从基于文本的报告迁移到结构化报告的系统方法和工具:基于DICOM结构化报告指南

Eduardo Beckhauser, V. A. Petrolini, Alexandre Savaris, A. V. Wangenheim, D. Krechel
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引用次数: 0

摘要

结构化报告系统是一套符合标准的实践,指导医生创建结构化文档,组织和简化他们的工作量。尽管有这些优势,许多医生仍然使用传统的方法来写他们的发现,比如自由文本报告。造成这种情况的一个主要原因是关于如何在报告环境中传播结构化报告程序的小惯例。这项工作提出了一种系统的方法,将系统例程从自由文本报告迁移到结构化报告,重点放在DICOM结构化报告指南上。为了评估这一建议,在巴西圣卡塔琳娜州综合远程医疗和远程医疗系统(STT/SC)的背景下创建了一个结构化的报告系统,并在一个涉及产科超声检查报告的案例研究中,由一组专家使用适当的模型进行了评估,显示了系统的高用户感知。结果是一组定义的前提和步骤,将远程医疗系统转变为完整的结构化报告环境。
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Systematic Approach and Tools for Migrating from Text-Based Reports to Structured Reports: Based on the DICOM Structured Reporting Guidelines
A structured reporting system is a set of standard-compliant practices that guides the physicians in order to create structured documents, organizing and simplifying their workload. In spite of this advantages, many physicians still use conventional methods to write their findings, like free-text reports. One main reason for this is the little convention on how to disseminate a structured reporting routine in the report environment. This work proposes a systematic approach to migrate a system routine from free-text reports to structured reports, focusing on the DICOM Structured Reporting guidelines. To evaluate this proposal, a structured reporting system was created in the context of the Santa Catarina State Integrated Telemedicine and Telehealth System (STT/SC), in Brazil, and, in a case study covering obstetric ultrasonography reports, was evaluated by a group of experts using the AdEQUATE model, showing a high user perception from the system. The results are a set of defined premises and steps that turns a telemedicine system into a complete structured reporting environment.
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