Article

Die elektronische Befund- und Bilddokumentation in der Sonographie

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Abstract

Der aktuelle Stand der computergestützten Befunderstellung und Dokumentation für die Sonographie wird dargestellt. Argumente für eine strukturierte Datenerfassung werden dargelegt. Es folgen Hinweise zur Integration von Systemen, zum Datenschutz und zur Bildspeicherung. The state of the art for computer-based generation and documentation of ultrasonography reports is described. Arguments for standard nomenclature and structured data collection are given. Remarks concerning system integration, data privacy, and image archiving follow.

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Chapter
This chapter reviews the main sources and uses of electronic data in the medical field. It provides a systematic description of the issues emerging regarding data quality, along with the possible remedial actions. Electronic Medical Records are the core of any computerized health information system. Data accuracy, that is, the correctness of the content of the data, which is often the concern when discussing quality of data, is only one of the ‘foundational features’ or dimensions that contribute to data quality. To establish data quality within a healthcare setting and to prevent data quality issues in the system or at least limit their consequences, it is important to develop comprehensive strategies, which include both automated and manual procedures. The chapter summarizes the principal data quality issues which affect the principal source of medical data classified as administrative databases, health surveys, patients medical records, clinical trials and clinical epidemiology studies.Controlled Vocabulary Termsclinical trials; database; qualitative data
Article
Klassifikationen wie ICD-10 sind immer zweckgebundene Abbildungen einer Domäne. Die streng hierarchischen, sich gegenseitig ausschließenden Klasseneinteilungen stellen zwangsläufig einen Kompromiss dar; unter anderem mit der Verwendung von Restklassen. Unterhalb der aggregierenden Klassenebene ist eine verarbeitbare Begriffsebene notwendig. Erst sie ermöglicht eine semantische Datenintegration oder Anwendungen wie wissensbasierte Entscheidungsfunktionen. Eine Vielzahl von Begriffen mit ihren Bedeutungen und Bezeichnungen wird mit Terminologien wie LOINC bereitgestellt. Für große Fachgebiete lassen sich Terminologien aber nicht mehr durch einfache Aufzählung realisieren. So wie Menschen Sprache nach dem ,,LEGO-Prinzip“ verwenden, d. h. durch Zerlegung in kleinste Bausteine (Vokabular) und regelkonformes Kombinieren zu sinnvollen Sätzen (Grammatik), so werden in kompositionellen Terminologien wie SNOMED CT komplexe Begriffe durch Verwendung einer geeigneten Logik rechnergestützt verarbeitet. Solche Terminologien ermöglichen eine maschinelle Interpretation ausgetauschter Patientendaten, z. B. für Prüfmodule zur Verbesserung der Arzneimitteltherapiesicherheit.
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Die Qualitätssicherung sowie die Verbesserung der Ausbildungssituation im Bereich der Abdomensonographie ist eine kontinuierliche und nachhaltige Herausforderung. Ziel der hier dargestellten Untersuchung war es, die Ausbildungssituation und die Qualitätssicherungsmaßnahmen an den deutschen Universitätskliniken für Ärztinnen und Ärzte in den Abteilungen für Gastroenterologie sowie das Lehrangebot für Studierende zu untersuchen. Im Rahmen einer Umfrage an den deutschen Universitätskliniken wurde nach den durchführenden Abteilungen der Abdomensonographie, Anzahl der Untersuchungen, Geräteausstattung, Ausbildungssituation, Qualitätssicherung im Bereich der Routinediagnostik und Lehrangeboten für Studierende im Bereich Ultraschall gefragt.
Chapter
Die rapide Entwicklung der Mikroelektronik mit starker Verbesserung der Preis/Leistungsrelation eröffnet nicht nur in der Technologie der Ultraschallgeräte selbst neue Möglichkeiten, sondern auch in der Befunddokumentation und in der Gestaltung des medizinischen Arbeitsplatzes. Unsere Entwicklungen, die im Jahr 1984 begannen, setzten sich die folgenden Ziele: sofortige Verfügbarkeit elektronisch gespeicherter Befundtexte unter verschiedensten Fragestellungen. Zugriff auf Befunde von mehr als einem Arbeitsplatz aus. Strukturierung der Befunddaten. Speicherung auch von Bildern. Erleichterung der Eingabe durch Entwicklung einer multimodalen Oberfläche mit Komponenten eines wissensbasierten Systems.
Chapter
In der Medizin hat sich der Einsatz von Computern zur Befunderstellung bisher kaum durchgesetzt. Der Hauptgrund dafür ist, daß die hohen Ansprüche der medizinischen Dokumentation kaum durch konventionelle Programme realisiert werden können.
Article
Es werden die Erfahrungen mit der Ultra-schall-Dokumentationssoftware CUBUS und CUBUS-Stati-stik (1) im klinischen Routinebetrieb der II. Medizinischen Abteilung des Städtischen Krankenhauses München-Bogen-hausen und die Ergebnisse einer Umfrage dargelegt. Seit 1.8.1988 befindet sich CUBUS in den Versionen V 1.01 bis V 2.02 im klinischen Routineeinsatz. In der Version V 2.02 sind bis Oktober 1991 10 850 Datensätze gespeichert. Die Hardware-Installation erfolgte auf einem Personalcomputer (Siemens PCD-2, 40MB, 640 KB RAM) in einer Einplatzversion mit einem Laserdrucker. Die Bedienung wird arbeitsteilig von Pflege- und Arztpersonal vorgenommen. Um die Akzeptanz der erstellten Befundausdrucke zu überprüfen, führten wir eine Umfrage bei klinisch tätigen Ärzten des Krankenhauses durch. Von den 86 Ärzten, die 95 % der Befundausdrucke erhalten, antworteten 58 % (n = 50). In den Antworten wurden unter Vorgabe der Beurteilung gut, zufriedenstellend, ausrei-chend und schlecht Fragen nach Aufteilung, Schriftbild, Ver-ständlichkeit, Vollständigkeit und Gesamtbcurteilung beant-wortet. Die Gesamtbeurteilung gut bzw. zufriedenstellend wurde in 54 % bzw. 42 % abgegeben. Für die Einzelkriterien (siehe oben) ergaben sich gut bzw. zufriedenstellend in 62 % bzw. 34 %, in 58 % bzw. 32 %, in 68 % bzw. 18 % und in 74 % bzw. 24 %. Die Einhaltung der Terminologie wurde in 84 % anerkannt. Weitere Ergänzungen z. B. Bilddokumentation, auch solche über die Endosonographie, werden die Vorteile der standardisiertcn Befundeingabe und des in unserer Umfrage erhobenen guten Eindruckes des Befundausdruckes aus-bauen, so daß die relative Eingabezeit von etwa 30 % der Untersuchungszeit entsprechend gercchtfertigt ist.
Article
This article has no abstract; the first 100 words appear below. (Second of Two Parts) Interpreting Diagnostic Procedures Electrocardiograph (Table 3) Efforts are under way to minimize sources of observer disagreement in electrocardiographic interpretation by use of codes, averaging of readings, computer analysis, and other methods.³⁵³⁶³⁷ Even with completely reliable computerized reading, the diagnostic implications of electrocardiographic changes depend on the patient's age, sex, and clinical situation. In the following studies, the clinical information available to the readers varied. Gorman and his associates³⁰ compared two independent interpretations of an unselected series of 561 electrocardiograms of adult inpatients. The tracings were read first by one of three electrocardiographers and then by one . . . I am indebted to Dr. Martin Liebowitz, of the Department of Medicine, and Dr. Sherman Kieffer, of the Department of Psychiatry and Behavioral Science, for critical reviews of the manuscript, and to Dr. William J.C. Yuan, of the Department of Applied Mathematics and Statistics, State University of New York at Stony Brook, for statistical consultation. Source Information From the Department of Psychiatry and Behavioral Science, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794, where reprint requests should be addressed to Dr. Koran.
Article
The majority of physicians consider the use of free dictation for medical reports to be essential in many domains. One of the main criticisms of structured data entry is the possible lack of flexibility and completeness. Electronic documentation systems exist for endoscopy and ultrasonography examinations which are based on structured input as well as on free dictation. Endoscopy and ultrasonography reports based on free dictation were evaluated for omissive errors. The data evaluated was drawn from a database of 18,239 gastroscopy and 3,340 colonoscopy reports dictated by 28 physicians over 74 months, and 18,834 ultrasonography reports dictated by 37 physicians over 42 months. The error rates varied from 0% to 41.8% depending upon the particular feature and the particular examination, but were usually below 15%. The results were independent of the experience of the examiner. This study provides baseline measurements of omissive error rates for selected findings in gastrointestinal endoscopy and abdominal ultrasonography which can be used as standards for the development and evaluation of systems for collection of clinical data.
Article
The impact of the clinical database system SISCOPE on medical services was evaluated and objective data compiled on the quality of information recording and reporting using a fully structured data entry system compared to traditional free text reporting. 1565 upper endoscopy reports produced with SISCOPE over a period of 12 months were assessed for completeness and compared to 152 and 208 free text reports done 4 months before and 1 month after the study period, respectively. Data on four common gastrointestinal findings (esophageal varices, ulcers, polyps and tumors) were evaluated. Physicians' compliance with the new system was good, as reflected by a constant level of quality of reporting over time, although a very slight decline in the ratio of computer generated reports to the total number of examinations was noted. Structured reports had an 18% missing data rate and contained 60% more relevant information than free text reports, which had a 48% missing data rate. No educational effect of the system was seen as missing data rates returned to pre-computerization levels just one month after the end of the study. It is concluded that menu-driven structured data entry systems result in production of far superior reports as compared to free text systems, probably due to their reminder effect.
Article
Because of the visual complexity of medical images and the intensive tutorial experience required to develop image recognition expertise, professional training programs have concentrated on educating limited numbers of experts. Videodisk and CD-ROM (compact disk read only memory) image storage media now make it possible for a microcomputer workstation to provide a learning environment substantially equivalent to that of conventional time-consuming tutorial methods. A demonstration hypermedia program on echocardiography was constructed that provides a user-controlled learning environment with instant access to 54,000 video frames encompassing 1,200 clinical items. The instructional module is controlled by a microcomputer, which provides electronic linkage to relevant graphics, animations, text, categorized data bases, and digitized sound. The system has been successfully used in a residency program as the primary instructional tool for achieving an intermediate level of clinical expertise. Hypermedia offer substantial advantages over conventional books as a clinical reference source.
Article
Insight into the current status of endoscopy reports is needed for a discussion on the desirability and feasibility of (more) standardized endoscopy reporting. We collected, from ten endoscopists, 181 reports in two diagnostic and two indication categories. An inventory was made of the subjects dealt with in the reports, such as: indication, premedication, therapy plan, and descriptive aspects of ventricular ulcers and lower tract polyps. To assess endoscopists' opinions on their reports, 16 randomly selected reports were reviewed by the ten endoscopists, using the Delphi method. The reports varied enormously in content and detail; 19 of the 28 subjects were not explicitly described in more than 50 % of the studied reports. Such variation in the contents of reports may decrease the quality of care. The large number of topics that endoscopists indicate to be missing in their reports (on average 14 topics per report) suggests that more detail should be given in endoscopy reports. The current method of reporting causes endoscopists to omit information that they consider important. Due to the low overall consensus among endoscopists on which specific topics to include (eight or more endoscopists agreed on 15 % of topics) we conclude that general criteria for the contents of reports cannot yet be formulated. However, the fact that the endoscopists agreed with more than one-third of the remarks made by colleagues opens a perspective towards identifying criteria for the formalization of certain report categories.
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The advantage of using a computer to automate routine calculations and print out charts of the obstetrical ultrasound examination is obvious. This report describes a software designed to simplify the documentation and analysis of ultrasound data in obstetrics. The system is easy to use, even for persons with little computer knowledge. The programme was written in FoxBase+/Mac (Fox Software, Inc., USA). FoxBase+/Mac takes full advantage of the easy-to-learn, easy-to-use Macintosh interface and is also very fast. Another advantage of this software is that it can be used in teaching. Non-experienced examinators can double-check the correctness of their scanning planes by observing the ultrasound pictures with the markers indicating the right measurement sites and the lists of standard values of biometrical parameters for the corresponding gestational age on the screen. In routine obstetrical ultrasound examinations it takes less than 5 min to enter the foetal biometry data and print out reports. These reports are informative and easy to interpret.
Conference Paper
An integrated workstation developed for use in clinical medicine is described. The specific application domain is gastroenterology with endoscopic, ultrasonic, and laboratory units. The following modules for data collection and management during ultrasound examinations have been implemented and tested: a multimodal user interface with speech and symbol recognition to reduce complexity in human-machine interaction, knowledge-based components to support the user and to structure dialogues dynamically, and techniques for handling multimedia documents that consist of images, text, structured text, graphics, and digitized speech. The system was implemented using networked frontend and backend workstations under UNIX
Article
Medical data are defined and collected with a marked degree of variability and inaccuracy. The taking of a medical history, the performance of the physical examination, the interpretation of laboratory tests, even the definition of diseases, are surprisingly inexact. We consider the implications of this reality for computerized medical information systems, quantitative techniques for medical diagnosis, and the evaluation of bioengineering technology.
Datenbanken netzversetzt
  • R Finkelstein
Bildverarbeitung in der Ultraschalldiagnostik
  • Hj Zweifel
Der sonographische Befund aus dem Computer
  • N Heyder
  • P Lederer
  • H Schmidt
  • U Grassme
Konkurrierende Aufzeichnungsverfahren in der Sonographie
  • Hj Zabel
  • A Lorenz
  • G Van Kaick