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PubMed2002

Implementing the DICOM Grayscale Standard Display Function for mixed hard- and soft-copy operations.

The aim of this work was to implement the DICOM Grayscale Standard Display Function (GSDF) at all stages of image presentation for computed radiography (CR) and direct digital radiography (DR) modalities. Cathode-ray tubes (CRT) were calibrated according to vendor procedures. Printer look-up-tables (LUT) were measured. Custom LUTs were created and loaded. Fuji CR gradation processing parameters were adjusted to accommodate a GSDF printer LUT. Conformance to the GSDF for hard-copy and soft-copy displays was measured with DICOM Part 14 procedures. One system was intended to completely incorporate the GSDF, although the hard-copy result was correct. The CR systems required creation of custom GSDF printer LUTs, adjustment of gradation processing parameters, and/or calibration of CRT luminance response at the quality control station. The picture archiving and communication system workstations from one vendor required third-party software for calibration. Current implementations of DICOM GSDF by vendors may be inconsistent or nonexistent. Significant effort by in-house staff must be expended to properly incorporate the GSDF.

Data Display↗

PubMed2002

PACS implementation in a university hospital in Tuscany.

We describe cost/benefit analysis for the implementation of a picture archiving and communication system in the Department of radiology of University of Siena, Italy. We also highlight technical and functional innovations provided by information of several department units: cost conversion, workflow optimisation and operator development. We analysed: operator costs, paper costs, film costs, chemical costs, costs of optical disks and location rent for hardware and software of RIS/PACS. The results show that advantages provided by PACS implementation derive from a workflow optimization and saving of human resources rather than from a reduction in films and chemicals. Moreover, better management of radiological unit provides improved handling of clinical information, resulting in reduced time to initiate clinical action, with reduction in average length of patient stay and improvements in overall health outcomes.

Cost-Benefit Analysis↗

PubMed2003

Enterprise-wide CR implementation: the Shands Healthcare System experience.

Major healthcare systems are comprised of hospitals and clinics of different sizes and locations. Many such enterprises are already using picture archiving and communication systems (PACS) and computed radiography (CR) in their main hospitals. The integration of other hospitals and clinics into PACS is a more complex problem. The introduction of CR in remote facilities presents problems, as patient populations, department sizes, and work flow patterns may differ among facilities, and inadequate implementation programs may lead to disruption of patient care services. Although the University of Florida has had an operating PACS for years, facilities affiliated with the Shands Healthcare System (SHS) had not been incorporated into PACS until recently. This article presents the 5-year process to convert all film-screen radiological services to CR in the main hospital, five affiliated community hospitals, and four clinics. The article shows the importance of leadership by the medical physicist from inception of the project through installation and clinical implementation.

Computer Communication Networks↗

PubMed2003

Implementing a MIRC query interface for a database driven teaching file.

This paper describes the authors' experience with integrating an existing database-driven teaching file with the RSNA (Radiological Society of North America) Medical Imaging Resource Center (MIRC). MIRC is the product of an RSNA-sponsored initiative to enable medical institutions to share their electronic medical content (images, text, and multimedia) by creating a distributed repository accessible from the Internet. An existing database-driven teaching file, developed by the authors and used extensively by the University of California San Francisco (UCSF) Department of Radiology since 1998, was retrofitted to include an interface for handling broadcast queries initiated by a MIRC query service. These queries take place through the exchange of XML documents via HTTP. After all the storage services have responded, the results are collated by the query service and presented to the user. The teaching file and MIRC interface were developed using the 4th Dimension Relational Database Management System (RDBMS). The integration process primarily involved mapping the "MIRCdocument" schema to the teaching file's schema, translating the actual MIRC query into the internal query language of the database and extending the access control mechanisms of the teaching file to allow public access. A working implementation of the interface required only 3 days of development time, with refinements taking place over several months. Interface development was greatly aided by MIRC's use of well-established Internet standards. This project has demonstrated the feasibility of implementing a MIRC interface on an existing teaching file server.

Computer-Assisted Instruction↗

PubMed2006

Budget variance analysis of a departmentwide implementation of a PACS at a major academic medical center.

In this study, the costs and cost savings associated with departmentwide implementation of a picture archiving and communication system (PACS) as compared to the projected budget at the time of inception were evaluated. An average of $214,460 was saved each year with a total savings of $1,072,300 from 1999 to 2003, which is significantly less than the $2,943,750 projected savings. This discrepancy can be attributed to four different factors: (1) overexpenditures, (2) insufficient cost savings, (3) unanticipated costs, and (4) project management issues. Although the implementation of PACS leads to cost savings, actual savings will be much lower than expected unless extraordinary care is taken when devising the budget.

Academic Medical Centers↗

PubMed2006

Commentary: an economic perspective on implementing evidence-based depression care.

Despite the development of cost-effective evidence-based models for treating depression in primary care, economic and organizational barriers often impede sustainability in routine clinical practice. Under the Depression in Primary Care: Linking Clinical and System Strategies program, the Robert Wood Johnson Foundation (RWJF) funded eight demonstration grants to implement clinical changes in depression care alongside changes in contractual relationships, payment methods and other economic arrangements. The preceding articles summarize the specific economic and organizational changes implemented under four of these demonstration projects. This commentary highlights certain elements that appear critical to successfully re-align system incentives to support evidence-based depression care based in part on the experiences of these four sites.

Depression↗

PubMed2006

Guest editors' introduction: implementing evidence-based mental health practices and performance measures in Massachusetts.

In September 2005, a one day educational forum on implementing evidence-based mental health practices and performance measures in Massachusetts was held at Brandeis University. Factors for successful implementation are reviewed. Papers in this issue cover theory, concrete actions, and best practices that will aid policy makers, providers, and consumers in improving their behavioral health services.

Evidence-Based Medicine↗

PubMed2006

Aligning measurement-based quality improvement with implementation of evidence-based practices.

Two models for improving quality of care have been adopted by segments of the US mental healthcare system. Measurement-based quality improvement (MBQI) is routinely conducted by many provider organizations (including practices, hospitals and health plans), either at their own initiative or at the behest of payers and oversight organizations. Systematic implementation of evidence-based practices (EBPs) is being undertaken by several state mental health authorities and by other systems of care, working in collaboration with services researchers and stakeholders. Although they are distinct approaches, MBQI and EBP implementation (EBPI) overlap in their objectives and means. This article explores the degree to which these two approaches are aligned and whether further coordination between them could yield greater effectiveness or efficiency.

Community Mental Health Services↗

PubMed2005

Applying the readiness to change model to implementation of family intervention for serious mental illness.

Family intervention for serious mental illness is known to be highly efficacious in reducing patient relapse, improving social functioning, enhancing caregivers' knowledge of mental illness, and ultimately reducing overall costs of care. However, very few families receive services. The reasons for this gap between empirical findings and program implementation are complex and not yet fully understood. Prochaska and DiClemente's Readiness to Change Model provides a helpful structure for understanding key issues for the four relevant stakeholders (patients, family members, clinicians and administrators). Staging each stakeholder group and applying corresponding "interventions" (processes of change) are useful in a site's implementation of family services.

Caregivers↗

PubMed2005

Implementing recovery oriented evidence based programs: identifying the critical dimensions.

In the decades of the 1990s many mental health programs and the systems that fund these programs have identified themselves as recovery-oriented. A program that is grounded in a vision of recovery is based on the notion that a majority of people can grow beyond the catastrophe of a severe mental illness and lead a meaningful life in their own community. First person accounts of recovery and empirical research have led to a developing consensus about the service delivery values underlying recovery. The emphasis on recovery-oriented programming has been concurrent with a focus in the field on evidence-based practices. We propose that evidence based practices be implemented in a manner that is recovery compatible. Program dimensions for evidence based practice, such as program mission, policies, procedures, record keeping and staffing should be consistent with recovery values in order for a program to be considered to be recovery-oriented. This article describes the critical dimensions of such value based practice, regardless of the service the recovery oriented mental health programs provide (e.g., treatment, case management, rehabilitation). The aim of this first attempt at conceptualizing recovery-oriented mental health programs is to both provide direction to those involved in program implementation of evidence based mental health practices, as well as providing a stimulus for further discussion in the field.

Adaptation, Psychological↗

PubMed2005

Implementing family-centered interventions within the public middle school: linking service delivery to change in student problem behavior.

The Adolescent Transitions Program is a family-centered intervention strategy designed to reduce problem behavior and prevent drug use within a public school environment. A parent consultant within a Family Resource Center (FRC) provided universal, selected, and indicated interventions that enhanced and supported positive parenting practices known to serve as protective factors. Implementation of the 3-year FRC model involved 584 students and their families in 4 middle schools. Analyses focused on the dynamics and effects of parent consultant activities and services. Differences in school "adoption" of the FRC services were found to be a function of both passage of time and school environment. Despite significant variation in implementation across schools, FRC services significantly reduced the growth in problem behavior over the course of the middle-school years. The implications of these findings for dissemination of empirically supported, school-based, family-centered interventions are discussed.

Adolescent↗

PubMed2006

Barriers of HIPAA regulation to implementation of health services research.

Although many perspectives on the impact of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on health services research have been wide spread, little empirical evidence has been reported about HIPAA-related barriers during the implementation of research projects. Using three cases of health services research projects, this study examined practical barriers created by HIPAA regulation. During the stage of implementation of the three projects, we experienced some HIPAA-related concerns, previously raised in the field of health services research. We found that technically complicated consent forms and privacy protection forms as well as socially-sensitive clinical conditions make patients less willing to participate in research projects; concerns about safety of patient medical information makes health organizations more hesitant to let researchers have access to the patient's information, especially through electronic transfer; more restrictive IRB processes and challenging patient recruiting processes make health services researchers reluctant to go through the process; and as a result, they may compromise with the scientific soundness of the project. Overall, HIPAA complicates the research process and requires more resources and longer time to conduct research.

Chicago↗

PubMed2005

Non-linear mixed effects modeling - from methodology and software development to driving implementation in drug development science.

Few scientific contributions have made significant impact unless there was a champion who had the vision to see the potential for its use in seemingly disparate areas-and who then drove active implementation. In this paper, we present a historical summary of the development of non-linear mixed effects (NLME) modeling up to the more recent extensions of this statistical methodology. The paper places strong emphasis on the pivotal role played by Lewis B. Sheiner (1940-2004), who used this statistical methodology to elucidate solutions to real problems identified in clinical practice and in medical research and on how he drove implementation of the proposed solutions. A succinct overview of the evolution of the NLME modeling methodology is presented as well as ideas on how its expansion helped to provide guidance for a more scientific view of (model-based) drug development that reduces empiricism in favor of critical quantitative thinking and decision making.

Algorithms↗

PubMed2006

Implementing an evidence-based preventive intervention in neighborhood family centers: examination of perceived barriers to program participation.

: This study examined parents' perceived barriers to participation in a multicomponent prevention program implemented by a community agency serving culturally diverse urban neighborhoods. The Early Risers Participation Interview (ER-PI), modeled after Kadzin et al.'s (1997) Barriers to Treatment Participation Scale, was administered to parents (N = 138) of children who were screened for disruptive behavior and were randomized into a two-year intervention condition. Results showed that the perceived barriers score provided significant information in differentiating low and high participators after controlling for child, parent, and family characteristics. Early identification and resolution of parents' perceived barriers to participation may be key to implementing multifaceted preventive programs successfully in inner-city neighborhoods. EDITOR'S STRATEGIC IMPLICATIONS: The authors present promising practices for client engagement and retention. The experimental, longitudinal design is notable, especially in the evaluation of a community-run prevention program.

Adult↗

PubMed2005

The ARC organizational and community intervention strategy for implementing evidence-based children's mental health treatments.

This paper reviews the implications of organizational and community intervention research for the implementation of effective mental health treatments in usual community practice settings. The paper describes an organizational and community intervention model named ARC for Availability, Responsiveness and Continuity, that was designed to support the improvement of social and mental health services for children. The ARC model incorporates intervention components from organizational development, interorganizational domain development, the diffusion of innovation, and technology transfer that target social, strategic, and technological factors in effective children's services. This paper also describes a current NIMH-funded study that is using the ARC intervention model to support the implementation of an evidence-based treatment, Multisystemic Therapy (MST), for delinquent youth in extremely rural, impoverished communities in the Appalachian Mountains of East Tennessee.

Appalachian Region↗

PubMed2005

Stochastic differential equations in NONMEM: implementation, application, and comparison with ordinary differential equations.

PURPOSE: The objective of the present analysis was to explore the use of stochastic differential equations (SDEs) in population pharmacokinetic/pharmacodynamic (PK/PD) modeling. METHODS: The intra-individual variability in nonlinear mixed-effects models based on SDEs is decomposed into two types of noise: a measurement and a system noise term. The measurement noise represents uncorrelated error due to, for example, assay error while the system noise accounts for structural misspecifications, approximations of the dynamical model, and true random physiological fluctuations. Since the system noise accounts for model misspecifications, the SDEs provide a diagnostic tool for model appropriateness. The focus of the article is on the implementation of the Extended Kalman Filter (EKF) in NONMEM for parameter estimation in SDE models. RESULTS: Various applications of SDEs in population PK/PD modeling are illustrated through a systematic model development example using clinical PK data of the gonadotropin releasing hormone (GnRH) antagonist degarelix. The dynamic noise estimates were used to track variations in model parameters and systematically build an absorption model for subcutaneously administered degarelix. CONCLUSIONS: The EKF-based algorithm was successfully implemented in NONMEM for parameter estimation in population PK/PD models described by systems of SDEs. The example indicated that it was possible to pinpoint structural model deficiencies, and that valuable information may be obtained by tracking unexplained variations in parameters.

Algorithms↗

PubMed2006

Toward the implementation of mental health consumer provider services.

Encouraged by the New Freedom Commission, mental health systems such as the Veteran Administration (VA) are now becoming more recovery-oriented. Consumer providers (CPs)--those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems--are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed, and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.

Adult↗

PubMed2006

Issues in design and implementation in an urban birth cohort study: the Syracuse AUDIT project.

The Syracuse AUDIT (Assessment of Urban Dwellings for Indoor Toxics) project is a birth cohort study of wheezing in the first year of life in a low-income urban setting. Such studies are important because of the documented serious risks to children's health and the lack of attention and published work on asthma development and intervention in communities of this size. We studied 103 infants of mothers with asthma, living predominantly in inner-city households. Our study combines measurements of a large panel of indoor environmental agents, in-home infant assessments, and review of all prenatal and postnatal medical records through the first year of life. We found multiple environmental pollution sources and potential health risks in study homes including high infant exposure to tobacco smoke. The prevalence of maternal smoking during pregnancy was 54%; postnatal environmental tobacco smoke (ETS) exposure was nearly 90%. The majority (73%) of homes showed signs of dampness. Participants' lives were complicated by poverty, unemployment and single-parenthood. Thirty-three percent of fathers were not involved with their children, and 62% of subjects moved at least once during the study period. These socioeconomic issues had an impact on project implementation and led to modification of study eligibility criteria. Extensive outreach, follow up, and relationship-building were required in order to recruit and retain families and resulted in considerable work overload for study staff. Our experiences implementing the project will inform further studies on this and other similar populations. Future reports on this cohort will address the role of multiple environmental variables and their effects on wheezing outcome during the first year of life.

Adult↗