Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity.
(9/561)
OBJECTIVE: To evaluate the influence of computer-based reminders about influenza vaccination on the behavior of individual clinicians at each clinical opportunity. DESIGN: The authors conducted a prospective study of clinicians' influenza vaccination behavior over four years. Approximately one half of the clinicians in an internal medicine clinic used a computer-based patient record system (CPR users) that generated computer-based reminders. The other clinicians used traditional paper records (PR users). MEASUREMENTS: Each nonacute visit by a patient eligible for an influenza vaccination was considered an opportunity for intervention. Patients who had contraindications for vaccination were excluded. Compliance with the guideline was defined as documentation that a clinician ordered the vaccine, counseled the patient about the vaccine, offered the vaccine to a patient who declined it, or verified that the patient had received the vaccine elsewhere. The authors calculated the proportion of opportunities on which each clinician documented action in the CPR and PR user groups. RESULTS: The CPR and PR user groups had different baseline compliance rates (40.1 and 27.9 per cent, respectively; P<0.05). Both rates remained stable during a two-year baseline period (P = 0.34 and P = 0.47, respectively). The compliance rates in the CPR user group increased 78 per cent from baseline (P<0.001), whereas the rates for the PR user group did not change significantly (P = 0.18). CONCLUSIONS: Clinicians who used a CPR with reminders had higher rates of documentation of compliance with influenza-vaccination guidelines than did those who used a paper record. Measurements of individual clinician behavior at the point of each clinical opportunity can provide precise evaluation of interventions that are designed to improve compliance with guidelines. (+info)
Successful implementation of a comprehensive computer-based patient record system in Kaiser Permanente Northwest: strategy and experience.
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Kaiser Permanente Northwest (KPNW) has implemented a computer-based patient record (CPR) system for outpatients. Clinicians at KPNW use this comprehensive CPR to electronically document patient encounters; code diagnoses and procedures; maintain problem lists; order laboratory tests, radiology tests, and prescriptions; and send patient-specific messages and referrals to other medical providers. More than 700 clinicians, representing more than 20 medical and surgical specialties, and 2600 support staff in 31 geographically separate sites use this system as the information foundation of delivery and documentation of health care for KPNW's membership of 430,000. As of May 1998, more than four million visits and two million telephone calls had been processed and documented into the system. More than 5000 outpatient visits are processed and documented each weekday. From an integrated clinical workstation, clinicians also access e-mail, an extensive results-reporting system, and sites on both the internet and KPNW's intranet. This article describes a strategy for and experience with the implementation of a large-scale, comprehensive CPR in an integrated HMO. This information may be useful for persons attempting to implement CPRs in their own institutions. (+info)
Support of quality and business goals by an ambulatory automated medical record system in Kaiser Permanente of Ohio.
(11/561)
Kaiser Permanente of Ohio has developed a Medical Automated Record System (MARS) to address the business and clinical needs of the organization. The system is currently used by 220 physicians and 110 allied health personnel. To support the quality initiatives of the organization, the system has been programmed to generate reminders, at the moment of care, on compliance with clinical guidelines. This article details examples of compliance improvements with guidelines for the use of aspirin in coronary artery disease, use of influenza vaccinations in members older than 64 years of age, and stratification of asthmatic patients into severity levels; it also summarizes other quality improvements. MARS provides a data stream for electronic billing, which saves the organization the cost of manual billing. In addition, this system reduces operating costs, in particular the number of staff needed to deliver charts and the cost of printing forms. Cost-benefit analysis demonstrates that the system can produce savings in excess of maintenance costs. (+info)
Panning for genes--A visual strategy for identifying novel gene orthologs and paralogs.
(12/561)
We have developed a rapid visual method for identifying novel members of gene families. Starting with an evolutionary tree, 20-50 protein query sequences for a gene family are selected from different branches of the tree. These query sequences are used to search the GenBank and expressed sequence tag (EST) DNA databases and their nightly updates using the tfastx3 or tfasty3 programs. The results of all 20-50 searches are collated and resorted to highlight EST or genomic sequences that share significant similarity with the query sequences. The statistical significance of each DNA/protein alignment is plotted, highlighting the portion of the query sequence that is present in the database sequence and the percent identity in the aligned region. The collated results for database sequences are linked using the WWW to the underlying scores and alignments; these links can also be used to perform additional searches to characterize the novel sequence further. With traditional "deep" scoring matrices (BLOSUM50) one can search for previously unrecognized families of large protein superfamilies. Alternatively, by using query sequences and EST libraries from the same species (e. g., human or mouse) together with "shallow" scoring matrices and filters that remove high-identity sequences, one can highlight new paralogs of previously described subfamilies. Using query sequences from the glutathione transferase superfamily, we identified two novel mammalian glutathione transferase families that were recognized previously only in plants. Using query sequences from known mammalian glutathione transferase subfamilies, we identified new candidate paralogs from the mouse class-mu, class-pi, and class-theta families. (+info)
Genes expressed during the differentiation of pancreatic AR42J cells into insulin-secreting cells.
(13/561)
Pancreatic AR42J cells have the feature of pluripotency of the common precursor cells of the pancreas. Dexamethasone (Dx) converts them to exocrine cells, whereas activin A (Act) converts them into endocrine cells expressing pancreatic polypeptide. A combination of Act and betacellulin (BTC) converts them further into insulin-secreting cells. The present study identifies some of the genes involved in the process of differentiation that is induced by these factors, using the mRNA differential display and screening of the cDNA expression array. The expression levels of 7 genes were increased by Act alone, and a combination of Act and BTC increased the expression of 25 more genes. Of these, 16 represented known genes or homologues of genes characterized previously. Nine of the identified genes were unrelated to any other sequences in the database. An inhibitor of the mitogen-activated protein kinase pathway, PD098059, which blocks the differentiation into insulin-secreting cells, inhibited the expression of 18 of the 25 genes, suggesting that the proteins encoded by these genes are associated with the differentiation into insulin-producing cells. These include known genes encoding extracellular signaling molecules, such as parathyroid hormone-related peptide, cytoskeletal proteins, and intracellular signaling molecules. Identification and characterization of these differentially expressed genes should help to clarify the molecular mechanism of differentiation of pancreatic cells and the gene products that enable the beta-cells to produce insulin. (+info)
Finding-specific display presets for computed radiography soft-copy reading.
(14/561)
Much work has been done to optimize the display of cross-sectional modality imaging examinations for soft-copy reading (i.e., window/level tissue presets, and format presentations such as tile and stack modes, four-on-one, nine-on-one, etc). Less attention has been paid to the display of digital forms of the conventional projection x-ray. The purpose of this study is to assess the utility of providing presets for computed radiography (CR) soft-copy display, based not on the window/level settings, but on processing applied to the image optimized for visualization of specific findings, pathologies, etc (i.e., pneumothorax, tumor, tube location). It is felt that digital display of CR images based on finding-specific processing presets has the potential to: speed reading of digital projection x-ray examinations on soft copy; improve diagnostic efficacy; standardize display across examination type, clinical scenario, important key findings, and significant negatives; facilitate image comparison; and improve confidence in and acceptance of soft-copy reading. Clinical chest images are acquired using an Agfa-Gevaert (Mortsel, Belgium) ADC 70 CR scanner and Fuji (Stamford, CT) 9000 and AC2 CR scanners. Those demonstrating pertinent findings are transferred over the clinical picture archiving and communications system (PACS) network to a research image processing station (Agfa PS5000), where the optimal image-processing settings per finding, pathologic category, etc, are developed in conjunction with a thoracic radiologist, by manipulating the multiscale image contrast amplification (Agfa MUSICA) algorithm parameters. Soft-copy display of images processed with finding-specific settings are compared with the standard default image presentation for 50 cases of each category. Comparison is scored using a 5-point scale with the positive scale denoting the standard presentation is preferred over the finding-specific processing, the negative scale denoting the finding-specific processing is preferred over the standard presentation, and zero denoting no difference. Processing settings have been developed for several findings including pneumothorax and lung nodules, and clinical cases are currently being collected in preparation for formal clinical trials. Preliminary results indicate a preference for the optimized-processing presentation of images over the standard default, particularly by inexperienced radiology residents and referring clinicians. (+info)
Challenges associated with the incorporation of digital radiography into a picture archival and communication system.
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Digital radiography (DR) has recently emerged as an attractive alternative to computed radiography (CR) for the acquisition of general radiographic studies in a digital environment. It offers the possibility of improved spatial and contrast resolution, decreased radiation dose due to improved efficiency of detection of x-ray photons, and perhaps most importantly, holds out the promise of increased technologist productivity. To achieve maximum efficiency, DR must be completely integrated into existing information systems, including the hospital and radiology information systems (HIS/RIS) and, when present, the picture archival and communication system (PACS). The early experience with the integration of DR at the Baltimore Veterans Affairs Medical Center (VAMC) has identified several challenges that exist to the successful integration of DR. DR has only recently been defined as a separate Digital Imaging and Communications in Medicine (DICOM) modality and images obtained will, at first, be listed under the category of CR. Matrix sizes with some DR products on the market exceed the current size limitations of some PACS. The patient throughput may be substantially greater with DR than with CR, and this in combination with the larger size of image files may result in greater demands for network and computer performance in the process of communication with the HIS/RIS and PACS. Additionally, in a hybrid department using both CR and DR, new rules must be defined for prefetching and display of general radiographic studies to permit these examinations to be retrieved and compared together. Advanced features that are planned for DR systems, such as dual-energy subtraction, tomosynthesis, and temporal subtraction, will likely require additional workstation tools beyond those currently available for CR. (+info)
Temporomandibular joint pantomography using charge-coupled device, photostimulable phosphor, and film receptors: a comparison.
(16/561)
Our objective was to compare the accuracy and practicality in use of three available imaging receptors for temporomandibular joint (TMJ) imaging; namely, two computer-assisted and one traditional analog x-ray film system. A standardized tissue-equivalent encased human skull specimen was imaged using lateral and posteroanterior (PA) pantomographic projections with the Orthopantomograph OP 100 (Instrumentarium Imaging, Tuusula, Finland) and three different receptor modalities: (1) Ektavision film with Ektavision screens (Eastman Kodak, Rochester, NY); (2) DenOptix photostimulable phosphor screens (Dentsply/Gendex, Chicago, IL); and (3) the charge-coupled device (CCD) receptor, DigiPan (TREX/Trophy Radiology, Marne-la-Vallee, France). The effective focal trough was found for each receptor using lead resolution grids placed at fractional millimeter distances along empirically determined beam projection angulations. The time to acquire and process images was also established. We found that the CCD system permitted real-time display, whereas the use of traditional film took 2 minutes to load the cassette in a darkroom and perform the exposure, and then a further 2 minutes to unload and process. The storage phosphor took 3 minutes to unload the cassette and process the image and a further 20 seconds to clear the plate following laser scanning. Film produced the greatest maximum resolution followed by the storage phosphor and the CCD. In conclusion, CCD-based TMJ pantomography provided an instant image. The photostimulable phosphor system used was the least satisfactory in terms of the time expended to obtain an image, but provided better spatial resolution than the CCD. Ektavision film/screens provided the best spatial resolution in this investigation. (+info)