Putting technology in place successfully

BACKGROUND

This article discusses how to integrate clinical and administrative workstations into your dental practice from the planning phase to the implementation phase. The author discusses the costs that are associated with integrating technology, as well as the hardware components and configuration. He then discusses in greater detail the core clinical technologies and how they tie in together to facilitate building a cohesive digital patient record.

CONCLUSIONS

There are no shortcuts to successfully integrating technology into a dental practice. A significant commitment of time, energy and money is a prerequisite to building a secure and reliable computer network that incorporates all clinical and administrative applications.

PRACTICE IMPLICATIONS

Technology is reinventing the world, and dentists need to keep pace with the people they serve. These new and not-so-new technologies will enhance dental services and productivity, which ultimately will raise the bar for the standard of care in dentistry.

Teleradiology in orthopaedics

Teleradiology is a means of electronically transmitting radiographic image files from one location to another. Technologic advances in digital imaging, telecommunications, digital storage, and viewing technologies have made teleradiology readily available and reasonably affordable. The five components of a teleradiology system include: a sending station, a transmission network, a storage device, a viewing station and, a software package. The advantage of teleradiology is the mobility of digital images. In contrast to plain radiographs that only can be seen in one location at a time, multiple persons who are at different locations can view digital images simultaneously. When applied to orthopaedic trauma applications, when the consulting orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, disposition planning of patients from emergency departments or outlying hospitals, and planning of surgical procedures. These systems also improve the comfort level of consulting orthopaedic surgeons and potentially limit the risk of litigation for incorrect diagnosis. The quality, convenience, and effectiveness of teleradiology systems should improve as the technologies continue to mature. Having radiographic images available on handheld devices, such as cell phones, is likely to be a reality in the near future.

Assistive technology and computer adaptations for individuals with spinal cord injury

Spinal cord injury (SCI) commonly occurs in individuals during important years for formation of vocational goals, resulting in low post-injury employment rates and higher costs to society. Individuals with SCI who are employed have improved quality of life. Assistive technology, often available at modest cost, can help individuals with SCI to compensate for functional limitations, overcome barriers to employability, enhance technical capacities and computer utilization, and improve ability to compete for gainful employment.

UMIN--current status and future perspectives

UMIN, fully funded by the Japanese government, is the largest and most versatile public academic information center for biomedical sciences in the world, and is considered as indispensable information infrastructure for the Japanese medical community. As of April 1st 2004, all Japanese national universities, including UMIN, will be incorporated as independent administrative entities. After the incorporation, each national university will have authority to determine its own budget, organization, etc. by itself, and will also be able to carry out profit-making business related to its activities under certain constraints. Thus we suspect that UMIN will inevitably be faced with a strong demand to undertake profit-making business at an early stage. Even in this case, we believe that UMIN should continue to provide its information services to the Japanese medical community free of charge as it has done, utilizing earnings from its profit-making business that services commercial companies, because the success of UMIN has depended on the cooperation and sympathy of the community in the past, and will continue to do so.

[Conception and data transfer analysis of an open-source digital image archive designed for radiology]

PURPOSE

Implementation of a self-designed, web-based digital image archive incorporating the existing DICOM infrastructure to assure distribution of digital pictures and reports and to optimize work flow. Assessment after three years.

MATERIALS AND METHODS

Open-source software was used to guarantee highest reliability and cost effectiveness. In view of rapidly increasing capacity and decreasing costs of hard discs (HDs), HDs were preferred over slower and expensive magneto-optical disk (MOD) or tape storage systems. The number of installed servers increased from one to 12. By installing HDs with increased capacities, the number of servers should be kept constant. Entry and access of data were analyzed over two 4-month periods (after 1.5 and 2 years of continuous operations).

RESULTS

Our digital image archive was found to be very reliable, cost effective and suitable for its designated tasks. As judged from the measured access volume, the average utilization of the system increased by 160 %. In the period from January to April 2002, the users accessed 239.8 gigabyte of the stored 873.7 gigabyte image data (27 %). The volume of the stored data added 20%, mainly due to an increase in cross-section imaging.

CONCLUSION

The challenge of developing a digital image archive with limited financial resources resulted in a practicable and expandable solution. The utilization, number of active users and volume of transferred data have increased significantly. Our concept of utilizing HDs for image storage proved to be successful.

Quantification of cytokine gene expression using an economical real-time polymerase chain reaction method based on SYBR Green I

Assessment of cytokine expression has become crucial to understand host responses to infections as well as autoimmunity. Several approaches including Northern blot, RNase protection assay and enzyme-linked immunosorbent assay have been used for this purpose, but they are time consuming, labour intense, and relatively large quantity of the samples is usually required. Recently, a technique termed real-time reverse transcriptase-polymerase chain reaction (RT-PCR) has been developed to determine genetic expression with great sensitivity and specificity; however, specialized instrumentation and costly reagents are usually needed. We aimed at using low-cost reagents for real-time PCR. This was achieved by adapting a conventional RT-PCR protocol to the quantitative real-time format, by the addition of the SYBR Green I reagent. We validated the approach by assessing the cytokine gene expression of murine splenocytes upon stimulation with phorbol 12-myristate 12-acetate (PMA)-ionomycin. The results using this technique were compared with those obtained with the well-established gene array method. We conclude that the use of the SYBR Green I reagent during real-time RT-PCR provides a highly specific and sensitive method to quantify cytokine expression with accuracy and no post-PCR manipulation.

Evaluation of a "no-cost" Internet technology-based system for teleradiology and co-operative work

The aim of this study was to assess the suitability of a no-cost system based on standard Internet technology components for teleradiology. The system was composed of free software (communication, DICOM viewer, compression) and standard off-the-shelf hardware components. For different image (CR, CT, MR) and network types (LAN and ISDN) the File Transfer, Audio and Video Conference, and Co-operative Work properties were examined and compared with the literature referring to standard complete packages and dedicated teleradiology systems. The main advantages of the no-cost system are: price; ease of use; independence from specific hardware; and potential connection to any possible partner. The performance of the File Transfer and the Audio and Video Conference was comparable to the other system groups with slight disadvantages in the usability. For Co-operative Work the employed "application sharing" technology does not meet the clinical requirements, which applies identically to the standard complete packages. Here the specialized systems prove superior, although they are proprietary. With minimal restraints the evaluated no-cost solution can be used for File Transfer and Conference scenarios. The usage for Co-operative Work with ISDN is not recommended, unless for the purpose of gaining experience or when dealing with small amounts of cases or images.

Incentives and barriers that influence clinical computerization in Hong Kong: a population-based physician survey

OBJECTIVE

Given the slow adoption of medical informatics in Hong Kong and Asia, we sought to understand the contributory barriers and potential incentives associated with information technology implementation.

DESIGN AND MEASUREMENTS

A representative sample of 949 doctors (response rate = 77.0%) was asked through a postal survey to rank a list of nine barriers associated with clinical computerization according to self-perceived importance. They ranked seven incentives or catalysts that may influence computerization. We generated mean rank scores and used multidimensional preference analysis to explore key explanatory dimensions of these variables. A hierarchical cluster analysis was performed to identify homogenous subgroups of respondents. We further determined the relationships between the sets of barriers and incentives/catalysts collectively using canonical correlation.

RESULTS

Time costs, lack of technical support and large capital investments were the biggest barriers to computerization, whereas improved office efficiency and better-quality care were ranked highest as potential incentives to computerize. Cost vs. noncost, physician-related vs. patient-related, and monetary vs. nonmonetary factors were the key dimensions explaining the barrier variables. Similarly, within-practice vs external and "push" vs "pull" factors accounted for the incentive variables. Four clusters were identified for barriers and three for incentives/catalysts. Canonical correlation revealed that respondents who were concerned with the costs of computerization also perceived financial incentives and government regulation to be important incentives/catalysts toward computerization. Those who found the potential interference with communication important also believed that the promise of improved care from computerization to be a significant incentive.

CONCLUSION

This study provided evidence regarding common barriers associated with clinical computerization. Our findings also identified possible incentive strategies that may be employed to accelerate uptake of computer systems.

OR automation systems

An operating room (OR) automation system is a combination of hardware and software designed to address efficiency issues in the OR by controling multiple devices via a common interface. Systems range from the relatively basic--allowing control of a few devices within a single OR--to advanced designs that are capable of not only controlling a wide range of devices within the OR but also exchanging information with remote locations.

Implementation and integration of regional health care data networks in the Hellenic National Health Service

BACKGROUND

Modern health care is provided with close cooperation among many different institutions and professionals, using their specialized expertise in a common effort to deliver best-quality and, at the same time, cost-effective services. Within this context of the growing need for information exchange, the demand for realization of data networks interconnecting various health care institutions at a regional level, as well as a national level, has become a practical necessity.

OBJECTIVES

To present the technical solution that is under consideration for implementing and interconnecting regional health care data networks in the Hellenic National Health System.

METHODS

The most critical requirements for deploying such a regional health care data network were identified as: fast implementation, security, quality of service, availability, performance, and technical support.

RESULTS

The solution proposed is the use of proper virtual private network technologies for implementing functionally-interconnected regional health care data networks.

CONCLUSIONS

The regional health care data network is considered to be a critical infrastructure for further development and penetration of information and communication technologies in the Hellenic National Health System. Therefore, a technical approach was planned, in order to have a fast cost-effective implementation, conforming to certain specifications.

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!

CROW for large scale macromolecular simulations

CROW (Columns and Rows Of Workstations - http://www.sicmm.org/crow/) is a parallel computer cluster based on the Beowulf (http://www.beowulf.org/) idea, modified to support a larger number of processors. Its architecture is based on point-to-point network architecture, which does not require the use of any network switching equipment in the system. Thus, the cost is lower, and there is no degradation in network performance even for a larger number of processors.

Development of a handheld computer documentation system to enhance an integrated primary care clerkship

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

Info tech's next step. What's driving the race to market this new generation of clinical systems?

A new generation of clinical IT systems has hit the market all at once. Is this vigorous competition vendor driven, or has health care--and the technology needed to support it--fundamentally changed? And what does it all mean for hospitals struggling to decide where to spend the big bucks it takes to remain technologically viable?

[Improving productivity by implementing RIS and PACS throughout the clinic: a case study]

PROBLEM

How are improvements in productivity in connection with RIS/PACS to be defined? What do they cost? To limit the problem to the relevant topics, we first describe the objectives of a radiology department and the identified bottlenecks in the workflow. How to define and assess the improvements is discussed.

METHODS

The case in question for this study is the RIS/PACS project at the "Klinikum der Universität München, Campus Grosshadern". The goals of the project and its present status are reviewed. The project is not yet completed, so this is a "midterm" report.

RESULTS AND DISCUSSION

We describe the status of the achieved and not yet achieved goals and of the eliminated bottlenecks. On the plus side, for example, nearly 100% of all digitally generated images (except mammogramms) are digitally archived. They are accessible to the same percentage in radiology via PACS and in the hospital via the webbased intranet image distribution system when needed. In some radiology areas, such as multislice CT, already the reporting can no longer be performed without softcopy image interpretation. However, the full elimination of hardcopy images is still not reality, since the distribution to DICOM viewers for selected requesters with demands for almost reporting quality, high cost image displays is still in the testphase. To reduce film costs, images are being printed on a high resolution paper printer in addition to the intranet distribution during this transition period. On the negative side, due to a lack of job positions in the transcription rooms, about 40% of the reports are still being handwritten by radiologists. Furthermore, the dictated and transcribed reports are usually still not available early enough in the RIS and thereby in the intranet report distribution of the hospital. Here only a speech recognition system can remedy the situation. As soon as this problem is solved and the image distribution to the DICOM viewers works routinely, the reports and the images will be accessible within minutes to maximally within some hours after the examination.

CONCLUSION

The goals reached so far suffered delays due to unforeseen problems and pitfalls. Altogether, a quieter operation and workflow in radiology has already been achieved, due to less inquiries from the requestors for unfinished examinations, images and/or image copies.

Electronic patient records for dental school clinics: more than paperless systems

The Electronic Patient Record (EPR) or "computer-based medical record" is defined by the Patient Record Institute as "a repository for patient information with one health-care enterprise that is supported by digital computer input and integrated with other information sources." The information technology revolution coupled with everyday use of computers in clinical dentistry has created new demand for electronic patient records. Ultimately, the EPR should improve health care quality. The major short-term disadvantage is cost, including software, equipment, training, and personnel time involved in the associated business process re-engineering. An internal review committee with expertise in information technology and/or database management evaluated commercially available software in light of the unique needs of academic dental facilities. This paper discusses their deficiencies and suggests areas for improvement. The dental profession should develop a more common record with standard diagnostic codes and clinical outcome measures to make the EPR more useful for clinical research and improve the quality of care.

Decision criteria and characteristics of Norwegian general dental practitioners selecting digital radiography

OBJECTIVES

To evaluate Norwegian general dental practitioners' decision criteria and characteristics for choosing digital radiographic equipment.

METHODS

A questionnaire was sent to all dental practitioners in Norway (n = 3940). They were categorised on the basis of their responses as either a 'digital radiography' (DR) or 'non-digital radiography' (non-DR) dentist. Demographic, clinical, and electronic technology variables were recorded. Dentists ranked on a six-point scale their reasons for choosing or not choosing digital radiography. Their responses were analysed by logistic regression.

RESULTS

Two thousand, one hundred and ninety-nine dentists (56%) replied. Three hundred and nine (14%), (219 men, 86 women and four not stated) had chosen to use digital radiography. The logistic regression analysis revealed that gender, age and years in dentistry were not significant factors in determining their decision, whereas working in a private or group practice was. The number of computers in the practice was the most important of the electronic technology variables. The non-DR dentists strongly agreed that 'digital radiography is too expensive' and were 'satisfied with film'. The DR dentists strongly agreed that the 'use of chemicals can be avoided', 'patient dose is reduced', and 'archiving is facilitated'.

CONCLUSION

Working in a private or group practice or using multiple computers were significant factors in choosing digital radiography.