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PubMed2005

A Home Integral Telecare System for HIV/AIDS Patients.

VIHrtual Hospital is a telemedicine web system for improving home integral care of chronic HIV patients through the Internet. Using the videoconference, chat or messaging tools included in the system, patients can visit their healthcare providers (physician, psychologist, nurse, psychiatrist, pharmacist, and social worker), having these access to the Electronic Patient Record. The system also provides a telepharmacy service that controls treatment adherence and side effects, sending the medication to the patient's home by courier. A virtual community has been created, facilitating communication between patients and improving the collaboration between professionals, creating a care plan for each patient. As a complement, there is a virtual library where users can find validated HIV/AIDS information helping to enhance prevention. This system has been developed using low cost technologies in order to extend the number of patients involved in its trial. Thus, VIHrtual Hospital is now on trial in the Hospital Clinic (Barcelona, Spain) involving a hundred patients and twenty healthcare professionals during two years.Although we are still waiting for the final results of the trial, we can already say that the use of telemedicine systems developed ad hoc for a chronic disease, like HIV/AIDS, improve the quality of care of the patients and their care team. The system described is a good example of the possibilities that technologies are offering to create new chronic patient care models based on telemedicine.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Precise nanoliter fluid handling system with integrated high-speed flow sensor.

A system for accurate low-volume delivery of liquids in the micro- to nanoliter range makes use of an integrated miniature flow sensor as part of an intelligent feedback control loop driving a micro-solenoid valve. The flow sensor is hydraulically connected with the pressurized system liquid in the dispensing channel and located downstream from the pressure source, above the solenoid valve. The sensor operates in a differential mode and responds in real-time to the internal flow-pulse resulting from the brief opening interval of the solenoid valve leading to a rapid ejection of a fluid droplet. The integral of the flow-pulse delivered by the sensor is directly proportional to the volume of the ejected droplet from the nozzle. The quantitative information is utilized to provide active control of the effectively dispensed or aspirated volume by adjusting the solenoid valve accordingly. This process significantly enhances the precision of the fluid delivery. The system furthermore compensates automatically for any changes in the viscosity of the dispensed liquid. The data delivered by the flow sensor can be saved and backtracked in order to confirm and validate the aspiration and dispensing process in its entirety. The collected dispense information can be used for quality control assessments and automatically be made part of an electronic record.

Biological Assay↗
PubMed2005

Integrated neuronavigation system with intraoperative image updating.

OBJECTIVE: Recently, MRI has entered the field of image-guided surgery as a new intraoperative imaging modality. In spite of its obvious benefits, this type of iMRI scanner has some drawbacks that have limited its utilization. The goal of the work presented here was to overcome some of these disadvantages. METHODS: A system that allows intraoperative images to be acquired during surgery and have the ability to conduct surgery outside the constraints of the narrow gap of the open magnet was implemented. Ability to conduct tasks inside the scanner with real-time image guidance was also maintained. The system allowed navigation with neuronavigation tools both inside the gap of an open magnet and outside the magnet, utilizing two different optical camera-sets and a dynamic reference frame. Automatic patient registration was implemented. RESULTS: The average difference between tracking position measured outside and inside the magnet was 0.8 +/- 0.1 mm. CONCLUSION: In the work presented in this note we have introduced a dynamic reference frame to compensate for transport of the patient to a location outside the scanner employing a second camera set. The integrated system showed adequate accuracy.

Equipment Design↗
PubMed1996

A global two component signal transduction system that integrates the control of photosynthesis, carbon dioxide assimilation, and nitrogen fixation.

Photosynthesis, biological nitrogen fixation, and carbon dioxide assimilation are three fundamental biological processes catalyzed by photosynthetic bacteria. In the present study, it is shown that mutant strains of the nonsulfur purple photosynthetic bacteria Rhodospirillum rubrum and Rhodobacter sphaeroides, containing a blockage in the primary CO2 assimilatory pathway, derepress the synthesis of components of the nitrogen fixation enzyme complex and abrogate normal control mechanisms. The absence of the Calvin-Benson-Bassham (CBB) reductive pentose phosphate CO2 fixation pathway removes an important route for the dissipation of excess reducing power. Thus the mutant strains develop alternative means to remove these reducing equivalents, resulting in the synthesis of large amounts of nitrogenase even in the presence of ammonia. This response is under the control of a global two-component signal transduction system previously found to regulate photosystem biosynthesis and the transcription of genes required for CO2 fixation through the CBB pathway and alternative routes. In addition, this two-component system directly controls the ability of these bacteria to grow under nitrogen-fixing conditions. These results indicate that there is a molecular link between the CBB and nitrogen fixation process, allowing the cell to overcome powerful control mechanisms to remove excess reducing power generated by photosynthesis and carbon metabolism. Furthermore, these results suggest that the two-component system integrates the expression of genes required for the three processes of photosynthesis, nitrogen fixation, and carbon dioxide fixation.

Carbon Dioxide↗
PubMed2000

RadStation: client-based digital dictation system and integrated clinical information display with an embedded Web-browser.

RadStation is a digital dictation system having an integrated display of clinical information. The three-tiered system architecture provides robust performance, with most information displayed within one second after a request. The multifunctional client tier is a unique client/browser hybrid. A Web browser display window functions as the client application's data display window for clinical information, radiology reports, and laboratory and pathology results. RadStation provides a robust platform for digital dictation functionality. The system's internal status checks ensure operational integrity in a clinical environment. Also, the programmable dictation microphone and bar-code reader supplant the mouse as the system's primary input device. By merging information queries into existing work flow, radiologist's interpretation efficiency is maintained with instant access to essential clinical information. Finally, RadStation requires minimal training and has been enthusiastically accepted by our radiologists in an active clinical practice.

Computer Peripherals↗
PubMedDate not supplied

Interprofessional referral patterns in an integrated medical system.

OBJECTIVE: To determine the interreferral patterns among physicians and complementary and alternative medicine (CAM) providers in an independent practice association integrated medical system. METHOD: Data from a 1-year period were collected on referral patterns, diagnosis, number of visits, cost, and qualitative aspects of patient care. The independent practice association provided care for approximately 12,000 patients. RESULTS: In the selected integrative network, there are those primary care physicians (PCPs) who refer and those who do not. Among those PCPs that refer to CAM, a preference is shown for a limited number of providers to whom they refer. Although doctors of chiropractic get more referrals, they are also more concentrated among selected providers than are doctors of oriental medicine. CONCLUSION: This study shows the interreferral patterns among the PCP and CAM providers working within an integrated medical system. One effect of being in the network for doctors of chiropractic and doctors of oriental medicine might be the possible interreferrals between each other.

Chiropractic↗
PubMed1997

Risk sharing in an integrated delivery system.

Development of an effective risk-sharing plan within an integrated delivery system (IDS) involves a complex decision-making process, in which the IDS should carefully assess its options to determine which will best suit its needs. In general, an IDS needs to consider four basic issues: how centralized the financial control of the risk-sharing plan should be; how the plan should be structured (eg, the number and size of budgets, interim provider payment, and the method for allocating surpluses and deficits to provider groups and individual providers); what risk-sharing strategies should be pursued; and how to avoid potentially catastrophic risk.

Budgets↗
PubMed2004

Towards a flexible integration of clinical guideline systems with medical ontologies and medical information systems.

The integration of a computer-based system dealing with clinical guidelines with a medical ontology can provide several advantages, including standardization and knowledge sharing. Furthermore, in order to operate in the clinical practice, guideline systems must also interact with the hospital databases to retrieve patients' data. Unfortunately, currently there seems not to be any "standard" consensus model either for the medical ontology or for (the conceptual structure of) patient databases (even if several interesting proposals have been carried out). In this paper we show how we are extending the GLARE guideline manager in order to strictly interact with both a medical ontology and a patient Database, in such a way that GLARE is not committed to any specific ontology and database (i.e., different ontologies and/or databases can be used).

Humans↗
PubMed1998

Pharmacology of pain processing systems.

Integration of nociceptive signaling comprises peripheral, spinal, and supraspinal sites of the nervous system. Various excitatory or inhibitory neurotransmitter and--modulator systems participate in pain processing and modulation. Chronic pain states are associated with functional and structural alterations of nociceptive pathways. The numerous dynamic changes in the pharmacologically distinct systems offer novel targets for selective pharmacotherapy.

Analgesics↗
PubMed1995

The clinical information system GastroBase: integration of image processing and laboratory communication.

GastroBase, a clinical information system, incorporates patient identification, medical records, images, laboratory data, patient history, physical examination, and other patient-related information. Program modules are written in C; all data is processed using Novell-Btrieve data manager. Patient identification database represents the main core of this information systems. A graphic library developed in the past year and graphic modules with a special video-card enables the storing, archiving, and linking of different images to the electronic patient-medical-record. GastroBase has been running for more than four years in daily routine and the database contains more than 25,000 medical records and 1,500 images. This new version of GastroBase is now incorporated into the clinical information system of University Clinic in Prague.

Clinical Laboratory Information Systems↗
PubMed1998

Developing an integrated information system for specialized addiction treatment agencies.

This article outlines the development of an integrated information system for specialized alcohol and drug treatment agencies in Ontario, Canada. The system is being developed following a strategic planning process involving provincial funding ministries and coalitions of service providers. An overview of the system's development is provided and the implementation of one subcomponent, a client-tracking system, is described. Some challenges to the implementation of this component are identified.

Alcoholism↗
PubMed2004

Variation in implementation and use of computerized clinical reminders in an integrated healthcare system.

OBJECTIVES: To identify patterns of use of computerized clinical reminders (CCRs) across an integrated healthcare system and describe institutional factors associated with their implementation. STUDY DESIGN: Cross-sectional study. METHODS: At a national electronic health record (EHR) meeting, we surveyed 261 participants from 104 Veterans Health Administration (VHA) healthcare facilities regarding the number and types of CCRs available at each facility. Potential explanatory measures included perceived utility and ease of use of CCRs, training and personnel support for computer use, EHR functionalities, and performance data feedback to providers at each facility. RESULTS: The number of conditions with CCRs in use at a facility ranged from 1 to 15; most reported implementation of reminders for 10 of the 15 conditions surveyed. The most commonly implemented CCRs, used in more than 85% of facilities, were for conditions with VHA national performance measures (eg, tobacco cessation, immunizations, diabetes mellitus). The least commonly implemented CCRs were for post-deployment health evaluation and management, medically unexplained symptoms, and erectile dysfunction. Facilities that had implemented greater numbers of clinical reminders had providers who reported greater ease of use and utility of the reminders (P= .01). CONCLUSIONS: VHA facilities vary markedly in their implementation of CCRs. This effect may be partly explained by greater incorporation of clinical reminders for conditions with performance measures. Further study is needed to determine how to best implement clinical reminders and the institutional factors important in their use.

Attitude of Health Personnel↗
PubMed2002

Lessons from the evaluation of the ACCESS program. Access to Community Care and Effective Services.

The authors summarize the main findings of the ACCESS (Access to Community Care and Effective Services) program and offer lessons for policy makers. Data from studies at the site level and the client level, which were presented in the two previous articles in this issue of Psychiatric Services, are summarized and synthesized with the authors' collective experience with the ACCESS program. The results of the evaluation suggest that although service systems integration can be improved, targeted efforts to implement strategies for integration do not produce better client outcomes. Efforts to integrate service systems can be supported by their effects on some organizational relationships within the mental health service system but not by their widespread effects across human services or their direct effects on clients.

Community Mental Health Services↗
PubMed2002

Multicenter comparative evaluation of six commercial systems and the national committee for clinical laboratory standards m27-a broth microdilution method for fluconazole susceptibility testing of Candida species.

Fluconazole susceptibility among 800 clinical Candida isolates (60% C. albicans) and two control strains (C. krusei ATCC 6258 and C. parapsilosis ATCC 22019) was tested with the NCCLS M27-A method (gold standard) and six commercial products (Candifast, disk, Etest, Fungitest, Integral System Yeasts, and Sensititre YeastOne). Results were classified as susceptible, susceptible-dose dependent, or resistant using M27-A breakpoints or, for Fungitest, Integral System Yeasts, and Candifast, as susceptible, intermediate, or resistant, according to the manufacturers' instructions. Concordance with NCCLS M27-A results was analyzed with the chi(2) test. Intra- and interlaboratory reproducibility was also evaluated. NCCLS M27-A (90.1%), Etest (93.1%), Sensititre YeastOne (93.1%), disk (96.7%), Fungitest (92.6%), Integral System Yeasts (40.6%), and Candifast (6.0%) classified the indicated percentages of C. albicans isolates as susceptible. Among non-C. albicans strains, the percentages of susceptible isolates were as follows: NCCLS M27-A, 74.0%; Etest, 83.8%; Sensititre YeastOne, 64.1%; disk, 60.6%; Fungitest, 76.6%; Integral System Yeasts, 28.3%; and Candifast, 27.4%. All methods except Candifast and Integral System Yeasts showed good agreement with NCCLS M27-A results for both C albicans and non-C. albicans isolates. Intralaboratory reproducibility was excellent for NCCLS M27-A, Etest, Sensititre YeastOne, disk, and Fungitest (88 to 91%). Similar results emerged from the interlaboratory reproducibility evaluation. Our findings indicate that some commercial methods can be useful for fluconazole susceptibility testing of clinical Candida isolates. Those characterized by a lack of medium standardization and/or objective interpretative criteria should be avoided. Particular caution is necessary when testing is being done for clinical and epidemiological purposes.

Antifungal Agents↗
PubMed1998

Collaborating outside the box: three years later.

BACKGROUND: In 1992, 15 employers in Minneapolis-St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. ICSI IN THE EVOLVING MINNEAPOLIS MARKETPLACE: From a business standpoint, ICSI members stood to gain market share by being members of ICSI and the "chosen" consortium. From a professional standpoint, they could realize the fulfillment and satisfaction of knowing that they were innovating, improving care, reducing waste, and sharing their knowledge with others. A NEW MARKET MODEL: To drive the same kind of change for the entire care delivery system in the region, not just for the subset that happened to win the original bid, BHCAG changed the purchase model in February 1995--enrollees could now choose among 16 to 20 discrete care delivery systems instead of preferentially channeling them to the ICSI-HealthPartners network of group practices. All the care systems had become competitors on every level, including quality of care. The "special" customer-supplier relationship between BHCAG and the ICSI medical groups was no longer present. LESSONS LEARNED: Despite major changes in the market dynamics, with the marked decline in the business reason for collaboration which had prompted ICSI to form in the first place, physicians, nurses, and administrative staff from participating medical groups continue to devote massive effort to the development and implementation of best practices.

Commerce↗
PubMed1992

Quality control of laboratory results in real time.

An integrated informatic system may have an important role in identifying and reducing those errors which affect the reliability of laboratory results. The present work reports on the development of a system that, by means of a computer connected with laboratory instrumentation, allows monitoring of global error (bias, random, gross) using classical statistical quality control systems, integrated by auxiliary methods built on a database stored in the computer. These methods succeeded in greatly reducing bias and random error in the most frequent laboratory tests. Further methods to find, quantify, and reduce the gross and extra-analytical errors are under development.

Clinical Laboratory Information Systems↗
PubMed1995

Collaborating outside the box: when employers and providers take on environmental barriers to guideline implementation.

BACKGROUND: In 1992 15 employers in Minneapolis/St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating functionally like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. PROVIDERS AND EMPLOYERS COLLABORATE: To reduce costs ICSI has implemented 16 of 80 planned guidelines. Teams including members from clinics and BHCAG develop best-practice algorithms. Each guideline is then reviewed and piloted before being implemented in all ICSI clinics. MANAGING EXTERNAL ENVIRONMENT: The guideline on cystitis in healthy women eliminated two costly practices-obtaining a urine culture and visiting the doctor. Yet many physicians and the clinics were afraid of losing significant revenue because they were reimbursed by BHCAG on a fee-for-service basis. In turn, BHCAG's hands were tied. If they changed to a capitated payment system, they would face onerous state insurance requirements. The solution lay in collaborating at a higher level. ICSI and BHCAG leaders persuaded the state legislature to pass a new law that allowed BHCAG to capitate providers without state regulation. As a result, the cystitis guideline is now widely implemented in ICSI clinics. LESSONS LEARNED: The cystitis guideline experience highlights the need to manage the external environment so that it reinforces, rather than inhibits, quality improvement in medical practices. Guidelines will not be implemented unless the macro-environment into which they are introduced is supportive.

Contract Services↗