The impact of PACS on the information flow

It is likely that changes in hospital operational practices made possible by the introduction of a whole hospital PACS will require the present information and data patterns to be changed significantly. Some of the factors which will affect the flow of data and information are considered, and the implications of comparing the costs of installing ‘whole hospital’ PACS systems in different institutions are discussed.     

Overview of capacity data

This paper presents an overview of the data from 15 cases collected with the CAPACITY software for cost analysis of PACS. The data suggest that both hospital wide and partial PACS implementations do not pay back yet. Only Nuclear Medicine PACS systems may be introduced cost-neutral in the near future. Because of the assumed price drop of hardware components of 5–25% per year, hospital wide and partial PACS may allow cost savings within the next 10–20 years. There are major differences in viewpoints concerning the required PACS configurations and their costs. The experiences with the CAPACITY software suggest the need for the establishment of key rules, for designing a PACS configuration and for estimating PACS costs.     

Influence of health care systems on the market for picture archiving and communication systems

An analysis is given of the relation between health care systems and the PACS market. Two driving forces exist in the market: quality and price. It is argued that the quality driven market is mainly independent of the health care system and will be the force that drives the introduction of the health care system and will be the force that drives the introduction of PACS in the forthcoming years. Finally a change of focus is suggested from only archiving and communication to a more general concept of image networking, serving more goals than only the goal of working filmlessly.     

Benefits of coordinated action in PACS evaluation

PACS, a health care technology still in its developmental stage, aims to improve the management of diagnostic imaging investigations. As the technology has not been comprehensively assessed, data and facts to justify its clinical, economic and other benefits are to date insufficient. Through internationally coordinated action, it is expected to obtain a faster and more comprehensive technology assessment of PACS as well as recommendations for optimization of the system and guidelines for its rational use in various health care environments.     

Information processing in miniature brains

Since a comprehensive understanding of brain function and evolution in vertebrates is often hobbled by the sheer size of the nervous system, as well as ethical concerns, major research efforts have been made to understand the neural circuitry underpinning behaviour and cognition in invertebrates, and its costs and benefits under natural conditions. This special feature of Proceedings of the Royal Society B contains an idiosyncratic range of current research perspectives on neural underpinnings and adaptive benefits (and costs) of such diverse phenomena as spatial memory, colour vision, attention, spontaneous behaviour initiation, memory dynamics, relational rule learning and sleep, in a range of animals from marine invertebrates with exquisitely simple nervous systems to social insects forming societies with many thousands of individuals working together as a 'superorganism'. This introduction provides context and history to tie the various approaches together, and concludes that there is an urgent need to understand the full neuron-to-neuron circuitry underlying various forms of information processing-not just to explore brain function comprehensively, but also to understand how (and how easily) cognitive capacities might evolve in the face of pertinent selection pressures. In the invertebrates, reaching these goals is becoming increasingly realistic.     

PACS experiences in Trieste

The installation of a commercial PACS in the Hospitals of Trieste has been the start-point for a project of technology assessment, aimed at the evaluation of technical, clinical and economic aspects related to the introduction of this new and expensive technology in the health care system. During more than two years of use of this system in the clinical environment, several research activities have been carried out concerning the analysis of the organization of radiology departments in Italy, the analysis of work and data volumes, the evaluation of technical and clinical performances of PACS versus conventional film-based radiology, the integration between PACS and RIS, the experimentation of teleradiology applications. An overview of the most important activities and related results is given in this paper as well as some indications about future developments of the Trieste Project.     

Evaluation of PACS-induced organizational change

Filmless digital imaging with a PACS will affect health care institutions by changing the handling of clinically relevant information, altering needed staffing levels, and possibly affecting both the quality and cost of care. Economic evaluation of PACS compares the costs and/or benefits of PACS with those of all other relevant alternatives. Other evaluations may focus on narrower research questions. This paper discusses methodological considerations in economic evaluation, methods of time measurement, and the methods and results of several applied assessments of PACS effects on the medical imaging department or the hospital.     

IMPAX PACS在黑龙江省区域化医疗远程会诊中的初步应用

目的:研究黑龙江省不同医疗机构之间新型协同服务模式,加强垦区各级医疗机构的信息化基础建设,建立基于医学影像存档与通信传输系统(Picture Archiving and Communications System,PACS)的数字化医疗区域。方法:将哈尔滨医科大学附属第四医院现有的影像数据归档,集成到IMPAX PACS数据中心(Internet Data Center,IDC),作为整个区域医疗的影像中心。通过IDC交换平台的延伸覆盖,以及医院信息系统(Hospital Information System,HIS)与XERO集成,可经网络调阅IDC中的影像,实现远程影像会诊。结果:建立基于IMPAX PACS的区域医疗;工程覆盖1家省会大医院和垦区2家综合性医院、5家二级医院、11家农场医院,实现联网医院间的影像学远程会诊。结论:PACS区域远程医疗系统的建立为基层百姓就医提供方便,影像学远程会诊可有效避免影像学重复检查,双向转诊、信息共享给患者带来更多的便利和实惠,具有巨大的社会效益。     

Inventory issues in incremental FMS implementation

In recent years, numerous studies have demonstrated convincingly that impressive benefits can be obtained by the adoption of flexible manufacturing systems (FMSs). To obtain the benefits of an FMS requires the development of a completely integrated system. However, FMS implementations are frequently done incrementally through the introduction of subsystems such as flexible machining centers into an existing conventional system. The purpose of this research is to investigate some of the operational issues associated with the introduction of a CNC (computer numerically controlled) machine tool into a conventional system. The primary objective of the present study is to explore the relative effects on inventory holding cost of installing a single CNC at different locations within three different system configurations. Additionally, the study examines the sensitivity of these impacts to changes in (1) System utilization; (2) the ratios of setup times to run times in the conventional work centers; and (3) the rates of increase in holding costs for parts as they move through the system. Results indicated that, in general, introduction of a CNC into an otherwise conventional system reduces inventory holding cost for the system as a whole. However, the degree of this reduction varies depending on the position of the CNC in the system. In some cases the reduction in inventory holding cost is substantial, while in other cases it is relatively small.     

Cost-benefit analysis for intentional plant introductions under uncertainty

Worldwide, we rely on introduced plants for the essentials of human life; however, intentional plant introductions for commercial benefit have resulted in invaders with negative environmental, economic or social impacts. We argue that plant species of low expected economic value should be less acceptable for introduction than species of high economic value if their other traits are similar; however, key traits such as likelihood of escape and costs of escape are often highly uncertain. Methods do not currently exist which allow decision makers to evaluate costs and benefits of introduction under uncertainty. We developed a cost-benefit analysis for determining plant introduction that incorporates probability of escape, expected economic costs after escape, expected commercial benefits, and the efficiency and cost of containment. We used a model to obtain optimal decisions for the introduction and containment of commercial plants while maximizing net benefit or avoiding losses. We also obtained conditions for robust decisions which take into account severe uncertainty in model parameters using information-gap decision theory. Optimal decisions for introduction and containment of commercial plants depended, not only on the probability of escape and subsequent costs incurred, but also on the anticipated commercial benefit, and the cost and efficiency of containment. When our objective is to maximize net benefit, increasing uncertainty in parameter values increased the likelihood of introduction; in contrast, if our objective is to avoid losses, more uncertainty decreased the likelihood of introduction.     

PACS辅助教学在医学影像学实习教学中的应用探讨

尝试应用影像存储及传输系统(Picture Archiving and Communication System,PACS),对我院临床本科生进行影像学实习教学。首先应用PACS建立电子影像学图片库,学生在PACS联网的计算机上学习教学内容,通过定期随堂测验、期末考试和课后问卷调查评估PACS辅助教学的教学效果,对PACS辅助教学在医学影像学实习教学中的应用价值进行探讨。与以往传统医学影像学实习教学方法相比,PACS辅助教学在医学影像学实习教学中具有激发学生学习主动性、提高学习效率和学生读片能力的优越性,显著提高教学效果和教学质量,对促进医学影像学教学改革具有重要意义。     

Grading quality of evidence and strength of recommendations

Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.     

Current views on the functionalities of PACS

The concept of PACS has evolved from a central storage of medical images to a distributed data and image management system. The trend and evolution of the definition and design of PACS systems is described in this paper. Special emphasis on the concept of distributed and open architecture is given with a discussion of the advantages and disadvantages of each approach. A hospital-wide PACS system designed based on a distributed architecture integrated with a Hospital Information System (HIS) at the University Hospital of Geneva is further described.     

PCR-Activated Cell Sorting for Cultivation-Free Enrichment and Sequencing of Rare Microbes

Microbial systems often exhibit staggering diversity, making the study of rare, interesting species challenging. For example, metagenomic analyses of mixed-cell populations are often dominated by the sequences of the most abundant organisms, while those of rare microbes are detected only at low levels, if at all. To overcome this, selective cultivation or fluorescence-activated cell sorting (FACS) can be used to enrich for the target species prior to sequence analysis; however, since most microbes cannot be grown in the lab, cultivation strategies often fail, while cell sorting requires techniques to uniquely label the cell type of interest, which is often not possible with uncultivable microbes. Here, we introduce a culture-independent strategy for sorting microbial cells based on genomic content, which we term PCR-activated cell sorting (PACS). This technology, which utilizes the power of droplet-based microfluidics, is similar to FACS in that it uses a fluorescent signal to uniquely identify and sort target species. However, PACS differs importantly from FACS in that the signal is generated by performing PCR assays on the cells in microfluidic droplets, allowing target cells to be identified with high specificity with suitable design of PCR primers and TaqMan probes. The PACS assay is general, requires minimal optimization and, unlike antibody methods, can be developed without access to microbial antigens. Compared to non-specific methods in which cells are sorted based on size, granularity, or the ability to take up dye, PACS enables genetic sequence-specific sorting and recovery of the cell genomes. In addition to sorting microbes, PACS can be applied to eukaryotic cells, viruses, and naked nucleic acids.     

How Radical Was IT-Enabled BPR? Evidence on Financial and Business Impacts

Many large claims have been made about the payoffs that can and must be made from business process reengineering (BPR). Information technology is usually ascribed a critical role in BPR success. There is still a shortage of detailed information on the BPR phenomenon in terms of costs and results. This paper uses data from 168 UK-based organizations surveyed in the BPR heyday (1994–1996 period) to establish the size of expenditure, types of costs, and the types and size of benefits anticipated and experienced among these organizations. The majority were found to be “aiming low and hitting low,” though there was evidence of a small minority of organizations achieving something approaching what could be described as “breakthrough” results. The reasons for these results are discussed in detail and are related to the wider literature.     

Challenges and trade-offs in the management of invasive alien trees

Over 430 alien tree species worldwide are known to be invasive, and the list is growing as more tree species are moved around the world and become established in novel environments. Alien trees can simultaneously bring many benefits and cause substantial environmental harm, very often leading to conflicts over how they should be managed. The impacts grow over time as invasions spread, and societal perceptions of the value of alien trees also change as understanding grows and as values shift. This leads to a dynamic environment in which trade-offs are required to maximise benefits and minimise harm. The management of alien tree populations needs to be strategic and adaptive, combining all possible management interventions to promote the sustainable delivery of optimal outcomes. We use examples, mainly from South Africa (where issues relating to invasive alien trees introduced for forestry have received most attention), to argue for holistic and collaborative approaches to alien tree management. Such approaches need to include bold steps, such as phasing out unsustainable plantation forestry that is based on highly invasive species, and in which the costs are externalised. Furthermore, it would be advisable to impose much stricter controls on the introduction of alien trees to new environments, so that problems that would arise from subsequent invasions can be avoided.     

Variation in mating system among birds: ecological basis revealed by hierarchical comparative analysis of mate desertion

Since most bird species are socially monogamous, variation among species in social mating systems is determined largely by variation in the frequency of mate desertion. Mate desertion is expected to occur when the benefits, in terms of additional reproductive opportunities, outweigh the costs, in terms of reduced reproductive success from the present brood. However, despite much research, the relative importance of costs and benefits in explaining mating system variation is not well understood. Here, we investigate this problem using a comparative method. We analyse changes in the frequency of mate desertion at different phylogenetic levels. Differences between orders and families in the frequency of desertion are negatively associated with changes in the potential costs of desertion, but are not associated with changes in the potential benefits of desertion. Conversely, differences among genera and species in the frequency of desertion are positively associated with increases in the potential benefits of desertion, but not with changes in the potential costs of desertion. Hence, we suggest that mate desertion in birds originates through a combination of evolutionary predisposition and ecological facilitation. In particular, ancient changes in life-history strategy determine the costs of desertion and predispose certain lineages to polygamy, while contemporary changes in the distribution of resources determine the benefits of desertion and thereby the likelihood that polygamy will be viable within these lineages. Thus, monogamy can arise via two very different evolutionary pathways. Groups such as albatrosses (Procellariidae) are constrained to social monogamy by the high cost to desertion, irrespective of the potential benefits. However, in groups such as the accentors (Prunellidae), which are predisposed to desertion, monogamy occurs only when the benefits of desertion are very limited. These conclusions emphasise the additional power which a hierarchical approach contributes to the modern comparative method.     

Zorgzwaartebekostiging in de AWBZ: een vertrouwenwekkende ontwikkeling?

Towards a new system of costs reimbursement in Dutch long-term care facilities: a confidence-building development? Against the background of an increasingly ageing society, the Dutch government is redefining its role with regard to providing and financing care for the elderly. This results in restricting the benefits of the Exceptional Medical Expenses Act (AWBZ) to the care for severely dependent elderly – especially old people with dementia – who are in need of long term care that cannot be ensured on the market. In accordance with this policy, geriatric rehabilitation and (medical) care aimed at recovery will be transferred to the basic health insurance. One of the steps towards this restricted coverage of the AWBZ is the introduction of a new, but questionable method of costs reimbursement. Not only does this method lack transparency, it also entails the use of time-consuming, inefficient and bureaucratic questionnaires with a doubtful reliability. The question is raised whether this procedure is a right and trustworthy step to ensure the quality of care for dependent elderly.     

Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente

ObjectiveTo compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California.MethodsThe adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators.ResultsThe per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS.ConclusionsThe widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

What is already known on this topic

Comparisons of healthcare systems in different countries have to be undertaken with great care but can be instructiveThe overall healthcare system in the United States is more expensive than the NHS and population health outcomes are no betterThe US healthcare system comprises many discrete and unique subsystems, including the health maintenance organisations

What this paper adds

An integrated, non-profit health maintenance organisation in California (Kaiser Permanente), with over six million members, costs about the same as the NHS but performs considerably betterKaiser''s superior performance is mainly in prompt and appropriate diagnosis and treatmentThese findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment     

Cost-Effectiveness of Introducing the SILCS Diaphragm in South Africa

Background

Though South Africa has high contraceptive use, unintended pregnancies are still widespread. The SILCS diaphragm could reduce the number of women with unmet need by introducing a discreet, woman-initiated, non-hormonal barrier method to the contraceptive method mix.

Methods

A decision model was built to estimate the impact and cost-effectiveness of the introduction of the SILCS diaphragm in Gauteng among women with unmet need for contraception in terms of unintended and mistimed pregnancies averted, assuming that the available contraceptives on the market were not a satisfying option for those women. Full costs were estimated both from a provider’s and user’s perspective, which also accounts for women’s travel and opportunity cost of time, assuming a 5% uptake among women with unmet contraceptive need. The incremental cost-effectiveness ratio is computed at five and 10 years after introduction to allow for a distribution of fixed costs over time. A probabilistic sensitivity analysis was conducted to incorporate decision uncertainty.

Results

The introduction of the SILCS diaphragm in Gauteng could prevent an estimated 8,365 unintended pregnancies and 2,117 abortions over five years, at an annual estimated cost of US$55 per woman. This comes to a cost per pregnancy averted of US$153 and US$171 from a user’s and provider’s perspectives, respectively, with slightly lower unit costs at 10 years. Major cost drivers will be the price of the SILCS diaphragm and the contraceptive gel, given their large contribution to total costs (around 60%).

Conclusions

The introduction of the SILCS diaphragm in the public sector is likely to provide protection for some women for whom current contraceptive technologies are not an option. However to realize its potential, targeting will be needed to reach women with unmet need and those with likely high adherence. Further analyses are needed among potential users to optimize the introduction strategy.