Internship report Department of Nuclear Medicine

Academic Medical Centre, Amsterdam University of Amsterdam - Academic Medical Centre Frank van Swieten lectures - Braunschweig Students: Alexander Scheffer 5800978 Suraja Padarath 5745039 Supervisors: Dr. T. de Wit W.J. ter Burg, MSc 28 juni 2010

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Table of contents 1. Introduction .................................................................................................................................... 4

2. Methods ......................................................................................................................................... 5

3. Results ............................................................................................................................................ 6

3.1 The main enterprise functions .................................................................................................... 6

Patient intake .............................................................................................................................. 7

Preparation of radiopharmaceutical.............................................................................................. 7

Preparation of the patient ............................................................................................................ 9

Execution of diagnostic procedures............................................................................................... 9

Decision making......................................................................................................................... 10

Report writing and medical discharge ......................................................................................... 10

3.2 The application components..................................................................................................... 11

3.2.2 Computer based application components ........................................................................... 12

3.2.3 Communication servers ..................................................................................................... 15

3.3 The physical and communication tools ...................................................................................... 16

3.3.1 Camera’s ........................................................................................................................... 16

3.3.2 Servers.............................................................................................................................. 17

3.4 3LGM2-model .......................................................................................................................... 18

3.5 Dynamic business process ........................................................................................................ 24

3.5.1 Activity-diagram ................................................................................................................ 24

3.5.2 Use case diagram............................................................................................................... 26

3.6 Assessment ............................................................................................................................. 26

3.6.1 Quality of data................................................................................................................... 27

3.6.2 Quality of computer-based application components and their integration ............................ 27

3.6.3 Quality of physical data processing systems ........................................................................ 28

3.6.4 Quality of overall architecture ............................................................................................ 28

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3.6.5 Quality of process .............................................................................................................. 29

3.7 Analysis of two main problems ................................................................................................. 29

Problem 1: HotLab ..................................................................................................................... 29

Problem 2: Hermes-PACS communication ................................................................................... 30

3.8 Recommendation on information management strategies ......................................................... 30

3.9 Differences in information processing ....................................................................................... 31

4. Discussions ................................................................................................................................... 32

5. Acknowledgements ....................................................................................................................... 33

6. References .................................................................................................................................... 34

7. Appendix ...................................................................................................................................... 35

3LGM2 images ............................................................................................................................... 35

Matrices ....................................................................................................................................... 41

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1. Introduction Nuclear medicine is a specialty of medicine that uses radioactive isotopes and relies on the process of radioactive decay in the diagnosis and treatment of diseases. The radioactive isotopes are combined with pharmaceuticals to form a so called radiopharmaceutical. This takes place at the HotLab where there is a controlled and secured environment because of the dangers of radiation exposure. The radiopharmaceuticals are taken intravenously of orally. After that, gamma-cameras (external detectors) capture and form images from the emitted radiation. There are different cameras in use on the department, each with its own specified function. The radiopharmaceutical has specific properties that allows the nuclear medicine to image the extent of a disease-process in the body. The diagnostic tests primarily show the physiological function of the body. So nuclear medicine does not show anatomical images of a kidney such as MRI, but image the function of, for example, a kidney to analyze if it works well. At the moment, most cameras also include a CT-scanner, which allows the physician to combine the physiological function and anatomy of a patient. On the department of nuclear medicine at the Academic Medical Center in Amsterdam, 12.000-13.000 nuclear examinations are performed each year. For these examinations the physicians use 7 different camera's, which are also used to perform research. The nuclear physician injects the radiopharmaceutical and makes a diagnosis. The medical nuclear worker controls the cameras. ... We have followed an internship for three weeks on this department. We analyzed the structure of information processing and described one typical process. Using this analysis, we will make an assessment of the quality of information processing, the infrastructure and architecture. In addition, we will discuss two main problems on the department and give recommendation for information management strategies. To reduce the complexity of our model, we focused on the process concerning patient care and not on the supply management, scheduling and resource allocation. We also excluded the hospital administration, research and educational procedures from the analysis. The department of nuclear medicine also gives special treatment using radiopharmaceuticals for patient who have thyroid problems. We have not modeled this function of the department.

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2. Methods In order to make an analysis of the nuclear medicine we collected information by interviewing, observation and site visits. Before starting, we studied the AMC website and did a background search on the department and its main functions. We used a bottom-up approach, which means that we try to make an model from all the information gotten from the interviews and site visits. From the background search we knew what main functions we wanted to analyze, which places we wanted to visit and what personnel we wanted to interview. During our introduction at the department on the first day, we received the names of the most important people at the department and immediately started making appointments with them, as we knew physicians and clinicians do not have a lot of time. We modeled our analyzes using the 3LGM2-tool. This is an tool provided by the University of Leipzig. It consist of 3 layers, namely the domain, logical tool and physical tool layer. At the domain layer, we modeled the main enterprise functions of the department. At the logical tool layer all the applications are modeled, for example the system used for making appointments. The physical tool layer models the physical component, like the actual camera. This tool also offers functions for analysis of the model. To describe one typical business process we use the UML-activity tool. From the site visits we hope to have collected most of the problems that occur on the department of nuclear medicine at the AMC.

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3. Results 3.1 The main enterprise functions The department of nuclear medicine has a couple of important functions:

• Patient intake • Preparation of radiopharmaceutical • Preparation of patient • Executions of diagnostic procedures • Decision making • Report writing and medical discharge

Figure 1 : All enterprise functions regarding patient care and archiving within the department of Nuclear Medicine

Legend Enterprise function

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Patient intake One of the main functions of the department is the patient intake. By this we mean scheduling appointments, checking the patient identification, administrative admission and printing a day list. This all happens at the administrative desk by administrative workers. The nuclear medicine research request-form is processed at this desk. The administrative workers check the order for completeness, then a nuclear physician judges the order for correctness. They have to decide if the requested research is right for the patient. To do so, they use the patient history. If it is correct, the physician puts his or her signature on the order. Every morning, the workers print a list of the patients that are scheduled for the day. The list is ordered by type of camera and time. Also additional information about patients, like height and weight, is printed on the list. When a patient checks in at the desk, an administrative worker collects the department's patient record and research-order and line the patients name through on the day list. If a patient checks in for the first time, they enter the patient information into the system and create a new patient record.

Figure 2 : Subfunctions and entity types of the enterprise function Patient intake

Preparation of radiopharmaceutical Another main function of the department is the preparation of the radiopharmaceutical. This is done by medical nuclear workers and at a special place on the department, called the HotLab. Here, they also generate a daily list with the patients scheduled for that day, but at this location the patients are ordered by needed pharmaceutical. An important activity at the HotLab is the ordering of the radioactive substance. Using the patient list of the next day, they order the substances from an external vendor. Orders can be placed till 3 o'clock PM

Legend Enterprise function

Entity type

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and cancelled until 12 o'clock AM. This generates an ordering list. With the ordering list the medical nuclear workers receive the substances at 7 o'clock AM. They check if all of the substances they have ordered are actually delivered. The delivery comes with a packing list which the workers sign and archive. Because of security reasons and risk of radiation exposure, everything is controlled and checked. The radiopharmaceutical can be taken orally. In this case, the nuclear worker prepares a pancake in which the radiopharmaceutical is put into. The radiopharmaceutical can also be taken intravenously using a syringe. An yellow label with information about the radiopharmaceutical and information about the patient to whom that specific radiopharmaceutical belongs is transferred from the pancake or syringe to the order when the patient has taken the radiopharmaceutical.

Figure 3 : Subfunctions and entity types of the enterprise function Preparation radiopharmacon

Legend Enterprise function

Entity type

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Preparation of the patient A nuclear physician has to decide how the patient is going to take the radiopharmaceutical. This depends on the kind of research requested and the state of the patient. There are three options if the radiopharmaceutical has to be taken intravenously: in active state while riding a bicycle, in an active state simulated by using dopamine, or in rest. The injection in active state takes place at the exercise room, in rest at the dosage room or in the camera room while is patient lying in the camera, depending on the type of research. Only the nuclear physician is qualified to inject the radiopharmaceutical. He or she also has to put his or her signature on the yellow label that came with the pharmaceutical.

Figure 4 : Subfunctions and entity types of the enterprise function Preparation of the patient

Execution of diagnostic procedures Using the daily patient list and order, the medical nuclear worker prepares the machine for the patient. By this we mean, looking up the patient information, place attributes on the camera, cleaning the bed. There are several cameras and rooms where this can happen. The image is taken and reconstructed and the medical nuclear workers checks the image quality and edits the images using specific camera software, so the nuclear physician can use them for diagnosing. During the execution of the diagnostic procedures, the medical nuclear worker can update the order with information concerning the patient. For instance, if the patient has moved or went to the toilet, this vital information is written on the order so nuclear physician can take this into account during decision making. Also raw image data is generated from the camera. By this we mean the actual intercept of radiation emitted by the patient. The camera software evaluates the raw data and realizes an image. Because every camera is necessary, can differ in image type and is sometimes specialized on a body part, we have modeled the 4 sub function for each camera/diagnostic procedures. In this way the different camera software are not redundant, because each camera software has 4 sub functions.

Legend Enterprise function

Entity type

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Figure 5 : Subfunctions and entity types of the enterprise function Execution of diagnostics and therapeutic procedures

Decision making The nuclear physician analyses the images and with the use of literature and external findings of the patient, he generates a diagnosis. This diagnosis, which will be written about in the report, will be used to support the choice of treatment for the requesting department or care institution.

Figure 6 : Subfunctions and entity types of the enterprise function Decision making

Report writing and medical discharge The diagnosis the physician generated has to be reported. In a report room they dictate their findings using a speech recognition program. If the physician is in training the report is always checked by the

Legend Enterprise function

Entity type

Legend Enterprise function

Entity type

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supervisor. If the findings are serious, the physician calls or telephones the applicant of the research to inform him or her about the situation. If not, the administrative workers print and fax or post the results to the applicant. The report is also printed and put into the patient record. After this the patient is discharged.

Figure 7 : Subfunctions and entity types of the enterprise function Patient discharge and transfer to other institutions

3.2 The application components 3.2.1 Paper based application components Nuclear medicine patient record This is the general patient record that is used on the department of nuclear medicine. It contains the following forms:

Request nuclear medicine research This can be the general or cardiac research request form for the nuclear medicine department. Physicians outside the hospital can use this form to request a research. The form can be posted of faxed. The form contains extra fields which are filled in during the diagnostic process.

Report A report is generated in the report room by physicians. It is initially a digital report but at the end of the patient process the report is printed and added in the department’s patient record.

Legend Enterprise function

Entity type

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Blood flow research results When a blood flow research is performed, the camera’s software automatically generates a report with images, diagrams and textual information (this research is only supported by a gamma-camera where a full body exam is possible). This result is printed and put in the patient record.

Effort registration During the injection in active state, information about the patient’s preparation is filled in on this form.

ECG When the radiopharmacon is injected while the patient is in active state, an ECG is created with the computer based application component Case (see 3.2.2, Case and Muse).The ECG is printed and added to the record. Physicians use the ECG during decision making

Daily patient list The daily patient list is generated at the administrative desk. It contains all the patient that are scheduled for that day ordered by camera, and time. This list is also generates at the HotLab but that the patients are only ordered on time. Administrative workers, physicians and medical nuclear worker all have a day list. When a patient checks in and when a image has been taken the personnel marks an X on the day list.

3.2.2 Computer based application components The department of nuclear medicine uses a lot of applications, both directly as indirectly, for example a communication server. These applications can be divided into computer-based components and paper-based components.

Hermes Hermes is the most important software product within the nuclear medicine department. It is used to edit, store and show all the images taken within the department, and communicates the images to the rest of the hospital. It also communicates with the Picture Archiving and Communication System (PACS) at the radiology department to send the images back and forth. Images from 6 camera are stored on Hermes, and Hermes sends working list to 2 cameras.

Camera software Almost each camera has its own software product to support the camera functions and image reconstruction and editing.

Neurofocus (SME) Neurofocus is the software for the SME. It is the only (camera) software product at the department that runs on the Apple operating system. Therefore, it has to send its pictures via another server, called Bigsmerv, in order to send it to Hermes.

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Xeleris (GE Infinia Hawkeye) Xeleris is used with the Infinia Hawkeye, a SPECT-CT camera. This software product provides comprehensive processing, image reviewing and networking for all routine nuclear imaging protocols. It receives its patient information from Mitra and is able to send its images to the Hermes server.

Syngo CT (E-CAM + Symbia) Syngo CT is the software product used for the SPECT-camera E-CAM and the Symbia Truepoint SPECT-CT camera. It receives its patient information from Mitra and is able to send its images to the Hermes server.

QDR (DEXA) The QDR software product is used to acquire and reconstruct the data generated by the DEXA camera. With the acquired images, the bone density of a patients (group of) bones can be automatically calculated.

Extended Brilliance Workspace (Gemini TruFlight) The software product for the PET-CT camera Gemini TruFlight is used to acquire, reconstruct and view images.

PACS (IMPAX) The PACS software (Picture Archiving and Communication System) is located at the radiology department and used to edit, store, and view large images made by the different cameras within a hospital. PACS almost has the same functionalities as Hermes. Images from one camera are directly stored on the PACS. Regularly, PACS and Hermes synchronize all the images. So all the images are both stored on PACS and Hermes.

X/Care X/Care is the software that functions as an agenda for the entire AMC. It’s used to schedule the appointments and functions as a base for the creation of day lists and ordering the radioactive substances. One of the downsides of the use of X/Care for the department of nuclear medicine is that each step in the process, e.g. the injection of the radiopharmaceutical in the exercise room, has to be inserted manually. Although there are predefined steps for each type of research, these steps cannot be stored in the software itself. Also, each appointment needs to be coded to be used in Filemaker and the “Daily patient list creator”.

Filemaker Filemaker is a database system which is used in the HotLab. It’s used to:

1. create a list of patients and needed radioactive substances 2. order the radioactive substances

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3. administrate the available and used radioactive substances

To execute these tasks, Filemaker collects the appointments from X/Care. The title information in each appointment is used to select the needed radioactive substances for each patient. Filemaker is meant for small database systems. In the HotLab, is actually uses more than thousand scripts to complete its tasks.

Case and Muse Case is the software used in the exercise room when the patient is injected while in active state. It measures blood pressure, heart rate and creates an ECG, which is printed for the patient record and sent to the rest of the hospital digitally using MUSE. From there on, the rest of the physicians can access the digital ECG via the AMC Zorgdesktop.

G2 Speech G2 Speech is a voice-recognition suite which is used to create reports. Physicians can dictate their findings using a Dictaphone, which is also used to interact with the software using buttons. This is a very fast and natural way of creating a report. The audio data is send via the AMC-network to one of the G2 Speech servers, where it is converted to text and sent back. The text is then added to the report.

ZorgDesktop The AMC Zorgdesktop (Care Desktop) is used as a portal to view all kinds of patient data within the AMC. Data can be directly shown in the Zorgdesktop, or it can open the required software to present the data. The Zorgdesktop is used for small tasks at the department of nuclear medicine, e.g. viewing lab results. In the rest of the AMC however, it is needed to view images taken by the department and read the reports stored at the information system of the radiology department, where the reports of the nuclear medicine department are also stored. By this information system we mean in this case an application component, not the whole information system.

HIS The HIS, or the Hospital Information System, is an application component at the AMC that supports the main hospital functions such as patient registration and billing. It consists of a lot of smaller application components. However, only two of them are used often at the department:

Patient registration (PatReg) PatReg is used to register patients which are new to the hospital. The patient information can also be accessed again by other programs, so information doesn’t need to by entered again completely. It is a centralized system and therefore is used for patient registration by all departments.

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Medical proceedings registration For billing in the Netherlands it is needed to store all medical proceedings executed by physicians and nurses. Together with the found diagnosis, a bill can be made and sent by the creditors. This application component is used to register these proceedings and therefore, needs to be used daily.

Daily patient list creator This application, made in MS Access, is used to generate a daily patient list. It collects its data from the AMC’s appointment system, X/Care. The list of patients is used as a schedule for each room or site at the department, so the right person is helping the right patient at the right place and time. It also functions as a treatment plan: it contains information about the treatment, dosage of the radioactive material and patients length and weight. This information was also taken from the original appointment.

3.2.3 Communication servers

Mitra Mitra is a kind of communication server used at the radiology department. It is used to automatically send working lists, containing general patient information, to 5 cameras at the AMC. The other two cameras receive working list via Hermes. Every time an appointment has been scheduled, the information is transported trough Cloverleaf and Zouga to the RIS. The RIS is sending the information via the Zouga, Cloverleaf and Impact to the Mitra. Impact Impact is one of the communication servers at the AMC. It is part of the application component ZIS and used to communicate with the rest of the hospital’s information system. Cloverleaf Cloverleaf is used to connect most of the application components known in the AMC. It supports a lot of communication protocols and makes communication possible between external and internal developed applications. Zouga Zouga (Zeer Open Universele Geneeskundige Applicatie) is an integration service which is mainly used to integrate applications within the AMC Zorgdesktop. It was developed by the AMC’s own IT-department.

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Figure 8 : All application components regarding to patient care and archiving used by the department of Nuclear Medicine

3.3 The physical and communication tools

For this paper, we will only discuss the most important physical tools at the nuclear medicine department: the cameras and used servers.

3.3.1 Camera’s

DEXA The DEXA camera, or Hologic QDR bone densitometers is an camera which uses X-rays to measure bone density. While making the pictures the unit above the patient moves. A Dexa-examination takes approximately 10-20 minutes.

Diacam The Siemens Diacam gamma camera is designed for SPECT, whole body and planar nuclear studies. It's design permits close patient positioning essential for diagnosing. This camera is mostly used for research

Legend Computer based app. component

Central app. component

Central communication server

Paper based app. component

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of: the kidneys, the heart (the ejection fraction) and the parathyroid. While taking pictures this camera does not moves, it must be manually set by the laboratory.

E.CAM The Siemens E.cam is a single-detector system, used for SPECT and whole body scans.

Gemini TruFlight The Gemini TruFlight from Philips has a PET- and CT-scanner, to create images with radiation and anatomical information.

Infinia Hawkeye The GE Infinia Hawkeye has a SPECT- and CT-scanner, to create images with radiation and anatomical information.

Symbia Truepoint The Symbia Truepoint from Siemens is a double-detector SPECT system and also has a CT-scanner. Therefore, this camera can also use the CT-scanner for anatomical information.

SME This camera is designed to make brain images. The patient’s head goes in the camera, and 12 heads inside the camera will rotate to collect image data. At the department, this camera is mostly used for research.

3.3.2 Servers

Bigsmerv Bigsmerv is used to send images from the SME-camera to the Hermes-server, since the SME-software is not able to send the data directly to Hemes. Bigsmerv and Hserver1 share the same (network) hard disk

Hserver1, 2 and 3 Hserver1, Hserver2 and Hserver3 are the image storage and –reconstruction servers located at the department. They support the new Gold III software, which allows the Hermes desktop clients to retrieve image data from the servers, and the older Gold II software. For this last application component, the servers act as a application server: the GUI is sent to the physician’s workstations, but the software is running on one of the servers.

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Figure 9 : All physical and communication tools regarding image creation

3.4 3LGM2-model Information that is sent varies from images to patient information and appointments. Different event-type-message-type-combinations have been created. Events are creating a patient list, making a appointment, doing a ECG test, sending an image, sending patient information, sending a report and printing a report. Messages that are to be send are linked to the event type. Entity types are grouped in a dataset type, which is stored in a database of a system. Dataset types are the appointment, the daily patient list, the ECG, the images, the order, the report.

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We have generated a couple of matrices to check if our model is complete. In the matrix each function is supported by an application component and all the application components are stored on a physical component. We also checked if every entity type is used and updated by a function. In table 1, the columns are filled with the application component and the rows with the physical components. What immediately stands out are the Hermes workstation where different software are running on. This, however, can’t be seen as a problem, since workstations are meant to do multiple, relatively simple tasks. In table 2, the columns are filled with the application component and the rows with functions. If a row is empty, it has no connection with an application component, the function is probably a main function as only the sub functions are connected with a component. As for redundancy, you can conclude that images are both stored and viewed on PACS and Hermes. Besides that, images can also be viewed using Imageviewer (a component of the AZD), Hermes and PACS. Crucial decision making functions are using a lot of component. The four sub functions of execution of diagnostic procedures are properly divided by the different camera software. Although, for preparing the machine the paper-based application component day list, information label and the request form are used.

In table 3, the columns are filled with the entity types and the rows with the functions. It is clear that all the entity types are used or updated. The empty rows, as said before, are main functions, which are there to group the subfunctions.

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Table 1 : Physical tools (left) supporting application components (top)

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Table 2 : Enterprise function (left) supported by application components (top)

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Table 3 : Entity types used (Green), updated (orange) or both (blue) by enterprise functions (left)

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3.5 Dynamic business process

3.5.1 Activity-diagram An activity diagram is made of the patient intake process, the patient preparation process and the diagnostic process. This all is modeled in one diagram. The process starts with the patient checking in at the administrative desk. The administrative worker first checks the appointment and then collects the patient record and order. From all the patients that are scheduled for that day, the record has already been collected from the hospital record archive and are now in the locale archive. All research orders are also located at the administrative desk. Every camera, the dosing room and the exercise room have an in-box at the desk. The worker puts the record, including the order, in the right in-box and sends the patient to the waiting room. The physician or physician assistant regularly checks the in-box at the desk. If they see a record, they know a patient has arrived.

The patient preparation always starts with the injection of a radiopharmaceutical. So, at first the record is always in the inbox for the dosage room or the exercise room. The decision of injection in active or rest is up to the physician and made according to the type of research. Furthermore, an active state can be accomplished by two ways, one using dopamine and the other using a bicycle. When an injection is needed in rest, this can also happen in two ways. The first is in the dosing room, where the patient needs to wait for a while after the injection. The other one is at the camera were the image is taken immediately after injection.

From the doses room and the exercise room, the record goes back to the administrative desk, but this time into the box of the camera were the patient is scheduled. Sometime physicians hand over the record to the medical nuclear workers in the camera room. They prepare the patient for the image and take the image. A image is always checked by a physician for correctness. After that the patient can go home, and the nuclear worker starts with editing the images for analysis. The physician uses the constructed images for the diagnosis and report his findings. At the end of the process the administrative worker prints the report and stores it into the patient record.

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Figure 11 : Activity diagram of patient intake, diagnostic process and discharge

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3.5.2 Use case diagram In this use case diagram, all the actors that are involved in the process from the patient intake untill the diagnostic process are mentioned, with their performing task.

Figure 12 : Use case diagram of patient intake, diagnostic process and discharge

3.6 Assessment Three major approaches to quality assessment are typically distinguished: quality of structures, quality of processes, and quality of outcome.

Those concepts can be transferred to health information systems. In this context, quality of structures refers to the availability of technical or human resources needed for information processing (e.g., number and availability of computer systems and other ICT, i.e. the HIS infrastructure). Quality of processes deals with the quality of the information processes that are necessary to meet the user’s needs. Quality of outcome describes whether the goals of information management have been reached, or, in a broader sense, to what extent for example a hospital information system contributes to the goals of the hospital. In our assessment will not discuss the quality of outcome, since we do not know what the goals of information management on the department are.

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3.6.1 Quality of data At the department of nuclear medicine the integrity of the data is high. Every patient has a unique patient identification number which is used all over the hospital. Also, the general patient information, such as name, address, telephone and insurance number are stored in one central database, which can be accessed by almost every system who needs patient information. So, there is integrity of data. Besides that, when a physician dictates a report, he or she first scans a barcode that contains the patient identification number. So, this object is linked to and identified with that specific patient.

The reliability of data is also very high. For example, when a radiopharmaceutical is injected, the label is signed by a responsible nuclear physician. Even when a physician assistant writes a report, the findings are always checked and signed by the supervisor.

As to completeness and availability, the department sometimes suffers from a missing patient record, or an order which can't be found or has not even been sent to the administrative desk. That is because the order can be made in different form. The order can be faxed, posted or via an electronic ordering system. And it can occur that the order is placed in all the three different ways or not.

Accuracy is a very important aspect, especially at the HotLab, were everything is documented. There should be no errors in the measurement of radioactive substance. Special equipment and an extra check assure high accuracy.

As for standardization, there is a standard form of writing a report that is used in the report room. A report must always include specific chapters, which are already in the report. Blank spaces need to be filled in to complete the report.

The images taken in the camera room, are immediately available in the report room for diagnosing. However, the availability is not that high in the entire department; at the HotLab there is no immediate list available of the used and unused radioactive substances.

3.6.2 Quality of computer-based application components and their integration The overall quality of the computer-based application components at the department of nuclear medicine is good. Application components function as they should. For example: the software which allows the physician to dictate his findings into a predefined form is specially made for the hospital environment and understands even the most difficult words used. Besides this, it also supports typing and allows the user to deviate from the template.

The application components within the department have a very high efficiency. Applications normally fulfill their tasks within a second. The camera’s however, need ten to 30 minutes to create an image. This is, however, due to the relatively slow decay of the radioactive elements: a lot of radiation is needed to create a correct image. To keep the processing time to a minimum, the software creates the images on the fly; it starts reconstructing while the camera is still busy.

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The maintainability of the overall software is average. Most computer-based application components can be changed relatively easily. Some research at the department can even temporarily be taken over by another camera, if a camera's software is updated or in maintenance. However, the maintainability of the application components used in the HotLab is poor. The software used at this site, FileMaker, contains over a thousand scripts. Furthermore, only one person at the hospital has full knowledge about the system.

Because the department uses a "best-of-breed" approach for the used computer-based application components, the application components use standardized communication protocols like HL7 and DICOM. Also, communications between application components are made mostly via communication servers. Therefore, it should be possible to transport components to another environment, or put new components in the environment of the department. The only exception is the image software Hermes and the Diacam camera, which uses a software component from Hermes and an communication protocol from Hermes: interfile. It is possible that after removing one of these two, there could be a problem communicating with new application components.

At the moment of writing, the HotLab at the department struggles with new guidelines and statutory requirements for the ordering and handling of radioactive materials. Their current system does not meet these guidelines, and therefore has a certification problem. The system that is currently tested at the HotLab does have a certification.

The AMC uses a lot of standard, and also some non-standard, interfaces for communication. A few examples are HL7, DICOM, HTTP and ODBC as standard protocols, and interfile and facelink as non-standard protocols. At this moment , three central communication servers are used to solve integration problems. However, a single star structure is preferable.

3.6.3 Quality of physical data processing systems As for the availability, computers are in every room and can easily be accessed as for all the needed software. However, the nuclear department cannot function without the cameras. They do dominate the physician-patient relationship but that is the necessity. No mobile tools are in use but the computers that are used do not have a multiple usability. For example, in the camera room, there is a workstation were the camera software runs and a different workstation were the imaging and archiving software runs. None of the tools allow easy data entry by a touch screen.

3.6.4 Quality of overall architecture The department uses both computer-based and non-computer-based information processing tools. The different actors work smoothly with the components but they do not integrate efficiently. For example, the report is still printed for the patient record. A lot of information is written on the order during the process. The architecture has a lot of different computer-based component, each with its own database. The Hermes system is a redundant system, as is has the same functionalities as the PACS. Actually, the Hermes functions as a communication server. It can send working list which Hermes receives from the Broker Mitra. And it sends pictures to PACS which it receives from all the different camera's.

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We do not think that the architecture is fully saturated, because the most important process of the department, the process of the order, is still conventional. It should be easy to add a new camera and thus software to the information system, since the standard is to communicate with Hermes. As Hermes has its own communication protocol, called Interfile, all software programs can connect with Hermes. The functional leanness of the architecture is low. Functions like archiving of images and generating day list are supported by two application components, namely Hermes and PACS, Day list Creator and FileMaker. So the architecture can be described as a ACn, Vn, CPn, a mix between spaghetti en and star architecture and since ACn an Vn architecture always are of DBn style, data redundancy is nearly unavoidable. A clear example of this is the image storage in Hermes and in PACS, and even the communication between them for synchronization the images.

3.6.5 Quality of process The most important benefits computer support can bring to information systems is that data can be recorded ones but used multiple times. This is the case with the patient information, this is recorded once at the administrative desk in PatReg system and anywhere in the hospital available.

There is also a transfer of data from the digital storage device of the record to the paper report printed at the administrative desk. This transcription is associated with a media crack. The people who work with the most information processing tools are the medical nuclear workers. They have the control over a camera and thus software.

3.7 Analysis of two main problems

Problem 1: HotLab FileMaker is the software application that is used at the HotLab. It facilitates the lab with functions like ordering, creating daily patient lists and archiving. To fulfill these functions, Filemaker at the HotLab uses a lot of scripts. It has a connection with the hospitals appointment system to collect patient appointments and information. The current situation is that when the inspections of Housing, Spatial Planning and Environment (VROM) visits the department to inspect the use of radioactive substances, FileMaker cannot give an up to date list of the used and unused radioactive substances. This can only be done at the end of the day. Besides this, FileMaker uses a lot of scripts (over a thousand) to run the daily functions. These scripts make the system very hard to maintain. Also, many scripts are currently unused and, as a result, outdated. Furthermore, only a few people at the department know how to manage and maintain this database system. FileMaker generates a day list of the patient that are scheduled for that day. To do so, FileMaker imports the appointment from X/Care and edit this list using scripts so only the information that is needed is used. The appointment for the nuclear department are special, because there are combination appointments. X/Care is able to arrange an appointment for determining the right dose of radioactivity, the reservation of the camera, scheduling the laboratory assistant and the physician at the same time.

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But the administrative workers experience a lot of problems when scheduling such a combination appointment. At the HotLab a yellow label is generated that contains the patient information and information about the radiopharmaceutical. This label is put on the order. During the process from patient intake till patient discharge, a lot is written on the order. Archiving of this information is legally required. If this label was digitally stored, like the rest of the radiopharmaceutical information, the complete set of data would be available at one place, instead of in both computer- and paper-based form. A possible solutions for the problems with FileMaker is the new software IBC 606 from vendor Veenstra. Currently this application runs in a pilot version on the department. This software can give a automatic up to date list of the radioactive substance used and unused. It also has a functions for appointment scheduling in which it meets the requirement of the users. IBC 606 is a software that is legally permitted by pharmacies for ordering, archiving and management of radioactive substances. It has the potential to digitally archive the label information.

Problem 2: Hermes-PACS communication Hermes is the image software and storage system used at the department of nuclear medicine. Images made at the cameras can be reconstructed, edited and viewed with this software. Every now and then, images are transferred between Hermes and PACS, which is located at the radiology department. PACS basically fulfills the same needs for the radiology department and therefore makes Hermes redundant. Also, working lists are sent from Mitra (also called the 'Broker') to the cameras to provide them with the needed patient information. However, two cameras, the SME and the Diacam, get their patient information from Hermes. This function would be more maintainable when it is provided by only one system, for example only by Mitra.

A possible solution is to use PACS as the only image constructing and storing system in the radiology and nuclear medicine department. This would create a DB1-architecture in this subsystem. The current version of the PACS system fully supports all the needs for the department of nuclear medicine. In this situation, Mitra can be used to send the working lists to all cameras.

3.8 Recommendation on information management strategies

Looking back at our internship, the department of nuclear medicine at the AMC has overall a quite good information system. However, when we look beyond the patient-care process, there are some things that can be improved. The HotLab-system needs to be renewed to improve the maintainability. Also, one of the PACS systems needs to be eliminated to improve maintainability. Our recommendation would be to eliminate Hermes and use the PACS system located at the radiology department. Of course, this cannot be at the expense of other quality factors, such as availability and efficiency.

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Another recommendation for the department would be to digitalize the order and the yellow information label. With this done, the department is fully saturated. It would also work more efficiently, probably.

The AMC’s information system is now in a transformation process to implement a full digital patient record. Some departments are already using it, and it would be a good improvement if the whole AMC, including our department, would use the digital patient record. This would make the paper based patient record superfluous and increase the data integration and availability.

3.9 Differences in information processing The hospital visited in Germany by the students from Braunschweig had a data integration. Almost the entire department suffered from media cracks. Images where made with the camera’s and then printed for diagnostics and archiving. Other departments used the same paper based images for their diagnostics. In our opinion, using paper based storage for the images taken will lead to a lower image quality. Also, because images are printed once, there is a lack of needed redundancy. Once the print is lost, faded or destroyed, there is no back-up. The use of a PACS system would solve this problem. Finally, the final reports are recorded by the physicians and then typed out and printed by the administrative workers. This is a very time-consuming situation, as the information is created twice (in sound and textual form) and has to be checked again by the physician. Also, if there is a mistake in the report, the process needs to be done again. Using a voice recognition application component, the tasks of the physician and administrative worker can be merged into one. This will improve the integrity and accuracy of the reported data.

There were almost no differences between the department of nuclear medicine and radiology at the AMC. However, research request and patient record archiving are completely computer based. Furthermore, the radiology department only has one PACS system, while the nuclear medicine department has two. These two things can be seen as an example for the nuclear medicine department, as they would reduce redundancy and increase data integration and availability.

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4. Discussions Regarding to our internship at the department of nuclear medicine, a couple of remarks can be made. First of all, there is a possibility that connections in the logical and physical tool layer do not reflect the true connections. At the time of our internship, not all connections were very clear to the hospitals IT-department and the local IT-department. For example, the hospitals IT-department has a lot of servers to which it is not known exactly what function they perform. Furthermore, if a connection is known, it is not always known or documented which data is transported. Finally, there is a lot of contradiction in the models of the hospital’s IT-department, the model of the radiology department and the information provided by the IT-department located at the department of nuclear medicine. We tried to find a way to create a 3LGM2-model which would include all information provided and would be as close to the actual hospital information system as possible.

As for the modeling itself, we had some problems with the tool used to create the 3LGM2-model and the creation of the matrices to support our quality assessment. For example, the camera’s at the department all use different software to reconstruct, edit and view the taken images. In the model, it is clear that there is no functional redundancy, but there are just different software packages delivered with each camera, due to the difference in vendors. In the matrix however, it cannot be seen there is actually a functional leanness, and not a functional redundancy. We tried to fix this by making extra enterprise functions for each camera, so every subfunction of them would only point to a single application component. Another problem is that some connections are inherited, and others not. This means that some connections seen at the matrices are not meant to be there. There will also be blank rows or columns in these matrices. These blank rows and columns are, however, due to a superfunction, super-application components or super logical-tools, which are sometimes used to group components.

Finally, our model has to be seen as a simplified model of the department. Due to the short time span and the complexity of the department’s and hospital’s information system, simplification was needed. However, we feel that we have modeled enough to create a sufficient base for our quality assessment.

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5. Acknowledgements

We would like to acknowledge all the individuals for their support during the analysis and modeling of the system.

Dr. T.C de Wit - Nuclear physician

Dr. B.W.A Kee - Nuclear physician

W.M. de Jong, BSc - Medical nuclear worker

M.S. Kartashova - Physician-assistant

Dr. R.J. Bennik - Physician-assistent

M.Y. Jansen-van Goch - Admnistrative worker

V.D.V. Klappe - Medical nuclear worker

C.M. van der Kroon - Medical nuclear worker

M. F. Lam - Medical nuclear worker

M. Mathoera - Administrative worker

J.C. Meijs - Administrative worker

A.F. van Moerkerken - Medical nuclear worker

R.C. Ozsoy - Physician-assistant

Dr. H.J. Verberne - Nuclear physician

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6. References

Health Information Systems, Architectures and Strategies. A. Winter, R. Haux, manuscript 2010

Technische documentatie, integratieplatform. E. Beekman, AMC

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7. Appendix

3LGM2 images

Figure 13 : Overview of the function Patient intake and its corresponing application and physical components

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Figure 14 : Overview of the function Preparation of the radiopharmacon and its corresponing application and physical components

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Figure 15 : Overview of the function Preparation of the patient and its corresponing application and physical components

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Figure 16 : Overview of the function Preparation of diganostic and therapeutic procedures its corresponing application and physical components

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Figure 17 : Overview of the function Decision making and its corresponding application and physical components

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Figure 18 : Overview of the function Patient discharge and transfer and its corresponding application and physical components

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Matrices

Table 4 : Entity types (left) stored on database systems (top)