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Improving Patient Care: The Use of a Digital Teaching File to Enhance Clinicians' Access to the Intellectual Capital of Interdepartmental Conferences

¹ Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039..
² Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039.
³ Division of Hematology and Oncology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039.
⁴ Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039.
⁵ Vivalog Technologies, Seattle, WA.
⁶ The Parishsoft Company, Ann Arbor, MI 48106.

Received April 23, 2003; accepted after revision August 29, 2003.

 
Address correspondence to M. J. Halsted (mark.halsted{at}cchmc.org).

Abstract

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OBJECTIVE. We describe a simple method for creating teaching cases from clinical data, radiologic images, surgical images, and images from pathologic slides that are presented at tumor board conferences.

CONCLUSION. The resulting interdisciplinary case files are of educational value both during and after conference presentations and can be used by clinicians to gather appropriate historical, laboratory, imaging, surgical, and pathologic data on their patients. This system improves the efficiency and accuracy in gathering patient histories when care is transferred among clinics, the emergency department, and wards.

Introduction

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Intellectual capital is an important asset of the academic medical institution. Clinically useful information is presented and discussed daily at interdisciplinary conferences, and many clinical decisions are made at these conferences. Unfortunately, much of the information presented at these exchanges is not recorded. Increasing communication between the clinicians involved in the patient's care would avoid a loss of intellectual capital and provide an opportunity to improve patient care.

This problem is particularly acute when the patient is transferred among the clinics, the emergency department, and the wards. Each transfer increases the risk that critical pieces of historical and diagnostic information will be missed or misinterpreted.

Our institution holds a weekly tumor board conference. At this working conference, oncologists, radiologists, surgeons, and pathologists discuss the diagnosis and management of perplexing cases. Until recently, we conducted this conference as follows: One of the oncology fellows prepared a 10-page written handout describing the clinical presentation and course of each patient. He or she presented this information orally, pausing to let the radiologist present radiographic findings on an overhead projector. The surgeons discussed their surgical findings, and the pathologist used a slide projector to present histopathologic findings. The oncologists then discussed the appropriate treatment of the patient. At the conclusion of the conference, participants left the room, discarding the written handout on their way out the door. No permanent record was kept of the multidisciplinary findings presented at the board.

Our Solutions

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Case Preparation
To capture the information discussed at this interdisciplinary conference and thereby optimize the accurate transfer of clinical information among caregivers, we developed and implemented the following method: We adapted our radiology department digital teaching file, which is based on the MyPACS teaching file management software (Vivalog Technologies, Seattle, WA) [1], so that the clinical, radiologic, and histopathologic data from each case would be permanently recorded, organized, and stored, making it instantly retrievable at any time from any location using the hospital intranet.

The mechanism we use to create digital cases for presentation is quite simple. A template is created for the case so that the oncology fellow, radiologist, surgeon, and pathologist can each enter text and images independently of one another at any time and from anywhere on the hospital intranet. (Figs. 1 and 2).

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Photograph of capture screen shows portion of template used to enter cases.

View larger version (45K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —Photograph of sample radiologic and histopathologic images that are ready to be added to presentation.

The oncology fellow assigned to present the case prepares the text describing the clinical setting as before, except that now the text is entered directly into teaching file data fields. Information provided includes patient demographics such as age, sex, and race; recent history and clinical presentation; earlier medical history, medications, allergies, immunizations, and family and social history; findings from physical examination, laboratory results, imaging and other diagnostic tests; and surgical findings and histopathologic results. After the diagnostic and staging information is entered, details are provided regarding the disease, its usual course and treatment, and specifics of the patient's actual clinical course. Finally, the therapeutic plan and prognosis are discussed, and literature references are given.

The radiologist then uses a simple screen capture method to add radiologic images to the presentation from the PACS (picture archiving and communication system). This process takes only a few seconds per image [2]. The pathologist adds histopathologic images. The surgeons can add digital photographs depicting findings from the clinical examination or intraoperative photographs. The system accepts images in any common graphics format, including portable network graphics (PNG), Joint Photographic Experts Group (JPEG), bitmap (BMP), graphics interchange format (GIF), and tagged information file format (TIFF).

The presenters now prefer entering their text and images directly into the teaching case file instead of producing a handout, as was our prior procedure. The flow of the case can be refined by entering all the information into a single location. Each presenter can see the work of the others while they prepare their section, whereas in the past each presenter worked alone, not knowing how the other presenters approached the case. The new system improves case organization.

Case Presentation
The oncology fellow, radiologist, surgeon, and pathologist present the case directly from the teaching file using a digital projector. The presentation frequently includes a didactic teaching session in PowerPoint (Microsoft, Redmond, WA) based on the clinical data and literature regarding the diagnosis. This portion of the presentation is prepared by the oncology fellow and uploaded directly into the teaching file.

The system provides access before the board meeting to the entire case with all of its text and images and allows participants to rehearse their presentations. In the past, presenters did not know before the conference precisely how their portion of the case would fit into the overall presentation. The new system also simplifies the mechanics of presenting text and images from different media. Having all data in one location and viewable using a digital projector eliminates the distraction and pauses we experienced in the past when presenters switched from a paper presentation to an overhead projector for cut film or transparencies to a slide projector for pathologic images.

Even presentations made directly from the PACS system were inefficient because they required searching for the appropriate images, panning, windowing, and zooming to illustrate the findings, and they could not incorporate histopathologic images with presentation text. The PACS system also makes patient identification information difficult to conceal. This deficiency was a particular concern because we routinely conduct tumor board conferences over an interactive live video link with other institutions.

With the new system, the presentation flows smoothly while the screen scrolls from the clinical data to the radiologic and histopathologic images. The software automatically standardizes the size and format of images so that they appear to be of similar size when presented. Image size can be changed if necessary during the case presentation, but standardization limits visual distractions during the presentation.

Case Updates
We do not routinely update the clinical information after cases have been presented at the tumor board, but if relevant developments occur, we sometimes update the teaching files to reflect them. We now think of the cases in the teaching file as "snapshots" of a patient's course at the time the case was presented, and this approach has proven useful to clinicians, both by providing interesting case studies and by acting as reference points while clinical care for the patient continues.

At the conclusion of the conference, the finished case and PowerPoint presentation automatically become a permanent part of the teaching file. They are therefore available to anyone with access privileges to the hospital intranet as interesting cases that include clinical, radiologic, surgical, and histopathologic correlations.

Confidentiality and Clinical Application

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that no protected patient information be divulged during conferences. Presenters need to know the identity of the patient to be discussed before the conference so that they can prepare text and images. Per HIPAA regulations, this identity is e-mailed to presenters in encrypted form. During the conference, no patient identifiers are revealed or discussed; none appear in the text or images presented. After the conference, we keep a separate confidential database associating the random teaching-file case numbers with the actual patient identification information. Those health care providers with a legitimate need to know the identity of a patient for purposes of delivering care may apply for permission to learn the case number from an administrator; permission is granted under specific limited and appropriate circumstances. In this way, when the patients whose cases have been presented at the tumor board are seen in clinic or admitted to the hospital, their caregivers have rapid access to a thorough synopsis of their history and pertinent imaging, surgical, and histopathologic findings. This improved access to clinical information is particularly valuable for improving the quality of care in teaching institutions, where patients have long and complicated clinical courses and house staff changes frequently.

Alternative Methods

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Our system uses the MyPACS teaching file software, which is available either as a free Web-based service or, if local installation is desired, is also available for purchase at www.mypacs.net. The same ends can be achieved in a number of ways. For example, case data can be stored in an Access database (Microsoft), either on a computer or on a network server. Access provides an easy way to create forms from database tables, and images can be stored directly in the database. Users could find data later using the Access file directly from a computer located in the conference room or from a server in the hospital network.

For more scalability and wider availability, a database could be created and published on the Web. Some commercial database products such as FileMaker Pro (Apple Computer, Cupertino, CA), which runs on either PCs or Macintosh computers, can be used in conjunction with a Web server to provide Web publishing capability. Others can be Web-enabled using Microsoft's Front Page or another middleware software product, such as Active Server Pages (Microsoft), Cold Fusion (Macromedia, San Francisco, CA), or solutions from open sources, such as Perl or PHP: Hypertext Preprocessor (Zend). You will need some help from a programmer to take full advantage of these products. Finally, medical teaching archive solutions are available, such as those reviewed on the Web [3].

Conclusion

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We have implemented a system to prevent the loss of valuable information from our tumor board conferences. The benefits of this system include more efficient preparation of cases; more effective and less distracting presentation of cases during conferences; a rapidly growing teaching file incorporating text and images providing clinical, radiologic, surgical, and histopathologic correlation; and rapid access to clinical information during subsequent care delivery for patients whose cases have been presented at the tumor board.

Finally, our new approach has few, if any, disadvantages. Case entry is no more time-consuming than the old way, and conferences have run more smoothly and efficiently since we implemented it.

References

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1. Weinberger E, Jakobovits R, Halsted MJ. MyPACS.net: a Web-based teaching file authoring tool. AJR2002; 179:579 –582[Abstract/Free Full Text]
2. Halsted MJ, Moskovitz J, Johnson ND, Perry L. A simple method of capturing PACS and other radiographic images for digital teaching files or other image repositories. AJR2002; 178:817 –819[Abstract/Free Full Text]
3. Diagnostic Imaging.com Web site. Available at: www.diagnosticimaging.com/pacsweb/stories/news12160202.shtml. Accessed October 27, 2003

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Halsted, M. J. Articles by Halsted, D. G. Search for Related Content PubMed PubMed Citation Articles by Halsted, M. J. Articles by Halsted, D. G. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?