to address these problems. A common theme in the range of proteomics offerings was the prioritization of potential novel targets on the basis of their accessibility to drugs and their functional link to disease phenotypes. Informatics and in silico offerings also concentrated on fast, accurate, drug-focused workflows built on large integrative databases and novel data-mined algorithms.

Animals↗

PubMed2003

Medical decision support systems: old dilemmas and new paradigms?

OBJECTIVES: The purpose of this paper is to examine past and present medical decision support systems and the environment in which they operate and to propose specific research tracks that improve integration and adoption of these systems in today's health care systems. METHODS: In preamble, we examine the objectives, decision models, and performances of past decision support systems. RESULTS: Medical decision support tools were essentially formulated from a technical capability perspective and this view has met limited adoption and slowed down new development as well as integration of these important systems into patient management work flows and clinical information systems. The science base of these systems needs to include evidence-based medicine and clinical practice guidelines and the paradigms need to be extended to include a collaborative provider model, the users and the organization perspectives. The availability of patient record and medical terminology standards is essential to the dissemination of decision support systems and so is their integration into the care process. CONCLUSION: To build new decision support systems based on practice guidelines and taking into account users preferences, we do not so much advocate new technological solutions but rather suggest that technology is not enough to ensure successful adoption by the users, the integration into practice workflow, and consequently, the realisation of improved health care outcomes.

Cooperative Behavior↗

PubMed2003

Rapid prototyping strategy for a surgical data warehouse.

OBJECTIVES: Healthcare processes typically generate an enormous volume of patient information. This information largely represents unexploited knowledge, since current hospital operational systems (e.g., HIS, RIS) are not suitable for knowledge exploitation. Data warehousing provides an attractive method for solving these problems, but the process is very complicated. This study presents a novel strategy for effectively implementing a healthcare data warehouse. METHODS: This study adopted the rapid prototyping (RP) method, which involves intensive interactions. System developers and users were closely linked throughout the life cycle of the system development. The presence of iterative RP loops meant that the system requirements were increasingly integrated and problems were gradually solved, such that the prototype system evolved into the final operational system. RESULTS: The results were analyzed by monitoring the series of iterative RP loops. First a definite workflow for ensuring data completeness was established, taking a patient-oriented viewpoint when collecting the data. Subsequently the system architecture was determined for data retrieval, storage, and manipulation. This architecture also clarifies the relationships among the novel system and legacy systems. Finally, a graphic user interface for data presentation was implemented. CONCLUSIONS: Our results clearly demonstrate the potential for adopting an RP strategy in the successful establishment of a healthcare data warehouse. The strategy can be modified and expanded to provide new services or support new application domains. The design patterns and modular architecture used in the framework will be useful in solving problems in different healthcare domains.

Colorectal Surgery↗

PubMed2003

The empty OR-process analysis and a new concept for flexible and modular use in minimal invasive surgery.

The reproducible advantages of minimal invasive surgery have led to a worldwide spread of these techniques. Nevertheless, the increasing use of technology causes problems in the operating room (OR). The workstation environment and workflow are handicapped by a great number of isolated solutions that demand a large amount of space. The Center of Excellence in Medical Technology (CEMET) was established in 2001 as an institution for a close cooperation between users, science, and manufacturers of medical devices in the State of Schleswig-Holstein, Germany. The future OR, as a major project, began with a detailed process analysis, which disclosed a large number of medical devices with different interfaces and poor standardisation as main problems. Smaller and more flexible devices are necessary, as well as functional modules located outside the OR. Only actuators should be positioned near the operation area. The future OR should include a flexible-room concept and less equipment than is in use currently. A uniform human-user interface is needed to control the OR environment. This article addresses the need for a clear workspace environment, intelligent-user interfaces, and flexible-room concept to improve the potentials in use of minimal invasive surgery.

Equipment and Supplies↗

PubMed2003

Actual aspects of image-guided surgery.

Use of surgical navigation systems is becoming an increasingly important part of both planning and performing intracranial and spinal surgery. Numerous clinical reports have described neuronavigation as a useful adjunct to surgery that allows neurosurgery to be less invasive and more effective. Although the method of image-guided surgery was introduced more than a decade ago, new technologies have changed and refined the procedure substantially. This chapter summarizes the recent developments of advanced image-guided surgery. For most operations, microscope navigation has replaced pointer navigation. Using the microscope as the localizing device, the workflow is not interrupted and microsurgical procedure can be continued as usual. New chip technology allows integration of magnetic resonance images, angiography findings, endoscopic view, or other pictures in the eyepiece of the microscope. A new method of patient registration is laser scanning and surface matching. When using high-quality images, this new method can be used without additionally acquired images, may reduce costs, simplify the pre-registration procedure, and increase application accuracy compared to skin-fiducial registration. Moreover, integration of other imaging modalities is becoming an increasingly used feature and provides useful information during surgery.

Brain Mapping↗

PubMed2003

Analyzing computer based patient records: a review of literature.

A wide-ranging literature review of computer-based patient record (CPR) implementation over the past decade reveals that clinical, workflow, administrative, and revenue enhancement benefits of the CPR outweigh barriers and challenges--but only if healthcare organizations redesign certain work processes. Among other key efforts, organizations must train and motivate users to navigate CPR systems, as well as develop a common structured language. Clinicians who used CPRs found that electronic access to clinical information saves time and provides a thorough and efficient way to manage patient information.

Decision Support Systems, Clinical↗

PubMedDate not supplied

The path of least resistance: is there a better route?

In May 2000, the radiology department at Stanford University Medical Center embarked on a five-year journey toward complete digitization. While the end goal was known, there was much less certainty about the steps involved along the way. Stanford worked with a team from GE Medical Systems to implement Six Sigma process improvement methodologies and related change management techniques. The methodical and evidence-based framework of Six Sigma significantly organized the process of "going digital" by breaking it into manageable projects with clear objectives. Stanford identified five key areas where improvement could be made: MR outpatient throughput, CT inpatient throughput, CT outpatient throughput, report turnaround time, and Lucile Packard Children's Hospital CR/Ortho throughput and digitization. The CT project is presented in this article. Although labor intensive, collecting radiology data manually is often the best way to obtain the level of detail required, unless there is a robust RIS in place with solid data integrity. To gather the necessary information without unduly impacting staff and workflow at Stanford, the consultants working onsite handled the actual observation and recording of data. Some of the changes introduced through Six Sigma may appear, at least on the surface, to be common sense. It is only by presenting clear evidence in terms of data, however, that the improvements can actually be implemented and accepted. By converting all appointments to 30 minutes and expanding hours of operation, Stanford was able to boost diagnostic imaging productivity, volume and revenue. With the ability to scan over lunch breaks and rest periods, potential appointment capacity increased by 140 CT scans per month. Overall, the CT project increased potential for outpatient appointment capacity by nearly 75% and projected over $1.5 million in additional annual gross revenue. The complex process of moving toward a digital radiology department at Stanford demonstrates that healthcare cannot be healed by technology alone. The ability to optimize patient services revolves around a combination of leading edge technology, dedicated and well-trained staff, and careful examination of processes and productivity.

Appointments and Schedules↗

PubMed2003

A predictable precision cast for multi-unit screw-retained implant prosthesis: rationale and technique.

The aim of this article is to describe a technique derived from the premachined cylinder luting technique with the goal to predictably fabricate a highly precise master cast. An impression can be taken directly at implant level or, with some technique modification, at the abutment level. Concurrently, multiple techniques can be employed to fabricate the final framework with the assurance that a framework that fits the cast will fit in the mouth. This predictability improves the workflow of the restoring dentist and laboratory technician since multiple framework try-ins and adjustments are eliminated.

Dental Implantation, Endosseous↗

PubMed2003

Leveraging information technology towards enhancing patient care and a culture of safety in the US.

OBJECTIVES: To heighten awareness about the critical issues currently affecting patient care and to propose solutions based on leveraging information technologies to enhance patient care and influence a culture of patient safety. METHODS: Presentation and discussion of the issues affecting health care today, such as medical and medication-related errors and analysis of their root causes; proliferation of medical knowledge and medical technologies; initiatives to improve patient safety; steps necessary to develop a culture of safety; introduction of relevant enabling technologies; and evidence of results. RESULTS AND CONCLUSION: Medical errors affect not only mortality and morbidity, but they also create secondary costs leading to dissatisfaction by both provider and patient. Health care has been slow to acknowledge the benefits of enabling technologies to affect the quality of care. Evaluation of recent applications, such as the computerized patient record, physician order entry, and computerized alerting systems show tremendous potential to enhance patient care and influence the development of a culture focused on safety. They will also bring about changes in other areas, such as workflow and the creation of new partnerships among providers, patients, and payers.

Humans↗

PubMed2003

A collaborative platform for consensus sessions in pathology over Internet.

The design of valid databases in pathology faces the problem of diagnostic disagreement between pathologists. Organizing consensus sessions between experts to reduce the variability is a difficult task. The TRIDEM platform addresses the issue to organize consensus sessions in pathology over the Internet. In this paper, we present the basis to achieve such collaborative platform. On the one hand, the platform integrates the functionalities of the IDEM consensus module that alleviates the consensus task by presenting to pathologists preliminary computed consensus through ergonomic interfaces (automatic step). On the other hand, a set of lightweight interaction tools such as vocal annotations are implemented to ease the communication between experts as they discuss a case (interactive step). The architecture of the TRIDEM platform is based on a Java-Server-Page web server that communicate with the ObjectStore PSE/PRO database used for the object storage. The HTML pages generated by the web server run Java applets to perform the different steps (automatic and interactive) of the consensus. The current limitations of the platform is to only handle a synchronous process. Moreover, improvements like re-writing the consensus workflow with a protocol such as BPML are already forecast.

Computer Systems↗

PubMed2003

Electronic signatures for long-lasting storage purposes in electronic archives.

Communication and co-operation in healthcare and welfare requires certain Trusted Third Party (TTP) services describing both status and relation of communicating principals as well as their corresponding keys and attributes. Additional TTP services are needed to provide trustworthy information about dynamic issues of communication and co-operation such as time and location of processes, workflow relations, and system behaviour. Electronic signatures based on asymmetric cryptography are important means for securing the integrity of a message or file as well as for accountability purposes including non-repudication of both origin and receipt. These electronic signatures along with certified time stamps are especially important for electronic health records (EHR), electronic archives in general, and other typical purposes of a long-lasting storage. Apart from technical storage problems (e.g. lifetime of the storage devices), this paper needs to look for mechanisms of e.g. re-signing of messages, archive details, or whole archives.

Access to Information↗

PubMed2003

Enabling virtual emergency healthcare enterprises using Web services.

Emergency healthcare delivery involves a variety of activities performed from the time of a call to the ambulance service till the time of patient's disposal from the emergency department of a hospital. As these activities are performed in at least two organizations (i.e. ambulance service and hospital) and they are interrelated to form inter-organizational healthcare processes, collaboration and coordination become a vital issue for patients and for emergency healthcare service performance. Web-based workflow systems in conjunction with web services present a new way for service-oriented integration (SOI) of disparate systems and for developing distributed applications within and between organizations. Thus, through process automation and the use of web services ambulance service and hospital emergency departments can automate their operations by making information available where and when needed and by providing an infrastructure for the integration of pre-hospital and in-hospital emergency healthcare. A prototype implementation of this approach is presented in this paper.

Computer Systems↗