Experiences with a prototype tracking and verification system implemented within an imaging center

RATIONALE AND OBJECTIVES: Most health care facilities currently struggle with protecting medical data privacy, misidentification of patients, and long patient waiting times. This article demonstrates a novel system for a clinical environment using wireless tracking and facial biometric technologies to automatically monitor and identify staff and patients to address these problems. MATERIALS AND METHODS: The design of the location tracking and verification system (LTVS) was based on a workflow study which was performed to observe the physical location and movement of patient and staff at the Healthcare Consultation Center II (HCC II) running hospital information systems, radiology information systems, picture archive and communication systems, and a voice recognition system. Based on the results from this workflow study, the LTVS was designed using a wireless real-time location system and a facial biometric system integrated with the radiology information system. The LTVS was tested for its functionality in a laboratory environment, then evaluated at HCC II. RESULTS: Experimental results in the laboratory and clinical environments demonstrated that patient and staff real-time location information and identity verification can be obtained from LTVS. Warning messages can immediately be sent to alert staff when patient's waiting time is over a predefined limit, and unauthorized access to a security area can be audited. Additionally, patient misidentification can be prevented during the course of examinations. CONCLUSIONS: The system enabled health care providers to streamline the patient workflow, protect against erroneous examinations and create a security zone to prevent, and audit unauthorized access to patient health care data required by the Health Insurance Portability and Accountability Act mandate.     

Radiology 1984. A conflict of high technology and high cost

Radiology is confronted now by exciting but challenging times. The excitement derives from dramatic technological advance; the challenge from the economic constraints on health care delivery. The large and growing expense of providing health care is readily apparent and high technology medicine can too easily be blamed for the growth. The pressures for improved service at no extra cost will demand much of the negotiating skills of our specialty and our ability to survive administrative confusion and fragmentation. Equally, manpower planning is a feature of modern medicine. Often this is done from inadequate data and as a specialty we must continue to think constructively about our own future in this context, not least in recognizing the contribution of women to our specialty. Forces also to be recognized are decentralization, electronic information transfer, concerns about radiation exposure and litigation. Not least we need to be better able to define our specialty as its scope is now changing rapidly. For the future I hope that we can be part of the development of the controls which we must inevitably face; we should lead in instituting cost-accounting in our departments; we must be at the leading edge of technological change in both imaging and data transfer, and we must be both more business-like as well as act effectively as the patient's advocate. Radiology has an important and growing responsibility in patient care and most of the technological advances both improve that care and can be justified economically. I am proud to be a radiologist in 1984.     

Ethical Aspects of Patient Information in Radiation Oncology

BACKGROUND: While legal aspects of patient information in radiotherapy are often discussed in clinical literature, ethical aspects are mainly a topic of debate only in bioethical literature. Nevertheless, patient information about radiation oncology has many ethical implications which must be considered in order to provide an optimal patient care. Therefore, this publication describes these ethical aspects from a clinical perspective. METHODS: The basis of this project was a Medline search (1990-2002) using the key words "radiotherapy" and "patient information" for the first part, and "radiotherapy" and "ethics" for the second part. RESULTS: The clinical papers (n = 55) demonstrate a serious attempt to improve patient information in clinical practice. Most articles deal with various discussion aids like booklets, audiotapes and others, or deal with the patients' information needs and preference. Under ethical aspects (n = 26 papers), palliative radiotherapy confronts the physician with many unsolved problems concerning telling the truth and the patient's misunderstandings which are often observed. The most important ethical principles of patient information are truth, autonomy, informed consent, and hope. For each of these, a definition is provided, as well as a detailed discussion of various typical situations in radiation oncology such as adjuvant therapy or palliative treatment. CONCLUSION: Considerations regarding the ethical aspects of patient information can provide an impulse to clinical improvement. Therefore, research in this field should be intensified in the future, especially in the area of palliative radiotherapy.     

The clinical reality of implementing formal risk assessment and management measures within high secure forensic care

This paper describes the successful implementation of a formal violence risk assessment and management strategy within a high secure forensic care facility. The aim of the implementation was to ensure that each patient had a formal violence risk assessment and management plan that was shared and applied to clinical practice by the patient's clinical team. The process as a whole, from risk assessment to risk management including appropriate care and treatment documentation, is outlined. In this way, this paper also describes the difficulties and problems encountered within the organizational reality of implementation projects. Suggestions and recommendations on how to avoid and manage these are made.     

Can hospitals prohibit euthanasia? An analysis from a European human rights perspective

At present, in four European countries euthanasia and/ or physician assisted suicide (PAS) are tolerated under strict legal conditions. However, in practice these patient groups are often deprived of the possibility to undergo such decisions. Particularly Catholic health care institutions have developed policies which restrict the internal application of the law. Yet, the legitimacy of such policies is questionable. From a European human rights perspective it can be defended that the freedom of association allows hospitals to develop policies elaborating their ethical stances on euthanasia and PAS. However, to respect the patient's right to self-determination the concerned hospitals should at least inform current and future patients about the restrictive policy and deal carefully with euthanasia and PAS requests. If a patient's wish remains seriously incompatible with the ethical stances of the hospital, at least reasonable and attainable alternatives (such as a referral to a tolerant regional hospital) should be offered.     

PR: a positive program, not professional rhetoric

A great deal of literature dealing with holistic medicine has been published in recent years. The proponents of holistic care seem concerned with treating the whole patient. Influencing factors such as environment, social background, individualism, etc. are all considered in establishing the patient's treatment. Traditional medicine appears to be more directly involved with the discovery and eradication of organic disease. It is proposed that one facet of the holistic concept be applied to our current system of health care delivery. A patient relations program takes manpower, time, money and a genuine interest in the patient. But the rewards far outweigh the costs. The patient, it is felt, is treated with greater understanding and concern. This elicits a positive comment from them to the attending technologist. The technologist is gratified that his efforts are noticed, and he continues to work at improving the professional services offered to a caring patient. It works! You can be justifiable proud of the radiology aides, secretaries, registered technologists and radiologists that continually strive to provide this personalized service to the "Whole Patient."     

Morality, ethics, and radiologists' responsibilities.

The goal of this discussion was to address the matter and methodology of ethics and critical thinking and to ask several questions about the relationship between ethics and radiology. Questions about the nature of the moral and how ethics inform decision making raise our awareness and may provide new understanding about moral thinking. Why is medicine a moral endeavor? Overridingness, universalizability, and other-regarding virtues were discussed. How do ethics inform medical decision making? Ethical theories, including parentalism, autonomy, and the engagement model, were discussed. What are radiologists' ethical responsibilities? Our ethical responsibilities as radiologists entail seven briefly described elements: assessing the appropriateness of the imaging examination, participating in the informed consent process, protecting patient interests, providing excellent image interpretation, communicating effectively with physicians and patients, seeking continued learning, and continuously improving quality. Of these responsibilities, competence, loyal concern for the patient's well-being, and respect for his or her person provide the basis for trust in the patient-physician relationship. If the central paradox in medicine is the tension between self-interest and altruism, then responsibility to the patient in this trust has the greatest force and overrides other obligations. Finally, our challenge is to critically examine our and each other's professional role and the extent to which we achieve excellence in our contribution to patient care; to break out of comfortable habits and reflect on new, alternative ways of knowing as caregivers; to think about what we are doing in medicine and the consequences for the human mind and spirit of our patients, our colleagues, and ourselves; and to provide a forum for this important dialogue in our practices, residency programs, and continuing education curricula.     

Healthcare Disparities in Interventional Radiology

Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.     

Effectiveness in meeting recommended standards for annual diabetic eye examinations at a veterans health administration facility

This study determined the effectiveness of one Veterans Affairs Medical Center facility at providing annual diabetic eye examinations. A medical records review of a simple random sample of 350 diabetic patients was conducted to assess the impact of delayed access to care, practitioner referral patterns, patient no-show rates, and sample sizes used in performance reports. A 55.6% adherence rate was found, which increased to 81% when adjusted for future scheduled appointments. A high rate of physician referral for diabetic eye care was documented (68.9%), with a 10.2% patient no-show rate. The primary factor adversely affecting diabetic eye examination rates at this facility was a delayed access to care, complicated by an increased demand for eye care services. Also, sample sizes used in official performance reports were not sufficient to accurately determine true examination rates at the local level.     

Clinicians' access to diagnostic imaging information at an academic center: perceived impact on patient management.

We studied the efficiency with which clinicians were able to obtain the results of radiologic studies during visits to the radiology department in an effort to determine how often delays occurred and, if so, how they were perceived to have influenced patient care. We monitored 322 physician's visits to four locations within the radiology department in search of imaging information or consultative services. The average duration of these visits was 6.2 min (range, 38 sec-55 min). Two hundred forty-three visits (75%) were completed successfully, and 10 additional visits were for consultation purposes only. In 43% of the 69 unsuccessful visits, physicians indicated that lack of access to imaging information would definitely (38%) or possibly (6%) result in delays in diagnosis and/or therapy. In 17% of the unsuccessful visits, physicians indicated that the inability to access imaging information would definitely (13%) or possibly (4%) extend the patient's length of stay in the hospital. Our study suggests that better access to imaging information may prevent delays in patient management decisions, thereby substantially reducing costs and potentially improving patient care.     

Seeking psychological treatment as a cure for a medical problem.

Today health care providers are more likely to experience legal, moral and ethical dilemmas regarding their treatment principles given the climate of health care. Clinical practice in the United States is being affected by many external forces which can affect patient care. Government and insurance companies are attempting to legislate treatment as evidenced by DRG's and reimbursement patterns. Hospital and clinic administrators are pressuring faculty and staff to increase revenue by participating in more income generating activities. Within this milieu of dwindling resources, consumers continue to demand a variety of health care services. A case example of a woman who asked for a psychological intervention to treat a medical condition is presented. This case focuses on the important issue of offering efficacious treatments to informed patients with carefully diagnosed disorders. Whether scientific, ethically-based treatments are being rendered when any of the criteria, efficacious, informed and diagnosed are altered or missing, is open to doubt. This case is presented, not as a model of clinical management, but rather to stimulate discussion and generate ideas on how to better address future situations: (a) Where the patient requests an available treatment for a problem which would not be directly helped by such treatment; (b) how far must a clinician go to insure that informed consent has been reached?; (c) what is the physician's responsibility in providing what a patient wants in the way of treatment?; and (d) conversely, should clinicians provide medical interventions (at the patient's insistence) for psychological problems, for example, provide a penile prosthetic implant to a man whose disorder is clearly psychogenic impotence?     

Malignant hyperthermia susceptibility and the trauma patient

Assorted casualties are expected from combat. Triage of the wounded may result in some going directly to surgery. Although every minute is essential, anesthetic care of these trauma patients must adhere to all established standards of care. A timely preoperative assessment must include identifying the patient's risk for malignant hyperthermia (MH). If a patient is found to be malignant hyperthermia susceptible, all appropriate measures must be taken to provide the patient with a safe anesthetic. In the forward, austere military environment, anesthesia providers may experience logistical and manpower constraints when administering anesthesia. In this setting, it may be more even more crucial for preoperative recognition of MH and when this is not possible, focus must shift to perioperative detection and early treatment. The following case report emphasizes the importance of preoperative recognition and having an established MH protocol and access to dantrolene.     

Dosimetric audit in brachytherapy

Dosimetric audit is required for the improvement of patient safety in radiotherapy and to aid optimization of treatment. The reassurance that treatment is being delivered in line with accepted standards, that delivered doses are as prescribed and that quality improvement is enabled is as essential for brachytherapy as it is for the more commonly audited external beam radiotherapy. Dose measurement in brachytherapy is challenging owing to steep dose gradients and small scales, especially in the context of an audit. Several different approaches have been taken for audit measurement to date: thimble and well-type ionization chambers, thermoluminescent detectors, optically stimulated luminescence detectors, radiochromic film and alanine. In this work, we review all of the dosimetric brachytherapy audits that have been conducted in recent years, look at current audits in progress and propose required directions for brachytherapy dosimetric audit in the future. The concern over accurate source strength measurement may be essentially resolved with modern equipment and calibration methods, but brachytherapy is a rapidly developing field and dosimetric audit must keep pace.     

Highlights of the annual meeting of the European Association of Nuclear Medicine,Lausanne 1993

Conclusion The organisers and scientific committee are to be congratulated on a successful Congress. The oral and poster presentations have demonstrated the themes and distractions for nuclear medicine in the future. The objective measurement of organ function is taking on a role in the medical audit and outcome analysis of many medical and surgical procedures applied to the heart, brain, kidneys, etc. The move to combine specificity with sensitivity means more precise tissue characterisation as an aid to diagnosis, therapy and prognosis, particularly for malignant disease and in inflammtory disorders. The quality service that nuclear medicine provides for the patient and the medical pratitioner requires a stable and secure health care environment. Correspondence to: K.E. Britton     

The work of forensic physicians with police detainees in the Canberra City Watchhouse

Forensic physicians provide both medical care and forensic consultations to detainees in police custody. There is a paucity of Australian data regarding characteristics of detainees and the type of work provided by forensic physicians in this setting. This retrospective audit of a clinical forensic service in Canberra, Australia will assist with service planning, future data collection and the training of forensic physicians.     

Development of a clinical chart audit programme

Radiation oncology charts containing medical information and treatment details are the major methods of communication between the various personnel involved in delivering radiation therapy to the patient. It is paramount to good patient care for this communication to be clear, precise and accurate in detail. A regular chart audit should be a part of the quality assurance programme of every radiation oncology department. The primary aim of this study was to develop and assess an objective and quantitative programme for reviewing radiation oncology charts, thereby improving the quality of communication and hence patient management. A secondary aim was to compare the charts of radically treated patients with those treated palliatively. A pilot study using a new chart review tool, developed at the Perth Radiation Oncology Centre, was carried out over an 8-month period. A sample of charts, representing 25% of our treatment group, were assessed using the tool on a monthly basis. A total of 156 charts were reviewed during this time period. Fifty-six per cent were radical treatments and 44% were palliative. The overall mean chart scores significantly improved over the time of this study (P < 0.001). The individual radiation oncologists' scores were also seen to improve during the study period. The alpha coefficients for intra-rater and inter-rater reliability were 0.99 and 0.88, respectively. The chart review programme was found to be an easy-to-use and a reliable tool by both medical and non-medical reviewers. It appeared to have a positive influence on the standard of radiation oncology charts in our department.     

Day-case peripheral angioplasty using nurse-led admission, discharge, and follow-up procedures: arterial closure devices are not necessary

AIM: To audit the safety of day-case peripheral arterial intervention without the use of arterial-closure devices using nurse-led admission, discharge, and follow-up procedures. MATERIALS AND METHODS: Patients referred for elective, peripheral vascular intervention were selected for day-case care according to pre-determined criteria using telephone triage. Post-procedure haemostasis was achieved using manual compression. After 3h bed-rest, patients were mobilized and discharged at 5h. Patients were contacted by telephone next working day to audit complications. RESULTS: One hundred and eighty-three elective day-case peripheral interventions were performed over 2 years, predominantly using 6 F sheaths. No closure devices were used. Five patients (2%) returned to the department because of persistent groin symptoms the next day. One of these had a false aneurysm. Four required no further treatment. A single patient returned at day 6 with a delayed false aneurysm. CONCLUSION: Day-case peripheral vascular intervention can be safely performed in appropriately selected patients without the use of arterial closure devices. Specialist radiology nurses have a major role in the counselling, care, and follow-up of these patients.     

Medical malpractice in the age of technology: how specialty societies can make a difference

In the United States, medical malpractice litigation, and the rising cost of malpractice insurance, is a crisis that threatens to restrict patient access to high-risk services, especially obstetrics and certain surgical procedures. Radiation Oncology, though a small specialty, is very technologically oriented. Because the history of product liability and malpractice litigation in this country parallels the technologic revolution, practitioners of this specialty are clearly at risk for litigation. Because legislative relief is unlikely to be forthcoming in the near future, many specialty societies have assumed the responsibility for devising means to protect members from frivolous law suits, without compromising a patient's right to due process. To date, Radiation Oncology societies have not taken a leadership role in this movement, preferring instead to cede this responsibility to the American College of Radiology. Opportunities exist for specialty societies to define standards of care and establish guidelines for expert witness testimony. To date, the courts have been supportive of these efforts. Herein, we summarize some of the salient issues of the malpractice crisis facing Radiation Oncology and offer suggestions for change within the specialty to better address the malpractice problem.     

Lumbar discography: an update

Discogenic pain most commonly affects the low back, buttocks, and hips and is thought to be a byproduct of internal disk degeneration. It is postulated that progressive annular breakdown and tearing results in biomechanical and/or biochemical stimulation of the pain fibers that reside in the outer one third of the annulus. Although multiple imaging modalities, most notably MRI, can show morphologic abnormalities of the spine, discography remains the only test that provides physiologic information regarding what role a given intervertebral disk plays in a patient's symptom complex. The controversy surrounding discography is here to stay until more definitive, well-designed studies are performed. In the meantime, there are certain things that can help the discographer maximize the accuracy of the test: 1. Always try to inject one "normal" disk as a "control level." 2. Be alert for factors that are associated with an increased false-positive rate (abnormal non-anatomic pain maps, a history of chronic pain of spinal or nonspinal origin, abnormal psychometric testing, and prior surgery at the injected disk level). In these cases, special attention should be directed to both the patient's verbal and nonverbal cues during disk injection. 3. Do not give any audible clues as to what level is being injected or when the injection is starting or finishing. In this regard, we find it very helpful to have one of our personnel talk with the patient during this portion of the procedure while closely observing the patient for any nonverbal cues regarding their pain response. This distraction is preferable to a silent room where the patient is intensely focused on what is going on with the injections. We also find that music playing during the procedure helps to relax and often distract the patient as well. 4. If the results are equivocal at a level (i.e., you are unable to determine whether or not the patient's pain response was truly concordant), go on to inject another disk level and then come back to reinject more contrast into the disk in question. As radiologists, we tend to focus on the technical aspects of a procedure and the anatomic/morphologic information it provides. However, it cannot be emphasized enough that when performing lumbar discography, the assessment of the patient's pain response during the injection is the most important component of the procedure, and requires not only technical skills, but an understanding of how best to avoid some of the pitfalls that can lead to inaccurate results.