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Software for primary healthcare in a developing country. Background and problem statement.

Nurses in primary healthcare (PHC) clinics carry a heavy administrative burden, much of which can be computerized. Advantages and disadvantages of computerization and issues related to patient records and other requirements of computerized systems are well documented. However, not much attention has been given to users' needs in PHC environments in developing countries. Users in township areas have very specific needs because of a lack of previous exposure to computers and a reluctance to change working habits. Some general software requirements that system developers should consider are discussed.

Attitude of Health Personnel↗

Self-scheduling with Microsoft Excel.

Excessive time was being spent by the emergency department (ED) staff, head nurse, and unit secretary on a complex 6-week manual self-scheduling system. This issue, plus inevitable errors and staff dissatisfaction, resulted in a manager-lead initiative to automate elements of the scheduling process using Microsoft Excel. The implementation of this initiative included: common coding of all 8-hour and 12-hour shifts, with each 4-hour period represented by a cell; the creation of a 6-week master schedule using the "count-if" function of Excel based on current staffing guidelines; staff time-off requests then entered by the department secretary; the head nurse, with staff input, then fine-tuned the schedule to provide even unit coverage. Outcomes of these changes included an increase in staff satisfaction, time saved by the head nurse, and staff work time saved because there was less arguing about the schedule. Ultimately, the automated self-scheduling method was expanded to the entire 700-bed hospital.

Attitude of Health Personnel↗

FDA regulation of medical software.

Currently the FDA is reviewing its policy on the regulation of computer software in the medical arena. Healthcare practitioners hope that the FDA will take the least possible regulatory action required by law to fulfill its public health responsibility and will take into account the unique status of the ever-changing software industry. Innovations in telemedicine and medical informatics have yielded significant improvements in the quality and cost of healthcare, and the imposition of cumbersome regulatory requirements on the medical software industry would slow the development and introduction of medical software products.

Software Validation↗

Physiologic monitoring systems.

Physiologic monitoring systems monitor vital physiologic parameters so that clinicians can be informed of changes in a patient's condition. They typically consist of several distinct components, including a central station, bedside monitors, and ambulatory telemetry transmitters and receivers. We previously evaluated physiologic monitoring systems in our January-February 1999 issue (Health Devices 28[1-2]). For this update, we have tested systems from two additional suppliers, using the same criteria and test methods that we used for the eight systems in the original study. As in the earlier Evaluation, we have examined how each system functions as a whole, rather than focusing on the performance of individual components. We judged the systems primarily on adaptability, alarm implementation, and human factors design. In the Conclusions, we compare all 10 units evaluated to date. We also provide updated product information for the systems evaluated in our original study; in some cases, the changes that have been made to those systems have caused us to revise our ratings. We rated all the systems based on their capabilities for each of six applications: (1) critical care unit, (2) emergency department, (3) intermediate care unit and general medical/surgical floor, (4) operating room, (5) postanesthesia care unit, and (6) transport. As in our earlier study, we have determined that most of the evaluated systems have drawbacks for one or more of the evaluated applications. In our January-February 1999 Evaluation of physiologic monitoring systems (Health Devices 28[1-2]), we discussed the issues surrounding the purchase and use of these systems. In this introduction, we recap the most significant points from that discussion, provide some new information about ambulatory telemetry and wireless networks, and briefly describe the components of this Update Evaluation.

Equipment Design↗

Body composition of growing and adult cats as measured by use of dual energy X-ray absorptiometry.

BACKGROUND AND PURPOSE: Total body scans were performed on 89 domestic cats of various ages, using dual energy x-ray absorptiometry (DEXA) to determine body composition, including fat, lean, and bone mineral content. Bone mineral density results from scans also are presented. METHODS: This cross sectional study included data for cats from a closed colony and from privately owned cats. Data were grouped by age and were analyzed by sex and reproductive status to provide information as to the rate of growth of the individual components of body composition. RESULTS: The results indicate that the rate of accretion of bone mineral, fat, and lean tissue differs throughout maturation and by sex. Regressions are provided to highlight age- and sex-related differences. CONCLUSIONS: The results of this study emphasize the benefits of examining the growth of each component of body composition when studying the effects of nutrition, disease processes, or therapeutic interventions.

Absorptiometry, Photon↗

A procedure for evaluating primary health care software.

Managers in health care often find themselves in the difficult position of having to make decisions regarding the purchasing of software and hardware which they are not qualified to make. The aim of this paper is to support health managers in their decision making by means of a procedure and an instrument that can be used to evaluate primary health care software. A seven step approach to the evaluation process is proposed and each step is discussed in detail. The paper concludes with a proposed software evaluation instrument that is suitable for application in the health care environment.

Decision Making↗

[Use of dental CT software progarms (Dentascan) for optimal arthroscopic CT of knee menisci].

The need for CT automated multiaxial programs of reconstruction, able to accommodate with complex curvilinear anatomic structures has recently been satisfied by Dental Software Programs--"DENTASCAN"--essentially developed for implantology. Taking advantage of the very close likeness of dental archs and menisci of the knee in terms of form--variable complex curvilinear structures--and size, our study shows the advantages of "DENTASCAN" program to optimize the study of the menisci with Spiral Arthro-CT (SACT). The results obtained on a series of 228 menisci are compared with Conventional Arthrography (CA). 11.85% of additional lesions are found with SACT and 30.2% of all lesions demonstrated by CA are also more adequately described by SACT associated with "DENTASCAN". Moreover, fissures and ulcerations of the tibio-femoral cartilages, undiagnosed by preliminary CA are found in 20, 8% of patients with SACT. We conclude that SACT is much more effective and reproducible than CA for the study of the knee and we promote the use of Dental CT Software Programs like "DENTASCAN" for the study of the femorotibial and meniscus complex. Additional work is now necessary to compare the effectiveness of SACT with MRI or arthro-MRI of the knee with valuation of arthroscopy.

Arthrography↗

Rewards of automated testing. Identifying problems before rollout can avoid system disruption.

PROBLEM: Needed order management application that performed consistently and met high demands. SOLUTION: Load testing identified specific problem areas. RESULTS: Precise description of problems and their occurrence helped speed resolution and ensured successful implementation. KEYS TO SUCCESS: Testing of conditions that emulated expected demands at early stage of design and planning.

Cancer Care Facilities↗

Requirements development for a patient computing system.

Critical parts of the software development life cycle are concerned with eliciting, understanding, and managing requirements. Though the literature on this subject dates back for several decades, practicing effective requirements development remains a current and challenging area. Some projects flourish with a requirements development process (RDP) that is implicit and informal, but this approach may be overly risky, particularly for large projects that involve multiple individuals, groups, and systems over time. At Partners HealthCare System in Boston, Massachusetts, we have applied a more formal approach for requirements development to the Patient Computing Project. The goal of the project is to create web-based software that connects patients electronically with their physician's offices and has the potential to improve care efficiency and quality. It is a large project, with over 500 function points. Like most technological innovation, the successful introduction of this system requires as much attention to understanding the business needs and workflow details as it does to technical design and implementation. This paper describes our RDP approach, and key business requirements discovered through this process. We believe that a formal RDP is essential, and that informatics as a field must include proficiencies in this area.

Boston↗

EMGLAB: objective outcome measures in neurophysiological testing.

The aim of this work was to objectively measure and quantify the results of various neurophysiological tests and indirectly provide objective outcome measures for neurological therapy and rehabilitation. We have studied the silence of Electromyographic (EMG) activity after evoking motor potentials with magnetic cortical stimulation. Since different criteria were previously used to determine the level where the silence of muscle activity ends, an objective computer aided method was developed. This analysis was further developed to include objective testing of surface EMG, long latency reflexes, reciprocal inhibition of the H-reflex, H-reflex recovery curve and decrement testing. Responses were recorded at different sampling frequencies, depending on the application, time window, filter settings, etc. The developed software proved to be a fast and objective tool, able to standardize the determination of different neurophysiological tests, and as such a valuable tool facilitating multi-center studies and diminishing human bias. The software reduced the study time with each patient. Until date we have used the software with the Medtronic, Medelec and BTS EMG instruments.

Diagnosis, Computer-Assisted↗

An expert system for fault management assistance on a space sleep experiment.

The expert system, Principal Investigator-in-a-box, or [PI], was designed to assist astronauts or other operators in performing experiments outside their expertise. Currently, the software helps astronauts calibrate instruments for a Sleep and Respiration Experiment without contact with the investigator on the ground. It flew on the Space Shuttle missions STS-90 and STS-95. [PI] displays electrophysiological signals in real time, alerts astronauts via the indicator lights when a poor signal quality is detected, and advises astronauts how to restore good signal quality. Thirty subjects received training on the sleep instrumentation and the [PI] interface. A beneficial effects of [PI] and training reduced troubleshooting time. [PI] benefited subjects on the most difficult scenarios, even though its lights were not 100% accurate. Further, questionnaires showed that most subjects preferred monitoring waveforms with [PI] assistance rather than monitoring waveforms alone. This study addresses problems of complex troubleshooting and the extended time between training and execution that is common to many human operator situations on earth such as in power plant operation, and marine exploration.

Adult↗

Computed Tomography of dental arches with dedicated software: current state of applications.

Since the introduction of the "Dentascan" reconstruction program, the use of CT in the field of odontostomatology has attracted growing interest from both radiologists and dentists. Over the years, the potential applications of Dentascan have extended from the management of implantology-related issues to the study of all jaw bone diseases relevant to dentists. This paper describes the technical aspects and current diagnostic capabilities of computed tomography of the dental arches with dedicated software, by presenting a wide selection of case studies.

Dental Arch↗

Computer prediction of hard tissue profiles in orthognathic surgery.

The purpose of this retrospective study was to analyze the accuracy of computer predictions by CASSOS (Computer-Assisted Simulation System for Orthognathic Surgery) 2001 software (2000 SoftEnable, Technology). Forty adult patients who had undergone orthognathic surgery were evaluated. Pre- and postsurgical lateral cephalographs were scanned into the computer, and 71 landmarks for each cephalograph were digitized. Digitization error was assessed from repeated digitizations. A customized cephalometric analysis consisting of 14 measurements was used in this study. Predicted and actual postsurgical hard tissue landmarks were compared using the Student t test. Results showed good correlation between repeated digitization for all measurements. There were no statistically significant differences in 10 of the 14 measurements. The differences that were statistically significant were in angular measurements for SNA angle, upper incisor to maxillary plane angle (U1-MxP), interincisal angle (U1-L1), and upper incisor to anterior cranial base angle (U1-SN). The greatest mean difference measured was the interincisal angle (U1-L1) which, although statistically significant, was clinically insignificant. This investigation showed that CASSOS 2001 software provides accurate hard tissue prediction for orthognathic surgical procedures.

Adolescent↗

[Low-dose chest CT with millimetric thin slices: myth or reality?].

PURPOSE: To evaluate the diagnostic accuracy of millimetric thin slices low dose chest CT. MATERIALS AND METHODS: Forty one patients underwent a chest CT thin slices (1 mm every 10 mm) exploration using both a 170 milliamperage and a low dose acquisition using 80 mA. The examination were read by 2 senior radiologists specialized in chest imaging without knowledge of acquisition parameters and in a random order. A statistical analysis of interobserver agreement was performed using Kappa analysis. Doses of both acquisition were estimated by compagning the dose length product calculated by the CT software and be using a simulation software. RESULTS: Excellent interobserver and intermodalities agreements were found. A 53% decrease in dose was estimated with the low dose modality compare to the normal dose. CONCLUSION: Low dose thin slice chest CT using 80 mA has a similar diagnosis accuracy as standard dose thin slice chest CT and delivers half dose of irradiation.

Adult↗