PACS development in Austria: a discussion of success criteria and success factors.

OBJECTIVES: The paper uses the example of PACS (Picture Archiving and Communication System) in Austria (where some of the earliest large PACS projects were realised and led to a high penetration with state-wide networked PACS installations) to discuss success criteria and success factors of medical information systems. METHODS: The paper describes the development of digital imaging in medicine and classifies the impact of systems according to their first or second order effects on patient care. The historic goals of PACS and the technical infrastructure in the eighties are shortly described. The paper then outlines the early PACS projects in Austria and their different approaches as well as the present state of PACS in Austria. RESULTS: After giving a definition of success, success criteria (which allow to decide whether a system is in fact a success or not) are discussed in general--the final criterion being routine use--and in detail and it is concluded that PACS in Austria was and is indeed successful. CONCLUSION: The analysis of success factors shows a multitude of influences but the most decisive ones are the practical ability of the system to deliver a real service to health care and the ability to support the (key) users in their work and goals.

Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study.

A controlled randomized study of endoscopic evacuation versus medical treatment was performed in 100 patients with spontaneous supratentorial intracerebral (subcortical, putaminal, and thalamic) hematomas. Patients with aneurysms, arteriovenous malformations, brain tumors, or head injuries were excluded. Criteria for inclusion were as follows: patients' age between 30 and 80 years; a hematoma volume of more than 10 cu cm; the presence of neurological or consciousness impairment; the appropriateness of surgery from a medical and anesthesiological point of view; and the initiation of treatment within 48 hours after hemorrhage. The criteria of randomization were the location, size, and side of the hematoma as well as the patient's age, state of consciousness, and history of hypertension. Evaluation of outcome was performed 6 months after hemorrhage. Surgical patients with subcortical hematomas showed a significantly lower mortality rate (30%) than their medically treated counterparts (70%, p less than 0.05). Moreover, 40% of these patients had a good outcome with no or only a minimal deficit versus 25% in the medically treated group; the difference was statistically significant for operated patients with no postoperative deficit (p less than 0.01). Surgical patients with hematomas smaller than 50 cu cm made a significantly better functional recovery than did patients of the medically treated group, but had a comparable mortality rate. By contrast, patients with larger hematomas showed significantly lower mortality rates after operation but had no better functional recovery than the medically treated group. This effect from surgery was limited to patients in a preoperatively alert or somnolent state; stuporous or comatose patients had no better outcome after surgery. The outcome of surgical patients with putaminal or thalamic hemorrhage was no better than for those with medical treatment; however, there was a trend toward better quality of survival and chance of survival in the operated group.

Expert systems as a support for radiological diagnosis.

Given the fact that despite high expectations, expert systems have still an almost negligible impact on the practice of medicine, the present trends and methods for medical expert systems are discussed. An analysis of the diagnostic process in radiology leads to a discussion about possible computer support and on the conditions of use and acceptance of such systems.

[Computer-assisted diagnosis of bone tumors and tumor-like skeletal diseases: critical evaluation of its clinical use]. / Computerunterstützte Diagnostik von Knochentumoren und tumorähnlichen Skeletterkrankungen: kritische Bewertung des klinischen Einsatzes.

Thirty-four patients with bone tumours and tumour-like abnormalities of the skeleton, of varying ages, were examined by a computer-aided diagnostic program; the accuracy, clinical usefulness and specific advantages and disadvantages of the program have been evaluated. This was done by two statistical methods, both with showed high accuracy and reliability of the system (97% and 88.2%). In addition to the diagnostic results, the growth rate of the lesion could be estimated. This indicates the biological behaviour of the tumour independently of the histological diagnosis.

[ACOnet (Austrian Academic Computer Network) as data carrier for teleradiologic consultations]. / Das ACOnet (Austrian Academic Computer Network) als Datenträger für teleradiologische Konsultationen.

PURPOSE: To assess the feasibility of image transfer for teleradiologic consultations using the Austrian Academic Computer Network (ACOnet). The ACOnet corresponds between the main universities to a MAN (Metropolitan Area Network) with a transfer rate of 4 Mbps. Its use is free of charge for university institutions. MATERIALS AND METHODS: 1740 test image data sets and 620 image data sets for teleradiological consultations were exchanged without annotations between the Departments of Diagnostic Radiology of the universities of Innsbruck and Graz, using the ACOnet. RESULTS: Data transmission was reliable and fast with an average transfer capacity of 170.2 kBytes/s (94-341 kBytes/s). There were no major problems with image transfer during the test phase. CONCLUSION: Due to its high transfer capacity, the ACOnet is considered a reasonable alternative to the ISDN service.

SAP and partners: IS-H and IS-H* MED.

OBJECTIVES: The Styrian Hospital Organization with 21 hospitals including the Graz University Hospital, and the Heidelberg University Hospital implemented a new HIS based on SAP/R3, ISH, ISH* MED with the objective to have an integrated system to support patient administration and management, patient care, clinical documentation, research etc. METHODS: Heidelberg University Hospital chose a step by step method for the introduction of the system, beginning with patient administration (ISH) and proceeding with clinical functions (ISH* MED). In Styria, the full functionality was implemented--as part of the selection process--in one peripheral hospital and in the Ear, Nose and Throat (ENT) Department of the Graz University Hospital, including special documents to support the processes in the highly specialized ENTunits. RESULTS AND CONCLUSIONS: The standard modules are performant, stable and basically well accepted. Particularly in Graz, it has been shown that the requirements of highly specialized departments for work flow management, documentation and integration of subsystems and data from different sources can be fulfilled by special documents and programs--although at the expense of additional workload particularly in the initial phases of such a project.

Side effects and responsibility of medical informatics.

Medical informatics systems have the ultimate goal to improve the quality of health care. However, these systems have also the potential to compromise the quality of health care if they are misused, intrinsically faulty or entail unexpected side effects. The purpose of the paper is to discuss examples from the experience of the author, where well-intended medical informatic applications proved to have potentially harmful effects or side effects. It is argued that medical informaticians (MI) have an extended professional responsibility, which covers not only the state of the art technical planning, an implementation of information processing systems in medicine, but also the final result for the patient. In order to discuss professional duties of medical informaticians, a modification of the Software Engineering Code of Ethics and Professional Practice developed by ACM/IEEE is proposed as a guideline. For several examples, these guidelines are used to analyze possible actions and professional responsibility.

The internal challenges of medical informatics.

Haux's [7] basic assumption that the object of medical informatics is: "... to assure and to improve the quality of healthcare as well as the quality of research and education in medicine and in the health sciences ..." is taken as a starting point to discuss the three main topics: What is the meaning of medical informatics (i.e. what should be the main activities of medical informatics to bring maximum benefit to medicine)? What are the achievements and failures of medical informatics today (again considering the impact on the quality of healthcare)? What are the main challenges? Concerning the definition of medical informatics it is argued that one should not hide the link to basic informatics and, for that matter to computers, completely behind abstract definitions. After an analysis of the purposes of the definition of a discipline, a differentiated definition of the scope of medical informatics, rather general when concerning the field of scientific interest, more focused when concerning the practical (constructive) applications, is proposed. Contrasting Haux's chapter on achievements of medical informatics we concentrate on and analyse non fulfilled promises of medical informatics to derive lessons for the future and to propose 'generic' (or core) tasks of medical informatics to meet the challenges of the future. A set of 'internal challenges' of medical informatics to change priorities and attitudes within the discipline is put forward to enable medical informatics to meet the 'external challenges' listed by Haux.

HIS purchase projects in public hospitals of Styria, Austria.

The Steiermärkische Krankenanstaltenges. m.b.H (KAGes) is a company, owned by the province of Styria in Austria, which operates 21 hospitals with about 8000 beds and 14000 employees, serving a population of ca. 1.2 million people. KAGes has purchased a new hospital information system (HIS) for its hospitals. Within the strategic IT plan and the 'system structure new' (SSN) project, a methodology was developed for making an effective HIS purchase. Several steps of this project are described in the paper, request for product information, evaluation of vendor proposals, product presentations, test site evaluation, reference site visits and selection of vendor finalists. The authors present the internal project management methodology, including the structure of the project team, project information management through intranet, criteria for different steps of the evaluation and evaluation site organization. Four major HIS vendors with leading HIS products qualified for this stage of the project (evaluation site). About 60 teams with 400 members (end users and IT-experts) have assessed all the products installed, during one or more, repeated test sessions. The decision on which new HIS to purchase were based on the recommendations derived from this evaluation. After completing SSN-project with the suggestion to KAGes-top-management for negotiations with two vendor finalists, the new project named MEDOCS was started mid-1999. Two pilot installations (one general hospital and one teaching hospital department) are nowadays in the pilot implementation and subsequent roll-out (including substitution of the legacy system) is scheduled until the year 2003.

The Austrian Academic Computer Network and its usefulness for teleradiology.

To study the value of the Austrian Academic Computer Network (ACOnet) for teleradiology, 1740 test image data-sets and 620 image data-sets were exchanged between the departments of diagnostic radiology of the Universities of Innsbruck and Graz using the ACOnet service. Data transmission was reliable and fast with an average transfer capacity of 170 kByte/s (range 94-341). During the test phase, no major problems with image transfer occurred. Assuming that problems like security of patient data-sets, data compression and data verification can be solved, the ACOnet service would be a useful additional tool for telemedicine applications throughout Austria and eastern Europe.

HIS purchase project: preliminary report.

The KAGes (Krankenanstaltenges.m.b.H) is a company, owned by the state of Styria in Austria, which operates 20 hospitals with about 8,000 beds and 14,000 employees, serving a population of ca. 1.2 million people. KAGes is on its way to purchase a new hospital information system (HIS) for it's hospitals. Within the strategic IT plan and the "System Structure New" (SSN) project a methodology was developed, for making an effective HIS purchase. Several steps of this project are described in the paper: request for product information, evaluation of vendor proposals, product presentations, test site evaluation, reference site visits and selection of vendor finalists. The authors present the internal project management methodology, including the structure of the project team, project information management through intranet, criteria for different steps of the evaluation and evaluation site organization. Four major HIS vendors with leading HIS products qualified for this stage of the project (evaluation site). About 60 teams with 400 members (end users and IT-experts) have assessed all the products installed, during one or more, repeated, test sessions. The decision on which new HIS to purchase will be based on the recommendations derived from this evaluation. Two pilot installations (one general hospital and one teaching hospital department) are planned for implementation in the year 1999/2000 and subsequent roll-out (including substitution of the legacy system) is scheduled until the year 2003.

Paperless hospital: reality, dream or a nightmare?

Public Hospitals of Styria (KAGes) are implementing new hospital information system (MEDOCS--MEdical and nursing DOcumentation and Communication network of Styria) in its 21 hospitals. One of the outstanding features of this system is the coverage of virtually all communication and documentation functions related to the patient. This should be the way to fulfill the conditions for gradually removing the paper as an information medium from daily hospital practice. This approach will be tested in the MEDOCS project at two evaluation sites. In this paper the authors discuss in form of "pros and contras" the chances and risks of this approach, as well as possible strategies during the steps of implementing the "paperless" hospital. Besides of general technological, medical and cultural considerations the paper discuss also the technical and economical aspects of "paperless" hospital implementation and production.

[PACS-2000]. / PACS-2000.

Digital radiology and picture archiving and communication systems (PACS) with filmless reporting at electronic workstations are a great challenge for radiology. There are the possibilities of improving the quality of diagnosis, of working more efficiently and of achieving economic savings, but on the other hand the position of radiology within the hospital may be put at risk. The technical means for the implementation of PACS are largely available. Wide acceptance in the market depends inter alia on the availability of open systems with standardized interfaces.

[Renal osteopathy and bone mineralisation in patients treated with dihydrotachysterol during long term dialysis (author's transl)]. / Renale Osteopathie und Knochenmineralisation bei Dauerdialyse-Patienten

21 hypocalcemic patients on regular hemodialysis were treated for 2 months with 0.2 mg and for a further 2 months with 0.46 mg dihydrotachysterol daily. 8 normocalcemic patients served as a control group. Radiological and radiodensitometric investigations were undertaken in all patients at regular intervals. Slight signs of renal osteopathy with a predominant osteomalacic component could be established in the skeletal X-ray in 55% of all patients. Compared with a healthy collective, all dialysis patients showed a small but significant reduction of bone mineralisation radiodensitometrically before the beginning of treatment. During treatment with dihydrotachysterol, the patients showed a significant demineralisation of the skeleton. In four cases the characteristics of the osteopathy also increased in the skeletal radiography. During the same period of observation, none of the untreated patients showed any change of the bone mineralisation.

Experience with the AURA free-text documentation system.

AURA is a free-text system designed to facilitate automatic documentation of radiological reports, with the goal of making the information in the reports accessible for case location, feedback, and statistical evaluation without changing the regular routine of the radiologist. A simple interactive search language makes retrieval easy. Search criteria can be formulated in medical terms and do not require programming ability.