Preparing Structured Surgical Operation Reports
by Jussi Yliaho and Heino Poutanen
The Finnish LEIKE project has developed a software system for preparation
of structured surgical operation reports. The project involves three Finnish
partners: VTT Information Technology, Medici Data Ltd. and Oulu University
Hospital.
In Finland, first trials of computerization of health care related activities
were done in the beginning of 80's. Since those days indisputable improvements
have been made in areas like patient flow control and others of more or
less administrative nature. However, one field where the improvements have
not been as convincing as desired is the patient record, ie the core business
of health care, describing the care provided. Clinicians' demand for rapid
and detailed data storage as well as easy data retrieval with power of
structured data still exists. The main problems, which have not made it
easier to meet the challenge, have been the huge size of medical terminology
needed in such modern systems and the lack of semantic theories for representing
that terminology. The GALEN (Generalized Architecture for Languages, Encyclopedias
and Nomenclatures in Medicine) project and its successor GALEN-IN-USE of
EU have provided a good basis for terminological services needed to handle
that complexity (see article in this issue).
As the overall patient record consists of several subdomains, it was
not possible in a project with dimensions of LEIKE project, to cover all
the subdomains. It was also known that operation reports represent good
examples of detailed and structured clinical descriptions. Therefore the
LEIKE project was charged with to meet the challenge in the field of structured
operation reports. These form approximately 1-5 % of the overall patient
record. From the domain of operations, arthroscopic knee operations were
selected mainly because it was a common procedure and it represented different
subdomains of diagnostic and curative operations from various sides.
Main objectives were to provide more and better data about surgical
procedures and to preserve the richness of medical language in the reports.
As a presumption for the project was that structured data improves the
information content and quality of the operation report as well as the
possibilities for advanced further processing of the information.
Terminological services that are needed by LEIKE are provided by a programmable
knowledge server, ROIS, from Nijmegen University, The Netherlands. The
idea is that knowledge of concepts and their relations which is needed
in operation reports, is stored in a semantic network type ROIS model,
consisting of nodes and links. The model is programmed in GRAIL (Galen
Representation And Integration Language). LEIKE can use this knowledge
through a Dynamic Data Exchange (DDE) communication by asking the ROIS
to access and return needed fragments of the knowledge. For example, LEIKE
can ask ROIS to return a list of all possible indications to a certain
operation and the user of LEIKE, a doctor, can then pick the right indication
to the operation report. In case that the right indication is not found
in the model, the user can always type it in as free text.
Default operation reports have been specified for the most common arthroscopic
knee operations. When preparing a new operation report, the doctor reads
the default report and makes changes to those parts that are not suitable
to the current operation. Changing is made rapidly by using hyperlinks
in the default text. Through them the user starts communication with the
ROIS server and as the result, the text in the operation report is changed
correspondingly.
LEIKE stores the operation report in a structured, relational database
and the user can also perform SQL queries and save the results for further
processing. As LEIKE is an add-on extension module to Medici Data's patient
record software MD-MIRANDA, the prepared operation report text is attached
to overall patient record managed by MD-MIRANDA. LEIKE was developed in
Windows environment and in near future it will be adapted to work as a
client with Windows-NT version of MD-MIRANDA server.
Please contact:
Jussi Yliaho VTT Information Technology
Tel: +358 3 3163111
E-mail: Jussi.Yliaho@vtt.fi
Heino Poutanen Medici Data Ltd.
Tel: +358 8 3155653
E-mail: Heino.Poutanen@medicidata.com
