Process reengineering: the role of a planning methodology and picture archiving and communications system team building.

The acquisition of a picture archiving and communications system (PACS) is an opportunity to reengineer business practices and should optimally consider the entire process from image acquisition to communication of results. The purpose of this presentation is to describe the PACS planning methodology used by the Department of Defense (DOD) Joint Imaging Technology Project Office (JITPO), outline the critical procedures for each phase, and review the military experience using this model. The methodology is segmented into four phases: strategic planning, clinical scenario planning, installation planning, and implementation planning. Each is further subdivided based on the specific tasks that need to be accomplished within that phase. By using this method, an institution will have clearly defined program goals, objectives, and PACS requirements before vendors are contacted. The development of an institution-specific PACS requirement should direct the process of proposal comparisons to be based on functionality and exclude unnecessary equipment. This PACS planning methodology is being used at more than eight DOD medical treatment facilities. When properly executed, this methodology facilitates a seamless transition to the electronic environment and contributes to the successful integration of the healthcare enterprise. A crucial component of this methodology is the development of a local PACS planning team to manage all aspects of the process. A plan formulated by the local team is based on input from each department that will be integrating with the PACS. Involving all users in the planning process is paramount for successful implementation.

Large-scale PACS implementation.

The transition to filmless radiology is a much more formidable task than making the request for proposal to purchase a (Picture Archiving and Communications System) PACS. The Department of Defense and the Veterans Administration have been pioneers in the transformation of medical diagnostic imaging to the electronic environment. Many civilian sites are expected to implement large-scale PACS in the next five to ten years. This presentation will related the empirical insights gleaned at our institution from a large-scale PACS implementation. Our PACS integration was introduced into a fully operational department (not a new hospital) in which work flow had to continue with minimal impact. Impediments to user acceptance will be addressed. The critical components of this enormous task will be discussed. The topics covered during this session will include issues such as phased implementation, DICOM (digital imaging and communications in medicine) standard-based interaction of devices, hospital information system (HIS)/radiology information system (RIS) interface, user approval, networking, workstation deployment and backup procedures. The presentation will make specific suggestions regarding the implementation team, operating instructions, quality control (QC), training and education. The concept of identifying key functional areas is relevant to transitioning the facility to be entirely on line. Special attention must be paid to specific functional areas such as the operating rooms and trauma rooms where the clinical requirements may not match the PACS capabilities. The printing of films may be necessary for certain circumstances. The integration of teleradiology and remote clinics into a PACS is a salient topic with respect to the overall role of the radiologists providing rapid consultation. A Web-based server allows a clinician to review images and reports on a desk-top (personal) computer and thus reduce the number of dedicated PACS review workstations. This session will focus on effective strategies for a seamless transition. Critical issues involve maintaining a good working relationship with the vendor, cultivating personnel readiness and instituting well-defined support systems. Success depends on the ability to integrate the institutional directives, user expectations and available technologies. A team approach is mandatory for success.

Endosonographic imaging of pancreatic pseudocysts before endoscopic transmural drainage.

BACKGROUND: Endoscopic drainage of pancreatic pseudocysts has become an established alternative to surgery. We performed endosonography before endoscopic drainage to find out whether detailed anatomic information would help in the selection of appropriate candidates and result in a reduction of complications. PATIENTS AND METHODS: Between April 1992 and July 1995 endosonography was performed in 32 patients, referred for endoscopic pseudocyst drainage, to determine the minimal distance between the pseudocyst and the gut, to identify interposed vascular structures, and to determine the optimal site for drainage. RESULTS: Endosonography failed to identify a pseudocyst in 3 patients and in 2 patients the lesion was inconsistent with a pseudocyst. In 7 patients transmural drainage was considered inappropriate: in 4 the distance between the gut and the cyst was too large, in 2 varices were present between the cyst and the gut, and in 1 patient normal pancreatic parenchyma was present between the cyst and the gut. In 20 patients endosonography was followed by ERCP, and in 19 endoscopic drainage was attempted. Transmural drainage was successful in 16 patients. Endosonography changed management in 37.5% of the patients. CONCLUSION: Endosonography provides essential information prior to endoscopic drainage of pseudocysts, leading to a change in therapy in one third of patients.

Estimating production benefits through simulation of group and individual feeding of dairy cows.

Objectives were 1) to develop DMI and milk prediction equations, 2) to use these equations to simulate group and individual feeding of dairy herds, and 3) to estimate effects of group and individual feeding on FCM production. University of New Hampshire data were used to predict DMI from previous DMI and cow and ration characteristics. The same data were used to predict milk production from DMI and previous milk production. Feeding was simulated for 100 cows over 50 4-wk periods in a number of trials. Effects of individual feeding, additional groups, herd calving intervals, and within-herd variation of annual milk production per cow on daily FCM per cow were isolated in average and high producing herds. Changing from one group to individual feeding can increase daily FCM per cow by .5 to 1.1 kg and two groups to individual feeding by 0 to .8 kg without changing total herd nutrient intake. Reallocation of the same amount of nutrients to two groups instead of one can increase daily milk production by .15 to .8 kg of FCM per cow, reallocation to three groups instead of two by 0 to .6 kg of FCM per cow, and reallocation to four groups instead of three by 0 to .35 kg of FCM per cow.