Preparing medical students for a filmless environment: instruction on the preparation of electronic case presentations from PACS

RATIONALE AND OBJECTIVES: As the use of picture archiving and communication systems (PACS) expands and radiology departments become increasingly filmless, it will become increasingly necessary to teach physicians how to use PACS and download diagnostic images. The authors developed an instruction method in which medical students enrolled in a radiology clerkship were taught how to use the PACS, download digital images, and incorporate them into an electronic case presentation. The feasibility and potential benefits of this instructional method were studied prospectively. MATERIALS AND METHODS: Between June and October 1999, all 36 medical students enrolled in Harvard Medical School's core radiology clerkship at Massachusetts General Hospital, Boston, were required to give an electronic radiology case presentation with images downloaded from the departmental PACS. They were taught how to download images, edit them, and then import them into PowerPoint software. They were also given access to the hospital information system to obtain pertinent clinical information. At the formal presentations, the images were displayed with a liquid crystal display (LCD) projector. The students were surveyed on the Ist and last days of the clerkship regarding their learning experiences. RESULTS: Before the radiology clerkship, 81% of the students had never given an electronic presentation with computer and LCD projector, 83% had no PACS experience, and 56% had no PowerPoint experience. All students learned to prepare and deliver electronic presentations of radiologic cases downloaded from PACS. Their presentations were informative, innovative, and entertaining, and the images were well displayed. The students praised the instruction highly and thought their new skills would serve them well. CONCLUSION: Teaching medical students how to prepare and deliver electronic presentations of radiologic cases downloaded from PACS proved to be very feasible and well appreciated by the students.     

Impact of filmless radiology on frequency of clinician consultations with radiologists.

OBJECTIVE: The purpose of the study was to determine the impact of filmless operation on the relative frequency of in-person consultations in the radiology department between radiologists and clinicians. CONCLUSION: The transition to filmless operation at the Baltimore Veterans Affairs Medical Center was associated with an 82% reduction in the in-person consultation rate for general radiography and a 44% reduction for cross-sectional imaging despite an increase in the volume of studies. The major reason for this decrease was the convenient access to current and prior images provided by the PACS (picture archiving and communication system). Radiology departments contemplating a transition to filmless operation should prepare for communication with clinicians to shift from being mostly in person to being conducted more and more through electronic forms of communication.     

Effect of filmless imaging on the utilization of radiologic services

PURPOSE: To determine the effect of a large-scale picture archiving and communication system (PACS) on in- and outpatient utilization of radiologic services. MATERIALS AND METHODS: Data were collected at the Baltimore Veterans Affairs (VA) Medical Center (BVAMC) before and after implementation of an enterprise-wide PACS; the numbers and types of imaging examinations performed for fiscal years 1993 and 1996 were evaluated. These data were compared with those from a similar academic medical center, the Philadelphia VA Medical Center (PVAMC), and with aggregate data obtained nationally for all VA hospitals over comparable periods. RESULTS: Inpatient utilization, defined as the number of examinations per inpatient day, increased by 82% (from 0.265 to 0.483 examinations per patient day) after a transition to filmless operation at BVAMC. This is substantially greater than the increases of 38% (from 0.263 to 0.362 examinations per patient day) and 11% (from 0.190 to 0.211 examinations per patient day) at the film-based PVAMC and nationally, respectively. Outpatient utilization, defined as the number of examinations per visit, increased by 21% (from 0.108 to 0.131 examinations per visit) at BVAMC, compared with a 1% increase (from 0.087 to 0.088 examinations per visit) at PVAMC and a net decrease of 19% (from 0. 148 to 0.120 examinations per visit) nationally. CONCLUSION: The transition to filmless operation was associated with increases in inpatient and outpatient utilization of radiologic services, which substantially exceeded changes at PVAMC and nationally over the same interval.     

Construction of a quality assurance system for images in general radiography in a filmless environment: construction of an accurate and swift workflow

When medical records went digital at our hospital, we also went filmless. In the general radiography department, we were forced to change the workflow, so we created a new one. We introduced a system of quality assurance for images between consoles and PACS. As our original improvement, we added to the system a function to automatically narrow down patient images and a function to automatically sort images. We divided quality assurance for images into 1st and 2nd quality assurance and defined and managed it. In addition, we measured the time for each process of the workflow with and without film use. We compared 10 cases of chest and abdomen radiographs with 10 cases of bone radiographs. As a result, by using this system of quality assurance for images, we were able to cut three minutes from each examination, leading to quicker work.     

Evaluating medical students on radiology clerkships in a filmless environment: use of an electronic test prepared from PACS and digital teaching collection images

RATIONALE AND OBJECTIVES: The competency of medical students in radiology clerkships is traditionally evaluated with film images, projected slides of photographed films, or printed reproductions of films. As radiology departments switch to filmless imaging, it seemed appropriate to determine the feasibility of an electronic evaluation prepared directly from digital images. MATERIALS AND METHODS: The image-based portion of a multiple-choice final examination was prepared as a PowerPoint presentation that included images downloaded from the departmental picture archiving and communication system (PACS) or digital teaching collections. The images were downloaded as bitmap files, imported to Adobe Photoshop for image editing, converted to tagged image file format, and finally imported to PowerPoint, where they were combined with text to create 50 questions. A liquid crystal diode projector displayed the questions, with a timer set to advance them automatically. RESULTS: The examination was easy and inexpensive to prepare (no photography costs). In an initial survey of 25 students, 17 (71%) of 24 students rated the resolution of images as excellent and five (21%) as good. No student gave an image a poor rating. Students preferred that images cover at least 40%-50% of the slides, and most approved of a blue background. An original allowance of 30 seconds per slide was reported to be too fast; the interval was increased to 45 seconds. CONCLUSION: An electronic final examination for medical students, prepared with images downloaded from PACS or digital teaching collections, is feasible, easy to prepare, and cost-effective, and it provides an excellent display of test images.     

Image display in the operating room: eliminating the barriers in the transition to filmless radiology

As hospitals endeavor to transition from film-based radioloogy to electronic or filmless radiology, one limitation is an effective means for accessing the electronic image archive during surgical procedures. The dependency on using reference images during surgical procedures is a critical function. Scott & White Memorial Hospital in Temple, TX, has been progressively moving toward an electronic paradigm for access to medical information. As the radiology department began to eliminate film as a medium for image presentation and image archiving, it was realized that the hospital needed to provide an electronic solution for the display of images in the operating room (OR) as reference during the surgical procedure. The goals in this project were, therefore, multifold: provide electronic access to images and image files directly within the operating suites, eliminate lost films, and reduced delays caused by lost or unavailable films. The end solution utilized the same Web-based software for all devices, but varied the hardware to meet the individual's or group's needs. The success in this project was not contained to cost savings in radiology, which was realized by reducing film library personnel and eliminating films printed specifically for the surgical environment, but also in greater magnitude for the hospital in improving efficiency of the OR support staff and by directly stimulating a reduction in the average OR time needed for the surgical procedures.     

The 1987 Gordon Richards memorial lecture: the future of radiography--cassetteless or filmless?

A six-year experience of the first cassetteless radiology department has shown that it produces considerable improvement in speed and efficiency of patient handling, reduced physical labor for the technician, and substantial financial savings, amounting to approximately one third of the total non-medical budget. This is contrasted with the potential cost of a totally digital (filmless) department. The digital acquisition devices and their image processing systems are considerably more expensive. Image display comparable to conventional radiographys (for example the full-sized chest film) is markedly inferior in resolution and totally prohibitive in cost. Image storage and recall of the same amount of data as currently handled by the conventional department are presently beyond the capabilities of any commercial communications system, and the potential cost is completely unacceptable. Projections of the imminent advent of the filmless department are grossly over-optimistic, whereas the development of cassetteless systems offers an alternative route to improved patient handling and increased cost-efficiency.     

Interpretation of bone scans using a video display. A necessary step toward a filmless nuclear medicine department

Digital processing, storing, and interpretation of scintigraphic images from a PACS system has been postulated as an efficient, cost-saving measure that may obviate the need for analog film. In order to replace analog film, documentation that images can be interpreted from a digital video display with accuracy at least equal to film must be obtained. Analog film was compared with video images in 28 patients with cancer suspected to be metastatic to bone. Images were acquired with a gamma camera and processed in 256 x 256 word mode by the use of the Medical Data Systems A3 computer. Adjustment of gray scales provided operator-controlled digital contrast enhancement. Video and film images were independently interpreted by two experienced nuclear medicine physicians, each blinded to the other modality. A linear four-color scale was then substituted for the gray scale, and images again interpreted. Lesions were interpreted as positive or equivocal and verified through follow-up scans over a minimum of six months. Of the 28 patients, 22 proved to have metastases, in whom 129 lesions were confirmed by follow-up scintigrams. 124 of these lesions (96.1%) were detectable on both analog film and video images. An additional three proven metastatic lesions on video images were absent or equivocal on analog studies, increasing sensitivity for video images to 98.4%. Five further lesions seen on the video screen represented rib fractures and regressed on follow-up examination. All lesions seen on black-and-white video were also seen when the color scale was applied.(ABSTRACT TRUNCATED AT 250 WORDS)     

Loratadine in the high performance aerospace environment.

BACKGROUND: Authors have unanimously reported that 10 mg of loratadine does not produce sedation. A small risk of sedation may exist and may not have been discovered by those studies due to their small sample size. HYPOTHESIS: Using combined data, there is no increased risk of sedation over placebo for patients using 10 mg of loratadine daily. METHODS: Literature search and meta-analysis of published data was performed. RESULTS: Pooled data showed sedation in 25 of 517 patients given 10 mg of loratadine, and 24 of 510 patients given placebo. The relative risk was 1.03, with a confidence interval from 0.59 to 1.77. Sleepiness was objectively studied using the multiple sleep latency test. Patients treated with 10 mg of loratadine did not have excess sleepiness induced; patients treated with 40 mg of loratadine did. Using 10 different methods, 20 studies did not find performance impairment in subjects given 10 mg of loratadine. Two performance studies, digit substitution and driving, showed impairment with 20 mg and 40 mg of loratadine, respectively. Physiologic studies using resting EEG had conflicting reports. There was no impairment detected in altitude studies or vestibular studies. No centrifuge or color vision data were found. CONCLUSION: Ingesting 10 mg of loratadine daily does not have sedative effects or impair cognitive-motor performance. Higher doses have demonstrated impairment. Aviation concerns that have not been addressed include centrifuge studies and color vision studies. It would be reasonable to employ loratadine in the high performance aerospace environment if these latter tests prove to be negative.     

An autonomous in situ detection system for radioactivity measurements in the marine environment.

A new detection system named "KATERINA" is developed and applied for measuring marine radioactivity using NaI(Tl) as a crystal. This apparatus is designed for qualitative and quantitative radionuclide detection in the marine environment with maximum depth of deployment 400m. A detailed study for the enclosure of the system and for the electronics development is performed. The system offers volumetric activities in Bq/m(3) using the marine efficiency calibration, which is measured by dilution of three reference sources ((99m)Tc, (137)Cs, and (40)K) in a special tank. The calibration procedures for energy, energy resolution and efficiency were analyzed with particular attention to the factors that affect the calibration parameters. The underwater detector is tested in the field for acquiring radon daughters ((214)Pb and (214)Bi) in a region where submarine groundwater discharge exists in the coastal zone.     

Training medics for the combat environment of tomorrow

Advanced training for medics and corpsmen in the field would help prevent deaths and disabilities. Courses in Basic Trauma Life Support (BTLS) and Advanced Trauma Life Support (ATLS) can be used as a format for standardizing the approach to the injured patient. It can be integrated into the military setting along with the basic survival skills needed by the unit's medical provider.     

Methicillin-resistant staphylococci. Identification and distribution in the hospital environment

Occurrence of methicillin resistant staphylococcal strains in hospital environment is more frequently found. These strains are multiresistant so that diseases caused by them require a special therapeutical approach. They are significant causative agents of intrahospital infections which may have epidemic character. Using two methods for detection of methicillin resistant staphylococcus 335 strains were tested. Methicillin resistance was found in 36 (20.6%) of 175 strains of St. aureus and 49 (30.5%) strains of coagulase negative staphylococci. The largest number of methicillin resistant strains is isolated from materials of patients hospitalized at surgical and hematological clinics.     

Virtual environment for lower-extremities training

This study proposed virtual reality (VR) as a modality of lower-extremities training. A kinematic model of a human body and a corresponding virtual figure were developed, in order to visualize the movements of the subject in a real-time virtual environment on a large display, which represented a virtual mirror. An optical system with active markers was used to assess the movements of a training subject. A preliminary investigation was conducted with a group of healthy male subjects, who performed the stepping-in-place test by tracking the movements of the reference virtual figure, which represented a virtual instructor. Both figures were shown in the virtual mirror at the same time from the desired angle of view. Four stepping tasks featuring different cadences and hip angles were performed, with difficulty levels ranging from easy to demanding. The results obtained included basic kinematic and temporal parameters, which provided quantitative measures of a subject's adaptation to the virtual training environment, and thereby justifying the feasibility of the virtual mirror as a useful system in lower-extremities training applications.     

The retrograde tunnel: a method for the fixation of central venous catheters in the military environment.

Central venous catheters (CVCs) are prone to accidental removal during patient transportation. Of the casualties who require transfer between medical facilities, those with CVC in situ require additional vigilance to prevent loss of the CVC, which continues to occur despite various methods of fixation. The fashioning of a subcutaneous tunnel has become an integral part of the placement of central venous catheters. Several methods have been described, but the long-term CVCs in paediatric practice pose special problems, particularly that of the patients continually testing the CVCs fixation. Using a new polyurethane CVC, a retrograde tunnelling technique has been developed which affords immediate and secure fixation. We propose that this CVC, together with the technique of retrograde tunnelling, is the solution to inadvertent central venous line removal during patient transfer.     

Radiology survival in a cost-sensitive environment.

Based on a presentation made at the 1984 RSNA-Associated Sciences Workshop, this paper looks back on a year of change for the radiology community. Mr. Osborn identifies the strategies employed by those organizations that not only survived, but actually improved their financial position during the year.