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.
Jussi Yliaho VTT Information Technology
Tel: +358 3 3163111
Heino Poutanen Medici Data Ltd.
Tel: +358 8 3155653