Mobile x-ray devices like C-arms are routinely used in the operating room to assist in surgical interventions. C-arms need to be adequately operated to avoid unnecessary radiation exposure and intraoperative delays. We present a simulation-based training system to support training of operating room personnel in a virtual environment. To make learning more efficient and enjoyable we integrated aspects of gamification. In a game-like setting the user has to generate specific radiographs of a virtual patient. Game points are awarded with regard to image accuracy time needed and overall radiation exposure. To learn basics of C-arm handling and x-ray imaging non-medical objects can be examined as a first step. A virtual reality interface is provided to allow the user to interact with the C-arm in a more realistic way. User evaluations show that this approach is widely appreciated as providing a user-friendly and sufficiently realistic training tool with a high educational value for intraoperative C-arm imaging.

We designed, constructed, and evaluated a mobile medical care vehicle called "Rollende Arztpraxis" (rolling medical practice, RMP) that delivers the full medical care of a general practitioner to increase medical care supply in rural areas. Six communities have been identified, where the RMP has been visited 501 times in 14 months. Two different schedules of stops and treatment times have been tested. We show that the RMP treated mainly elderly and multimorbid patients. An accompanying study showed high acceptance and satisfaction of treated patients and treating doctors. An economic evaluation of three different utilization models with three treatment modes each showed no financial sustainability. We show that ambulatory care in rural areas can be complemented by a mobile care unit, if legal and financial barriers can be overcome.

Summary Introduction: This article is part of a Focus Theme of Methods of Information in Medicine on Health Record Banking. Background: Poor communication of health care information between health care providers (HCP) is still a major problem. One recent approach is the concept of Health Record Banking. Objectives: With this report we want to introduce the Lower Saxony Bank of Health (LSBH) to the international community. The main objective of this paper is to report and explain: 1) why this organization has been founded, 2) which basic principles have been set, 3) which services will be provided, 4) which type of organization has been chosen, and 5) which architectural framework has been selected. Methods: To report and discuss how we plan to achieve the intended objectives. Results: The LSBH was founded as an entrepreneurial company, regarding itself as a neutral third-party information broker. The bank does not store medical documents on its central servers but offers a document registry with links to documents stored at participating health care providers. Subject to valid patient consent, the LSBH grants access to these documents to authorized health care providers. To implement our services, we chose the established technical frameworks of the Integrating the Healthcare Enterprise (IHE) initiative using cross-enterprise document sharing (XDS). Conclusions: Different approaches to establish health information exchange (HIE) are in early stages and some have failed in the past. Health Record Banking can address major challenges described in the literature about HIE. The future will show if our provider-sponsored business model is sustainable. After reaching a stable network, we intend to add additional HCPs, e.g., care homes or ambulance services, to the network.

German medical care is going to suffer from a decreasing number of general practitioners due to demographic change. We study if ambulatory care in rural areas can be complementary ensured by a mobile care unit. A medical care van - the "rolling medical practice" (RMP) - has been constructed based on care scenarios created for rural communities in northern Germany. Performance and acceptance of the RMP is evaluated by constant monitoring of anonymized medical documentation and questionnaires. The RMP is visiting six villages on two days a week in a three-week interval. It is constructed from a standard van with a custom box body fully equipped for general care needs. Actually treated care cases meet expectations and are acute as well as chronicle symptoms. Case numbers range from 6 to 50 visits in 5 month. We showed that almost full ranged mobile medical care, as supplement to general medical supply is possible.

Results: The LSBH was founded as an entrepreneurial company holding a self-understanding as a neutral third party information broker. The bank does not store medical documents itself but offers a document registry granting access to authorized health care providers. To implement our services we used established technical frameworks of the Integrating the Healthcare Enterprise Initiative as crossenterprise document sharing (XDS). The rollout of the technical infrastructure has been accomplished. The integration and connection of the local components of the participating hospitals will follow soon.

OBJECTIVEMulticenter medical treatment requires health related data to be available across institutions. Since health information exchange solutions are emergent, fulfillment of privacy needs, including patients' informed consent, is vital for successful data exchange.METHODSWe designed a software supported consent process for the recently founded Lower Saxony Bank of Health (LSBH) with regard to particularities of German law. To implement the application, web technologies and well-described interfaces to IHE XDS profile components have been used.RESULTSA two staged process has been developed. A special consent application creates a customized form containing all orally given constraints defined by the patient. The form is printed out and signed by the patient while an electronic policy is created and registered at the LSBH.CONCLUSIONThe process completely reflects a conventional informed consent procedure but increases simplicity, clarity and understandability of the consent form. Technical and legal restrictions in Germany create a media split becoming a media crack in some environments. Availability of signature cards could improve the process by making it completely electronic.

Scattered radiation caused by the intraoperative use of mobile image intensifier systems (referred to as "C-arms") is the main source of radiation exposure for operating room personnel and surgeons. To keep this possibly harmful exposure at a minimum level, a deliberate use of radiation, knowledge about distribution of scattered radiation and appropriate behavior pattern are indispensable. Therefore in several countries knowledge concerning these aspects is taught in mandatory courses on radiation protection. Currently this teaching is typically based on non-interactive didactical methods (texts, pictures and videos). Because of the complexity of the knowledge field this restriction might lead to an insufficient understanding of the facts, an inappropriate behavior and therefore to an avoidable radiation exposure. This paper presents a new software module, which is able to simulate and visualize intraoperative radiation distribution and the resulting dose values for the attending persons within a few seconds (less than 30s). The developed components, which simulate the radiation transport using a graphics processing unit three times faster than comparable approaches, were integrated exemplarily in the computer based C-arm training system virtX. This extended training system improves the teaching through a prompt visual feedback on non-trivial scattered radiation facts in freely adoptable situations.

Background: Services for the elderly based on health-enabling technologies promise to contribute significantly to the efficiency and effectiveness of future health care. Due to this promise, over the last years the scientific community has designed a complex variety of these valuable innovations. A systematic overview of the developed services would help to better understand their opportunities and limitations. Objective: To obtain a systematic overview of services for the elderly based on health-enabling technologies and to identify archetypical service categories. Methods: We conducted a literature review using PubMed and retrieved 1447 publications. We stepwise reduced this list to 27 key publications that describe typical service archetypes. Results: We present six archetypical service categories, namely handling adverse conditions, assessing state of health, consultation and education, motivation and feedback, service ordering and social inclusion and describe their implementation in current research projects.

Mobile image intensifier systems (C-arms) are used frequently in orthopedic and reconstructive surgery, especially in trauma and emergency settings, but image quality and radiation exposure levels may vary widely, depending on the extent of the C-arm operator's knowledge and experience. Current training programs consist mainly of theoretical instruction in C-arm operation, the physical foundations of radiography, and radiation avoidance, and are largely lacking in hands-on application. A computer-based simulation program such as that tested by the authors may be one way to improve the effectiveness of C-arm training. In computer simulations of various scenarios commonly encountered in the operating room, trainees using the virtX program interact with three-dimensional models to test their knowledge base and improve their skill levels. Radiographs showing the simulated patient anatomy and surgical implants are "reconstructed" from data computed on the basis of the trainee's positioning of models of a C-arm, patient, and table, and are displayed in real time on the desktop monitor. Trainee performance is signaled in real time by color graphics in several control panels and, on completion of the exercise, is compared in detail with the performance of an expert operator. Testing of this computer-based training program in continuing medical education courses for operating room personnel showed an improvement in the overall understanding of underlying principles of intraoperative radiography performed with a C-arm, with resultant higher image quality, lower overall radiation exposure, and greater time efficiency. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.313105125/-/DC1.

Hintergrund und Fragestellung: Die korrekte intraoperative Positionierung und Einstellung eines mobilen Bildverstarkers (auch C-Bogen) kann zurzeit theoretisch mit Hilfe von Lehrbuchern erlernt, am Gerat selbst aber nur ohne visuelle Ruckmeldung, d.h. ohne ein zur Ausrichtung korrespondierendes Rontgenbild, trainiert werden. Hieraus ergibt sich die Fragestellung, inwiefern das Training der Handhabung und richtigen Einstellung des C-Bogens in verschiedenen Operationsszenarien durch ein C-Bogen Simulationssystem als Teil eines CBT-Systems (Computer Based Training) unterstutzt werden kann. Methoden: In Kooperation mit Arzten aus Unfallchirurgie und Radiologie wurde das computer-basierte Trainingssystem virtX entwickelt. virtX kann dem Nutzer verschiedene Aufgaben zur Einstellung eines C-Bogens stellen und die Ausfuhrung und das Ergebnis bewerten. Die Aufgaben konnen mit Hilfe eines Autorensystems erstellt und vom Trainierenden in verschiedenen Modi erfullt werden: im rein virtuellen Modus oder im kombinierten virtuell-realen Modus. Im rein virtuellen Modus steuert der Nutzer den virtuellen C-Bogen in einem virtuellen OP-Saal mittels einer grafisch-interaktiven Benutzungsoberflache. Im virtuell-realen Modus hingegen wird die Ausrichtung eines realen C-Bogens erfasst und auf den virtuellen C-Bogen ubertragen. Wahrend der Aufgabenerfullung kann der Benutzer zu jeder Zeit ein realitatsnahes, virtuelles Rontgenbild erzeugen und dabei alle Parameter wie Blendenstellung, Rontgenintensitat, etc. wie bei einem realen C-Bogen steuern. virtX wurde auf einem dreitagigen Kurs fur OP-Personal mit 120 Teilnehmern eingesetzt und auf der Basis von Fragebogen evaluiert. Ergebnisse: Von den Teilnehmern gaben 79 einen ausgefullten Evaluations-Fragebogen ab. Das Durchschnittsalter der 62 weiblichen und 15 mannlichen Teilnehmer (zwei o.A.) lag bei 34 ± 9 Jahren, die Berufserfahrung bei 8,3 ± 7,6 Jahren. 18 Personen (23%) gaben an, gelegentlich mit einem C-Bogen zu arbeiten, 61 (77%) arbeiteten regelmasig damit. Uber 83% der befragten Teilnehmer empfanden virtX als eine sinnvolle Erganzung zur herkommlichen Ausbildung am C-Bogen. Das virtuelle Rontgen wurde mit einer Zustimmung von 91% der befragten Teilnehmer als besonders wichtig fur das Verstandnis der Arbeitsweise eines C-Bogens beurteilt. Ebenso erhielt der kombinierte virtuell-reale Modus mit 84% Zustimmung einen vergleichsweise hohen Stellenwert. Schlussfolgerung: Die Befragung zeichnet ein positives Bild der Akzeptanz des virtX-System als substanzielle Erganzung zur herkommlichen Ausbildung am C-Bogen.

Intraoperative radiography based on mobile image intensifier systems (C-arms) is widely used during the treatment of trauma and emergency patients. These devices produce scattered radiation, potential hazardous for surgeon and operation room personal (ORP). The propagation and intensity of scattered radiation is not intuitive, is not perceivable by human senses and depends on many variables. At courses on radiation protection the knowledge of the behavior of scattered radiation and the modus operandi to minimize the radiation exposure should be taught to ORP and surgeons. Currently this can only be done theoretically using fixed pictures and precalculated videos. This paper presents an approach to interactively simulate and visualize scattered radiation with a computer based training system for mobile image intensifier systems. The simulation depicts radiation propagation and intensity for arbitrary C-arm adjustments and different irradiated materials. This teaching component focuses on improving the current radiation protection training with interactive visual and practical aspects.

Home telehealth services for elderly people promise to contribute to a more efficient health care in the future. Though isolated services at a patient's home might make sense for some applications, the full potential of home telehealth only arises through its integration into existing health information systems (HIS) and care processes. We know about traditional HIS architectures. However, so far no models exist, helping us to understand and describe the upcoming sensor-enhanced transinstitutional information system architectures for home telehealth services. To develop a nomenclature for sensor-enhanced transinstitutional health information system architectures. We conducted two systematic literature reviews, assessing typical services and users of home telehealth and key characteristics of transinstitutional health information system architectures. The information retrieved from both reviews was integrated to build the nomenclature sought after. We present a nomenclature of information and communication technology (ICT) architectures for home telehealth services. The developed dimensions provide an overview on typical users, services, operating organisations, information flow, geographical reach and architectural paradigms of sensor-enhanced transinstitutional health information systems. The developed nomenclature helps us to better understand the upcoming ICT architectures. However, we are still in need of further experiences with their application.

C-arm systems are used very frequently in trauma and orthopedic surgery. Radiation protection should be of the utmost importance in the use of such systems. Technicians, nurses, and surgeons usually position and manipulate the C-arm in the operating room (OR). Up to now, C-arm training is characterized by learning by doing. The virtX system is based on a different concept: The instruction and education process starts totally virtually -like a computer game, on a computer. After explanations of the program, the virtual C-arm training begins. The trainee can work with single-shot radiography or fluoroscopy in a virtual OR environment with table and patient. All regions of the body can be included in the x-ray examination. After successfully passing certain tasks, the learner goes on to a real C-arm, a real OR table, and a manikin. Simular to real working in an OR, he or she can perform all adjustments of the C-arm, the C-arm display, the table, and the patient, including positioning the manikin (patient) and moving the extremities or the OR table. The trainee can conduct tasks in single mode or fluoroscopy. The results are reflected by a feedback system that marks the correct position of the C-arm, patient, and table and displays the radiation time and dose rate. Several evaluations of trainees who used the virtX system show high acceptance and better results than after conventional C-arm training.

During the intraoperative radiograph generation process with mobile image intensifier systems (C-arm) most of the radiation exposure for patient, surgeon and operation room personal is caused by scattered radiation. The intensity and propagation of scattered radiation depend on different parameters, e.g. the intensity of the primary radiation, and the positioning of the mobile image intensifier. Exposure through scattered radiation can be minimized when all these parameters are adjusted correctly. Because radiation is potentially dangerous and could not be perceived by any human sense the current education on correct adjustment of a C-arm is designed very theoretical. This paper presents an approach of scattered radiation calculation and visualization embedded in a computer based training system for mobile image intensifier systems called virtX. With the help of this extension the virtX training system should enrich the current radiation protection training with visual and practical training aspects.

PURPOSE:To discuss an approach to improve education in C-arm operation and reduction of radiation hazards based on a computer based training and simulation system called virtX.METHODS:virtX is equipped with a visualization of scattered radiation and means to include patient positioning changes in radiograph simulation. virtX was integrated in a course for ORP and evaluated based on questionnaires.RESULTS:Response rate was 73 (n = 77), mean age 35.4 (+/-9.2) and professional experience 11.2+/- 10.4 years. 91% use a C-arm regularly, 8% casually and 1% not. 78% agree that the translation of patient dummy positioning changes to simulated X-ray images is sufficiently realistic, 1% disagree (neutral 17%). 79% state that they acquired new knowledge concerning avoiding unnecessary radiation exposure, 10% do not (neutral 11%).CONCLUSIONS:The virtX-approach of simulating radiograph generation including patient positioning and scattered radiation was evaluated positively concerning its suitability for imparting knowledge regarding radiation protection and C-arm operation.

Hintergrund und Fragestellung: Die durch röntgentechnische Diagnoseverfahren in der Medizin entstehende Strahlenbelastung für Patient und Personal soll laut Strahlenschutzverordnung so gering wie möglich gehalten werden. Um dieses zu erreichen ist ein professioneller und bedachter Umgang mit den Röntgengeräten unabdingbar. Dieses Verhalten kann derzeit jedoch nur theoretisch vermittelt werden, da sich ein Üben mit realer Strahlung von selbst verbietet. Daher stellt sich die Frage wie man die Strahlenschutzausbildung durch eine verbesserte Vermittlung der komplexen Thematik unterstützen kann. Methoden: Das CBT-System (Computer Based Training) virtX, welches das Erlernen der korrekten Handhabung mobiler Röntgengeräte unterstützt, wurde um Aspekte aus dem Bereich des Strahlenschutzes erweitert. Es wurde eine prototypische Visualisierung der entstehenden Streustrahlung sowie die Darstellung des Nutzstrahlenganges integriert. Des Weiteren wurde die Berechnung und Anzeige der virtuellen Einfallsdosis für das durchstrahlte Volumen sowie für den Bereich des Bildverstärkers hinzugefügt. Für die Berechnung und Visualisierung all dieser Komponenten werden die in virtX parametrisierbaren C-Bogen-Einstellungen, z.B. Stellung der Blenden, Positionierung des Röntgengerätes zum durchstrahlten Volumen und Strahlenintensität, herangezogen. Das so erweiterte System wurde auf einem dreitägigen Kurs für OP-Personal mit über 120 Teilnehmern eingesetzt und auf der Basis von Fragebögen evaluiert. Ergebnisse: Von den Teilnehmern gaben 55 einen ausgefüllten Evaluations-Fragebogen ab (Responserate 82%). Das Durchschnittsalter der 39 weiblichen und 15 männlichen Teilnehmer (einer o.A.) lag bei 33±8 Jahren, die Berufserfahrung bei 9,37±7 Jahren. Die Erfahrung mit dem C-Bogen wurde von einem Teilnehmer (2%) mit „Keine oder bisher nur Einführung erhalten“, von acht Teilnehmern (14%) mit „bediene einen C-Bogen gelegentlich“ und von 46 (84%) mit „bediene einen C-Bogen regelmäßig“ angegeben. 45 (92%) der Teilnehmer gaben an, durch die Visualisierung der Streustrahlung etwas Neues zur Vermeidung unnötiger Strahlenbelastung dazugelernt zu haben. Schlussfolgerung: Trotz einer bislang nur prototypischen Visualisierung der Streustrahlung können mit virtX zentrale Aspekte und Verhaltensweisen zur Vermeidung unnötiger Strahlenbelastung erfolgreich vermittelt werden und so Lücken der traditionellen Strahlenschutzausbildung geschlossen werden.

C-arm systems are used very frequently in trauma and orthopedic surgery. Radiation protection should be of the utmost importance in the use of such systems. Technicians, nurses, and surgeons usually position and manipulate the C-arm in the operating room (OR). Up to now, C-arm training is characterized by learning by doing. The virtX system is based on a different concept: The instruction and education process starts totally virtually - like a computer game, on a computer. After explanations of the program, the virtual C-arm training begins. The trainee can work with single-shot radiography or fluoroscopy in a virtual OR environment with table and patient. All regions of the body can be included in the x-ray examination. After successfully passing certain tasks, the learner goes on to a real C-arm, a real OR table, and a manikin. Simular to real working in an OR, he or she can perform all adjustments of the C-arm, the C-arm display, the table, and the patient, including positioning the manikin (patient) and moving the extremities or the OR table. The trainee can conduct tasks in single mode or fluoroscopy. The results are reflected by a feedback system that marks the correct position of the C-arm, patient, and table and displays the radiation time and dose rate. Several evaluations of trainees who used the virtX system show high acceptance and better results than after conventional C-arm training.

Summary Objectives: Operating room personnel (ORP) operating mobile image intensifier systems (C-arms) need training to produce high quality radiographs with a minimum of time and X-ray exposure. Our study aims at evaluating acceptance, usability and learning effect of the CBT system virtX that simulates C-arm based X-ray imaging in the context of surgical case scenarios. Methods: Prospective, interventional study conducted during an ORP course with three groups: intervention group 1 (training on a PC using virtX), and 2 (virtX with a C-arm as input device), and a control group (training without virtX) – IV1, IV2 and CG. All participants finished training with the same exercise. Time needed to produce an image of sufficient quality was recorded and analyzed using One-Way-ANOVA and Dunnett post hoc test (? = .05). Acceptance and usability of virtX have been evaluated using a questionnaire. Results: CG members (n = 21) needed more time for the exercise than those of IV2 (n = 20): 133 ± 55 vs. 101 ± 37 sec. (p = .03). IV1 (n = 12) also performed better than CG (128 ± 48 sec.), but this was not statistically significant. Seventy-nine participants returned a questionnaire (81% female, age 34 ± 9 years, professional experience 8.3 ± 7.6 years; 77% regularly used a C-arm). 83% considered virtX a useful addition to conventional C-arm training. 91% assessed virtual radiography as helpful for understanding C-arm operation. Conclusions: Trainees experienced virtX as substantial enhancement of C-arm training. Training with virtX can reduce the time needed to perform an imaging task.

Background and objectives: Currently the correct intrasurgical positioning and adjustment of mobile X-ray image intensifiers (C-arm) can be learned theoretically through the use of textbooks, the practical training with the device itself suffers from the lack of visual feedback, i.e. radiographs corresponding to the adjustment of the C-arm. This leads to the question, whether the training of correct operation and adjustment of a C-arm in different operation scenarios can be supported by a C-arm simulation system being part of a CBT system (Computer Based Training). Methods: In co-operation with physicians from accident surgery and radiology the computer-based training system virtX was developed. virtX confronts the user with different exercises of C-arm adjustment and evaluates their execution and the results. These tasks can be created with the help of an authoring tool and can be accomplished by the trainee in different modes: a pure virtual mode and a combined virtual-real mode. In the pure virtual mode the user controls the virtual C-arm in a virtual operating theatre via the graphic-interactive virtX user interface. In the virtual-real mode however the position and orientation of a real C-arm are detected and mapped onto the virtual C-arm. At any time during the completion of an exercise the user can produce a close-to-reality, virtual radiograph and can control all parameters, like the positions of the apertures, X-ray intensity, etc. virtX was used on a three-day course for OR personnel with 120 participants and evaluated using questionnaires.Results: 79 of the participants returned a questionnaire. The average age of the 62 female and 15 male participants (two n.s.) was 34 ± 9 years, their professional experience was 8.3 ± 7.6 years. 18 persons (23%) indicated to work occasionally with a C-arm, 61 (77%) worked regularly with it. Over 83% of the interviewed participants considered virtX a useful addition to the conventional C-arm training. With an acceptance of 91% of the participants the virtual radiography was judged particularly important for understanding C-arm functioning. With 84% acceptance the combined virtual-real mode also got a comparatively high rating. Conclusion: The evaluation results show a high degree of acceptance of the virtX system as a substantial enhancement of conventional C-arm training.