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CHAPTER
7 AT A GLANCE:
SURGICAL INFORMATICS
Overview
Surgical informatics is in a nascent phase as a discipline today.
By definition, surgical informatics is the collection, storage/organization,
retrieval, sharing, and rendering of biomedical information
that is relevant to the care of the surgical patient. Its purpose
is to seamlessly use computer-based informatics programs to
provide comprehensive and decision making support to the health
care team. As a result of applying surgical informatics to both
usual and problematic surgical cases, improved decision making
and problem solving in surgery are possible.
Clinical
Needs
Significant
clinical issues that are currently limiting the development
of surgical informatics include disparate information systems,
and few checks and balances in available informatics systems
to guide surgeons in their tasks and decisions. Clearer requirements
for information and its presentation to surgeons and other professionals
have to be developed and made available during surgeries via
text, voice, and video images. Particular attention must be
devoted to building informatics systems that integrate preoperative,
operative, and postoperative information and making it available
where and when needed. Errors in the operating room (OR) related
to incomplete information can then be avoided.
Technical
Requirements
Standards
for procedures and use of surgical informatics must be defined
and implemented. These standards should encompass uniform language/terminology
as well as uniform and seamless electronic medical records that
will include patient and surgical information, billing, and
patient safety issues. Surgical informatics technology for the
Operating Room of the Future (ORF) needs to encompass processing,
storing, and indexing details on biomedical/kinetic markers,
tissue/pathologic recognition, and other information for instant
retrieval by surgeons.
Research
Priorities
Three
key research priorities that were identified by this Working
Group are:
1) Standards development in surgical informatics; 2) Precisely
defined uses of surgical informatics systems (e.g., for optimizing
the skills of surgeons, and for teaching students differently
and helping them to perform better); and 3) Intelligent agents
that can become virtual experts/consultants which will work
with surgeons in the OR.
The
full report of this Working Group appears below.
CHAPTER
7 :
SURGICAL INFORMATICS
…THE REPORT OF WORKING GROUP 6
| PARTICIPANTS
Adrian
Park, MD, University of Maryland Medical Center (Clinical
Leader)
Alan Liu, PhD, National Capitol Area Medical Simulation
Center (Technical Leader)
Mehran Armand, PhD, Johns Hopkins University
Howard Dady, Walter Reed Army Medical Center
Anthony Gallagher, PhD , Emory University
Gerry Moses, PhD, Telemedicine and Advanced Technology
Research Center (TATRC)
Stephen Schimpff, MD, University of Maryland Medical Center
(retired)
Jianchao Zeng, PhD, Howard University
James Zhang, PhD, Georgetown University
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7.1
OVERVIEW: IDENTIFYING THE WORK OF A NEW FIELD
Surgical
informatics is in a nascent phase as a discipline today. By
definition, surgical informatics is the collection, storage/organization,
retrieval, sharing, and rendering of biomedical information
that is relevant to the care of the surgical patient. Its purpose
is to seamlessly use computer-based informatics programs to
provide comprehensive and decision making support to the entire
health care team.
Medical
informatics overall has made great progress in recent years
but surgical informatics specifically has lagged in development,
usage and, hence, in usefulness. Since the operating room is
inherently high cost and high risk along with being a key driver
of hospital revenue, it follows that effective surgical informatics
systems should be developed. Surgeons, anesthesiologists, nurses,
supply managers, and hospital management could all benefit from
surgical informatics, with the result that operative procedures
would become safer, of higher quality, and more efficient.
It
is interesting to observe that the operating room and perioperative
environment employ increasingly sophisticated technology such
as laparoscopes, monitors and video devices, along with access
to digitized laboratory and imaging data. Still, software to
aid in direct care has been less than impressive, especially
given the progress in recent years with the electronic medical
record in use elsewhere in the hospital setting. This deficiency
in effective information for the OR suite has frustrated health
care professionals and slowed perioperative environment innovation.
It is not in anyone’s best interest to have a situation
where some elements and systems are automated while others remain
paper based.
As this Working Group noted, the basic needs in surgical informatics
involve, first of all, getting patients from the clinic to a
pre-operative holding area and then to the operating room (OR)
with the correct laboratory, imaging, and other needed data,
including the specific tools needed for the surgery. A related
issue involves enabling everyone to make optimal use of this
surgery-related information, data, and surgical tools. Improved
decision making and problem solving in the perioperative environment
should result from applying surgical informatics to both usual
and problematic surgical cases and needs.
7.2 CLINICAL ISSUES: ACHIEVING OPTIMAL PERFORMANCE BY
USING SURGICAL INFORMATICS IN THE OPERATING ROOM
The
significant issues that are currently limiting the development
of surgical informatics are typical of most new disciplines.
These issues include the presence of few, accepted standards
to guide the field’s development, and limited examples
in surgical informatics that have demonstrated success. Other
limitations include the following issues:
Clearly,
these clinical limitations must be addressed. Integration of
these disparate “pieces and parts” of today’s
surgical informatics technologies has to become a top priority
among all stakeholders.
In
particular, a clearer requirement must be defined for the surgery-related
information that is needed by the health care team. At least
three categories of information and assistance need to be available
to surgeons:
- Text-based
and voice data and video images (allowing captured data to be
fed into the informatics system).
- Intelligence
or content-based retrieval mechanisms (allowing the surgeon
to retrieve information that is similar to his current operative
findings and so compare features or other details).
- Means for
retrieving and rendering information – by voice and other
sensory output, or by display for visualization such as in a
3D model – that the surgeon can use during an operation.
Other
issues limiting the development of the field that must be addressed
are the following:
-
Getting
the Right Information. The unique environment of
the OR – busy, noisy, potentially chaotic – must
influence how the surgical information is presented. Visual
presentation is appropriate for some information while auditory
feedback may not work as well, for instance. Human factors
that are unique to the OR and its special environment should
be studied. For example, designers of instrumentation have
tried to build 3D camera systems for surgery when, in fact,
improving imaging quality in the OR might be more important.
- Starting
with the Basics. To build effective systems, experts
must examine today’s disparate systems and the high amount
of error in today’s OR. The new system itself needs to
be interactive and wireless, and it should integrate preoperative,
operative, and postoperative information. It should do so precisely
and the information should be made available where and when
needed. Complete and accurate patient records are needed to
ensure that the correct surgical tools are available for surgeries.
Today, many errors in the OR can be traced to incomplete patient
information and preparation.
Currently,
there are no automatic, smart, or otherwise nonhuman checks
and balances that will note if medication has not been given
or if a surgical tool set is incomplete prior to the start of
a surgery. Even more problematic is the absence of means for
assuring that patients have been properly prepared for surgeries
when they enter the OR. Information technology must ensure that
encounters with the patient have been tracked and information
about them is available and retrievable during surgeries.
- Fixing
Today’s Informatics Systems. Ideally, surgical
informatics should be mechanical and repetitive. The systems
should organize a range of detail so that the surgeon and anesthesiologist
do not have to personally examine more mundane details that
are gathered about patients and their surgeries (are they allergic
to a medication, did they get properly prepared for surgery,
and so forth). Rather, the system should automatically review
this data and alert personnel to any potential problems.
Solutions
to the limitations of current systems are not solely technical
in nature, or at least they do not require brand new and advanced
development, this Working Group noted. Rather, what is key is
an organizational effort to “buy into” the existing
technology and devise a system in which all pieces speak the
same language. The problem of competing agendas among surgeons,
anesthesiologists, nurses, hospital administrators, and the
information technology and equipment industries must be faced
and managed.
At
the same time, a nationally acceptable set of standards and
data to be collected must be developed. The content of this
database should begin with the needs of health care professionals
in the OR and then migrate across the whole hospital. Currently,
surgeons are devising workarounds for their information systems
or working with homegrown systems that are unreliable over the
long term. More productive solutions for data standards and
collection are obviously needed.
7.3 TECHNICAL NEEDS: FOREMOST, STANDARDS FOR SURGICAL
INFORMATICS
As
in all developing fields, a set of unified standards for procedures
needs to be developed. Surgical informatics standards ought
to be mandated, in fact, for advanced and safe surgeries in
the future, this Working Group agreed. The Working Group also
identified the players who should participate in the development
of surgical informatics standards, including government decision
makers, the hospital industry, the IT and equipment industries,
and surgeons. A periodic review of these standards ought to
take place every 5-10 years.
The
value of defining and using technical standards for surgical
informatics paves the way for insisting that all related equipment
be integrated and work well together. The federal government
may very well be the driver for requiring these standards.
Today,
there are no examples of an integrated hospital where all the
equipment works together. This is not because the equipment
does not work but because it cannot, without standards, work
together. Planning for equipment development must begin anew
and from hereon in, purchasers must insist that the new devices
and systems follow specific standards (as these standards become
articulated and agreed upon).
These
standards ought to be aimed toward encompassing uniform
-
language/terminology,
possibly developed with assistance from the National Library
of Medicine and its well established classification and indexing
systems.
- electronic
medical records including patient and surgical information,
billing and inventory details, and patient safety issues. These
records, in addition, ought to be seamless and transcend institutional
and other boundaries.
These
standards should ensure that information is readily accessible
to surgeons, whether the data are centrally stored and/or encoded
and designed to be worn by the patient.
Tomorrow’s
surgical informatics systems. Surgical informatics
systems must encompass the entire patient experience including
pre-op, surgery, and post-op. Technology for these systems must
be in a language and framework that is global and flexible.
It also must have a capacity to evolve and be upgraded.
Imaging
that is included as part of the surgical informatics systems
can have multiple uses. Apart from its use during surgery, the
imaging can be used for educational purposes. For example, procedures
that are recorded can be used for simulation and teaching. As
a result of using simulations, surgical training can be systemized.
Simulation can also be useful for surgical planning as shown
in the figure below.
This
Working Group believes that technology for the ORF already exists
for today’s usual surgical procedures. What is needed
is determining ways to accrue the data beyond mere video rendering.
The Working Group stressed the need for storing and integrating
multimodal/sensory inputted data, focusing on data streams of
video that will, for example, enable anatomic pattern recognition.
Video data streams may also include details on biomedical/kinetic
markers; tissue/pathologic recognition; patient monitoring;
and perhaps audio and tactile data. This information should
be processed, stored, and indexed for instant retrieval by surgeons
on an as-needed basis. A caveat about information storage was
provided by a group member, who noted that the goal should be
to store more information better than the human brain does.
Figure
7: 3D visualization for surgical planning.
The left and middle images show 3D reconstructions of a patient
with a large hiatal hernia (stomach bulging up into chest) for
whom a laparoscopic repair is planned. These images are visualized
on the computer to allow the surgeon to study and “fly”
through the anatomy preoperatively, paying particular attention
to relationships between the esophagus and herniated fundus
to the heart, lung, aorta, etc. The surgeon can also rehearse
port placement, the planned sequence of dissection, and other
operative procedures. These reconstructions can greatly enhance
patient care over the traditional approach of studying the plain
film available from a barium swallow (shown in the right image
here).
(courtesy of Adrian Park, MD, Barry Daly, MD, and Ivan George,
Univ. of Maryland Medical Center)
Protocols for accruing these data by using intelligent agents
or smart means of manipulating and rendering it ought to be
established and this is a key technical challenge. These intelligent
agents should enable:
This
information may be presented visually during surgeries in different
formats. These formats might include images that have been registered
and overlaid. The presentation might also be auditory, tactile,
or even be achieved by providing olfactory cues to surgeons.
Ultimately,
these intelligent agent systems could function as virtual experts
(incorporating the knowledge of numerous real-life surgical
experts) to assist surgeons, anesthesiologists, and nurses.
These virtual experts could provide information and opinions
in real time during surgeries about the best practices to be
used, and could advise the surgeon. They could also be used
for educational purposes to help students learn a particular
procedure.
7.4 RESEARCH PRIORITIES
Research
needs and priorities suggested by this Working Group are aimed
at improving the development and use of surgical informatics.
These include:
Standards
Development. There is a need for arranging a multi-level
conference among representatives from government, equipment
and information technology vendors, the hospital industry, and
the surgical community, to set surgical informatics standards,
like the DICOM standard that was developed for the imaging arena.
The federal government should take the lead in this effort.
Defining
Uses of Surgical Informatics. Surgical informatics
systems and their standards ought to develop from the perspective
of a surgeon and aim to optimize his or her skills. This development
can also help to teach students in a different way; that is,
using surgical informatics may allow them to practice procedures
in more specific detail and so perform better.
Development
of Intelligent Agents. There is a need to investigate
and develop a variety of intelligent agents which can be virtual
experts or consultants of two types: non-opinionated and opinionated.
A non-opinionated agent provides guidance based on “hard”
data, such as anatomy and physiology. For example, a non-opinionated
agent may warn the surgeon that he is too close to critical
vessels or nerves. An opinionated agent may contain a database
of different approaches for a particular course of action and
be guided by thousands of similar cases to assist the surgeon.
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