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sábado, 5 de abril de 2014

Diagnostic Imaging of the Hip for Physical Therapists


Original Editor - Rob Sigler as part of the The Jackson Clinics Residency Project

Contents

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Links To Diagnostic Imaging Pages


Introduction

Figure 1: Hip anatomy
Figure 1: Hip anatomy

Imaging of the hip is advantageous due to its close proximity with the ilium, sacrum, lumbar spine, and assorted muscle and soft tissues. It is highly recommended that multiple images of the hip be taken to ensure correct diagnosis. First, it is recommended that at least one wide field of view be taken to encompass the entire ilium, sacrum, and hip. Second, a more specific image of the suspected region of involvement, which will allow for inspection of the suspected dysfunction.[1]

Hip Conditions/Pathology

Hip Osteoarthritis (OA)
Trochanteric Bursitis/Tendonitis
Femoroacetabular Impingement
Hip Fracture

Hip Osteoarthritis (OA)


Osteoarthritis (OA) is a multi-factorial condition that is essentially breakdown of hyaline cartilage along articulating joints, and is imaged most often with a radiograph or MRI. Radiographs are the most commonly used source of imaging for hip OA due to its ease of operation, low cost, quick results, and relatively high degree of accuracy. However, an MRI is considered the gold standard for hip OA since articular cartilage is visible and has a much higher resolution of surrounding tissues. There are multiple criteria that are used for OA, including multiple clinical predction rules that incorporate limited hip internal rotation, hip pain with certain activities, and stiffness in the morning for 60 minutes or less.  Research indicates that imaging techniques for hip OA usually have high sensitivity, but at the cost of lower specificity.[2]

Reading Radiograph for Hip OA:
  • Look for joint narrowing, subchondral sclerosis (increased white/bright location surrounding the joint), and osteophyte formation
Reading MRI for Hip OA:
  • Fast spin-echo images (ex, fast spin-echo T2-weighted fat-suppressed images) or gradient-echo images (ex, T1-weighted 3-dimensional fat-suppressed images)[2]
  • Look for joint narrowing, decreased signal frequency of hyaline cartilage, increased edema and osteophyte formation

Figure 2: Radiograph of hip with OA. Reprinted from medscape.com.  http://emedicine.medscape.com/article/392096-overview#a19

Trochanteric Bursitis/Tendonitis

Trochanteric bursitis/tendonitis is inflammation of the large bursa by the greater trochanter or tendons around the same region.  Clinically, trochanteric bursitis will likely be positive with max hip flexion, adduction, and internal/external rotation; as well as positive palpation to the affected bursa or tendon.  In addition, tendonitis should have a positive isometric contraction with activation to the affected muscle(s) only.  Radiographs are not as helpful in diagnosing trochanteric bursitis, as soft tissues and muscle are not visible to any degree. A T2 weighted MR image is considered the most beneficial when suspicious of hip bursitis and/or tendonitis due to its ability to detect edema and asymmetric sites of fluid accumulation. A fluid sensitive T2 would be beneficial to detect muscular strain, tears, or soft tissue lesions that may accompany trochanteric bursitis. This MRI technique allows for high sensitivity of detecting trochanteric bursitis.[1]

Reading MRI for Trochanteric Bursitis/Tendonitis:
  • Asymmetrical collection of fluid high signal intensity peripheral of bone
  • Presence of bursal distension


Figure 4: Coronal T2 weighted MRI of Trochanteric bursitis.  Evidence of bursitis from edema and inflammation in the left  hip, with no apparent bone pathology. Reprinted from tall et al, 2011.[1]


Hip Labral Tear


Labral tears are viewed with a conventional MRI (Figure 5) or MR arthrogram (MRA) (Figure 6).  Clinically, you would suspect a labral tear with consistent clicking, catching, or locking of the hip joint.  The clinician will further suspect a labral tear with a positive hip scour test and/or modified hip circumduction test.  In a conventional MRI, labral tears are continuous with the adjacent capsule and bony cortex, and therefore difficult to detect. An MRA should be considered before conventional MRI, as it is more specific and anatomical structures are more clearly delineated. MRA utilizes a dilute gadolinium solution and is injected around the hip and imaged in the same method of the conventional MRI, providing optimal visualization of the labrum and surrounding cartilage.[3][4] The sensitivity of conventional MRI was 30% with an accuracy rating of 36%, whereas sensitivity and accuracy of MRA for diagnosing hip labral tear were 100% and 94% respectively.[4]

Reading an MRA for Hip Labral Tear:
  • Presence of a triangle-like low signal intensity appearing adjacent to hyaline cartilage
  • Potential to view abscesses or edema associated with labral tears that may be visible as a “bubble” of low signal intensity


Figure 5: Hip labral tear examples. A) Hip labral tear in sagittal proton density weighted MRI sequence. B) Hip labral tear in axial proton density weighted MRI sequence. C) Hip labral tear with adjacent paralabral cyst in sagittal proton density weighted MRI sequence.  Reprinted from tall et al, 2011.[1]

Figure 6: Hip Labral tear.  Sagittal T1-weighted fat-suppressed image from MR arthrography of the left hip.  Reprinted from Omar et al, 2008.[5]

Femoroacetabular Impingement

Simply stated, a femoroacetabular impingement is a morphological impairment of the femoral head and acetabulum.  This conditon is hard to detect clinically without imaging, as it often goes unnoticed until the condition has caused other pathology such as a labral tear.  Thus, imaging of the hip is crucial with failure to respond to conservative treatments, as conditions such as femoroacetabular impingement will likely continue to cause damage.  An oblique (10° oblique from the midline) axial MRI sequence of the acetabulum is the most appropriate imaging for femoroacetabular impingement, since it allows calculation of the alpha angle. (Figure 7)[1] The alpha angle is the angle formed by the femoral head and the center of the anatomical neck.  A normal alpha angle is considered 55° or less.[1]

There are multiple types of abnormal shapes the femoral head presents with to lead to femoroacetabular impingement. The “cam type” involves wedging of an abnormal shaped femoral head into the acetabulum, which is most pronounced during hip flexion. This leads to chondral and labral injury secondary to shear forces. The “pincer type” (common in middle-aged women) involves excessive contact between the acetabular rim over the femoral head and neck junction, resulting in a pinching of the labral tissue. There was found to be 86–92% sensitivity in the detection of femoral and acetabular cartilage abnormalities including femoroacetabular impingement using axial MR imaging.[6]

Reading MRI for Femoroacetabular Impingement:
  • Assess the angle between the femoral head and the femoral neck, keeping in mind that normal is 55°
  • Abnormal shape to the femoral head (ex. Migration of the femoral head in one direction)
  • Congruency of the femoral head in the acetabulum


           Figure 7: Normal alpha angle. Reprinted from Orthopaedia.com

Figure 8: Femoroacetabular impingement. (A) Anteroposterior and (B) frog-leg lateral aspect of femoroacetabular impingement. (C) An oblique axial T1-weighted MRI indicating inflammation from impingement. (D) An oblique axial T1-weighted used to calculate the alpha angle. Reprinted from Medscape.com - “Cam Impingement.”

Hip Fracture


Hip fractures encompass a wide range of variety of types and imaging techniques. The most common types of hip fractures include stress fractures and occult fractures (not detectable via radiograph). Initially, radiographs are usually taken if fracture is suspected due to ease of use and immediate results. However, radiographs have a poor reliability of picking up fractures in early stages.[7] MRI is considered the gold standard due to high sensitivity in detecting hip fractures.[7]
Berger et al demonstrated that radiographs had a sensitivity of 15–35% on initial examination of stress fractures, increasing to 30–70% on follow-up visits.[7] The same study also indicated MRI having a specificity of 86%, sensitivity of 100%, accuracy of 95%, positive predictive value of 93%, and negative predictive value of 100%.[7]
It is suggested that the best method of detecting occult fractures is a combination of a T1 and T2 weighted MRI.[8]  This allows the differentiation of fractures versus soft tissue injuries, and is important as it will significantly alter the course of intervention.

Reading MRI for Hip Fracture:
  • Low intensity signal located within or on the edge of bone
  • T2 weighted MRI – edema surrounding bone
  • In the case of large fracture –displacement of bone


Figure 9: T2-weighted MRI indicatin8g R hip stress fracture and small amounts of edema. Reprinted from Taylor-Haas et al, 2011.[9]


References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Tall M a, Thompson AK, Greer B, Campbell S. The pearls and pitfalls of magnetic resonance imaging of the lower extremity. The Journal of orthopaedic and sports physical therapy. 2011;41(11):873-86. Available at:http://www.ncbi.nlm.nih.gov/pubmed/22048192. Accessed March 18, 2012.
  2. ↑ 2.0 2.1 Recht MP, Goodwin DW, Winalski CS, White LM. MRI of articular cartilage: revisiting current status and future directions. AJR. American journal of roentgenology. 2005;185(4):899-914. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16177408. Accessed March 24, 2012.
  3. ↑ Grainger a J, Elliott JM, Campbell RS, et al. Direct MR arthrography: a review of current use. Clinical radiology. 2000;55(3):163-76. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10708607. Accessed March 18, 2012.
  4. ↑ 4.0 4.1 Chan Y-S, Lien L-C, Hsu H-L, et al. Evaluating hip labral tears using magnetic resonance arthrography: a prospective study comparing hip arthroscopy and magnetic resonance arthrography diagnosis. Arthroscopy : the journal of arthroscopic related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2005;21(10):1250. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16226655. Accessed March 24, 2012.
  5. ↑ Omar I, Zoga A, Kavanagh E, Koulouris G, Bergin D, Gopez A, Morrison W, Meyers W. Athletic Pubalgia and “Sports Hernia”: Optimal MR Imaging Technique and Findings. Radiologial Society of North America. 2008;28; 1415-1438. Available athttp://radiographics.highwire.org/content/28/5/1415.full
  6. ↑ James SLJ, Ali K, Malara F, et al. MRI findings of femoroacetabular impingement. AJR. American journal of roentgenology. 2006;187(6):1412-9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17114529. Accessed March 24, 2012.
  7. ↑ 7.0 7.1 7.2 7.3 Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. European journal of radiology. 2007;62(1):16-26. Available at:http://www.ncbi.nlm.nih.gov/pubmed/17317066. Accessed March 31, 2012.
  8. ↑ Ohishi T, Ito T, Suzuki D, Banno T, Honda Y. Occult hip and pelvic fractures and accompanying muscle injuries around the hip. Archives of orthopaedic and trauma surgery. 2012;132(1):105-12. Available at:http://www.ncbi.nlm.nih.gov/pubmed/21874573. Accessed March 31, 2012.
  9. ↑ Taylor-Haas J a, Paterno MV, Shaffer MD. Femoral neck stress fracture and femoroacetabular impingement. The Journal of orthopaedic and sports physical therapy. 2011;41(11):905. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22048418. Accessed March 18, 2012.
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Diagnostic Imaging for Physical Therapists


Original Editor - Rob Sigler, Michael Kecman andDaniel Alcorn as part of the The Jackson Clinics Residency Project
Top Contributors - Rob Sigler, Kris Porter, Laura Ritchie and Daniel Alcorn

Contents

[hide]

Diagnostic Imaging for Physical Therapists

Imaging is a useful resource for musculoskeletal conditions and is an invaluable tool for physical therapists when used appropriately. Imaging such as MRI, X-ray, CT scans, and bone scans are prime examples of practical diagnostic imaging that facilitates accurate diagnosis, prognosis, intervention, and assessment of injuries and dysfunctions that physical therapists' address on a daily basis. It is important to know when imaging is appropriate, as unnecessary imaging will squander financial resources and increase potential for premature surgery. In many cases, studies indicate diagnostic imaging is underutilized such as x-rays identifying fractures or bone scans identifying osteoporosis[1]. There are also studies indicating over utilization of imaging, such as x-rays or MRI’s for acute and uncomplicated low back pain.[2][3][4]

Diagnostic Imaging for Body Regions

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a map of hydrogen atoms within the body. Hydrogen atoms are ideal for MRI because they possess a single proton and a large magnetic moment.[5] The magnetic field created by the magnets causes resonance from each proton in the hydrogen atom and the machine is able to obtain the proton’s position. Since approximately 75% of our bodies are made of water molecules, MR imaging is able to capture precise and detailed images of the viewed body region. Thus, the MRI takes a detailed "picture" of all hydrogen molecules in the body and is computed into an accurate representation of that body region. There are multiple types of MRI based on if the image is captured at a different decay of signal. A T1 weighted MRI captures early signal decay, that is, early after the protons are positioned. A T2 weighted MRI captures the late stage of signal decay, or after a small amount of proton migration from the original resonsance.[5]
MRI of the Brain
MRI of the Brain
MR Angiogram
MR Angiogram
Advantages of MRI
  • Better visualization of tissues
  • Better distinction of abnormalities
  • Multi-Plane imaging
  • No radiation
Disadvantages of MRI
  • Expensive
  • Extensive amount of time for accurate images
  • Movement artifact (image distortion)
  • 10% of patients can’t tolerate due to claustrophobia[5]
Common Abbreviations Used for MRI
  • FS – Fat Suppressed
  • FATSAT – Fat Saturation
  • STIR - Short Inversion Recovery Time Imaging
  • FSE – Fast Spin Echo
  • Gad – Gadolinium

Hybrid MRI Sequences occurs with manipulation to the type and frequency of radiofrequency and cause echoes. A gradient echo adds sensitivity or iron-complexes such as articular cartilage defects and hemorrhaging in muscle, but conversely decreases resolution on metal hardware (such as pins or screws) from a surgery. Spin echo adds the benefit of increased tissue contrast and better visualization of meniscal tears. Stimulated echo reduce interference of signal and therefore may be used to look at specific molecular movements within tissue.[5]
T1 Weighted MRI
  1. Demonstrates good anatomic structures
  2. Fat and meniscal tears appear bright white
  3. Water, CSF, muscle, tendons, and ligaments appears light to dark gray
  4. Air and cortical bone appears dark
T2 Weighted MRI
  1. Demonstrates contrast between normal and abnormal (can identify abnormal lesions of fluid)
  2. Water and CSF appears bright white
  3. Fat, muscle, tendons, ligaments and cartilage appear light to dark gray
  4. Air and cortical bone appears dark (unless fluid is in the lung)
Proton density (PD) images
  1. An image simply of the density of protons
  2. A more dense area of protons will appear white (cortical bone, bone marrow)
  3. A less dense region will appear darker (fluids, soft tissues)

Contraindications for MRI
  1. Pacemakers,aneurysm clips, cochlear implants, and orbital foreign bodies
  2. Projectiles in the room (includes oxygen tanks, IV poles, stethoscopes, hair pins, etc

Radiograph (X-Ray)

Radiography is the use of X-rays to view non-uniformly composed material. In the medical field, radiography is used to diagnose or treat patients through the recording of images of the internal structure of the body. These images assess the presence or absence of disease, foreign objects, and structural damage or anomaly. The term x-ray refers to the radiation beam and x-ray particles, not to the film plate itself. X-ray films should be referred to as films, plain films, radiographs, or a plain film study when dialoging within the medical community.[6]
Potential areas for film and/or processing errors:[6]
Heel effect – a source of visual error related to x-ray production, due to the fact that x-rays released by the machine are not uniform. There are two ends to an x-ray machine, a cathode end and anode end. The cathode end releases more photons than the anode end, which results in over-exposure of the film at the cathode end and under-exposure at the anode end. Due to this fact, technicians will position the patient on the table in a manner such that the thickest portion of the body region being studied is placed nearest the cathode end of the tube and the thinner end is placed near the anode end.
Artifact – An error in the perception of the visual image of the radiograph, usually seen as an abnormal finding or foreign body. Artifacts occur when the cassettes that house the x-ray film plates get exposed to finger prints or small debris.
Exposure – A measure of the amount of ionizing radiation determined by 3 factors: time, x-ray energy, and the quantity of the x-ray photons. Exposure can be manipulated by the technician to highlight structures of interest. Over-penetration will tend to enhance bone visibility, while under-penetration will enhance soft tissue visibility.
Movement – A blurring in the image as a result of movement by the patient the moment the x-ray exposure is made.
Film processing – An error that occurs during the processing of the film can result in disturbances in the contrast, detail, or density of the image displayed.


Radiodensity is a representation of the relative tissue density, based on the appearance of the tone of the tissue (white, gray, or black). The following structures may be found on a medical radiograph (in order of increasing radiodensity):[6]
Air – black appearance, often seen in structures such as the lungs, bowels, trachea
Fat – dark gray appearance, often seen in structures such as thicker adipose tissue
Muscle, tendon, organ tissue – appears “neutral” or mid-gray
Bone – cancellous bone appears as light gray, while cortical bone appears as white
Contrast media - white appearance
Metal – white appearance, often seen in structures such as jewelry, dental fillings, or
orthopedic hardware
Caution to the radiograph viewer/interpreter – There is an inherent error that occurs when a 2-dimensional image is created to depict 3-dimensional structures that are often superimposed on one-another. Due to this fact, radiographic studies of specific body regions often include 3 or more views from different angles.
Four principle sources of radiographic error:[6]
  1. Enlargement occurs because the x-ray beams exit the machine in an expanding conical pattern (similar to a flashlight beam). As a result, objects placed closer to the beam source appear larger than objects placed further away from the beam source.
  2. Elongation is produced by the increased beam angle at the periphery of the x-ray beam cone. As a result of the increased beam angle, objects in the periphery of the x-ray beam appear smeared or spread compared to objects in the center of the beam.
  3. Foreshortening is the opposite effect of elongation. This occurs when the body region to be studied is placed at an angle to the primary x-ray beam, resulting in the appearance of decreased length.
  4. Superimposition occurs because anatomic structures are often stacked on one another, forcing the x-ray beam to penetrate multiple structures before arriving at the film plate. Superimposition can create the appearance of increased density of structures, or the appearance of novel structures altogether.


Computerized Axial Tomography (CT Scan)


Computed Tomography (CT) is an imaging technique that takes multiple x-rays from different angles and creates cross-sectional images of a body part. Cross-sectional slices are typically 1-3 mm thick, depending upon the type and location of the tissue. CT scans are primarily used for bony pathologies, but can also be used for soft tissue dysfunction. CT scans are not as effective at detecting soft tissue pathology as MRIs because there is not enough differentiation in the x-ray absorption of injured and healthy tissue. Other benefits of CT scans are that they are fast, relatively inexpensive and often a good alternative to MRIs if an MRI is contraindicated.[7]
CT Scan of the Brain
CT Scan of the Brain
CT Angiogram
CT Angiogram
Indications for CT Scans:
  1. Traumatic injuries
  2. Degenerative conditions, such as stenosis and osteoarthritis when an MRI is contraindicated
  3. Post-operative conditions
  4. Neoplastic conditions
  5. Infectious processes
  6. Image guidance during injections, biopsy’s and aspirations
  7. Abnormalities of bony alignment, such as scoliosis
  8. Processes involving the spinal cord when MRI is contraindicated[8]

Bone Scan

Bone scan is an imaging technique that uses a radioactive compound to identify areas of healing within the bone. Bone scans work by drawing blood from the patient and tagging it with a bone seeking radiopharmaceutical. This radioactive compound emits gamma radiation. The blood is then returned to the patient intravenously. As the body begins its metabolic activity at the site of the injury, the blood tagged by the radioactive compound is absorbed at the bone and the gamma radiation at the site of the injury can be detected with an external gamma camera. A bone scan can be beneficial in determining injury to the bone within the first 24-48 hours of injury or when the displacement is too small to be detected by an x-ray or CT scan.[7]
Indications for Bone Scans:
  1. Primary and metastatic bone neoplasms.
  2. Disease progression or response to therapy.
  3. Paget’s disease of bone.
  4. Stress and/or occult fractures.
  5. Trauma – accidental and non-accidental.
  6. Osteomyelitis.
  7. Musculoskeletal inflammation or infection.
  8. Bone viability (grafts, infarcts, osteonecrosis).
  9. Metabolic bone disease.
  10. Arthritides.
  11. Prosthetic joint loosening and infection.
  12. Pain of suspected musculoskeletal etiology.
  13. Myositis ossificans.
  14. Complex regional pain syndrome (CRPS 1). Reflex sympathetic dystrophy.
  15. Abnormal radiographic or laboratory findings.
  16. Distribution of osteoblastic activity prior to administration of therapeutic radio-pharmaceuticals for treating bone pain.[9]

References

  1. ↑ Van Tulder MW, Tuut M, Pennick V, Bombardier C, Assendelft WJJ. Quality of primary care guidelines for acute low back pain. Spine. 2004;29(17):E357-62. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15534397.
  2. ↑ Freeborn DK, Shye D, Muttooty JP, Eraker S, Romeo J. Primary Care Physicians ’ Use of Lumbar Spine. Journal of General Internal Medicine.3-9.
  3. ↑ Carey TS, Garrett J, Back C, Project P. Patterns of Ordering Diagnostic Tests for Patients with Acute Low Back Pain. Medicine. 1996.
  4. ↑ Anon. Isaacs_MRI_2004.
  5. ↑ 5.0 5.1 5.2 5.3 McMahon KL, Cowin G, Galloway G. Magnetic resonance imaging: the underlying principles. The Journal of orthopaedic and sports physical therapy. 2011;41(11):806-19. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21654095. Accessed March 16, 2012.
  6. ↑ 6.0 6.1 6.2 6.3 Biederman, R. E., Wilmarth, M. A., & Editor, C. M. D. T. (n.d.). Diagnostic Imaging in Physical Therapy Avoiding the Pitfalls. Diagnostic Imaging.
  7. ↑ 7.0 7.1 Swain J, Bush K. Diagnostic Imaging for Physical Therapists. St. Louis: Saunders Elsevier; 2009
  8. ↑ College, A. ACR – ASNR – ASSR – SPR PRACTICE GUIDELINE FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY ( CT ) OF THE SPINE. Diagnostic Imaging, 1-7. 2011
  9. ↑ College A. ACR PRACTICE GUIDELINE FOR THE PERFORMANCE OF ADULT AND PEDIATRIC SKELETAL SCINTIGRAPHY ( BONE SCAN ). North. 2007:1-5.
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quarta-feira, 2 de abril de 2014

When More Actually IS Better


POSTED ON  BY JULIE BARTELS

By: Julie Bartels and Mike Stoecklein
At the ThedaCare Center for Healthcare Value, we see our mission as transformation of the healthcare system to assure the delivery of consistent, high quality care, and better outcomes for patients. TransformationWe envision achieving this transformation in collaboration with patients and leaders in the provider, employer, insurer, and government communities.  Together, we can create a one-piece flow of value as depicted by the diagram on the right.  But it requires involvement on several different fronts.
One way that we support this work is through peer-to-peer learning networks.  At present, we have two such interdependent networks.  The Healthcare Value Network (HVN) is primarily focused on the upper right-hand part of the diagram, “Care Delivery Redesign with Focus on Value to the Patient.”  The Clinical Business Intelligence Network (CBIN) is primarily focused on the upper left-hand part of the diagram, “Transparency of Cost, Quality, Risk, and Consequences.”  Combined, they are two key drivers that help move organizations toward one-piece value flow.
The connection between these two networks is further illustrated in this short video clip featuring Julie Bartels, Executive Vice President, National Healthcare Information and Clinical Business Intelligence Network.
Value Must Run Across All SystemsAnother way to illustrate the connection between the two networks is shown in this diagram from Jacob Raymer, President of the Institute For Enterprise Excellence:Systems
The work system (center of the diagram) in healthcare is all about patient care and the processes that directly support that care (e.g., diagnostics, testing, medication).
There are three other types of systems that support the work system:
1) Support Systems that aid, assist, and strengthen the people who work in the work system.
2) Management Systems that align, monitor, and maintain the work system.
3) Improvement Systems that help people to signal, swarm and solve problems, and share what they have learned.
Where CBI FitsClinical Business Intelligence is sometimes associated with “information technology” (an example of a type 2 system), but it is more than that.  It is really about the flow of information through the enterprise, and the ability of the staff to interface with that information at the point of care.
There are two perspectives to be considered: 1) production, and 2) consumption.  Healthcare organizations are getting better at producing analytics thanks to the myriad of software vendors who provide bolt-on reporting packages to extract analytics from the Electronic Medical Record Systems.  Unfortunately, if that’s where Clinical Business Intelligence work stops, it is merely a form of very expensive waste.  The real value comes from the consumption of analytics, that is, the ability of the clinical staff to see, absorb, and respond to that incoming information during the patient’s visit and make smarter decisions that benefit the patient and the enterprise as a result.
So, true and sustainable value is derived through a constant game of catchball between turning raw data into meaningful information (Clinical Business Intelligence) at the bedside, and employing standard work and patient minded delivery (lean ) at the point of care.
Making Connections:  How Intelligence Feeds ImprovementIn summary, we see four hypotheses about the connection between lean thinking (the primary focus of the HVN) and Clinical Business Intelligence (the primary work of the CBIN):
Hypothesis #1: Lean transformation requires focused and iterative PDSA. PDSA requires creation, collection, and on-going monitoring of meaningful (actionable) metrics in the Plan and Study phases. The tighter the feedback loop between action and measure of impact, the more frequently the PDSA process can cycle through, and the quicker the insight and improvement.
Hypothesis #2: The value achieved through application of scientific thinking and adoption of lean methods can be accelerated or negatively impacted by the scope and speed of information flow.
Hypothesis #3: Manual information collection and management is possible but prone to many forms of waste: Waiting, Underutilized Human Talent (e.g. nurse data collection), and Defects (human error).   It may also limit the scope and pace of information available to support PDSA.
Hypothesis #4: Aligning lean and Clinical Business Intelligence with the mission of the enterprise and key performance indicators will accelerate and sustain performance improvements. PDSAThis is how we see it.  How does this match your experience?  Would you like to learn more and possibly participate in testing our hypotheses?  If so, contact Julie Bartels,jbartels@createvalue.org, or Mike Stoeckleinmstoecklein@createvalue.org to learn more.

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