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一种用于医学应用的新型报告生成方法:SISDS 方法及其应用。

A novel report generation approach for medical applications: the SISDS methodology and its applications.

机构信息

Gülhane Military Medical Academy, IT Department, Etlik, Ankara, Turkey.

出版信息

Int J Med Inform. 2013 May;82(5):435-47. doi: 10.1016/j.ijmedinf.2012.05.019. Epub 2012 Jul 2.

Abstract

BACKGROUND

Despite exciting innovation in information system technologies, the medical reporting has remained static for a long time. Structured reporting was established to address the deficiencies in report content but has largely failed in its adoption due to concerns over workflow and productivity. The methods used in medical reporting are insufficient in providing with information for statistical processing and medical decision making as well as high quality healthcare.

OBJECTIVE

The aim of this study is to introduce a novel method that enables professionals to efficiently produce medical reports that are less error-prone and can be used in decision support systems without extensive post-processing.

METHODOLOGY

We first present the formal definition of the proposed method, called SISDS, that provides a clear separation between the data, logic and presentation layers. It allows free-text like structured data entry in a structured form, and reduces the cognitive effort by inline editing and dynamically controlling the information flow based on the entered data. Then, we validate the usability and reliability of the method on a real-world testbed in the field of radiology. For this purpose, a sample esophagus report was constructed by a focus group of radiologists and real patient data have been collected using a web-based prototype; these data are then used to build a decision support system with off-the-shelf tools. The usability of the method is assessed by evaluating its acceptability by the users and the accuracy of the resulting decision support system. For reliability, we conducted a controlled experiment comparing the performance of the method to that of transcriptionist-oriented systems in terms of the rate of successful diagnosis and the total time required to enter the data.

RESULT

The most noticeable observation in the evaluation is that the rate of successful diagnosis improves significantly with the proposed method; in our case study, a success rate of 81.25% has been achieved by using the SISDS method compared to 43.75% for the transcriptionist-oriented system. In addition, the average time required to obtain the final approved reports decreased from 29 min to 14 min. Based on questionnaire responses, the acceptance rate of the SISDS methodology by users is also found to outperform the rates of the current methods.

CONCLUSION

The empirical results show that the method can effectively help to reduce medical errors, increase data quality, and lead to more accurate decision support. In addition, the dynamic hierarchical data entry model proves to provide a good balance between cognitive load and structured data collection.

摘要

背景

尽管信息系统技术创新令人兴奋,但医学报告在很长一段时间内一直保持不变。结构化报告的建立是为了解决报告内容的缺陷,但由于对工作流程和生产力的担忧,其采用基本上失败了。医学报告中使用的方法在提供统计处理和医疗决策以及高质量医疗所需的信息方面是不足的。

目的

本研究的目的是引入一种新方法,使专业人员能够高效地生成错误风险较低的医学报告,并可在决策支持系统中使用,而无需进行大量的后期处理。

方法

我们首先介绍了所提出的方法,称为 SISDS,它的正式定义,该方法提供了数据、逻辑和表示层之间的清晰分离。它允许以结构化形式输入类似于自由文本的结构化数据,并通过内联编辑和基于输入数据动态控制信息流来减少认知工作量。然后,我们在放射学领域的真实测试平台上验证了该方法的可用性和可靠性。为此,由一组放射科医生构建了一个食管报告示例,并使用基于网络的原型收集了真实患者数据;然后使用现成的工具构建了一个决策支持系统。通过评估用户对该方法的接受程度以及由此产生的决策支持系统的准确性来评估该方法的可用性。为了可靠性,我们进行了一项对照实验,比较了该方法与面向转录系统的性能,在成功诊断率和输入数据所需的总时间方面。

结果

评估中最引人注目的观察结果是,使用所提出的方法,成功诊断率显著提高;在我们的案例研究中,使用 SISDS 方法的成功率为 81.25%,而面向转录系统的成功率为 43.75%。此外,获得最终批准报告所需的平均时间从 29 分钟减少到 14 分钟。基于问卷回答,用户对 SISDS 方法的接受率也被发现优于当前方法的接受率。

结论

实证结果表明,该方法可以有效帮助减少医疗错误、提高数据质量,并导致更准确的决策支持。此外,动态分层数据输入模型被证明在认知负荷和结构化数据收集之间提供了良好的平衡。

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