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Computers in Radiology |
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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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.
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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.
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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).
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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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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].
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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.
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