text:
Automated Evidence-based Critiquing of Orders for Abdominal Radiographs: Impact on Utilization and Appropriateness
Objective: Inappropriate utilization of diagnostic testing has been well documented. The purpose of this study was to measure the impact of presenting real time, evidence-based critiques about the appropriateness of abdominal radiograph (KUB)orders on physician decision making.
Design: Prospective trial where evidence-based critiques were presented to ordering clinicians in two kinds of situations: (1) a KUB was likely to have a low probability of providing useful information, or (2) an alternative view(s) was more appropriate given the clinical circumstance. There were two phases of the trial: Phase 1 was a 9-week period where evidence-based critiques were presented at the time of ordering a KUB, followed by Phase 2, a 19-week period in which orderers were randomized to receive critiques either amended to include both institutional data regarding the utility of the critiques and stronger messages about the lack of utility of the study, or the same critiques as presented in Phase 1, depending upon indication. Based upon the radiologist's report of their interpretation of the exams, the results of the examinations were scored as positive, equivocal, or negative using structured criteria.
Results: 299 KUBs in Phase 1 and 385 KUBs in Phase 2 received at least one critique. Cancellation rates of low yield films were low, and were similar in Phase 1 and 2, 8/258 (3%) vs. 10/283 (4%). Compliance with the recommendation for alternative view(s) was higher: 19/104 (38%) in Phase 1 vs. 96/176 (55%) in Phase 2 (p = 0.006). The rules differentiated low-yield from non-low-yield films: 5% of low-yield films vs. 20% of non-low-yield films were positive in Phase 2 (p < 0.0001). Surgical physicians were less likely to cancel (p = 0.07) or to change to the suggested view(s) (p < 0.0001) than medical physicians or nurses.
Conclusions: The intervention identified clinical situations in which KUBs appeared to have a low clinical yield. In response to evidence-based critiques, providers were reluctant to cancel their order, but were more willing to change to different views. To reduce the number of inappropriate radiographic films, stronger incentives or interventions may be required.
Inappropriate utilization of diagnostic testing has been well documented.1–4 In attempts to improve the appropriateness of testing, multiple methodologies, including audit and feedback, education, rationing, and financial incentives, have been attempted.1–8 These strategies have enjoyed some success6,9 but require considerable time and effort to implement. Also, even when these approaches have been successful, their effects have often diminished soon after the interventions were discontinued.10
Interventions that improve physician decision making may be most useful when applied at the time of ordering. The advent of physician computer order entry (POE) allows for this possibility.11–13 In POE, orders are entered directly into an automated information system. The system can require structured ordering, and reminders can be presented at the time orders are written.
To date, studies using computer order entry have evaluated the impact of real-time reminders on the cost of test ordering,10,14,15 redundant laboratory testing,16 drug-drug interactions, and drug-lab interventions.11 However, the effect of real-time, automated critiques on the ordering of radiologic tests has not been reported.
In this study, we presented real-time comments about the appropriateness of abdominal radiographs (KUB) to physicians using a POE system, and we evaluated the impact of these critiques on their decision-making behavior.
Abdominal radiographs were chosen because they are performed frequently yet often provide little information; additionally there is substantial evidence regarding their utility for specific indications.17–32.
We hypothesized that real-time critiquing during the use of POE could decrease inappropriate KUB ordering, thereby eliminating unnecessary films, as well as improve the usefulness of the test by suggesting alternative view(s) that could provide better clinical information.
The study was conducted at the Brigham and Women's Hospital (BWH), a 720-bed tertiary care teaching hospital. Its integrated, computerized hospital information system runs on a 3,000-node local area network (LAN) with 486-based personal computers serving as workstations.11 Within this computerized information system, a POE application system was developed and was implemented in 1993.11 At BWH, the primary users of POE are housestaff and nurses. At the time of this study, all in-patient orders were entered through the POE system. Most orders are written using menus, and more than 90% are captured in coded form.11
Capturing the Reason for the Radiograph in Coded Form
To order a radiologic study at our institution, orderers are required to provide the "relevant history items" and items to "rule out or assess." Prior to the study, physicians ordering abdominal radiographs were required to enter the "relevant history items" and items to "rule out or assess" into a free text box. For this study, to permit critiquing, the patient's relevant history as well as items the physician wanted ruled out or assessed when ordering an abdominal radiograph were captured in coded form. To develop lists for these two fields, the free text reasons for a 2-month period were reviewed, put into categories, and ranked. The most common categorical reasons then were used for the structured KUB ordering form, which contained the 11 most commonly entered "relevant history" items and 10 commonly entered "rule out or assess" items. This structured ordering form was then tested and re-ranked before determining the final version (Fig. 1). Physicians were required to indicate at least one item from each section when ordering a KUB. A box for "other," in which free text could be entered if none of the items applied, was included. For all indications physicians could add free text to describe the patient's situation in more detail.
Development of Critiquing Messages
The literature regarding KUBs was reviewed,17–32 and lists of appropriate and inappropriate reasons for ordering a KUB were developed. From the common history and assessment items listed on the structured ordering form, eight combinations of history and assessment items that reflected inappropriate reasons for ordering a KUB were determined, based upon the literature and expert opinion in our medicine, surgery, obstetrics/gynecology, and radiology departments. These situations reflected instances in which, given the identified history and assessment items, a KUB was unlikely to add diagnostic information (see Appendix). The POE system was modified so that, when a physician entered certain history and assessment items (Appendix), a screen would be displayed stating that the test was unlikely to yield worthwhile information. For example, if G (right lower quadrant pain) and S (appendicitis) were chosen from the structured KUB ordering form (Fig. 1), a message would be presented to the effect that a KUB would be low yield and that an ultrasound test might be more useful (Fig. 2). When receiving a message that indicated that a film was likely to be of little value, the orderer had the option to cancel the order or to continue despite the critique. We refer to these kinds of messages as "low yield" messages.
Two situations in which an alternate view(s) might be superior to a KUB were also identified (Appendix). For example, if a KUB with both upright and supine views is ordered when perforation was suspected, a message would be displayed suggesting that a chest PA view and a KUB (supine alone) film would be preferable, unless the patient was unable to stand, in which case a lateral decubitus film of the abdomen and a KUB (supine alone) film would be recommended (Fig. 3). If both upright and supine views were ordered but neither perforation nor obstruction was suspected, a message would be displayed suggesting that the supine view alone would be sufficient. When a message suggested an alternate view(s), the orderer had the option to change to the suggested view(s), continue as ordered, or to cancel altogether.
For all exams, instructions directed the orderer to enter the most likely indication for the study first, the second next, and so forth. If more than one selection were chosen by the orderer for the "relevant history" or "item to rule out or assess," the evidence-based message would be triggered from the first item entered only. When available, full abstract(s) from scientific papers supporting the messages were accessible on-line at the time of receiving a message.18,19,21,22,26–31
Prior to implementation of the evidence-based messages, a letter of introduction and an explanation of the intervention were mailed via computer to all order-entry users. The letter was endorsed by the chairmen of the departments of Medicine, Surgery, Obstetrics/Gynecology, and Radiology.
Study Period and Outcomes
In Phase 1, from August 1, 1995, to September 30, 1995, all KUB in-patient orders were subject to the evidence-based messages. The main outcome measures were cancellation rates and the frequency with which orders were changed to suggested view(s). A secondary outcome was the yield of important diagnostic information in films that were predicted to be of low utility but were nevertheless obtained. (Films were graded by guided implicit review, described in the following section.)
In Phase 2, based on the findings from Phase 1, the evidence-based messages were amended, and orderers were randomized to receive either the same ("control group") or amended ("intervention group") messages. One message (Appendix, low yield rules, no. 5) was supposed to be amended for all future orders, as too many positive films were found when suggestions to cancel were overridden; however, the original rule was inadvertently displayed to the control group of orderers. Other "low yield" messages were amended to include data from the Phase 1 experience, further emphasizing that, for the given indications, KUB was likely to have little value. In addition, one of the alternate exam messages was re-written more emphatically. In Phase 2 of the evaluation of evidence-based messages (November 10, 1995, to March 21, 1996), all users of order-entry were randomized to receive either the initial or amended evidence-based messages to evaluate whether feed-back of institutional data and stronger messages might have a larger impact on ordering behavior than delivery of messages without local data alone.
KUB Film Radiographic Evaluation
The radiologists' transcribed reports of all KUBs were reviewed using a guided implicit approach by one reviewer (LH) and were scored as positive, equivocal, or negative. Specifically, the reviewer graded films as positive if any of the following were present: bowel obstruction, bowel ischemia perforated viscous, free air not following surgery, volvulus, misplaced feeding tube, evaluation of ureteral stent placement, evaluation of barium prior to CT scan, foreign body; as equivocal if one of the following were present: possible ileus, possible ileus vs. small bowel obstruction, moderately dilated loops of bowel, gastric distention, questionable ischemic changes, possible urinary tract stone, possible pneumatosis; or as negative in the presence of none of the above (normal film). To evaluate the consistency of interpretation, a random sample of 50 films were reviewed by a second reviewer using the same criteria. Percent agreement was 94%, and the kappa between the reviewers was 0.80, suggesting good agreement.
Rates of cancellation and change to suggested view(s) were calculated for both Phase 1 and 2 and compared by the chi square test. Rates of cancellation and change to suggested views were also compared within Phase 2 between the "control" and "intervention" groups. Rates of cancellation and change to suggested view(s) for all films were compared by type of orderer (medicine physician, surgery physician, nurse). Characteristics of patients (age, gender, race, clinical service) who received the KUBs were obtained from the computerized information system and compared across the two phases using the chi-aquare test for categorical variables, and Student's t test for continuous variables. The KUB results for low-yield and non-low-yield films were compared within the two phases by the chi-square test. The potential impact of KUB results upon clinical care for all positive films was evaluated through medical record chart review. The potential impact of canceled KUBs upon clinical care was evaluated through medical record chart review of patients in whom a KUB was canceled. Interrater reliability for KUB film results was determined using the kappa statistic. Time trend analyses of the number of KUBs during a 26-month period was performed using piece-wise regression.33
Overall, 681 patients had 1,244 KUB films performed during the 6-month trial: 190 patients during Phase 1 (380 films) and 491 patients during Phase 2 (864 films). Neither the patient characteristics nor the orderer type differed between the two phases (Tables 1A,1B).
|Phase 1 (N = 190)
|Phase 2 (N = 491)
|Age (mean, range)
|58.8 (18-90)
|58.5 (16-93)
|% Female
|91 (48)
|267 (54)
|% Male
|99 (52)
|224 (46)
|149 (78)
|366 (74)
|23 (12)
|72 (15)
|11 (6)
|24 (5)
|7 (4)
|29 (6)
|Clinical service
|81 (42)
|187 (38)
|100 (53)
|268 (55)
|9 (5)
|36 (7)
↵* P—phase 1 vs. phase 2.
In Phase 1, 79% of KUBs ordered resulted in at least one critique, either low yield or alternate exam, as compared with Phase 2, in which 45% of KUBs ordered resulted in at least one message (Table 2). Between Phase 1 and the start of Phase 2, a rule that had accounted for 32% of low-yield film reminders in Phase 1 was removed for one group of orderers in Phase 2, accounting for the majority of this difference. In Phase 2, there were no differences in the rate of cancellation of low-yield films, change to suggested view(s), or results of low-yield films between the two randomized groups. For this reason, all Phase 2 films are considered together.
Cancel rates for orders receiving a low yield message were low in both Phase 1-8/258 (3%)—and in Phase 2-10/283 (4%)—despite strengthening the messages and improving specificity (Table 2). The results were better for orders receiving an alternate exam message: 38% changed as suggested in Phase 1, versus 55% in Phase 2 (p = 0.006, Table 2). More specifically, for messages suggesting a KUB supine alone (Appendix, alternate exam rule no. 1), 33% (13/39) of the messages were followed as suggested in Phase 1, versus 40% (29/71) in Phase 2. For messages suggesting upright chest x-ray in addition to supine KUB (Appendix, alternate film rule no. 2), 40% (26/65) were followed in Phase 1 and 64% (67/105) in Phase 2.
The review of the KUB reports (Table 3) showed that the percentage of positive films was significantly lower and the percentage of negative films significantly higher for films that received a low-yield critique as opposed to those that did not in both Phase 1 and Phase 2. After the removal of one rule that included 80% of the positive films in Phase 1, only 3% of the remaining films within the low-yield category of Phase 1 were positive. With removal of this rule from one group of orderers prior to Phase 2 of the trial, 5% of films were positive. Of note, this rule was to have been removed from all orderers in Phase 2, but it inadvertently was displayed to the "control group" of orderers. If this had not occurred, the positive film rate in Phase 2 would have been even lower, approximately 3.5%.
|Phase 1*: N (%)
|Phase 2†: N (%)
|Low-yield Films
|Non-Low-yield Films
|Low-yield Films
|Non-Low-yield Films
|20/225 (9)
|12/255 (5)
After excluding the rule that was problematic from Phase 1, review of the positive films that resulted from indications prompting a low-yield message revealed a few results of clinical importance (Table 4). For Phase 1, of 3 films which were positive, none had any apparent effect on clinical outcome. In Phase 2, 12 positive films resulted from indications receiving a low-yield message. Of the 12 films, 6 were determined to have a significant effect on clinical outcome, and 6 were determined to have an indeterminate effect. Of these 12 films, 5 resulted from the orderer entering an inaccurate indication for the study, thus resulting in the presentation of a low-yield message that would not have occurred if the orderer had indicated the correct reason for the study. For example, one low-yield critique resulted from the orderer entering "nephrolithiasis" as the reason for ordering a film in a patient who was receiving follow-up KUBs for a known small bowel obstruction. Of the four positive films remaining (excluding the films resulting from mistakenly delivered reminders n = 3), two had a significant effect on clinical management (small bowel obstruction resulting in enema and lactulose, partial colonic obstruction resulting in flexible sigmoidoscopy), and two had indeterminate effects (feeding tube looped in mid-esophagus but no further radiologic evaluation; feeding tube at gastroesophageal junction but no further radiologic evaluation). For films scored as equivocal, 87% were read as possible ileus, 9% as possible stone in the urinary system, and 4% with other questionable findings (possible ischemic changes, possible splenic enlargement).
|Clinical Outcome
|Improving small bowel obstruction
|No further abdominal films or problems during hospitalization
|No change in management; follow-up KUB 1 week later without evidence of thumbprinting
|Thickened sigmoid colon
|Abdominal CT performed following day without evidence of pneumatosis; notable for colitis
|Small bowel obstruction
|Improvement in distention; treatment with lactulose
|Inaccurate reason entered
|Feeding tube looped in midesophagus
|No further films for feeding tube placement
|Small bowel obstruction
|Enema and lactulose, improvement in film findings
|Colonic obstruction, unchanged
|Clinical improvement, patient discharged without further films
|Inaccurate reason entered
|Barium throughout colon (pre-CT)
|Abdominal CT postponed for 10 days due to retained barium
|Inaccurate reason entered
|Partial small bowel obstruction
|Patient improved, then worsened, requiring laparoscopy
|Rule malfunction*
|Small bowel obstruction, unchanged
|Resolution with conservative therapy
|Rule malfunction
|Worsening of small bowel obstruction
|Clinical improvement with conservative therapy
|Inaccurate reason entered
|Incomplete small bowel obstruction
|Nasogastric tube already in place, improvement with conservative therapy
|Rule malfunction
|Partial colonic obstruction
|Flexible sigmoidoscopy performed next day
|Feeding tube at gastro-esophageal junction
|No further films
|Partial small bowel obstruction
|Colonoscopy and decompression from below
|Inaccurate reason entered
Includes all positive low yield films Phase 2, remaining positive films Phase 1 after removal of offending rule.
↵* Description of rule malfunction: A rule identified in Phase 1 that was associated with too many positive film findings when overridden was to have been removed for all orderers in Phase 2; however, the "control group" continued to receive this rule.
Low-yield film critiques were more likely to be received by medicine physicians and nurses than by surgical physicians for KUBs ordered (Table 5). In addition, alternative view(s) critiques were also more often received by medicine physicians and nurses than by surgical physicians. However, for orders receiving low-yield critiques, medicine physicians and nurses more often canceled the KUB than did surgical physicians, although this trend did not reach statistical significance (p = 0.07). Additionally, for orders receiving alternative view(s) critiques, suggestions to switch to an alternative view were more often adhered to by medicine physicians and nurses than by surgical physicians. The results of films performed, in spite of a low-yield critique, did not differ significantly among nurses, medicine, and surgical physicians (p = 0.65).
|Type of Provider
|No. KUBs Ordered Receiving* Low-yield Critique (%)
|No. KUBs Ordered Receiving* Alternate-view Critique (%)
|No. Low-yield KUBs Canceled (%)
|No. KUB Orders Changed to Suggested* View(s) (%)
|189/337 (56)
|120/337 (36)
|9/189 (5)
|75/120 (63)
|205/466 (44)
|85/466 (18)
|3/205 (1)
|26/85 (31)
|131/231 (57)
|69/231 (30)
|8/131 (6)
|33/69 (48)
↵* p < 0.001 medicine physicians versus surgery physicians versus nursing.
Because physicians might learn over time not to order examinations that are low yield, we evaluated the frequency with which KUBs were performed during the study period (Fig. 4) as compared with an 18-month period prior to the intervention period. There was no significant difference in the number of KUBs performed per month in the pre- as compared with the post-intervention period (p = 0.19). Similar results were found comparing the number of KUBs per admission per month between the two periods.
With the current results, annual charge savings of only $6,000 of a potential $98,500 were realized. This estimate is based upon a 4% cancellation rate of low-yield film orders (50% KUB one-view orders only—$83 charge—and 50% KUB two-view orders—$138 charge), and a 40% adherence to the critique to change from two KUB views to one ($55 charge saving per order).
In this study, we found that orderers were reluctant to cancel radiographs that were likely to be of low yield when presented with evidence-based messages in real time. This was the case even though review of the results of the films demonstrated that our rules for identifying low-yield indications were valid. Orderers were, however, more amenable to changing to the suggested view(s) when presented with suggestions to change the ordered test to an alternate examination. Thus, providers were willing to substitute but not forgo imaging once the decision to order a KUB had been made.
Changing physician behavior has been difficult,34 and efforts to improve decision-making behavior have met with a variety of results. A number of studies attempting to decrease inappropriate resource utilization have been unsuccessful, despite using a variety of methodologies, including education and feedback,3 education and audit,1 risk estimates, and triage recommendations.35 Interventions developed to improve the quality of care by suggesting additional and/or alternative testing have been more effective,15,36–41 compatible with the findings of this study that providers were more willing to substitute for or change the number of view(s) of KUBs than to cancel a planned examination.
There are several possible reasons why the orderers were unwilling to cancel the requested exams. First, the orderers in this study were residents, who were not directly responsible for the financial consequences of their actions. Second, the orderers may not have been the decision makers (e.g., 22% of KUB orders entered by nurses) but merely individuals carrying out the commands of more senior housestaff or attending physicians. They may not have felt that they were in a position to act independently upon the critiques. Third, failure may have been due to the mechanism by which the intervention was introduced. Except for a brief letter of introduction prior to turning on the intervention, no formal, direct education with the housestaff occurred, and critiques regarding the utility of KUBs for selected indications were presented by computer only. Perhaps if the housestaff had received educational lectures on the utility of KUBs in addition to the information provided on-line, a greater impact would have been realized. Alternatively, providing individualized retrospective data to the housestaff about their KUB-ordering behavior and its yield might have been helpful, a technique that has been variably successful.1,3,9,14 Fourth, the limited impact of the intervention could have been due in part to users' distrust regarding the validity of the critiques because of the display of a rule that, although later removed, initially had poor predictive value. However, it is unlikely that this played a large role, as there were few encounters with the KUB critiques per user, and thus it is unlikely that they "learned" to distrust the intervention. Involving the housestaff in the development of the criteria, another potentially successful technique,6 could also have been helpful in getting the housestaff to "buy in" to the validity of the evidence-based critiques.
Although the rules from which the critiques were developed successfully differentiated low-yield from non-low-yield KUBs, the intervention had only a small effect on utilization. The implementation of rules, or "guidelines," can be difficult; guidelines can be perceived to be of varying quality, ranging from clearly defined and proven rules to unproved suggestions.42 In addition, physicians may be hesitant to make a decision based upon guideline recommendations, particularly if they are concerned about the medical-legal implications of following a guideline that could result in an unfavorable clinical result. This concern has some validity, since guidelines have been used to incriminate as well as exonerate physicians, although generally physicians are on firmer ground when they follow guidelines.43 Additionally, although the rules utilized here were tested for their ability to identify low-yield utilization during the study and appeared to be effective, including data about their local performance in Phase 2 was no more successful at changing ordering behavior than the presentation of the literature-based critiques in Phase 1. Stronger interventions, such as requiring a radiology consultation of examinations likely to be of low yield or giving individual house officers' data on their respective ordering behavior to their superiors could have had a larger impact, but they would be more intrusive.
If orderers had canceled all low-yield films as suggested, two positive films that significantly affected clinical management would have resulted (0.8% of all low-yield films, excluding those that resulted from the orderer entering an incorrect reason for the KUB). Although it was our impression that films that were scored as equivocal would not result in a change in clinical management, it is possible that not performing these films could have affected patient outcomes. However, none of these films appeared to provide a definitive answer to a clinical question. Further diagnostic testing or reliance on clinical history and exam would be required, suggesting that the KUB was of little clinical benefit to the patient in these circumstances. In addition, there were 18 KUBs canceled in total; upon review of the medical record, none of these cancellations appeared to affect clinical management.
Interestingly, there were significant differences in ordering behavior between medicine and surgical physicians. Although surgical physicians were more resistant to suggestions to cancel and to change their orders, they were also less likely to receive a low-yield or alternate exam critique, suggesting that either their clinical judgment as to when a KUB study was necessary was better than the other orderers, or that the prevalence of disease that a KUB would detect was higher in their population. Different strategies may be necessary to affect behavior for different provider and patient groups. Future studies could focus on this as well as on other important areas, including user satisfaction with the decision-support systems. A satisfaction study performed at our institution prior to this study found high levels of satisfaction overall with the POE system,44 and a follow-up questionnaire found an average satisfaction score of 3.5 on a scale of 1–7 for suggestions regarding low-yield studies (unpublished data).
This study has several limitations. For one, it is not clear how the results will generalize to other settings. For example, if the KUB decision-support system were instituted in a setting where incentives were better aligned with its purpose—in a more mature managed-care environment, for instance, or one in which the orderers felt the financial impact of their actions—the results might have been more favorable. Also, while the financial savings were small, they could have been larger had the intervention been implemented in emergency and outpatient units, where the literature suggests the yield of KUBs may be lower than in the in-patient setting.26
We conclude that an intervention to identify low-yield KUBs was effective for identifying low-yield examinations, although simply presenting a computerized critique was rarely sufficient to convince providers to cancel orders. Providers were, however, more willing to "change direction"—that is, to order more appropriate views. To substantially reduce the number of inappropriate radiographic exams, stronger incentives or interventions may be required. Computers offer the opportunity to give patient-specific, real-time feedback to providers. This will undoubtedly prove an important tool for changing behavior; we are still learning how best to use it.
Supported in part by R01 HS08927 from the Agency for Health Care Policy and Research, Rockville, MD.
- American Medical Informatics Association


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Eminem & Royce Da 5'9" - Living Proof
Artist: Eminem
Featuring: Royce Da 5'9"
Album: Unreleased
Avg Rating: 4.2 ( 63 votes )
As those with their ears glued to the Internet grapevine may already be aware, Eminem and Royce Da 5'9" are Living Proof. Proof of… what, exactly? Well, you can take your pick: proof that Motown is a breeding ground for dope emcees, proof that artistic chemistry trumps pointless beef, proof that hard-hitting street music is alive and well… In any case, this unreleased joint, leaked to the 'net earlier this week but presented here in its final, tagless form, is proof that prior collaborations Bad Meets Evil and Session One (with Slaughterhouse) weren't flukes. Here, a currently-unknown beatsmith's hard-nosed bass-string arrangement sets the stage for the Detroit representatives' lyrically bruising back-and-forth. Shady's rhymes are even more aggressive, and provocative than usual, and Royce's unhinged imagery ("You might as well have cut the embryo out of my mama and played catch with the baby with AKs, with baby bayonets.") is no less jaw-dropping. Who comes out ahead? It would take hours for me to decide, so I'll let y'all do the honors – or, if you prefer, just sit back and bask in the dopeness.
Written by richard on Nov 17, 2010
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Cerebral Palsy Program
Contact Us: 215-590-7450
location Main Campus
Jump to navigation
The Cerebral Palsy Program is a multidisciplinary, weekly outpatient clinic that provides comprehensive care for children from birth to 21 years with cerebral palsy and related conditions. While there is no known cure for cerebral palsy, there are many interventions that can improve the function of children with this condition.
The Cerebral Palsy Program is the only pediatric interdisciplinary cerebral palsy program in Philadelphia, providing evaluations for more than 500 patients per year. We work very closely with specialists throughout the CHOP network to coordinate care for our patients.


text:
Originally Posted by Kerik
Nice work, Dana! What about ethyl alcohol for those of us that live in states where 190 Everclear is illegal?
I'm not sure what we're going to do about this, since you need a alcohol license in order to re-sell the stuff. I could always sell you a really expensive empty bottle, and send you the alcohol as a gift .


text:
Luis Suarez shared a touching dressing room video on his Twitter account, where he is thanking his wife and two kids, after beating England.
— Luis Suarez (@luis16suarez) June 19, 2014
The 27-year-old striker, who was playing his first game after he recently went through a knee surgery, and scored the opening goal for his team, also credited his physiotherapist Walter Ferreira, adding that he wouldn't have been able to play if it wasn't for him.
Even though Wayne Rooney had equalised the score with his crucial first goal in the World Cup, it went in vain as the Uruguay footie ace struck again, leading his team to a 2-1 win.
Luis Suarez shows why he deserves 'world class' label
Luis Suarez made his case for inclusion in the debate over the world's best player with both goals in Uruguay's 2-1 victory over England as he came back from injury and instantly punished Roy Hodgson's team. Cristiano Ronaldo and Lionel Messi can cite better all-round skill and trickery but when it comes to the games most valuable quality of all - putting the ball in the back of the net - Suarez is certainly in their company. Strangely, before the game, Hodgson had challenged Suarez to prove that he deserved to be placed in that 'world class' category. "I think he will only be at that level when he shows it on this particular stage," said the England manager, who must now think he was asking for trouble with that assessment. It was also a particularly odd view given that Suarez had been instrumental in Uruguay's run to the semi-finals in South Africa four years ago, scoring three times in the tournament. Read more


text:
BOISE -- For years developers of a local aquarium have been pre-selling season passes and asking supporters to sponsor animals, all while promising buyers the attraction would open soon.
After years of waiting season pass holders are getting their first look at the Idaho Aquarium today.
Some of these season pass holders have been waiting three and a half years.
While some were excited by what they saw, others we talked to weren't so sure.
Several sites were considered for the aquarium before those behind the project settled on a 10,000 square foot warehouse at the corner of Cole and Franklin roads in Boise.
Although the space is large, exhibits only fill a small portion of the aquarium. Ammon Covino with the Idaho Aquarium says exhibits are being built as funds become available.
There's a few animals that aren't in, said Covino. The big octopus is not in yet and he comes in next week. The eel tanks and lion fish are not in yet. But there are a handful of exhibits that aren't in and ready but they will be soon.
Friday evening those who purchased a season pass got their first glimpse of the aquarium before it opens to the public next week.
Some, like Wendy Griffith who purchased a family pass back in May 2008, were expecting a bit more, while others loved what they saw.
We were expecting to see shark tanks, puffins, said Griffith. On their website they had more exhibits listed.
I can't wait to see the shark exhibit and the sea otter exhibit and the seal, but you know for what it's worth they are doing a great job, said Gina Johnson.
Covino says larger exhibits like a shark tank and otter exhibit are still in the works.
The Idaho Aquarium officially opens its doors to the public on Dec. 16.
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Mixed reaction from patrons of Idaho Aquarium
Mixed reaction from patrons of Idaho Aquarium
BOISE -- For years developers of a local aquarium have been pre-selling season passes and asking supporters to sponsor animals, all while promising buyers the attraction would open soon.


text: Audio | video | interview | legal | podcast | media | transcription services california By smth0987 Transcriptionstar offers a wide range of audio, video, interview transcription... more » Transcriptionstar offers a wide range of audio, video, interview transcription services(1-877-323-4707). Prices are just 40% of those charged by local US services. Services include Medical Transcription and also transcriptioning for Media, Podcast, Business, Technical and Legal sectors « less Published January 29, 2009 100 views More Info » Full Credits smth0987 Uploader Stats & Data 1 Funny Votes 0 Die Votes 102 Views Published January 29, 2009 Categories: Animation Music Real Life Keywords: wide range Audio video medical transcription Transcription Services quote Media Podcast Business Technical Legal Dissertation MP3 Transcript Up Next: All The President's Mad Men AUTOPLAY Up Next In: 10 Audio Transcription Services Rekha Shankar's Wide-Range Character Reel LEGALLY BROWN TRAILER | Premieres September 23 Business Time - Bananas Follow Facebook Twitter Tumblr Instagram Browse Related Comments 4+ more View All ▶ smth0987 Vaguely Related Videos Vaguely RelatedPics & Words Advertisement Advertisement From Around the Web ZergNet


text:
You need a game plan and a backup game plan for when your game plan goes off course. And repete
The most important meal of the day, always sets the tone to how you are going to eat for the rest of the day and feel. Always have a nutritious meal already made on hand so you don't grab the sugary cereal or cookie in the cabinet. The best ones I have are slim fast shake or meal bar or some other meal supplement. I also make 1/2 cup of egg substitute the night before so all I have to do is reheat and grab a fuit or other health carb to go along with. Remember BE PREPARED!
How can I keep fighting the evils to be. Plan, Plan, Plan and then pray.
"Failure to plan is a plan for failure"- Unknown


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I copied a vimrc file from a windows box running gvim and tried using it on an OSX box. Turns out there are a bunch of characters that my unix vim doesn't like in the file. I assume they're Windows EOL characters or something - doesn't really matter. Anyway, Is there an easy way to remove them all at once, or convert the file to a unix friendly format?
Take the 2-minute tour ×
Super User is a question and answer site for computer enthusiasts and power users. It's 100% free, no registration required.
Ah, figured it out. To convert to a nice unix format, just use


text:
6 East 32nd Street, New York, NY 10016Map
+1 212 725 1333
email: email@example.com
Neighborhood: Midtown
Cuisine: Japanese,Seafood
Ichiumi is famous for it's 'All You Can Eat buffets', although unlike most buffets, Ichiumi has class and is an upscale restaurant in Manhattan. Try their delectable sushi and seafood, with a vast array of choices and preparations so that the menu is not repetitive. Ichiumi's also serves wines and beers for the perfect seafood experience. Food is fresh and prepared to meet the highest standards of quality and it's for an affordable price. So go on over and gorge out on the large spread of great seafood.
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text:
Wii U
Warning to anyone who has NEVER owned an HD gaming system before
DTY3 posted...
Yeah TC I tried playing Tales of Vesperia on a huge SDTV...
Tales of Vesperia plays just fine on an SDTV, me and my sisters had no issues at all.
Read the mania: http://www.fanfiction.net/~nonexistinghero
In SA2, it's Super Sonic and Hyper Shadow.
We have known Nintendo was releasing the Wii U since June 6, 2011, when they stated this was a HD console. That is 17 months. If folks didn't plan appropriately for the last 17 months, no sympathy.
GE 007 Wii FC: 3219 3898 2992 &. Minny
Parkers_Peter posted...
My God just get to the point.
The side details of the action on the screen will be cut off for the sdtv people.
Let's Get to the Top!
I played my xbox 360 for the first 4 years on a SDTV and i had no problems with it
Some days don't you wish you could high five the sun
nonexistinghero posted...
Coop14 posted...Jesus Christ this is sad. TC is trying to help, provides PROOF and so many of you act like damn middle school brats.
You didn't even read what I said did you? When did I ever insult anyone about having a SDTV? I have two of them, and I USE them. I was simply saying that there's an issue playing HD consoles on a SDTV, and that's an issue a LOT of people don't even know about. Stop being so hard headed and actually read what I said.
3DS FC - [1203-9218-7780] | XBL - [NettoSaito] | PSN - [NettoSaito] Please PM me with your FC!
My Backloggery Game List - http://www.backloggery.com/NettoSaito
I guarantee most Nintendo fans that visit Gamefaqs are fans of games period and have at some point in their life seen how an HD game looks compared to a SD game. I mean we all have access to the internet and presumably COmputer monitors that run in HD resolutions. Even if they only own a wii they would have known the difference already.
soul silver FC:1505 7978 9391; pearl FC:3911 0786 2278
nonexistinghero posted...
Coop14 posted...Jesus Christ this is sad. TC is trying to help, provides PROOF and so many of you act like damn middle school brats.
Well actually Rare made that patch because even with a HDTV the text was still crazy hard to read, so it definately was an issue on there part.
I played PS3 games on an SDTV before I had HD, the only thing I ever had problems with was loading screen text on Valkyria Chronicles. Turns out they were fictitious national anthems. What a letdown.
As a former SDTV only user, I can attest to the text being unreadable in some games, and certain things were cut out of the picture. It wasn't until after I platinumed Red Dead I got my HDTV, and tried it out on my new TV. I then discovered that the horse's had a stamina meter the whole time >_>
I'm just dickin aroouunnnd
My first PS3 was put on a little SDTV; until we got out new HDTV I had no idea the words on the screen in MGS4 were supposed to be readable. O_o


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1st BMG contest! <3
Normal RS Smart
Iridium w/ Gengar @ 521 gets Normal Smart Ribbon, $2,000, and $1,500 Contest Credits
Katsuya w/ Magmar @439 gets $1,500 + $1,000 Contest Credits
HKim w/ Bulbasaur @ 300 gets $1,500 + $500 Contest Credits
Apollo's Caterpie w/ Duskull @ 240 gets $1,000 + $500 Contest Credits
I judged this and get $2,000.
This was a pretty intense one. Magmar started out in the lead due to its stats and maxing out the voltage a few times, but after a lot of jamming moves and a Curse + D Bond combo, it was Gengar that took 1st place.


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Midwest Manufacturing Picks Up In October -Chicago Fed
- Details
- Published on Tuesday, 01 December 2009 12:38
The auto sector led the continuing pick-up in manufacturing activity in the U.S. Midwest during October, according to data published Monday.
The Midwest Manufacturing Index compiled by the Federal Reserve Bank of Chicago rose 0.5% to a seasonally adjusted level of 82.9, its fourth consecutive advance.
Source: Dow Jones Newswires


text:
Another Birthday Outfit!
Miami Heats Jersey, Jordan shoe, and heats hat! All Cake!
Tags: anniversary bar mitzvah baby shower birthday engagement graduation back to school fathers day retirement wedding miami heat jersey hat heat jordan michael jordan shoe
Please share and 'LIKE' my business page http://www.facebook.com/CAKESBYTIMBO . Enjoy, and Thank You!


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Myuna Farm
182 Kidds Road, Melbourne, VIC 3177Map
+61 3 9706 9944
email: email@example.com
Neighborhood: Dandenong Ranges & Yarra Valley
Set in a lovely wetlands environment close to Dandenong Creek and bike track, Myuna Farm seeks to educate as well as entertain children. An animal display, wetlands walk, education center and deer and ostrich farms are all very interesting and informative. For the younger ones there is a Thomas the Tank Engine to ride and lots of furry and feathered creatures to pat and feed. There is even a maze if you want the kids to get lost. The farm also provides riding lessons for the disabled.
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News from WTOP
News from the AP
Mike Causey
Shows & Panels
Shows & Panels
- Agency of the Month
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- The CFO Agenda: Delivering value from financial transparency and audit efforts in the public and private sector
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- Reducing Risk in the Cloud
- Reimagining the Next Generation of Government
Shows & Panels
- AFCEA Answers
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- Data-Centric Approaches to Government in the Cloud
- Delivering the Digital Government Mission
- Federal Executive Forum
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- Industrialized, Interoperable and Insight-driven Federal Health Panel
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- Mitigating Insider Threats in Virtual & Cloud Environments
- Moving Agency Applications to the Cloud with PaaS
- Reducing Risk in the Cloud
- Security in the Age of Targeted Attacks
- Air Traffic Management Transformation Report
- The Business of Cloud
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Shows & Panels
- Cloud-Driven Data Insights in Government
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- F-35 Lightning II Program
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- Reimagining the Next Generation of Government
- Transforming Business Operations at the Defense Department
Rescuers believe American schooner carrying 7 sank
Friday - 6/28/2013, 11:06am EDT
Associated Press
WELLINGTON, New Zealand (AP) -- Rescue crews searching for a classic American schooner carrying seven people believe the boat sank between New Zealand and Australia, although they haven't given up hope of finding survivors.
A third day of aerial searches Friday turned up no sign of the 85-year-old wooden sailboat or its crew. Named Nina, the boat left New Zealand on May 29 bound for Australia. The last known contact with the crew was on June 4. Rescuers were alerted the boat was missing on June 14, but weren't unduly worried at first because the emergency locator beacon had not been activated.
The six Americans on board include captain David Dyche, 58, his wife, Rosemary, 60, and their son David, 17. Also aboard was their friend Evi Nemeth, 73, a man aged 28, a woman aged 18, and a British man aged 35.
The leader of Friday's search efforts, Neville Blakemore of New Zealand's Rescue Coordination Centre, said it's now logical to assume the 70-foot (21-meter) boat sank in a storm but added that it's possible some crew members survived either in the life raft that was aboard or by making land.
On the day the boat went missing, a storm hit the area with winds gusting up to 110 kilometers (68 miles) per hour and waves of up to 8 meters (26 feet).
Blakemore said the Southern Hemisphere winter months tend to produce the year's worst storms, although he added that he wouldn't normally expect a sturdy and well-maintained craft like the Nina to sink in a storm like the one in early June.
Friday's search focused on the coastline around northern New Zealand, including the small Three Kings Islands. Rescuers were looking for wreckage or the life raft.
Blakemore said plane searches earlier this week covered a wide band of ocean between New Zealand and Australia. He said searchers were considering their options for the weekend.
He said the logical conclusion is that the boat sank rapidly, preventing the crew from activating the locator beacon or using other devices aboard, including a satellite phone and a spot beacon. He said that unlike many locator beacons, the one aboard the Nina is not activated by water pressure and wouldn't start automatically if the boat sank.
Dyche is a qualified captain, and he and his family are experienced sailors. Blakemore said the family had been sailing around the world for several years and was often joined on different legs by friends and sailors they met along the way.
Susan Payne, harbor master of the St. Andrews Marina near Panama City, Florida, said the couple left Panama City in the Nina a couple of years ago and sailed to Mystic Seaport in Connecticut, where they prepared for the trip.
New Zealand meteorologist Bob McDavitt was the last person known to have been in contact with the schooner, when the boat was about 370 nautical miles west of New Zealand.
He said Nemeth called him by satellite phone on June 3 and said, "The weather's turned nasty, how do we get away from it?"
He advised them to head south and brace for the storm.
The next day he got a text message, the last known communication: "ANY UPDATE 4 NINA? ... EVI"
McDavitt said he advised the crew to stay put and ride out the storm another day. He continued sending messages the next few days, but didn't hear back. Friends of the crew got in touch with McDavitt soon after that, and then alerted authorities.
Associated Press writer Melissa Nelson-Gabriel in Pensacola, Florida, contributed to this report.
Copyright 2013 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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Ranger Community
County Angus breeders recognized in 2012 evaluation report
Sep 7, 2012 - From staff reports:  Fremont County Angus breeders were recently recognized for their bulls listed in the 2012 Fall Sire Evaluation Report published by the American Angus ... [more]
Former Rustler earns Tom Trehearne Memorial Buckle
Sep 7, 2012 - From staff reports:  The 2012 Wind River Professional Rodeo Cowboys Association Rodeo Roundup in Riverton recognized professional cowboy Seth Glause, Cheyenne resident and former ... [more]
Dvergsdal, Harker to wed Oct. 11
Sep 7, 2012 - Staff:  Royl Dvergsdal, of Dubois, and Cathy Schulz, of Cody, are pleased to announce the engagement of their daughter Erica Ann Dvergsdal to Jason Ryan Harker, of ... [more]
Helton, Schuler marry
Sep 7, 2012 - Staff:  Faith Helton and Brett Schuler, of Rock Springs, married Sept. 1, 2012, in Riverton.
Building moved - 1984 (part 2)
Lander library televises London play
Sep 2, 2012 - Staff:  The Fremont County Library in Lander is presenting "The Curious Incident of the Dog in the Night Time," a live simulcast play by London's National Theatre, at ... [more]
Time for CWC play rehearsals
Sep 2, 2012 - Staff:  Central Wyoming College theater director Mike Myers is encouraging people to audition for two fall productions.
Cancer patient help gets an Eight Second Ride
Longtime workers note work holiday amid job satisfaction
P.E.O. awards education grant
County nonprofits receive Daniels Fund grants
Aug 31, 2012 - By Katie Roenigk, Staff Writer:  Organizations serving youth, seniors, and the homeless are among the recipients of $1,510,350 in grants to Wyoming nonprofits announced this week by the ... [more]
District 25 budget more 'restrictive'
Aug 31, 2012 - By Katie Roenigk, Staff Writer:  Fremont County School District 25 Superintendent Terry Snyder said local officials were conservative when forming the budget for this fiscal year, which began ... [more]
Ingalls to serve as Angus delegate
Aug 31, 2012 - From staff reports:  Dan E. Ingalls, of Riverton, has been elected as a delegate to the 129th Annual American Angus Association Convention of Delegates on Nov. 12 in Louisville, ... [more]
Kreider, Newlin to marry Sept. 8 in Pennsylvania
Aug 24, 2012 - By Emily Etheredge, Staff Writer:  Nancy and Steve Kreider, of Blue Bell, Pa., are pleased to announce the engagement of their daughter Ashleigh Kreider to Brett Newlin, of Chula Vista, Calif., ... [more]
City officials praise Riverton park employees
Aug 24, 2012 - By Emily Etheredge, Staff Writer:  Public services director Bill Urbigkit heaped praises on park superintendent Joel Blury and lands division manager Paul Throckmartin during the Riverton City ... [more]
Encana workers build Habitat home
Mackmiller named to '40 under 40' list
Aug 17, 2012 - By Christina George, Staff Writer:  Jeremiah Mackmiller, a 1997 Lander Valley High School graduate, was recently named to Sporting Goods Business Magazine's 40 under 40.
Schilling, Larsen to wed Aug. 25
Aug 17, 2012 - By Christina George, Staff Writer:  Willie and Kathy Schilling, of Riverton, are pleased to announce the engagement of their daughter Brianna Lee Schilling to Tyler John Larsen, son of Mark and ... [more]
Lander graduate to compete for seat on national FFA board
Aug 17, 2012 - By Christina George, Staff Writer:  Lander Valley High School 2010 graduate Odessa Oldham will be among 51 young adults to travel to Indianapolis to compete for one of six seats on the board for ... [more]
Riverton Tillman Scholar meets Sen. Enzi
Kinnear resident named to dean's list
Aug 10, 2012 - Staff:  Jesse Garza Jr., of Kinnear, was named to the University of Montana-Helena College of Technology spring semester's 2012 dean's list. He is enrolled and ... [more]
Shepherd, Gripon to wed Aug. 25
Aug 10, 2012 - Staff:  Kelly and Larry Foster and Ron and Michelle Gripon are pleased to announce the engagement of their daughter Jordyn Gripon to Jacob Shepherd, son of Molly and ... [more]
Rodeo auction nets more than $20,000 for Tough Enough
Sheridan grad finishes at Air Force Academy
Aug 3, 2012 - Staff:  Andrew John Ferries graduated from the U.S. Air Force Academy in Colorado Springs, Colo., with a bachelor of science degree in systems engineering ... [more]
Shoshoni Masons give citizenship awards
Bessey and Padilla to wed Aug. 18
Aug 3, 2012 - Staff:  Steve and Vickie Bessey, of Riverton, are pleased to announce the engagement of their daughter Amanda Bessey to Jerome Padilla, son of Isaac and Elizabeth ... [more]
Scott, Bray to marry
Aug 3, 2012 - Staff:  Mike and Audra Draper and Greg and Micheal Scott, of Riverton, are pleased to announce the engagement of their daughter Melissa Marie Scott to Devon Patrick ... [more]
Jul 27, 2012 - Staff:  Eickes to celebrate 40 years of marriage
Hancock, McCann to wed Sept. 22
Jul 27, 2012 - Staff:  Eunice Mushitz and Cal Hancock are pleased to announce the engagement of their daughter Angela Hancock to Tyler McCann.
Woolery named Teacher of the Year in New York
Jul 27, 2012 - Staff:  Former Riverton resident Robert Woolery, son of Dale R. and Judy A. Woolery of Riverton, was named 2012 "Teacher of the Year" by the Syracuse City of ... [more]


text:
A system which is primarily of use for lawyers, judges and electronic court reporters operates to correlate personal log notes with digitally recorded audio proceedings, such as courtroom proceedings. The notes may be made in conjunction with the computer actually recording the courtroom proceedings; or they may be made on personal computers separate from the computer recording the court proceedings. Identification of the proceedings is made on both the digitally recorded proceedings, as well as on the log notes; so that they are correlated. Each time a note is entered, the time at which the note is entered is placed as a time stamp in conjunction with the note. When the log notes are synchronized with the recorded court proceedings (either at the time the proceedings begin, or at any subsequent time), reference subsequently to that note time stamp allows direct immediate access to the same running time on the court proceedings, for subsequent review of either the recorded audio or a transcription made of that audio carrying the same time references.
1. A system for creating and entering log notes each time-linked to the recording times of a digital audio transcription record, including in combination:
a) at least one selected source of digitally recorded audio signals;
b) a computer including a memory for storing the digitally recorded audio signals and for allowing the stored digitally recorded audio signals to be played back, the digitally recorded audio signals associated with a running time corresponding to the times at which each of the audio signals were recorded;
c) the computer including a memory for storing digital signals corresponding to the specific individual log notes time linked to the digitally recorded audio signals, the computer associating a time stamp corresponding to the actual recording time of each of the log notes;
d) a display coupled to the computer, with the computer allowing the display to indicate file entries corresponding to the digitally recorded audio signals and corresponding to the log notes associated with unique file entries corresponding to the digitally recorded audio signals;
e) a play-back selection means associated with the computer allowing a user to play a desired file entry of digitally recorded audio signals associated with the corresponding log notes;
f) the computer being responsive to the play-back selection means for effecting the playing of the digitally recorded audio signals corresponding to the selected file entry; and
g) means responsive to selection by a user of a specific associated log note for effecting a time link of the time stamp associated with the selected log note to the running time of the digitally recorded audio signal and for automatically causing playing of that portion of the digitally recorded audio signal corresponding to the selected log note.
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17. A system for creating and entering log notes correlated in real time to a transcription record, including, in combination;
a) at least one selected source of recorded signals, the recorded signals associated with a date and a running time corresponding to the time at which the signals were recorded;
b) a computer including a memory for storing digital signals corresponding to specific individual log notes time linked to the running time of the recorded signals, the computer associating a time stamp with the recording of each of the log notes;
c) a display coupled to the computer with the computer allowing the display to indicate file entries of the recorded signals and corresponding to the log notes associated with a unique file entry corresponding to the recorded signals;
d) a selection means associated with the computer allowing a user to select a desired file entry from a list of file entries associated with the corresponding log notes;
e) means for correlating log notes corresponding to a specific file entry; and
f) means responsive to selection by a user of a specific log note for automatically causing the computer to locate that portion of the recorded signal time linked to the time stamp of the selected log note.
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26. A system for correlating a record of events occurring over time to recorded signals associated with a running time, including in combination:
a) at least one selected source of recorded signals associated with a running time corresponding to the time at which the signals were recorded;
b) a computer including a memory for storing digital signals corresponding to a record of events linked to the running time of the recorded signals, the computer associating a time stamp of the record of events with the stored digital signals of the record of events;
c) means for linking the time stamp of the record of events with the running time of the recorded signals; and
d) means responsive to selection by a user of a specific portion of a record of events for automatically causing the computer to locate the running time of that portion of the recorded signals linked to the time stamp of the selected portion of the record of events.
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This application is related to co-pending application Ser. No. 09/346,430, filed on Jul. 1, 1999 for a digital audio transcription system.
The present invention relates to a system for correlating log notes entered on a computer by persons during or subsequent to the recording of transcripts of proceedings. Specifically, the system correlates the notes to a recorded audio transcript to enable rapid and accurate access to specific portions of the transcript identified by the notes.
In conjunction with court proceedings and administrative hearings, it has been customary to provide a written transcript of the proceedings, with the help of a court reporter, for later review and reference. Basically, the proceedings are recorded on a stenographic writing machine, which is similar to a typewriter, but which is used for making a phonetic record of the spoken communications heard by the machine operator (court reporter) during the proceedings. Operators of such machines, such as court reporters, are trained and certified to capture a verbatim record of all testimony made during such court proceedings and administrative hearings.
During the actual hearing process, other persons present at the hearings, such as the judge and the lawyers for both sides, frequently make notes relevant to or corresponding to the testimony or other spoken conversation which takes place during the proceedings. In the past, it was necessary for the judge or the lawyers to correlate those notes with the subsequently produced transcript, requiring a relatively laborious manual search through the transcript to find the desired portions to which the notes were directed.
Recently, many courtrooms have switched to the production of an audio transcript recording of the proceedings. Judges or attorneys desiring a copy of the audio transcript are provided with copies of the recorded audio track, which then can be transcribed into a written transcript at a later date, if necessary. Originally, audio transcript recording systems relied upon magnetic tape as the recording medium. One or more microphones placed at strategic places in the courtroom picked up the voices of the judge, the attorneys and the witnesses. The microphones were connected through a mixer/pre-amplifier, which then fed a magnetic tape recorder for recording one or multiple audio tracks on the magnetic tape. Copies of the tape later were made by playing back the recorded tape and "dubbing" the audio tracks onto a new blank tape.
Various systems for accomplishing magnetic recording have been developed over the years. As with a written transcript of proceedings, however, any notes taken during the proceedings by the judge or the lawyers, for which a review of the actual recorded transcript was desired later, needed to be correlated by actually listening to a prepared reformatted magnetic tape recording of the transcript and then reversing or fast-forwarding to different sections until the desired section was found. Such correlation of notes with the transcript, again, was relatively time consuming and, particularly with respect to magnetic tape recordings, somewhat frustrating. This is true even though magnetic tape recording/playback equipment often includes a tape counter. Such tape counters are notoriously unreliable; so that even if a position were found through an initial correlation with a note, subsequent reliance on the counter to find that same position on a magnetic tape often resulted in a misalignment, which required further adjustment in order to hear the desired portion.
A computerized court reporting system for correlating the real time video/audio recording with the transcription made by the court is disclosed in the U.S. Pat. No. 4,924,387 to Jeppsen. In the system disclosed in the Jeppsen patent, a court reporting system provides simultaneous written and video record under the control of a single court reporter. The keystroke combinations made by the court reporter are recorded phonetically into a memory in the computer, which periodically obtains the current time and date from the system clock operating in conjunction with the video/audio recording to store these periodic time and date signals in conjunction with the keystrokes entered into the system. Thus, the subsequent written record, prepared from the stenographic keystrokes, includes time references which then can be used by persons present in the courtroom, or at some later date to correlate notes with the current time and date signals from the clock. The system, however, does not include a way for other persons to correlate notes with the record.
The U.S. Pat. Nos. 5,280,430 and 5,884,256 to Bennett are directed to a transcription network for use in a courtroom proceeding. The network has linked computer terminals for a court reporter, and for the various attorneys (and the judge) associated with the proceeding. A stenographic court reporter's terminal provides a speech-to-text conversion and communicates the text in real time through the network. This is accomplished through use of a computer aided transcription (CAT) system of the type which currently is in use in many courtrooms. CAT systems do not rely solely upon the paper tape for recording, but also electronically store the keystrokes in a built-in memory, or on a disk. In the system of the Bennett patents, the court reporter terminal provides speech-to-text conversion and communicates the text in real time through the network. Consequently, the text is displayed on the terminals at the different attorney locations, and at the judge, only slightly delayed from the actual speech being heard during the proceedings.
The different attorney interfaces in the Bennett system allow notes made by the attorney to be correlated to the currently displayed text, or to previously recorded text which can be viewed during the proceedings. The notes entered at each attorney's individual terminal are exclusive to that terminal (or to other terminals for attorneys associated with the first terminal). Notes from attorneys for one side, however, are not available to attorneys for the other side, unless specific procedural implementations agreed to by both sides are effected, when specific communication by way of the terminals is desired. In order for this system to work, however, it is necessary that all of the terminals are linked to the stenographic court reporter's terminal as the proceedings take place. The system does provide for marking of specific portions of the record, which is recorded in each computer terminal at times outside of the deposition or court proceedings, by scrolling through the record and marking or making notes appropriate to various questions and answers, as desired. Since the record is stored in the computer terminal, the marking is directly associated with the record; so that correlation with the marking and a record recorded elsewhere is not required.
Another feature of the Bennett patents is to allow the court reporter and attorneys to correlate the translated proceedings to the actual video/audio recording of those same proceedings. The correlation is effected by means of a synchronization scheme, which electronically associates each stenographically recorded question and answer with the actual position on the audio tape. The tape recorder is attached by a communication link to the reporter terminal. When an entire question and answer has been received, the reporter terminal requests and receives a position indication from the tape recorder counter. The marker position is generated by the tape recorder by a tape length counter and its associated circuitry. The reporter terminal then stores and associates each such position indication with the corresponding keystrokes. Afterwards, whenever necessary, the court reporter or attorneys can display the position indicator and locate the desired audio manually. The previously mentioned problems with locating audio on a tape by means of a position indicator continue to exist with this system; although an effort has been made to correlate the written record with the spoken record, simultaneously.
The U.S. Pat. No. 5,280,430 to Woods is directed to a computer aided transcription system which provides individualized electronic marking of stenographic records during the court proceeding. The system of this patent is directed to a stenographic transcriber functioning in conjunction with a CAT system. The court reporter keyboard is linked with the computer and the system also is directly linked to individual terminals for each of the attorneys and other persons, such as the judge, who may desire to mark the subsequently produced transcription record for personal follow up at a later time. The CAT system, operates in conjunction with the court reporter in a conventional manner. Simultaneously, however, whenever any one of the other independent terminals is operated, a reference signal is supplied to the CAT terminal corresponding to the operation of the mark or "flag" produced by the individual operating that terminal. Each of the individual terminals are separately encoded; so that when the written record subsequently is produced, it may be produced without any of the additional references; or individual copies carrying only the references for the particular terminal producing those references is produced. Thus, if there are four different attorney terminals linked to the system during the proceedings, a printed record provided to each of the attorneys uniquely carries his or her marks adjacent the transcript or text; and the marks of the other attorneys do not appear on that copy. Each individualized copy therefore is different from the others. The purpose of this system is to allow attorneys to reference a particular portion of the printed transcript without relying entirely upon hand written notes taken during the proceedings. Hand written notes taken during the proceedings using the Woods system may be subsequently manually correlated with the marks, which are reproduced in the transcription text, alongside that text. Searching for a particular portion of a record employing this technique is an improvement over notes taken without any correlation with the stenographic record. It still is necessary, however, to page through the record to find each of the sequential or corresponding marks for subsequent follow up. The actual text of the note is not displayed alongside the text, but necessarily is a part of some separate record, either in the form of separate note slips or a compilation of a number of individual notes made at some later date.
The system described in the above identified application is an improvement over the various prior art systems described above. In the system of co-pending application Ser. No. 09/346,430, a computer based audio digital transcription system is used to record and copy transcripts of court proceedings and administrative hearings. In the system of this application, the proceedings are specifically identified by a name or location, the date, and a running digitally recorded time corresponding to the various portions of the digital record. The time is continuously displayed, and, in a preferred mode, the clock display in the courtroom is the actual time recorded in conjunction with each segment of the digitally recorded audio proceedings. Consequently, any notes which are made by any of the attorneys, judges or other parties during the proceedings can be immediately correlated in the hand written note with the displayed time. Subsequently, when the recording is played back in the system disclosed in this co-pending application, the specific time may be entered; and the system immediately returns to that moment in the recording for review, as desired. Consequently, by entering the time when the event took place during the actual court proceeding, review instantly can be made without the long rewind or fast-forward procedure required with magnetic tape systems. Since an inaccurate length counter is not utilized, but a pre-recorded time reference to an actual time instead is used, the access to the desired testimony is accurate and immediate. Similarly, when the recorded testimony is transcribed into text form, a time stamp also can be inserted, if desired, alongside the text. Consequently, subsequent reference to a particular portion of transcript text to be made in conjunction with a note made during the proceeding can be rapidly effected by looking at the time written on the note to correlate with that same running time as it is displayed on the margin of the printed text. To access specific audio information, it only is necessary to enter the time of interest in conjunction with the playback of that particular audio record.
It is desirable to provide a system for correlating notes regarding proceedings captured by an audio digital recording system directly to the recorded audio for review purposes, whether the notes are taken during or after the recording of the proceedings.
Accordingly, it is an object of this invention to provide an improved system for correlating notes taken during an audio recording session with specific recorded audio segments.
It is another object of this invention to provide an improved system for correlating notes taken during an audio recording with specific segments of the audio recording for accessing such segments from the notes.
It is still another object of this invention to provide an improved log note system which may be operated on computers apart from an audio recording system for facilitating instant access to specific segments of the transcription by indexing the transcription in conjunction with the log notes.
It is a further object of this invention to provide an improved system for creating and entering log notes correlated to a digitized audio transcription system to facilitate indexing quickly and easily to segments of the recorded transcription corresponding to individual log notes.
In accordance with a preferred embodiment of the invention, a system creates and enters log notes correlated to a recorded transcription. The system includes a computer having memory for storing digital signals corresponding to specific individual log notes to be recorded. The computer associates at least a time with each note. The computer may or may not be associated with the system which is effecting the recording of a proceeding. A display may be coupled to the computer allowing the computer to display file entries for log notes associated with unique recorded transcription file entries. The log notes are correlated with the corresponding recorded transcription information; and the system is responsive to a-selected log note for automatically-locating that portion of a recorded transcription corresponding to the selected log note.
Reference now should be made to the drawings, in which the same reference numbers are used throughout the different figures to designate the same or similar components. This application is primarily designed to operate with the digital audio transcription system of the above identified application Ser. No. 09/346,430 filed Jul. 1, 1999, the specification of which is incorporated herein by reference, in its entirety. The log notes system which is described herein also is capable of operation with systems other than the one disclosed in the specification of the application incorporated herein by reference; but the primary utility of the log note system is in conjunction with such application.
Even though the co-pending application Ser. No. 09/346,430 is incorporated herein by reference, a brief overview of the system disclosed in that application, and its operation, is given here to establish the operating environment of a preferred embodiment of the present invention.
As shown in
As shown in
The output of the mixer 34 is supplied through a cable 36 to a card 46 in a personal computer 38, which includes a display monitor 40, a keyboard 42, and a mouse 44, or like pointing device. The computer 38 is used to provide a permanent digital recording in the manner disclosed in co-pending application Ser. No. 09/346,430. The computer 38 includes a sound card with one or more analog-to-digital circuits to convert the audio signals to digital signals, which then are stored, initially on the computer hard drive. The stored digital signals also then later can be played back or stored in a more permanent form of storage.
In many court proceedings, the individual attorneys also have personal computers or laptop computers present with them during the proceedings. Such a computer 47 is also shown in
In order to understand the manner in which the log notes are correlated and operate in conjunction with the digitally recorded audio transcription, a brief review of the recording panel and the playback panel of the digitally recorded audio proceedings is provided in conjunction with
To enable the archiving of the information to be recorded, the operator moves the mouse cursor over the button 59 of the media drive. Otherwise, archiving can be disabled by toggling off the button 59. By enabling archiving during recording, digital audio signals are copied to a permanent storage media quickly and automatically throughout the proceeding (which can be throughout the day). The manner in which such archiving is effected is described in detail in the co-pending application, incorporated by reference.
As with older audio tape recorder systems, the user "presses" (that is, places the mouse cursor over and left clicks) the prominent, circular "START RECORDING" button 48 on the recording panel shown in
Once the court is on record, the operator can listen to or monitor to all of the proceedings using the headphones 52, which are connected to the personal computer 38. As explained in the aforementioned co-pending application, this function is known as "confidence monitoring". During each recording session, the START RECORDING button 48 is lighted or brightens, and a large "CURRENT RECORD TIME" clock 53 is displayed on the recording panel. This indicates to the operator that the system is recording; and the time displayed by the "CURRENT RECORD TIME" clock 53 is the real clock time of the recording session at any particular moment. In other words, if the current time is 3:45 PM and 22 seconds, the "CURRENT RECORD TIME" display clock 53 displays "3:45:22". This is the official clock in the courtroom or administrative proceedings. Optionally, a large external clock display (not shown) can be connected to an available serial COM port on the computer 38; and this can be placed on the judge's bench, or in any other desired location. If there is a system failure which might stop the recording from taking place, the failure is noticed immediately because the clock 53 also stops instantly.
In addition to the current record time clock 53, the recording panel shown in
As mentioned, the operator can go on and off the record as frequently as needed by simply "pressing" the stop button 50 to go off the record, and by pressing the "start" button 48 to go back on the record. The buttons 48 and 50 of the recording panel also serve as a means for signaling the personal computer 38 to start recording of the digital signals, and for signaling the computer 38 to stop recording the digital signals, respectively, in order to define a recording session. Archiving of audio which had not already been copied to the permanent (archive) storage media immediately is copied whenever the archive function is turned on. The operator then can remove the archive media and store it for later retrieval, as needed.
As mentioned in the above identified co-pending application, there is no necessity for the operator to be concerned about saving files or naming files because the file creation and file naming are handled automatically by the software. As is readily apparent from the disclosure of the co-pending application, the file names of the audio files created reflect where (or what) and when they were produced, which is sufficient information to make them unique. This information also allows the content to be deduced from the file names themselves. It is important to note that because of the file naming strategy which is used, no database, proprietary or otherwise, is required to manage the audio as is the case with other digital court recording systems. Other specific operating features of the system during recording are explained in greater detail in the referenced co-pending application.
Once the audio has been recorded and exists in the recorded audio files, these files may be loaded and played back utilizing the software and system of the referenced co-pending application. Whenever an operator desires to play back a portion of the recorded digital transcript, either on the computer 38, during or after the recording session, or when a recording is inserted into a separate computer, such as the computer 47, for playback, the operator places the mouse cursor over the panel change button 76 and clicks the mouse button to signal that playback is desired. In this event, the monitor 40 or 45 of the personal computer 38 or 47 does not display the recording panel shown in
In order to access a recording for playback, a user must first select a virtual file that contains the desired digital audio transcript. The audio is selected based on the location label and date. As noted in the aforementioned co-pending application, all of the five minute files which meet the criteria of one location and one particular file are loaded under this same location label and date. To select a file, the user presses the "OPEN FILE" button 84 on the playback panel in conjunction with a mouse cursor. This action causes the monitor 40 or 45 of the affiliated computer to temporarily display a file listing or groupings of audio, as generally shown in
Similar to the recording panel shown in
As shown in
A pair of buttons 89 and 91 can be "pressed" with the mouse cursor rapidly to increment or decrement the current play time to a desired value. Alternatively, the user can simply place the mouse cursor over the hours, minutes or seconds portion of the current playtime window 88, then left click the mouse and thereby highlight a portion of the current playtime. The user then may type desired values for the current (recorded) playtime on the keyboard 42 or 49 of the computer in which the playback is being effected to cause playback to proceed immediately to such portion of the recorded audio. The clock will reflect the changing time from the playback at that selected portion, as playback continues.
The playback panel shown in
The playback panel of
In accordance with a preferred embodiment of the invention, in order to enable judges, attorneys or other parties to make notes during the initial recording of the proceedings, or subsequently during playback of previously recorded proceedings, the log note system and software disclosed hereinafter is implemented. Notes may be logged in the log note system by the person performing the audio recording of the proceedings during that recording in conjunction with the recording equipment described in conjunction with
Finally, the log notes themselves are divided into three different fields 160, 162 and 164, respectively, identified as "TIME", "SPEAKER", and "NOTE", in the preferred embodiment illustrated in
The log notes are a stand alone WINDOWS� application; although one of the primary features of the log notes, the representative panel of which is shown in
It should be noted that multiple instances of the log notes application may be running or open on a given user's system at any one time, but that only one log sheet is active for operation at a time. A log sheet is a single file which contains one or more log notes associated with audio from a specific location and day. Multiple log sheets can be created that are associated with the same audio; but each of the log sheets are independent of one another. To explain the various features and functions of the log notes system, the operation best is presented through particular use scenarios, as depicted in
A common scenario for creating a log sheet is when the user who is performing the audio recording, such as the ECR, is taking associated notes regarding the recorded proceedings. This is the situation where the ECR is recording courtroom proceedings, and also must take log notes of the proceedings for later use by the transcribers during the transcription process. For example, an ECR may take notes which clarify what is happening within the proceedings, such as when a witness is called, with notes bearing identifying information. Other notes may be taken when exhibits are introduced, identifying which participant is currently speaking, etc.
For a log sheet and notes for an audio currently being recorded, the user first initiates the recording session, as described above in conjunction with
At this point, and once the recording has begun, the user may enter new log notes into the log sheet. As described previously in conjunction with
In the present example, however, notes are to be entered against current audio recording; so that the next step is at the decision diamond 310, as to whether to enter a new note. In conjunction with the normal operation of the system, the answer is "yes"; so that new notes are entered at 312. This automatically initiates the dynamic time stamp inserted against the note at 314 on a continuous basis as each new note is entered. This occurs each time an entry is made, in either the speaker or the note fields 162 or 164, to produce the correlated time stamps in the field 160 which are identical to the time of the recording displayed in the window 53 as the proceedings progress.
Consequently, the notes which are taken during recording by the ECR are accurately correlated by time in the field 160, with the time at which the entry was made in either of the other two fields 162 or 164. This is indicated in
Reference now should be made to
When the glossary of the program is displayed on the computer screen 40 (in the present example), or 45 in conjunction with a subsequent playback or a creation of a log note apart from the recording computer 38, the display shows that it is for a log sheet folder 180 and a glossary 182. A window 184 displays glossaries for selection; and a selection "button" 186 may be used to display the various glossaries to be selected. This can be for identification of speakers, or for text strings to be entered into the note field 164. As displayed in
Similar glossaries may be used for entering the names of witnesses and attorneys, or other person who are expected to provide spoken dialogue during the proceedings; so that as these persons speak, the log note identifies the speaker. This can be done simply by pressing the assigned key, without having to type in the name each time it occurs. Thus, the speaker identification which is shown in Field 162 of both
The log sheets are automatically saved to the disk of the computer 38 or 47. A new log sheet, however, is not saved for the first time until the first note is actually entered. If no note is entered, no log sheet is saved, since basically, no log sheet actually was created. When the log sheet is completed, the user simply can close the log sheet for retrieval at a later time from the disk, and can also save the log sheet to another location, if desired.
The system function and operation here is one where the log sheet and the notes are created on the computer 47, for example, which is separate from and not physically or electronically connected with the computer 38 on which the sound recording is being made. An example of a situation utilizing this type of operation is one in which in which a judge or an attorney taking notes during a court proceeding does so on his or her notebook computer in the courtroom. Because the recording is not being performed on the same system as the log notes, the location label set on the recording system as described in conjunction with
The various other functions for this scenario are performed in the same manner as described above in the situation where the log notes are being entered on the same computer on which the recording is being made. There are some additional caveats, however. The date that is inserted into the log sheet field 156 is the system date of the local computer. Ordinarily, this date should match the date on the recording computer system (and therefore, match the date in the audio file names). It may not match, however, due to an inaccurately set computer clock. This is not critical, since this date automatically can be corrected when the audio associated with these log notes is available later for review in conjunction with the log notes.
It also should be noted that the time stamps which are added for each log note represent the system time of the local computer. These time stamps very well may be different from the time stamps which are made in conjunction with the audio recording. The variance in time between the log notes and the actual recording may range from a few minutes or seconds, due to inaccurately set computer clocks, to as much as several hours in the case of the user traveling from some other geographic location to the one in which the recording is being made. In any event, the time stamps also can be updated automatically later when the audio is played on a computer in conjunction with the log notes for subsequent review. The manner in which this synchronization is effected is covered in a subsequent section.
The situation here again is very similar to the original one described when the log notes are created in conjunction with the recorded audio. In this case, a previously recorded audio is loaded into the playback panel on a local system where the log notes is being used to create the new log sheet. A situation of this type may occur when an attorney receives audio from a proceeding that took place previously; and the attorney desires to review the proceedings and concurrently take associated notes for summarizing purposes.
The manner in which this is done is that the system is initiated and the subject audio is loaded in the playback panel for playback under control of the panel operation described previously in conjunction with
At this point, the user may enter new log notes into the log sheet, based on the current playback time of the loaded audio. This occurs automatically because the log sheet now is synchronized with the audio. At the moment the user enters a note, a time stamp immediately and automatically is inserted in the time field 160 of the particular note, in the same manner described above in conjunction with
Reference should be made to
Once a log sheet has been created as described in the different situations above, the sheet and notes contained can be used to review or navigate the corresponding audio. To open an existing log sheet, the user performs a search using the search interface shown in
Once an existing log sheet is opened, the user can click on any time stamp in the notes, which will automatically start the audio playback at the precise point (illustrated in
The automatic loading of the audio for the playback panel is dependent upon the audio existing in a drive/path location of the system described above mentioned co-pending application. Specifically, the system of that application maintains a list of drive/paths where it will "look" for audio when a request is made. This could include a recordings folder on the hard drive, a CD-ROM connected to the local system, a network drive location, or even a server or content manager database. This list can be modified by the user. In the event that audio cannot be found in the drive/path locations, the user is given the opportunity to manually browse for the audio.
When a specific log note time stamp is identified by placing a cursor over it and then left-clicking the mouse, on the log sheet, the current play time in the playback panel corresponding to that time of the log sheet automatically jumps to the time selected in the time stamp of the log sheet. As a consequence, the particular audio associated with the note immediately can be played. This is an advantage of the digitally recorded audio over the previously time consuming and cumbersome rewinding and fast-forwarding of magnetic tapes.
Because a log sheet can include many note field entries, the software provides the ability for the user to search for strings of text within the log sheet to locate specific occurrences of the text. For example, an exhibit number could be entered as the search string from the text note field 164; and then every occurrence of that number which exists in the log sheet rapidly is located and highlighted. The desired highlighted portions then can be identified by the cursor and clicked upon to cause the playback correlating to the time stamp for that log note to be effected in the playback of the audio.
As referenced in the foregoing sections, there may be situations where the log sheets, such as the log sheet of
The location label and date embedded in the audio files are considered fixed. These are not changed. When a log sheet is to be associated, the location label and date from the audio files must be passed to the log sheet and inserted into the fields 156 and 158, so that the log sheet will operate in conjunction with the audio.
Reference now should be made to
As referenced in previous sections, there may be situations when the time stamps in the field 160 of the log sheets do not reflect the correct time at which each note was created, relative to the audio with which it is associated. As mentioned previously, this may happen when an attorney creates a log sheet during a proceeding being recorded, and his/her computer system time does not match that of the recording system. Although the relative times between the different time stamps on the log sheet and the audio will be accurate, the times reflected by the time stamp on the log sheets will be either earlier or later, relative to the audio. In any event, when this situation exists the time stamps in the log sheet may be readily synchronized with the actual time of the audio.
The synchronization of the notes is outlined in
This is illustrated in
As mentioned previously, the generation of these log notes in conjunction with the preferred embodiment of the invention may be utilized with systems other than the system of the above referenced co-pending application; although ideally it is designed for operation with that system. The log note system itself allows rapid and accurate notes to be taken which may be correlated with any proceeding in which a time stamp is made. The log notes may be correlated in the present system with a written record carrying time stamps where that written record is made from digitally recorded audio proceedings, or from proceedings which are recorded in a conventional manner by a court reporter. So long as the transcript carries time references on its margins, log notes separately made may be correlated with the references in the transcript.
The foregoing description of the preferred embodiment of the invention should be taken as illustrative, and not as limiting. Various changes and modifications will occur to those skilled in the art for performing substantially the same function, in substantially the same way, to achieve substantially the same result, without departing from the true scope of the invention as defined in the appended claims.
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