Bob G. Thompson

Telemedicine and Geriatrics: Back to the Future

n unprecedented revolution in the telecommunications A industry is driving the emergence of a compelling new and powerful national information infrastructure. This infrastructure will provide universal access to interactive data and communications services from a variety of settings, including the home. Through high-speed electronic linkage, professionals who might otherwise interact only rarely can function as a virtual healthcare team through the rapid exchange of vital information and interactive deliberation and decisionmaking. A patient’s single contact with any team member can be a point of universal access to other team members and to a vast array of services and information. Time and travel are minimized for both patient and provider, and more timely and coordinated care is given and healthcare cost increases are dramatically reduced through increased efficiency and expansion of productive activity. In addition, it is conceivable and technologically feasible to place this capability at the patient’s geographic location to allow house calls, personal visits, access to diet, and other healthcare information and even components of the history, physical examination, and diagnostic procedures to be performed whether the patient is at home or traveling.

Nine reasons why healthcare delivery using advanced communications technology should be reimbursed.

The patient had experienced excellent health for most of his life except for recurrent kidney stones since the age of 17. He served in Africa with the Peace Corps and had malaria in 1967 with no evidence of jaundice at that time. In 1982, he had a urological operation at a medical center for recurrent kidney stones, which showed medullary sponge kidney. At that time his platelet function was normal, but his alkaline phosphatase was slightly elevated. There was no evidence of an enlarged spleen at operation. Other than recurrent kidney stones, the patient was in excellent health until March 1994 when he was seen again at a medical center for kidney disease. A CT scan showed an enlarged spleen, kidney stones, and a somewhat small liver. His liver enzymes and alkaline phosphatase were slightly elevated. The patient experienced increasing fatigue, weakness in both arms with occasional numbness, pain in both arms, and arthralgias. In April 1995, the patient was seen by his local gastroenterologist for persistent elevation of liver enzymes. The examination was notable for an enlarged spleen but not for ascites or edema. Laboratory findings showed pancytopenia, negative hepatitis B & C serologies, and a normal ferritin. A bone marrow examination was interpreted as normal. Chest X-ray was normal, without hilar adenopathy, masses, or signs of active disease; a liver/spleen scan showed splenomegaly as well as abnormal uptake of the tracer in the liver without space occupying lesions. In May 1995, the patient was seen at a major medical center for evaluation by a liver specialist. Additional history revealed a father who had stomach cancer with metastatic disease to the liver and a mother who died of

ACR-NEMA standards activity: an update

The ACR-NEMA Standard was published five years ago. Implementations are just now becoming available in a form other than a prototype. Though this seems like a long interval between the initial work and results, the organization responsible for the Standard, the ACR-NEMA Digital Imaging and Communications Standards Committee, has not been idle. Much of the progress which has been made is the result of cooperative work involving industry, the Committee and its Working Groups (WG), and the medical imaging user community. This paper will briefly review the history of the development of what is now a family of ACR-NEMA standards, describe the current activity of the Working Groups, and indicate in what directions the WGs are headed for both new and updated standards.

Functional Requirements For Interfacing PACS To RIS

This paper will discuss the functional requirements for interfacing Picture Archiving and Communications Systems (PACS) to todays radiology information systems (RIS). It is clear from the operational modeling study done at UNC, that a fully functional PACS will require the use of RIS data. For example, patient ID, scheduling, and information tracking are usually part of a RIS and must be available to the PACS. Similarly, the image tracking and index capabilities of the PACS will be used by the RIS. As part of our modeling data flow analysis research program, we have identified a number of these interactions. The interface points will be identified and discussed with emphasis on the operational impact of such an interface and efficiencies likely to be provided.

Information Flow Analysis As A Tool For Pacs Development

Multiple benefits for PACS development can be expected to derive from careful assessment or modeling of current system operations. Our approach to modeling the radiology department operations at UNC-CH is based on two assumptions: 1) a department consists of multiple, operationally similar modules and 2) individual modules can be sufficiently characterized by use of a single template. Our procedures and conclusions in developing the modality portion of this template are described. Future modeling work is directed towards characterizing interactions within radiology and between radiology and other clinics which should, we believe, complete the characterization for a single module of the radiology department.

Distance learning for hospital managers.

Telemedicine technology enabled this class to meet. The Chapel Hill instructor could not have traveled to Scotland Neck for the classes, and the class members could not have taken time away from their jobs to travel to Chapel Hill. The technology allowed the participants to fit the classes into their schedules. For the group of managers at this small, isolated hospital, the experience of participating in a management class with an expert was a positive one. They were introduced to standard management practices, learned new skills, and formed a support group/team onsite. The students felt close to the leader, yet the physical distance made her an outsider in a way that encouraged frankness. The technology seemed to foster the best of both worlds--intimacy, yet physical distance and, thus, safety. These new managers were able to take part in a course that taught tangible skills for improving their job performance and, more important, afforded access to resources outside of Halifax County. They were able to step away from their daily routine and interact with outsiders and each other in new ways, without the stress and expense of travel. The results of this pilot study indicate that distance learning is feasible for courses of this kind. Staff burnout and turnover are chronic problems in rural facilities, with isolation contributing to job dissatisfaction. Distance learning offers exciting possibilities for addressing these problems in healthcare settings across the country.

Remote consultation with a multiple screen FilmPlane radiology workstation

As hospitals geographically spread and radiologic services are required in remote locations, the radiologist increasingly must conduct a remote practice. Rapid image transmission from the remote site to the radiologist is important but only half the problem. First, the radiologist may need to view and discuss the images with the technologist to verify image quality or to specify the location of follow-up images. Second, the radiologist may need to discuss the case with another radiologist for a second opinion or for the advice of a sub-specialist. Third, and most importantly, the radiologist may need to discuss the case with the referring physician to better understand the text data, clinical history, and referring physicians clinical questions and concerns, and to better convey the location and extent of the clinical findings. In this paper we detail the requirements for a remote consultation workstation, present previous work on remote computer interaction, and describe the FilmPlane remote consultation workstation in detail. We then discuss the MICA medical communications project in which FilmPlane will be used for a remote consultation study between the UNC family medicine clinic and the main hospital 1/2 mile away.

Operational Modeling For PACS: How Do We Decide If It's Cost Effective?

The operational analysis project at UNC is continuing, with a major goal directed at prospective analysis of the effectiveness of technological capabilities and potential cost effects of PACS on the operation. We have now defined the major operational variables we believe will provide information to evaluate PACS technology. These operational variables, the modeling methodology and the methods of data collection are described. Our approach to statistical analysis of diagnostic quality is also briefly discussed.

Pacs: Part Of An Integrated Communications System

The Department of Radiology at the University of North Carolina-Chapel Hill (UNC) has developed the concept for an integrated picture archiving and communications system. A communications network has been installed, and computer facilities are being interfaced within radiology areas. Other projects include the establishment of a computer simulation model of departmental operations and assembly of a limited picture archival and communication system (PACS) beginning with the CT and NMR Modalities. While this approach may provide immediate clinical benefits, the initial thrust has been towards evaluation of prototype systems with flexibility for modifications. PACS operational parameters are being studied for their acceptability in support of radiology clinical services. The goal is to provide objective operational data as a basis for planning system improvements.

Digital Image Display Console Design Issues

Electronic image display has been envisioned as a means of alleviating some of the problems that expanding radiology departments have with film management, integration of multiple imaging modalities and as a means of improving the physicians diagnostic abilities through after acquisition image contrast enhancement. In an effort to provide an electronic image display suitable for general use, several educational institutions and industry have been in the process of developing computerbased image systems called picture archival and communication systems (PACS). Functional integration of the PACS components (network, archive, database management and display) presents problems which require the development of departmental modeling, a common communication protocol, image storage devices with enormous capacities, management software and display consoles. The latter has been the object of our focus.