Cloud-based Preoperative Planning for Total Hip Arthroplasty: A Study of Accuracy, Efficiency, and Compliance
|
|
- Gabriella Paul
- 8 years ago
- Views:
Transcription
1 Section Editor: Bennie G.P. Lindeque, MD Cloud-bsed Preopertive Plnning for Totl Hip Arthroplsty: A Study of Accurcy, Efficiency, nd Complince Joseph D. Mrtt, MD; Rmesh C. Srinivsn, MD; Willim J. Dhl, MD; Peter L. Schilling, MD; Andrew G. Urquhrt, MD Abstrct: As digitl rdiogrphy becomes more prevlent, severl systems for digitl preopertive plnning hve become vilble. The purpose of this study ws to evlute the ccurcy nd efficiency of n inexpensive, cloud-bsed digitl templting system, which is comprble with cette templting. However, cloud-bsed templting is substntilly fster nd more convenient thn cette templting or loclly instlled softwre. Although this is prcticl solution for this prticulr medicl ppliction, regultory chnges re necessry before the tremendous dvntges of cloud-bsed storge nd computing cn be relized in medicl reserch nd clinicl prctice. Totl hip rthroplsty (THA) is relible tretment for hip rthritis. Successful THA consistently relieves pin, improves function, nd restores biomechnics of the hip. However, improper component selection or mlposition cusing excessive wer, limblength discrepncy, frcture, or disloction cn led to erly filure or ptient disstisfction. Therefore, preopertive plnning is n importnt step for chieving successful outcome fter THA. 1-4 Prior studies exmining the ccurcy of templting hve shown more thn 90% ccurcy to within 2 sizes of the Drs Mrtt, Srinivsn, Dhl, Schilling, nd Urquhrt re from the Deprtment of Orthopedic Surgery, University of Michign, Ann Arbor, Michign. Drs Mrtt, Srinivsn, Dhl, Schilling, nd Urquhrt hve no relevnt finncil reltionships to disclose. Correspondence should be ddressed to: Andrew G. Urquhrt, MD, Deprtment of Orthopedic Surgery, University of Michign, 2912 Tubmn Center, 1500 E Medicl Center Dr, Ann Arbor, MI (ndrewu@med. umich.edu). doi: / implnt. However, the exct size of the component ws predicted in only 42% to 50% of cses for the cetbulr component nd 68% for the femorl component. 4,5 As digitl rdiogrphy hs become more prevlent, tools for digitl preopertive plnning hve become vilble for use by the treting surgeon. On-screen evlution of digitl imging does not ffect the ccurcy of interprettion. 6-8 However, when printed digitl rdiogrphs re combined with cette overly templting, correct component size is predicted ccurtely only 69% of the time. 9 Studies investigting the ccurcy of digitl templting hve produced vried results. Gonzlez Dell Vlle et l 10 showed consistently better ccurcy with conventionl templting compred with digitl templting in study of 69 ptients undergoing cemented THA. In contrst, Iorio et l 11 reported tht the men errors did not differ significntly nd concluded tht both cette nd digitl templting cn ccurtely predict the size of THA implnts. For these studies, digitl templting ws performed using softwre pckges instlled on site. 10,11 In the current study, the uthors used cloud-bsed softwre for digitl templting (HipCAT; University of Michign, Ann Arbor, Michign). Cloud computing is reltively new model in informtion technology tht provides fee-for-service ccess to computing resources vi the Internet. 12 It voids the high costs ssocited with trditionl in-house computing infrstructure deployment nd expnsion. Insted, computing is provided s metered service nd resembles the service provided by public utility compny tht supplies gs or electricity Advoctes of this model highlight its low cost, ese of doption, sclbility, nd performnce. 14,15 However, the model continues to be chllenged by concerns over privcy nd security. 12,16-18 Mny of the dvntges of cloud computing re pplicble to digitl templting 682 ORTHOPEDICS Helio.com/Orthopedics
2 systems. This digitl templting system did not require the purchse of dditionl hrdwre or softwre or softwre deployment. It lso voided the expense ssocited with systems integrtion by providing utility to import imges into the cloud sved from picture rchiving nd communiction systems (PACS) viewer (McKesson Corp, Sn Frncisco, Cliforni). All functions required for templting, reviewing, nd uploding imges re ccessible through Web browser. Privcy nd security concerns were ddressed with Helth Insurnce Portbility nd Accountbility (HIPAA)-complint encryption implemented on the Web browser bsed client nd the cloud-bsed service. The purpose of this study ws to mesure the ccurcy nd efficiency of cloud-bsed digitl nd cette templting for preopertive plnning of THA. The uthors lso ddress the regultory complince issues relted to cloud computing. Mterils nd Methods A retrospective review of 20 primry uncemented THAs performed between September nd December 2010 under the direction of 1 dult reconstruction fellowship-trined surgeon (A.G.U.) ws performed. Ptients who underwent prior THA on the contrlterl hip, hd metl implnts on the opertive side, or hd nonstndrd imging were excluded from the study. Stndrdized techniques were pplied when preopertive rdiogrphy ws obtined. Anteroposterior pelvis rdiogrphs were downloded from the PACS system. The downloded imges were deidentified nd then printed on nlog film or uploded s n encrypted file into the cloud-bsed templting softwre. The imges were then clibrted in the templting system bsed on the scling overly used by the PACS system nd mgnifiction mrker when present. In seprte session, the opertive report ws reviewed to determine the ctul implnted cetbulr nd femorl components for lter sttisticl comprison. Mesurement of Templting Accurcy One ttending (A.G.U.) nd 2 senior orthopedic surgicl residents (R.C.S., W.J.D) performed preimplnt ssessments of hip implnt sizing on the 20 cses with trditionl cette templtes nd with digitl templting softwre. This ws done in 2 sessions spced 2 weeks prt. Acette templting ws performed ccording to previously described stndrdized method. 3,17 Digitl templting ws performed ccording to the digitl templting softwre protocol, llowing mrking nd mesurement similr to cette templting (Figure). The templte results for both methods were compred with the ctul cetbulr nd femorl components implnted. Mesurement of Templting Timing The preprtion of ech preopertive pln by both methods ws individully timed by n Figure: Anteroposterior view of the pelvis fter preopertive plnning with digitl templtes. observer (J.D.M.) nd recorded. The timer begn when ech film ws hung on the lightbox or the imge ws loded. The timer ws stopped when the prticipnt indicted stisfction with the templting. Sttisticl Anlysis PASW Sttistics version 19 softwre (IBM, Armonk, New York) ws used for sttisticl nlysis. Interrter relibility ws mesured with intrclss correltion coefficients. Twotiled 1-smple t tests were used to ssess the ccurcy of templting by both of these methods for ech prticipnt. The time required to templte by ech method ws lso recorded. Differences in time for ech method of templting were nlyzed using pired t tests. Results Mesurement of Templting Accurcy Digitl templting predicted correct cetbulr component size within 2 sizes in 96% of cses nd within 1 size in 73% of cses. Acette overly templting ws similrly ccurte to 2 sizes in 86% of cses nd to 1 size in 63% of cses. Digitl templting predicted correct femorl component size within 2 sizes in 93% of cses nd 1 size in 75% of cses. Acette templting ws ccurte to 2 sizes in 98% of cses nd 1 size in 93% of cses. Tble 1 shows the distribution of error by size for ech component. Moderte nd comprble interrter relibility ws found with digitl nd cette templting of the cetbulr component (Tble 2). However, slightly lower interrter relibility ws found with cette templting of the femorl component compred with the digitl method. Anlysis of pooled mesurement dt showed significnt underprediction of femorl nd cetbulr component size with digitl nd cette AUGUST 2012 Volume 35 Number 8 683
3 Tble 1 Distribution of Acetbulr nd Femorl Component Error Acetbulr Component, % Femorl Component, % Error (sizes) Digitl Acette Digitl Acette Negtive error is underprediction of size. Tble 3 Acetbulr Component Size Accurcy Tble 2 Interrter Relibility s Assessed With Intrclss Correltion Coefficients Method Acetbulr Component Femorl Component Digitl Acette P,.001. Tble 4 Femorl Component Size Accurcy Prticipnt Digitl Error P Acette Error P , , ,.05 Combined , ,.05 Negtive error is underprediction of size. Prticipnt Digitl Error P Acette Error P , , ,.05 Combined , ,.05 Negtive error is underprediction of size. overly templting (Tbles 3, 4). Digitl mesurements resulted in greter underprediction of femorl component size (negtive error vlues, P,.005). Acette mesurements resulted in greter underprediction of cetbulr Tble 5 Time Required for Completion of Templting Prticipnt Digitl Time, sec Acette Time, sec P , , ,.005 Combined ,.005 component size (negtive error vlues, P,.05). However, the stndrd devition of the estimtion error with both digitl nd cette templting is reflective of the number of cses in which the components were oversized. Mesurement of Templting Timing Anlysis of the time required to complete the tsks reveled tht cette templting on verge took 2.07 times longer thn digitl templting. Although some vrition existed in the mount of time required for completion of the tsk by ech prticipnt, cette templting ws consistently slower (1.47 to 2.53 times longer to complete the tsk depending on the prticipnt). On verge, digitl templting required 64 seconds per cse nd cette templting required 133 seconds per cse (P,.005). Results for ech prticipnt re shown in Tble 5. Discussion In the current study, digitl nd cette templting were comprbly ccurte for plnning THA. Digitl nd cette templting predicted components to within 2 sizes in the vst mjority of cses (.90% of the time). Digitl nd cette templting lso showed comprble interrter relibility for the selection of ech component. The results re comprble with prior studies of the ccurcy of digitl nd cette preopertive templting with uncemented THA. Iorio et l 11 reported tht components could be predicted within 1 size in 60% to 74% of cses with digitl templting nd in 77% to 78% of cses with cette templting. The current uthors results showed prediction of components within 1 size in 73% to 75% of cses with digitl templting nd 58% to 93% of cses with cette templting. These results re lso comprble with prior 684 ORTHOPEDICS Helio.com/Orthopedics
4 studies exmining the ccurcy of cette templting in plnning uncemented THA; these studies reported exct prediction of component size 42% to 68% of the time nd within 2 sizes greter thn 90% of the time. 4,5 In contrst, Gonzlez Dell Vlle et l 10 reported tht nlog templting ws more predictble nd precise thn digitl templting. In their study, nlog templting predicted components within 1 size in 97% to 98% of cses, wheres digitl templting from scnned nlog rdiogrphs predicted components within 1 size in 81% to 94% of cses. However, in their study, cemented technique ws used for plcement of the femorl stem. 10 Multiple investigtors hve reported tht prediction of cemented components is more relible in preopertive plnning thn prediction of uncemented components. 10,18-20 Thus, if cemented technique for the femorl stem is used, nlog templting my be more ccurte thn digitl templting. To the uthors knowledge, no other studies to dte hve exmined the efficiency of nlog nd digitl templting. This study showed tht surgeons needed pproximtely hlf the time to prepre preopertive pln with digitl templting when compred with nlog templting. With the incresing prevlence of digitl rdiogrphy nd use of PACS in the hospitl nd office setting, digitl templting my be more efficient nd cost-effective method for preopertive plnning. Potentil benefits to surgeon nd hospitl include reduced expense from film production, secure storge, improved ccess, nd incresed efficiency of templting. Another dvntge of digitl templting is the ese of error correction. As result, digitl templting is vluble tool for teching nd discussion of cses, especilly in teching hospitl setting. A cloud-bsed system confers dditionl benefits beyond trditionl on-site PACS nd digitl templting systems. Cloud-bsed systems for electronic helth records nd medicl imging softwre my lower finncil brriers nd promote cquisition. 12 However, questions remin regrding the security nd privcy of informtion stored on these systems. Use of these systems in medicl pplictions must comply with the privcy nd security rules of the HIPAA Act nd of the Helth Informtion Technology for Economic nd Clinicl Helth Act. Federl lw requires tht third prties hndling protected helth informtion enter into Business Associte Contrct with the client tht stipultes dherence to privcy guidelines. Libility now extends to the business ssocites for violtions of the security provisions. 12,21 Development of these systems with focus on enhnced security is sensible when storing sensitive medicl dt. The digitl templting system used in this study encrypts ll medicl dt on the locl computer prior to trnsmission nd storge. With this pproch, in the event of security brech of the cloud, the dt remin unintelligible without ech user s encryption key. 15,22 These pproches to security nd legisltive policy mke the use of cloud computing fesible in the medicl industry. Conclusion Preopertive plnning for THA with cloud-bsed digitl templting is comprble with cette templting in ccurcy but offers the dditionl benefits of efficiency, cost svings, nd workflow improvement. Cloud-bsed medicl softwre cn be sfely implemented in complince with federl privcy nd security regultions. However, individul physicins nd institutions should be judicious consumers of nscent technology with potentil security nd privcy pitflls. References 1. Berry DJ, Hrmsen WS, Cbnel ME, Morrey BF. Twenty-five-yer survivorship of two thousnd consecutive primry Chrnley totl hip replcements: fctors ffecting survivorship of cetbulr nd femorl components. J Bone Joint Surg Am. 2002; 84(2): Chrnley J. Totl hip replcement by low-friction rthroplsty. Clin Orthop Relt Res. 1970; 72: Dell Vlle AG, Pdgett DE, Slvti EA. Preopertive plnning for primry totl hip rthroplsty. J Am Acd Orthop Surg. 2005; 13(7): Unnnuntn A, Wgner D, Goodmn SB. The ccurcy of preopertive templting in cementless totl hip rthroplsty. J Arthroplsty. 2009; 24(2): Crter LW, Stovll DO, Young TR. Determintion of ccurcy of preopertive templting of noncemented femorl prostheses. J Arthroplsty. 1995; 10(4): Roos JE, Chill B, Znetti M, et l. MRI of meniscl lesions: soft-copy (PACS) nd hrd-copy evlution versus reviewer experience. AJR Am J Roentgenol. 2006; 186(3): Shields T. PACS: pst, present nd future. Rdiol Technol. 2010; 81(5): Eklund K, Jonsson K, Lindblom G, et l. Are digitl imges good enough? A comprtive study of conventionl filmscreen vs digitl rdiogrphs on printed imges of totl hip replcement. Eur Rdiol. 2004; 14(5): Conn KS, Clrke MT, Hllett JP. A simple guide to determine the mgnifiction of rdiogrphs nd to improve the ccurcy of preopertive templting. J Bone Joint Surg Br. 2002; 84(2): Gonzlez Dell Vlle A, Comb F, Tvers N, Slvti EA. The utility nd precision of nlogue nd digitl preopertive plnning for totl hip rthroplsty. Int Orthop. 2008; 32(3): Iorio R, Siegel J, Specht LM, Tilzey JF, Hrtmn A, Hely WL. A comprison of cette vs digitl templting for preopertive plnning of totl hip rthroplsty: is digitl templting ccurte nd sfe? J Arthroplsty. 2009; 24(2): Schweitzer EJ. Reconcilition of the cloud computing model with US federl electronic helth record regultions. J Am Med Inform Assoc. 2011; 19(2) Ktzn Jr H. On n ontologicl view of cloud computing. J Service Sci. 2010; 3(1): Ntionl Institute of Stndrds nd Technology. Cloud Computing. AUGUST 2012 Volume 35 Number 8 685
5 nist.gov/itl/cloud/index.cfm. Accessed August 11, Armbrust M, Fox A, Griffith R, et l. A view of cloud computing. Commun ACM. 2010; 53(4): Ktzn Jr H. On the privcy of cloud computing. Int J Mng Info Syst. 2010; 14(2): Cllghn JJ, Rosenberg AG, Rubsh HE. The Adult Hip. 2nd ed. Phildephi, PA: Lippincott Willims & Wilkins; Gonzlez Dell Vlle A, Slullitel G, Picclug F, Slvti EA. The precision nd usefulness of preopertive plnning for cemented nd hybrid primry totl hip rthroplsty. J Arthroplsty. 2005; 20(1): Knight JL, Atwter RD. Preopertive plnning for totl hip rthroplsty. Quntitting its utility nd precision. J Arthroplsty. 1992; 7(suppl): The B, Diercks RL, vn Ooijen PM, Vn Horn JR. Comprison of nlog nd digitl preopertive plnning in totl hip nd knee rthroplsties. A prospective study of 173 hips nd 65 totl knees. Act Orthop. 2005; 76(1): U.S. Deprtment of Helth & Humn Services. Business Assocites. gov/ocr/privcy/hip/understnding/coveredentities/businessssocites.html. Accessed August 11, Amzon Web Services. Creting HIPAA-Complint Medicl Dt Applictions With AWS. whitepper-hip/. Accessed August 11, ORTHOPEDICS Helio.com/Orthopedics
Enterprise Risk Management Software Buyer s Guide
Enterprise Risk Mngement Softwre Buyer s Guide 1. Wht is Enterprise Risk Mngement? 2. Gols of n ERM Progrm 3. Why Implement ERM 4. Steps to Implementing Successful ERM Progrm 5. Key Performnce Indictors
More informationHow To Set Up A Network For Your Business
Why Network is n Essentil Productivity Tool for Any Smll Business TechAdvisory.org SME Reports sponsored by Effective technology is essentil for smll businesses looking to increse their productivity. Computer
More informationJaERM Software-as-a-Solution Package
JERM Softwre-s--Solution Pckge Enterprise Risk Mngement ( ERM ) Public listed compnies nd orgnistions providing finncil services re required by Monetry Authority of Singpore ( MAS ) nd/or Singpore Stock
More informationSmall Business Networking
Why network is n essentil productivity tool for ny smll business Effective technology is essentil for smll businesses looking to increse the productivity of their people nd business. Introducing technology
More informationHealth insurance exchanges What to expect in 2014
Helth insurnce exchnges Wht to expect in 2014 33096CAEENABC 02/13 The bsics of exchnges As prt of the Affordble Cre Act (ACA or helth cre reform lw), strting in 2014 ALL Americns must hve minimum mount
More informationHealth Information Systems: evaluation and performance of a Help Desk
536 Digitl Helthcre Empowering Europens R. Cornet et l. (Eds.) 2015 Europen Federtion for Medicl Informtics (EFMI). This rticle is published online with Open Access by IOS Press nd distributed under the
More informationSmall Business Networking
Why network is n essentil productivity tool for ny smll business Effective technology is essentil for smll businesses looking to increse the productivity of their people nd business. Introducing technology
More informationHow To Network A Smll Business
Why network is n essentil productivity tool for ny smll business Effective technology is essentil for smll businesses looking to increse the productivity of their people nd processes. Introducing technology
More informationSmall Business Networking
Why network is n essentil productivity tool for ny smll business Effective technology is essentil for smll businesses looking to increse the productivity of their people nd processes. Introducing technology
More informationClearPeaks Customer Care Guide. Business as Usual (BaU) Services Peace of mind for your BI Investment
ClerPeks Customer Cre Guide Business s Usul (BU) Services Pece of mind for your BI Investment ClerPeks Customer Cre Business s Usul Services Tble of Contents 1. Overview...3 Benefits of Choosing ClerPeks
More informationHealth insurance marketplace What to expect in 2014
Helth insurnce mrketplce Wht to expect in 2014 33096VAEENBVA 06/13 The bsics of the mrketplce As prt of the Affordble Cre Act (ACA or helth cre reform lw), strting in 2014 ALL Americns must hve minimum
More informationSmall Business Cloud Services
Smll Business Cloud Services Summry. We re thick in the midst of historic se-chnge in computing. Like the emergence of personl computers, grphicl user interfces, nd mobile devices, the cloud is lredy profoundly
More informationSmall Business Networking
Why network is n essentil productivity tool for ny smll business Effective technology is essentil for smll businesses looking to increse the productivity of their people nd processes. Introducing technology
More informationDlNBVRGH + Sickness Absence Monitoring Report. Executive of the Council. Purpose of report
DlNBVRGH + + THE CITY OF EDINBURGH COUNCIL Sickness Absence Monitoring Report Executive of the Council 8fh My 4 I.I...3 Purpose of report This report quntifies the mount of working time lost s result of
More informationGAO HOME MORTGAGE INTEREST DEDUCTION. Despite Challenges Presented by Complex Tax Rules, IRS Could Enhance Enforcement and Guidance
GAO United Sttes Government Accountbility Office Report to the Joint Committee on Txtion July 2009 HOME MORTGAGE INTEREST DEDUCTION Despite Chllenges Presented by Complex Tx Rules, IRS Could Enhnce Enforcement
More informationHealth insurance exchanges What to expect in 2014
Helth insurnce exchnges Wht to expect in 2014 33096CAEENABC 11/12 The bsics of exchnges As prt of the Affordble Cre Act (ACA or helth cre reform lw), strting in 2014 ALL Americns must hve minimum mount
More informationTotal Data Protection for Sensitive Data Wherever It May Flow
Totl Dt Protection for Sensitive Dt Wherever It My Flow PGP Corportion nd Protegrity protect sensitive dt throughout its lifecycle, while enforcing nd verifying policy requirements for complince. Protegrity
More informationUnleashing the Power of Cloud
Unleshing the Power of Cloud A Joint White Pper by FusionLyer nd NetIQ Copyright 2015 FusionLyer, Inc. All rights reserved. No prt of this publiction my be reproduced, stored in retrievl system, or trnsmitted,
More informationEconomics Letters 65 (1999) 9 15. macroeconomists. a b, Ruth A. Judson, Ann L. Owen. Received 11 December 1998; accepted 12 May 1999
Economics Letters 65 (1999) 9 15 Estimting dynmic pnel dt models: guide for q mcroeconomists b, * Ruth A. Judson, Ann L. Owen Federl Reserve Bord of Governors, 0th & C Sts., N.W. Wshington, D.C. 0551,
More informationThe LENA TM Language Environment Analysis System:
FOUNDATION The LENA TM Lnguge Environment Anlysis System: Audio Specifictions of the DLP-0121 Michel Ford, Chrles T. Ber, Dongxin Xu, Umit Ypnel, Shrmi Gry LENA Foundtion, Boulder, CO LTR-03-2 September
More informationIntroducing Kashef for Application Monitoring
WextWise 2010 Introducing Kshef for Appliction The Cse for Rel-time monitoring of dtcenter helth is criticl IT process serving vriety of needs. Avilbility requirements of 6 nd 7 nines of tody SOA oriented
More informationCombined Liability Insurance. Information and Communication Technology Proposal form
Comined Liility Insurnce Informtion nd Communiction Technology Proposl form Comined Liility Insurnce Informtion nd Communiction Technology - Proposl form This proposl form must e completed nd signed y
More informationNOTES. Cohasset Associates, Inc. 2015 Managing Electronic Records Conference 8.1
Cohsset Assocites, Inc. Expnding Your Skill Set: How to Apply the Right Serch Methods to Your Big Dt Problems Juli L. Brickell H5 Generl Counsel MER Conference My 18, 2015 H5 POWERING YOUR DISCOVERY GLOBALLY
More informationUtilization of Smoking Cessation Benefits in Medicaid Managed Care, 2009-2013
Utiliztion of Smoking Cesstion Benefits in Medicid Mnged Cre, 2009-2013 Office of Qulity nd Ptient Sfety New York Stte Deprtment of Helth Jnury 2015 Introduction According to the New York Stte Tocco Control
More informationSmall Businesses Decisions to Offer Health Insurance to Employees
Smll Businesses Decisions to Offer Helth Insurnce to Employees Ctherine McLughlin nd Adm Swinurn, June 2014 Employer-sponsored helth insurnce (ESI) is the dominnt source of coverge for nonelderly dults
More informationAnthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier PPO 800/20%/20%
Anthem Blue Cross Life nd Helth Insurnce Compny University of Southern Cliforni Custom Premier 800/20%/20% Summry of Benefits nd Coverge: Wht this Pln Covers & Wht it Costs Coverge Period: 01/01/2015-12/31/2015
More informationPerformance analysis model for big data applications in cloud computing
Butist Villlpndo et l. Journl of Cloud Computing: Advnces, Systems nd Applictions 2014, 3:19 RESEARCH Performnce nlysis model for big dt pplictions in cloud computing Luis Edurdo Butist Villlpndo 1,2,
More informationPatient Perceptions of Reimbursement for Arthroscopic Meniscectomy and Anterior Cruciate Ligament Reconstruction
Ptient Perceptions of Reimursement for Arthroscopic nd Anterior Crucite Ligment Reconstruction Kelechi R. Okoroh, MD; Roert A. Keller, MD; Nthn E. Mrshll, MD; Jonthn R. Lynch, MD; John-Michel Guest, BS;
More informationTest Management using Telelogic DOORS. Francisco López Telelogic DOORS Specialist
Test Mngement using Telelogic DOORS Frncisco López Telelogic DOORS Specilist Introduction Telelogic solution for Requirements Mngement DOORS Requirements mngement nd trcebility pltform for complex systems
More informationImprovements in glycemic control
CLINICAL report Ptient stisfction nd costs ssocited with insulin dministered by pen device or syringe during hospitliztion Improvements in glycemic control hve been shown to gretly reduce the progression
More informationFDIC Study of Bank Overdraft Programs
FDIC Study of Bnk Overdrft Progrms Federl Deposit Insurnce Corportion November 2008 Executive Summry In 2006, the Federl Deposit Insurnce Corportion (FDIC) initited two-prt study to gther empiricl dt on
More informationReasoning to Solve Equations and Inequalities
Lesson4 Resoning to Solve Equtions nd Inequlities In erlier work in this unit, you modeled situtions with severl vriles nd equtions. For exmple, suppose you were given usiness plns for concert showing
More informationHumana Critical Illness/Cancer
Humn Criticl Illness/Cncer Criticl illness/cncer voluntry coverges py benefits however you wnt With our criticl illness nd cncer plns, you'll receive benefit fter serious illness or condition such s hert
More informationActive & Retiree Plan: Trustees of the Milwaukee Roofers Health Fund Coverage Period: 06/01/2015-05/31/2016 Summary of Benefits and Coverage:
Summry of Benefits nd Coverge: Wht this Pln Covers & Wht it Costs Coverge for: Single & Fmily Pln Type: NPOS This is only summry. If you wnt more detil bout your coverge nd costs, you cn get the complete
More informationPROPERTY AND CASUALTY INSURANCE. Effects of the Nonadmitted and Reinsurance Reform Act of 2010
United Sttes Government Accountbility Office Report to Congressionl Committees Jnury 2014 PROPERTY AND CASUALTY INSURANCE Effects of the Nondmitted nd Reinsurnce Reform Act of 2010 GAO-14-136 Jnury 2014
More informationA COMPARISON OF ALCOHOL SCREENING INSTRUMENTS AMONG UNDER-AGED DRINKERS TREATED IN EMERGENCY DEPARTMENTS
Alcohol & Alcoholism Vol. 37, No. 5, pp. 444 450, 2002 A COMPARISON OF ALCOHOL SCREENING INSTRUMENTS AMONG UNDER-AGED DRINKERS TREATED IN EMERGENCY DEPARTMENTS THOMAS M. KELLY 1 *, JOHN E. DONOVAN 1, JANET
More information2015 EDITION. AVMA Report on Veterinary Compensation
2015 EDITION AVMA Report on Veterinry Compenstion AVMA Report on Veterinry Compenstion 2015 EDITION Copyright 2015 by the All rights reserved. ISBN-13: 978-1-882691-31-9 AVMA Report on Veterinry Compenstion
More informationQuality and Cost Evaluation of a Medical Financial Assistance Program
Qulity nd Cost Evlution of Medicl Finncil Assistnce Progrm Dougls A Conner, PhD; Arne Beck, PhD; Christin Clrke; Leslie Wright, MA; Koml Nrwney, MD, PhD; Neys W Berminghm Perm J 2013 Winter;17(1):31-37
More informationUNITED STATES DEPARTMENT OF AGRICULTURE Washington, D.C. 20250. ACTION BY: All Divisions and Offices. FGIS Directive 2510.
UNITED STATES DEPARTMENT OF AGRICULTURE Wshington, D.C. 20250 ACTION BY: All Divisions nd Offices FGIS Directive 2510.1 12-11-73 FEDERAL TORT CLAIMS I PURPOSE This Instruction: A Sets forth the bsic provisions
More informationLump-Sum Distributions at Job Change, p. 2
Jnury 2009 Vol. 30, No. 1 Lump-Sum Distributions t Job Chnge, p. 2 E X E C U T I V E S U M M A R Y Lump-Sum Distributions t Job Chnge GROWING NUMBER OF WORKERS FACED WITH ASSET DECISIONS AT JOB CHANGE:
More informationCorporate Compliance vs. Enterprise-Wide Risk Management
Corporte Complince vs. Enterprise-Wide Risk Mngement Brent Sunders, Prtner (973) 236-4682 November 2002 Agend Corporte Complince Progrms? Wht is Enterprise-Wide Risk Mngement? Key Differences Why Will
More informationSoftware Cost Estimation Model Based on Integration of Multi-agent and Case-Based Reasoning
Journl of Computer Science 2 (3): 276-282, 2006 ISSN 1549-3636 2006 Science Publictions Softwre Cost Estimtion Model Bsed on Integrtion of Multi-gent nd Cse-Bsed Resoning Hsn Al-Skrn Informtion Technology
More informationGFI MilArchiver 6 vs C2C Archive One Policy Mnger GFI Softwre www.gfi.com GFI MilArchiver 6 vs C2C Archive One Policy Mnger GFI MilArchiver 6 C2C Archive One Policy Mnger Who we re Generl fetures Supports
More informationFactors Related to Radiation Safety Practices in California
... PEER REVIEW Fctors Relted to Rdition Sfety Prctices in Cliforni JANET THOMPSON REAGAN, PhD ANITA MARIE SLECHTA, MS, R.T.(R)(M), FASRT Bckground A ntionl study of rdiologic technologists rdition sfety
More informationAN ANALYTICAL HIERARCHY PROCESS METHODOLOGY TO EVALUATE IT SOLUTIONS FOR ORGANIZATIONS
AN ANALYTICAL HIERARCHY PROCESS METHODOLOGY TO EVALUATE IT SOLUTIONS FOR ORGANIZATIONS Spiros Vsilkos (), Chrysostomos D. Stylios (),(b), John Groflkis (c) () Dept. of Telemtics Center, Computer Technology
More informationFactors Affecting Electronic Medical Record System Adoption in Small Korean Hospitals
Originl Article Helthc Inform Res. 2014 July;20(3):183-190. pissn 2093-3681 eissn 2093-369X Fctors Affecting Electronic Medicl Record System Adoption in Smll Koren Hospitls Young-Tek Prk, PhD 1, Jinhyung
More informationRecognition Scheme Forensic Science Content Within Educational Programmes
Recognition Scheme Forensic Science Content Within Eductionl Progrmmes one Introduction The Chrtered Society of Forensic Sciences (CSoFS) hs been ccrediting the forensic content of full degree courses
More informationGAO IRS AUDIT RATES. Rate for Individual Taxpayers Has Declined But Effect on Compliance Is Unknown
GAO United Sttes Generl Accounting Office Report to the Chirmn, Subcommittee on Oversight, Committee on Wys nd Mens, House of Representtives April 2001 IRS AUDIT RATES Rte for Individul Txpyers Hs Declined
More informationVoIP for the Small Business
Reducing your telecommunictions costs VoIP (Voice over Internet Protocol) offers low cost lterntive to expensive trditionl phone services nd is rpidly becoming the communictions system of choice for smll
More informationFile Storage Guidelines Intended Usage
Storge 1 Google Cloud 2 Other cloud storge Exmple or Box, Dropbox, Crbonite, idrive File Storge Guidelines Usge Fculty nd student collbortion Specil use cses. When non-lcc employee nd students need ccess
More informationThe Determinants of Private Medical Insurance Prevalence in England
The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Derek R. King, Elis Mossilos LSE Helth nd Socil Cre, London School of Economics nd Politicl Science LSE Helth nd Socil Cre Discussion Pper
More informationJuly 22, 2009. The Honorable Henry A. Waxman Chairman Committee on Energy and Commerce House of Representatives
United Sttes Government Accountbility Office Wshington, DC 20548 July 22, 2009 The Honorble Henry A. Wxmn Chirmn Committee on Energy nd Commerce House of Representtives The Honorble John D. Dingell Chirmn
More information2. Transaction Cost Economics
3 2. Trnsction Cost Economics Trnsctions Trnsctions Cn Cn Be Be Internl Internl or or Externl Externl n n Orgniztion Orgniztion Trnsctions Trnsctions occur occur whenever whenever good good or or service
More informationHelicopter Theme and Variations
Helicopter Theme nd Vritions Or, Some Experimentl Designs Employing Pper Helicopters Some possible explntory vribles re: Who drops the helicopter The length of the rotor bldes The height from which the
More informationTreatment Spring Late Summer Fall 0.10 5.56 3.85 0.61 6.97 3.01 1.91 3.01 2.13 2.99 5.33 2.50 1.06 3.53 6.10 Mean = 1.33 Mean = 4.88 Mean = 3.
The nlysis of vrince (ANOVA) Although the t-test is one of the most commonly used sttisticl hypothesis tests, it hs limittions. The mjor limittion is tht the t-test cn be used to compre the mens of only
More informationPrescriptive Program Rebate Application
Prescriptive Progrm Rebte Appliction Check the pproprite progrm box for your rebte. OID Internl Use Only Cooling FSO (Fluid System Optimiztion) Foodservice Equipment Heting Lighting Motors & Drives Customer
More informationYour duty, however, does not require disclosure of matter:
Your Duty of Disclosure Before you enter into contrct of generl insurnce with n insurer, you hve duty, under the Insurnce Contrcts Act 1984 (Cth), to disclose to the insurer every mtter tht you know, or
More informationAn Undergraduate Curriculum Evaluation with the Analytic Hierarchy Process
An Undergrdute Curriculum Evlution with the Anlytic Hierrchy Process Les Frir Jessic O. Mtson Jck E. Mtson Deprtment of Industril Engineering P.O. Box 870288 University of Albm Tuscloos, AL. 35487 Abstrct
More informationSyGEMe: Integrated Municipal Facilities Management of Water Ressources Swiss Geoscience Meeting, Neuchâtel, 21 novembre 2009 k
SyGEMe: Integrted Municipl Fcilities Mngement of Wter Ressources Tool presenttion, choice of technology, mn-mchine mchine interfce, business opportunities nd prospects 1. Introduction 2. Mn-mchine interfce
More informationImplementation Evaluation Modeling of Selecting ERP Software Based on Fuzzy Theory
Implementtion Evlution Modeling of Selecting ERP Softwre Bsed on Fuzzy Theory Xukn Xu 1, Ydong Jing 1 nd Zheng Shi 2 1 Informtion Mngement Deprtment, Chngzhou Cmpus, Hohi University, Chngzhou 213022, Jingsu,
More informationChromebook Parent/Student Information
Chromebook Prent/Student Informtion 1 Receiving Your Chromebook Student Distribution Students will receive their Chromebooks nd cses during school. Students nd prents must sign the School City of Hmmond
More informationSource Code verification Using Logiscope and CodeReducer. Christophe Peron Principal Consultant Kalimetrix
Source Code verifiction Using Logiscope nd CodeReducer Christophe Peron Principl Consultnt Klimetrix Agend Introducing Logiscope: Improving confidence nd developer s productivity Bsed on stte-of-the-rt
More informationMAX. As an increasingly larger share of Medicaid enrollees MEDICAID POLICY BRIEF
MAX CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICAID POLICY BRIEF Brief 14 December 2012 The Avilbility nd Usbility of Behviorl Helth Orgniztion Encounter Dt in MAX 2009 Jessic Nysenbum, Ellen Bouchery,
More informationNational Diabetes Audit. Report 1: Care Processes and Treatment Targets
Ntionl Dibetes Audit 2011 2012 Report 1: Cre Processes nd Tretment Trgets The Ntionl Dibetes Audit is commissioned by The Helthcre Qulity Improvement Prtnership (HQIP) promotes qulity in helthcre. HQIP
More informationNote: Principal version Modification Amendment Equivalence list Consolidated version from October 1 2014
Note: The following curriculum is consolidted version. It is leglly non-inding nd for informtionl purposes only. The leglly inding versions re found in the University of Innsruck Bulletins (in Germn).
More informationGFI MilArchiver 6 vs Quest Softwre Archive Mnger GFI Softwre www.gfi.com GFI MilArchiver 6 vs Quest Softwre Archive Mnger GFI MilArchiver 6 Quest Softwre Archive Mnger Who we re Generl fetures Supports
More informationRevisions published in the University of Innsbruck Bulletin of 18 June 2014, Issue 31, No. 509
Plese note: The following curriculum is for informtion purposes only nd not leglly inding. The leglly inding version is pulished in the pertinent University of Innsruck Bulletins. Originl version pulished
More informationUnderstanding Life Cycle Costs How a Northern Pump Saves You Money
Understnding Life Cycle Costs How Nrn Pump Sves You Money Reference: Hydrulic Institute (www.s.g) Introduction Wht Life Cycle Cost (LCC) Clculting Totl LCC LCC Components Wht Life Cycle Cost Life Cycle
More informationImproving Library Users' Perceived Quality, Satisfaction and Loyalty: An Integrated Measurement and Management System
Improving Librry Users' Perceived Qulity, Stisfction nd Loylty: An Integrted Mesurement nd Mngement System by Anne Mrtensen nd Lrs Gr0nholdt This rticle describes the development nd ppliction of structurl
More informationVoIP for the Small Business
Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become vible solution for even the
More informationContextualizing NSSE Effect Sizes: Empirical Analysis and Interpretation of Benchmark Comparisons
Contextulizing NSSE Effect Sizes: Empiricl Anlysis nd Interprettion of Benchmrk Comprisons NSSE stff re frequently sked to help interpret effect sizes. Is.3 smll effect size? Is.5 relly lrge effect size?
More informationTITLE THE PRINCIPLES OF COIN-TAP METHOD OF NON-DESTRUCTIVE TESTING
TITLE THE PRINCIPLES OF COIN-TAP METHOD OF NON-DESTRUCTIVE TESTING Sung Joon Kim*, Dong-Chul Che Kore Aerospce Reserch Institute, 45 Eoeun-Dong, Youseong-Gu, Dejeon, 35-333, Kore Phone : 82-42-86-231 FAX
More informationNavy Asbestos Medical Surveillance Program 1990 1999: Demographic Features and Trends in Abnormal Radiographic Findings
MILITARY MEDICINE, 171, 8:717, 2006 Nvy Asbestos Medicl Surveillnce Progrm 1990 1999: Demogrphic Fetures nd Trends in Abnorml Rdiogrphic Findings Gurntor: Dnielle M. Dell, MPH Contributors: Dnielle M.
More informationData replication in mobile computing
Technicl Report, My 2010 Dt repliction in mobile computing Bchelor s Thesis in Electricl Engineering Rodrigo Christovm Pmplon HALMSTAD UNIVERSITY, IDE SCHOOL OF INFORMATION SCIENCE, COMPUTER AND ELECTRICAL
More information2 Workload and duration of the Program 3 Courses 4 Types of course units and number of participants
The English version of the consolidted curriculum for the "Bchelor Progrm in Mngement nd Economics" is not leglly inding nd is for informtionl purposes only. The leglly inding text which regultes the different
More informationCharacteristics of Applicants Who Obtain Interviews at Orthodontic Postgraduate Programs
Originl Article Chrcteristics of Applicnts Who Obtin Interviews t Orthodontic Postgrdute Progrms Anil P. Ardeshn ; Courtney A. Fong b ABSTRACT Objective: To evlute pplicnt credentils tht re ssocited with
More informationImpact of the National School Lunch Program on Fruit and Vegetable Selection in Northeastern Elementary Schoolchildren, 2012 2013
Brief Reports Impct of the Ntionl School Lunch Progrm on Fruit nd Vegetble Selection in Northestern Elementry Schoolchildren, 2012 2013 Srh A. Amin, MPH Bethny A. Yon, PhD Jennifer C. Tylor, MS b Rchel
More informationVoIP for the Small Business
VoIP for the Smll Business Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become
More informationHow To Know What A Pressure Ulcer Is
Pressure Ulcers ecourse: Module 2 Quiz I 1. Blck, brown or tn tissue tht dheres firmly to the wound bed or ulcer edges nd my be either firmer or softer thn surrounding tissue is:. Eschr b. Slough c. Grnultion
More informationVoIP for the Small Business
Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become vible solution for even the
More informationVoIP for the Small Business
Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become vible solution for even the
More informationPre-Approval Application
Pre-Approvl Appliction In tody s rel estte mrket, Pre-Approved mortgge provides you the buyer with powerful tool in the home purchse process! Once you hve received your Pre-Approvl, you cn shop for your
More informationVoIP for the Small Business
VoIP for the Smll Business Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become
More informationPsychological health and safety in the workplace Prevention, CAN/CSA-Z1003-13/BNQ 9700-803/2013
Psychologicl helth nd sfety in the workplce Prevention, CAN/CSA-Z1003-13/BNQ 9700-803/2013 promotion, nd guidnce to stged implementtion This smple udit tool is n nnex of the Ntionl Stndrd of Cnd on Psychologicl
More informationVoIP for the Small Business
VoIP for the Smll Business Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become
More informationEcon 4721 Money and Banking Problem Set 2 Answer Key
Econ 472 Money nd Bnking Problem Set 2 Answer Key Problem (35 points) Consider n overlpping genertions model in which consumers live for two periods. The number of people born in ech genertion grows in
More informationAt our university, we are constantly looking for ways to help teacher education candidates improve their teaching.
FACTOR Anlysis of Intern Effectiveness Sid T. Womck, Ph.D. Shellie Louise Hnnh, Ed.D. Columbus Dvid Bell, Ed. D. Arknss Tech University Four fctors in teching intern effectiveness, s mesured by Prxis III-similr
More informationHillsborough Township Public Schools Mathematics Department Computer Programming 1
Essentil Unit 1 Introduction to Progrmming Pcing: 15 dys Common Unit Test Wht re the ethicl implictions for ming in tody s world? There re ethicl responsibilities to consider when writing computer s. Citizenship,
More informationCommercial Cooling Rebate Application
Commercil Cooling Rebte Appliction Generl Informtion April 1 st 2015 through Mrch 31 st 2016 AMU CUSTOMER INFORMATION (Plese print clerly) Business Nme: Phone #: Contct Nme: Miling Address: City: Stte:
More informationHow To Reduce Telecommunictions Costs
Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become vible solution for even the
More informationa GAO-03-568 GAO COLLEGE COMPLETION Additional Efforts Could Help Education with Its Completion Goals Report to Congressional Requesters
GAO United Sttes Generl Accounting Office Report to Congressionl Requesters My 2003 COLLEGE COMPLETION Additionl Efforts Could Help Eduction with Its Completion Gols GAO-03-568 My 2003 COLLEGE COMPLETION
More informationCurriculum for the Master Program in Business Education at the University of Innsbruck School of Management
The English version of the curriculum for the Mster Progrm in Business Eduction is not leglly inding nd is for informtionl purposes only. The legl sis is regulted in the curriculum pulished in the University
More informationGAO HIGHER EDUCATION. Federal Science, Technology, Engineering, and Mathematics Programs and Related Trends
GAO United Sttes Government Accountbility Office Report to the Chirmn, Committee on Rules, House of Representtives October 2005 HIGHER EDUCATION Federl Science, Technology, Engineering, nd Mthemtics Progrms
More informationHow To Understand And Understand The Benefits Of Accounting
This rticle ppered in journl published by Elsevier. The ttched copy is furnished to the uthor for internl non-commercil reserch nd eduction use, including for instruction t the uthors institution nd shring
More informationModule 2. Analysis of Statically Indeterminate Structures by the Matrix Force Method. Version 2 CE IIT, Kharagpur
Module Anlysis of Stticlly Indeterminte Structures by the Mtrix Force Method Version CE IIT, Khrgpur esson 9 The Force Method of Anlysis: Bems (Continued) Version CE IIT, Khrgpur Instructionl Objectives
More informationApplication Bundles & Data Plans
Appliction Appliction Bundles & Dt Plns We ve got plns for you. Trnsporttion compnies tody ren t one-size-fits-ll. Your fleet s budget, size nd opertions re unique. To meet the needs of your fleet nd help
More informationVoIP for the Small Business
VoIP for the Smll Business Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become
More informationHow To Get A Free Phone Line From A Cell Phone To A Landline For A Business
Reducing your telecommunictions costs Reserch firm IDC 1 hs estimted tht VoIP system cn reduce telephony-relted expenses by 30%. Voice over Internet Protocol (VoIP) hs become vible solution for even the
More informationThere is arguably no more exciting time in social work education than the field practicum or internship. The integrative
Student Perceptions of Integrtive Field Seminr: A Comprison of Three Models Helen Hrris, MSW, ED.D, LCSW, ACSW, DCSW Dennis Myers, Ph.D, MSSW, LCSW Bylor School of Socil Work Student perceptions of 63
More informationElectrical Engineering
Electricl Engineering R Wherever Energy Flows or Goods re Produced Our Electricl Engineering Group provides electricl design nd consulting services to electric & gs utilities, oil & gs pipelines, refineries,
More information