Evaluating the impact of service delivery initiatives on patients’ waiting times in diagnostic radiology: a mixed methods study

This thesis describes the impact of service delivery initiatives (SDIs) on patients’ waiting times within radiology departments. A systematic review of the literature (71 studies included) found the following broad type of SIDs: extended scope practice, quality management, productivity-enhancing technologies, outsourcing, pay-for-performance and multiple interventions. Ninety-six percent of the studies used either the pre- and post-intervention without control or the post-intervention only designs; but these designs are fundamentally weak and prone to bias. Furthermore, this thesis also described a case-study for the evaluation of the impact on patients’ waiting times of a 320-slice computed tomography (CT) scanner, speech recognition reporting and extended-working-hours within the Birmingham Heartlands Hospital (Heart of England NHS Foundation Trust), Birmingham. The evaluation combined the interrupted time series (ITS) design and qualitative interviews with healthcare professionals in a mixed methods approach. The mixed methods approach leverages the strengths of the quantitative and qualitative methods, so that the triangulation of the findings of one research method might be strengthened when supported by the findings of the other research method. The thesis used a distinctive implementation of ITS segmented regression which accounts for the changing trends of patients waiting times – an approach referred to as ITS ‘segmented spline’ regression

A situated method for modelling and analysing the efficiency of cognitive activity during the radiology reporting workflow using eye-tracking

The success of modern medical imaging systems has created a data overload problem, where an ever-increasing number of examinations, generate more images per study, which all need to be evaluated by radiologists or other reporting practitioners. This operational bottleneck hasthe potentialto create fatigue and burnout due to the high mental workload that is required to keep up with the demand. The focus of this problem centres around the cognitive complexity of the radiology reporting workflow, and the associated workstation interactions involved in diagnostic report generation. There has been a significant body of work evaluating the behaviour of radiologists using controlled laboratory-based techniques, but these non-naturalistic studies fail to address the highly context dependant nature of the radiology reporting workflow. For example, the early eye-tracking work of Charmody et al; the psychometric studies by Krupinksi et al; and also the workstation interaction evaluations of Moise et al; whilst highly principled, can be all be questioned on the grounds of ecological validity and authenticity. This thesis asserts that the only way to truly understand and resolve the radiology data overload problem, is by developing a situated method for observing the reporting workflow that can evaluate the behaviours of the reporting clinicians in relation to their authentic reporting context. To this end, this study has set out to develop a new approach for observing and analysing the cognitive activities of the reporters relative to the demands of their genuine working environment, and supported through the application of a Critical Realist’s perspective to naturalistic workplace observations. This goal was achieved through the development of four key project deliverables: • An in-depth exploratory study of the radiology overload problem based on an extensive literature review and situated observations of authentic reporting workflows. • A descriptive hierarchical activity modelof the reporting workflow that can be understood by both clinicians, application designers and researchers. • A generalised methodology and research protocolfor conducting situated observations of the radiology reporting workflow, using an analysis based on the process tracing of sequencesof Object Related Actions, captured with eye-tracking and multimodal recordings. • A set of case studies demonstrating the applicability of the research protocol involving 5 Radiology Consultants, 2 Radiology Registrars and one Reporting Radiographer at a single NHS Hospital within the UK. The final workflow evaluation of the case studies demonstrated that activities such as error correction, and the collection of supporting radiological information from previous studies is complex, time consuming and cognitively demanding. These types of activities are characterised by long, low utility actions that correspond to what Kahneman refers to as “Thinking Slow”. Also, the participants appeared to be self-optimising their workflow via a sparse use of complex functionality and system tools. From these observations, the author recommends that any intervention that can reduce the number and the duration of the object related actions used to produce radiology reports, will reduce cognitive load, increase overall efficiency, and go some way to alleviate the data overload problem. 4 This study establishes a new set of situated techniques that are able to capture and quantify the complex dynamicactivities that make up the radiology reporting workflow. Itis hoped that the ability to distil usefuland impactful insightsfrom the user’s workstation behaviours can be used as the basis for further development in the area of workflow analysis and redesign, which will ultimately improve the working lives of Radiologists and other Reporting Clinicians. Lastly, the generic nature of these techniques make them amenable for use within any type of complex sociotechnical human factors study related to the cognitive efficiency of the user

Complexity Reduction in Image-Based Breast Cancer Care

The diversity of malignancies of the breast requires personalized diagnostic and therapeutic decision making in a complex situation. This thesis contributes in three clinical areas: (1) For clinical diagnostic image evaluation, computer-aided detection and diagnosis of mass and non-mass lesions in breast MRI is developed. 4D texture features characterize mass lesions. For non-mass lesions, a combined detection/characterisation method utilizes the bilateral symmetry of the breast s contrast agent uptake. (2) To improve clinical workflows, a breast MRI reading paradigm is proposed, exemplified by a breast MRI reading workstation prototype. Instead of mouse and keyboard, it is operated using multi-touch gestures. The concept is extended to mammography screening, introducing efficient navigation aids. (3) Contributions to finite element modeling of breast tissue deformations tackle two clinical problems: surgery planning and the prediction of the breast deformation in a MRI biopsy device

Back to the future of IT adoption and evaluation in healthcare

This is a time of expansion, hope and change in the area of Health Information Technology (HIT). In this study, we provide an in-depth perspective into the adoption and diffusion of IT in healthcare based on a review of the current literature and upon expert panel assessments of adoption and diffusion issues, achievements to date, challenges facing key e-health technologies and future possibilities. These data are synthesised in the form of a research framework showing the main three areas of e-health (Electronic Medical Records, Clinical and Administrative systems and Telehealth) on three levels (individual, organisation and system). Current adoption and diffusion challenges and future possibilities are systematically presented via this research framework to inspire practice and research with both an individual and collective view of the key health systems currently confronting the healthcare sector

Department of Radiology-Annual Executive Summary Report-July 1, 2011 to June 30, 2012

93 page Department of Radiology Annual Executive Summary Report, July 1, 2011 to June 30, 2012, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States. Table of Contents Chairman, Vice Chairmen 1 Divisions and Directors 1 Committees and Chairmen 1 Radiology Department Faculty Rank 2 Faculty with Secondary Appointments 3 Clinical Divisions 4 Radiology Residents and Fellows 5 Department Organizational Chart 6 Department Administration Chart 7 State of the Department 8 Appendix I: Publications Journal Articles 23 Books and Book Chapters 31 Abstracts 35 Appendix II: Formal Scientific Presentations 50 Appendix III: Honors, Editorial Activities, Service to Regional or National Organizations 68 Appendix IV: Active Grants 82 Appendix V: Pending Grants 8

Department of Radiology-Annual Report-July 1, 1990 to June 30, 1991

Department of Radiology Annual Report, July 1, 1990 to June 30, 1991. Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States. 84 pages

Sonographers' experiences regarding the responsibility of report writing

Abstract: Due to a shortage of radiologists worldwide, sonographers had to assume the extended role of reporting on their own findings. It is, therefore, important for sonographers to have adequate training and the necessary skills to perform an ultrasound examination, interpret the images and describe ultrasound findings correctly. Although this advanced practice comes with increased professional recognition and better remuneration, it is also associated with greater levels of responsibility, the possibility of malpractice lawsuits if pathology was missed, high professional insurance costs and the need for additional training. Although sonographers in South Africa are trained in image interpretation and report writing, there is paucity in the literature on how they experience this added responsibility. The purpose/aim of this qualitative phenomenological study was, thus, to explore and describe how sonographers in the Gauteng province experience the responsibility of report writing. This was done with the aim of developing guidelines to assist sonographers in the execution of this duty and further develop the skills to provide better structured and coherent reports. Data were collected at different neutral locations in the Gauteng province whereby sonographers who are responsible for writing reports on the ultrasound examinations which they conduct, were invited to participate in the study. Purposeful snowball sampling allowed for information rich participants to be recruited into the study. Subsequently, data were collected from a total of 13 female sonographers who took part in focus group discussions. In addition, reflective field notes were compiled by the researcher during and after each discussion session. The views and opinions of the sonographers were analysed using content analysis during which three main themes emerged: 1. The challenges and difficulties sonographers face during the report writing process 2. Positive experiences which provide sonographers with a sense of empowerment 3. The need for skills development as a way forward for future sonographers Guidelines, based on the data collected and informed by literature, were subsequently suggested to support sonographers in their report writing role and better prepare student sonographers for clinical practice. The guidelines are predominantly aimed at assisting a) higher education institutions with curriculum review and b) ultrasound departments in vi providing practice standards in terms of reporting writing c) encouraging sonographers to take accountability for improving their professional standing through research and publications.M.Tech. (Radiography

Novel Applications and Refinements of Ultrasound Techniques in Perinatal and Infant Death Investigation

The decline in parental consent for perinatal autopsies has led to the development of less invasive autopsy techniques, primarily using imaging and in some cases acquiring tissue samples through laparoscopic techniques via small incisions. Whilst post-mortem MRI (PMMR) has been extensively tested, and shown to be a suitable modality for determining the cause of death/demise in the perinatal cohort, it is not widely available. This thesis explores the utility of a poorly explored, yet more accessible, cheaper, dynamic imaging modality widely used in ‘live’ paediatric imaging for the purposes of a less invasive autopsy – the perinatal post-mortem ultrasound (PMUS). I present a systematic review of the limited literature of PMUS diagnostic accuracy for perinatal death investigation encompassing 4 publications with 455 cases in total. This reveals an overall pooled whole body sensitivity rate of 73.3% [95% CI 59.9, 83.5] and specificity rate of 96.6% [95% CI 92.6, 98.4] . A comprehensive imaging protocol for whole body PMUS is also presented based on my own experience in scanning 272 perinatal deaths. An analysis in 130 of these cases with autopsy as a reference standard, showed that brain and abdominal diagnoses yielded the highest sensitivity rates (90.9% and 92.3% respectively), with spinal, cardiac and thoracic diagnoses yielding the lowest sensitivity rates (50%, 50% and 57.1% respectively). Imaging of the brain and heart however were the least likely to be of diagnostic quality (76.8% and 78.3% diagnostic cases respectively), particularly in macerated fetuses. In a subset of cases where PMUS and 1.5T PMMR were performed, there was no significant difference in whole body diagnostic accuracy rates (concordance rates for PMUS versus PMMR of 86.4% [95%CI 77.7, 92.0] versus 88.6% [95% CI 80.3, 93.7]), although PMMR yielded fewer non-diagnostic brain and cardiac examinations (2.9% and 2.9% non-diagnostic brain and cardiac PMMR cases versus 22.8% and 14.7% non-diagnostic PMUS cases). In the second part of my thesis, I describe the development of an ‘incisionless’ ultrasound guided biopsy method using a single entry site for the biopsy needle – the umbilical vein. This ‘INTACT’ biopsy method allowed for a ‘non-invasive’ autopsy with tissue sampling, with a biopsy success rate of 76.1% overall for all organs, with highest individual organ success rates >90% for heart and lungs. I conclude by discussing how best to incorporate PMUS into clinical practice and suggest areas for future researc