Учебники / Computer-Aided Otorhinolaryngology-Head and Neck Surgery Citardi 2002

to information from medical journals and textbook was difficult and expensive for non–healthcare providers. Widespread access to medical information on the Internet has the benefit of allowing patients to be more educated about their ailments, but this occurs at the risk of exposure to inaccurate and potentially harmful information. Physicians now must guide patients to sources of accurate information and provide context and interpretation of information that may be found on the Internet but that ultimately proves to be of questionable accuracy.

Additionally, surgeons must take responsibility to protect the confidentiality and privacy of their patients, since the Internet and other new information technologies potentially represent a serious threat to these important aspects of the physician-patient relationship and represent major medicolegal risks for the physician.

6.2TECHNOLOGIES THAT MAY AFFECT THE EVALUATION AND MANAGEMENT OF SURGICAL PATIENTS

The patient’s initial contact with the surgeon’s office will likely take place online. After being referred to a surgeon, the patient will access the surgeon’s Internet presence from home and/or from the referring physician’s office. In addition, other access methods, including wireless Internet devices, are feasible. The patient will be able to review information about the surgeon and other background information on the website. Using a secure form, the patient will then be able to request an appointment on the site in an arrangement that will be similar to booking an airline ticket. When the patient requests an appointment, he or she will be able to specify a preference for time and date. An algorithm within the system will automatically determine when an appointment will be available based upon the patient’s preferences, the surgeon’s existing schedule, and criteria set by the surgeon. For instance, if the surgeon only wants to see one vertigo patient per clinic day, once that appointment is taken a second patient with a similar complaint cannot be scheduled on that particular day without an override from the surgeon or his office staff. Insurance preauthorization will automatically be obtained and documented before confirmation of the appointment. Copayments and other fees will be collected through an online secure credit card transaction during appointment scheduling.

Internet-based appointment scheduling can also support other advanced functions. Patients will enter their demographic information, insurance information, chief complaint, medical history, and all other required preregistration information. This may potentially be transferred from the primary care physician’s records or from an online medical record repository that the patient maintains. Based on their chief complaint, the patient will be automatically queried about previous studies (e.g., x-rays, diagnostic tests) and consultations. Appropriate

release forms will be generated for the patient to acquire all appropriate studies and records, and the patient will be advised to obtain and bring these materials to the scheduled consultation.

When patients arrive at the surgeon’s office, they will be able to log in and update any of their information. In the waiting room, they will have access to online educational materials via the Internet. The surgeon may select these materials so that patients may review information relevant to their symptoms, conditions, and possible therapeutic interventions. Before seeing the patient, the surgeon will have access to all of the information given by the patient on a handheld device or desktop system.

While the surgeon sees the patient, they will have instant access to decision support software. Based on information mined from a database of the physician’s past experiences, data aggregated in large outcome’s databases and patientspecific criteria, the physician will be able to provide estimates of treatment success and long-term outcome.

The physician will be able to view diagnostic studies, including images, and show these to the patient. Algorithms will compare new diagnostic images to previous imaging studies, and differences will automatically be calculated. Images will also be compared to image libraries that are stored on the Internet for additional diagnostic information.

Educational materials and videos will be designated for the patient to review at a later time when they log on to the surgeon’s Internet site. Any diagnostic tests ordered will be routed to the appropriate lab through secure Internet connections. After completion of these tests, the physician will automatically be notified and the patient will be able to review the results with interpretation provided by the physician. This feedback can be automated based on the results of the test and annotated with specific information by the physician when warranted.

Prescriptions will be routed to the appropriate pharmacy and automatically delivered to the patient at a convenient time and place. When attempting to prescribe a particular medication, it will be checked against the formulary supported by the patient’s insurance company, the specific cost of the pharmaceutical, the potential interactions with existing prescriptions, the efficacy with respect to the current diagnosis, and the side effect profile. If better alternatives exist, they will be suggested by the system.

Of course, the physician will enter information into the patient’s medical record, but this record keeping will be much easier and less burdensome. Dictation, voice recognition software, handwriting recognition, keyboard, or even another interface may provide a means of record keeping that is comfortable for the surgeon, since it fits the work flow. Clinical images obtained in the clinic will be integrated into the record. Documentation will be consistent and encoded so that specific data will be able to be measured and compared between encounters or between patients. Diagnostic and evaluation and management coding will

be done automatically and will appropriately reflect the level of documentation. Data collection required for participation in multisite or multi-institution research studies will be facilitated by the system and automatically captured.

The patient’s entire record, including diagnostic tests, images, and video, will be able to be transported over the Internet for consultation with experts anywhere in the world. These consultations can be done in real time with video teleconferencing or in a store-and-forward manner, whereby the expert will review the material at his or her convenience and then render an opinion. General discussions about patient care among groups of physicians on the Internet already take place, and the addition of the ability to easily and quickly share images, video, and other data will greatly enhance the utility of these services.

Prior to entering the operating room, the surgeon may load radiographic and other information into a surgical planning system and determine the best surgical approach. The system may suggest alternatives correlating outcomes with experiences. Over the Internet and using a shared environment, the surgeon may walk through the surgical plan with other surgeons who will be involved in the case or with consulting experts. This may be done in real time or may be done asynchronously, depending on the availability of the individuals.

In the operating room, the surgeon will have access to the entire record, including imaging studies. They will be able to add intraoperative findings, images, and video to the record. Additionally, the surgeon will be able to access archived cases that may be similar in nature in order to determine the best approach to the current problem. Consulting surgeons can be available for remote tele-mentoring (to provide support and teaching during difficult cases), and teleproctoring (to provide training). Both tele-mentoring and tele-proctoring may also support surgeons undergoing remediation.

When patients return home they will be able to review their medical records via a secure connection. All of the technical medical language within the records will automatically be translated into lay terms. Appropriate internal and external links to reference materials, support groups, and other resources will be provided for patient education purposes. This may include videos and interactive activities to help educate the patient about an upcoming procedure. All pharmaceuticals will be linked to documents describing the medication’s purpose, side effects, interactions, and other information. Patients will be able to access this information at any time, to provide the information to other healthcare providers, and to export this information into their own personal medical record repository.

During the course of therapy, patients will be able to report to the physician’s office about their progress with regard to recovery. Physiological data collected with wireless devices and digital images will be transmitted over the Internet to the surgeon’s office when appropriate. Additionally, outcomes and patient satisfaction information will be collected through the surgeon’s web presence and utilized to improve patient care. Patients will also be able to request

actual patient encounters. Experience is limited to patients who present during the time the trainee is present in a particular location. Most institutions currently do not have a mechanism for capturing clinical experiences or storing them in a central data repository for future study.

One of the major benefits of electronic medical records and central data repositories is the potential for education that they will provide. Surgeons in training will have access to a vast library of past clinical experiences. Entering information about a current clinical situation into a query tool will allow them to review prior cases with similar characteristics. They will be able to review past imaging studies, surgical video, and longitudinal outcome data and be able to use this information to help broaden their ‘‘clinical’’ experience. Additionally, they will be able to obtain real-time outcome statistics for comparison to current situations.

Data ‘‘mining’’ of past clinical experiences will be an important new form of clinical research. When used to evaluate a large number of clinical experiences with significant descriptive data, it will allow researchers and training physicians to identify trends and correlations that were not previously apparent.

Interesting and rare cases can be identified, stripped of identifying information, and placed in an online educational ‘‘library.’’ These could be exchanged between institutions or archived in an Internet-based archive for use by individuals around the world. Through the use of XML (extensible mark-up language) or similar technology, these cases could be converted ‘‘on-the-fly’’ to interactive educational modules that would allow physicians in training to complement their clinical experience.

Currently, didactic sessions, anatomical dissection, and self-study of the medical literature and textbooks are the main supplements to clinical experience in surgical education. The shear volume of medical information and the logarithmic expansion of medical knowledge make mastery and integration of new information a difficult and stressful task. After developing an understanding of the vocabulary and a knowledge framework, effective physicians will need to develop skills that allow them to efficiently retrieve and manage relevant information.

One of the primary online educational resources essential for surgical training are tools that allow physicians to search the medical literature and access full text versions of this information. Examples of services that are currently available include PubMed from the National Library of Medicine (http:/ /www.nlm. h.gov/), which allows the user to search the medical literature (MEDLINE indexed journals) and view abstracts of specific articles. The full text of these articles can be ordered from the site and can be delivered by mail, fax, or over the Internet. Another example is MDConsult (http://www.mdconsult.com/), which provides full text access to nearly 40 textbooks and 50 medical journals for a subscription fee. MDConsult also provides additional value by adding context to the medical literature through services such as reviews of information from the

lay press with links to relevant full text articles from the literature, reviews of clinical topics, and practice guidelines.

Access to other databases that include information about pharmaceuticals, clinical trials, genetic information, basic science research, legal information, and administrative regulations will also be a critical source of current information that will supplement other educational materials. Knowledge of the available re- sources—as well as familiarity with the techniques to access this information— will be one of the most important skills that future physicians will need. Ideally, an interface that unifies access to important knowledge bases will be developed.

Internet-based videoconferencing will be an important platform for didactic sessions. Experts from around the world will be able to lecture and share information directly with interested trainees anywhere in the world without the need for and the disruption of travel. Individuals will be able to interact with and provide feedback to the experts through the Internet. Videoconferences will be archived and accessible by the trainee at any time and from any location with an Internet connection.

Similar to practicing surgeons, videoconferencing in the operating room will allow trainees to potentially learn from experts outside of their geographic area and will allow experts to have broader exposure to people within the field. Trainees could be monitored and mentored by experts from a distance, or conversely trainees could observe experts performing surgery and be able to interact with the surgeon during the case. Additionally, surgical skill could be assessed through tele-proctoring of surgeons by anonymous and objective experts as a component of certification or in lieu of multiple choice and oral examinations.

Surgical simulation and simulation of patient encounters will be another important method of surgical training and certification. The Internet will facilitate these technologies by allowing individuals to develop and contribute scenarios for use by trainees at other locations. Due to the significant expense required for development and maintenance, simulators may be developed as an ASP model, whereby an institution develops, administers, and maintains the simulator and charges subscription fees for access. Simulators will be an important tool for practicing surgical procedures and learning new procedures. Objective criteria can be developed to rate surgical skill, monitor progression, and compare the individual to other simulator users.

6.4 CONCLUSION

The Internet and other information technologies will significantly transform and improve the practice of medicine. Exact predictions of these changes are difficult, but it behooves the practicing physician to learn about and become involved in the development of these new applications.

one’’ paradigm of medical education to one that is more experienced-based. With simulators, hands-on experience is possible at an earlier stage in training, before direct patient involvement and its associated risk. Simulation can increase the availability of experience to the student and conserve the use of scarce tutoring resources. It can enable achieving larger case numbers and exposure to a wider variety of pathology in a compressed period, resulting in an acceleration of the learning curve. Potentially, the level of preparation can improve with a decrease in the cost and time of learning medical procedures, an urgency for teaching institutions that face mounting cost pressures to provide competitively priced services while also strapped with the requirement of educating surgeons. Medical training is expensive, with costs accumulating over a lifetime long after medical school and residency training. Simulation can play a significant role in continuing medical education by assisting, through standardized training and certification programs the dissemination of new procedures and technology that offer better and more cost-effective standards of care.

With the advent of medical digital imaging standards (i.e., DICOM) and the increasing appearance of medical image information infrastructures (i.e., PACS), the creation of patient-specific models from routine medical imaging exams will be available as simulations for training in the future. These simulations will include the latest instruments and computer-aided surgical devices allowing the surgeon to preoperatively plan and rehearse, or experiment with, competing surgical approaches.

This chapter will focus on the current state of the art of surgical simulation in otorhinolaryngology–head and neck surgery, including an overview of surgical simulators and expert systems. The development of the first endoscopic sinus surgical simulator will be discussed.

7.2 BACKGROUND

Computer generated simulators have been used for a number of years to train pilots. For decades, flight simulators have provided crewmembers experience that would be too difficult, too expensive, or even impossible to obtain otherwise. Today, simulation has become indispensable to maintain the operational readiness of our military forces through many roles: instruction and training, skills maintenance and evaluation, and mission rehearsal [1].

Although simulation is a mature technology in aviation, it is not as straightforward to build simulators for medical applications. Existing aviation simulators permit navigation within a virtual environment among mostly fixed objects (such as buildings and terrain) and some rigid moving objects (such as aircraft and ships). Medical procedures, on the other hand, involve complex interactions with anatomy that one can stretch, retract, cauterize, and cut. Anatomy has dynamic physiological behavior, complex shape, and internal structure that are difficult

ode ray tube (CRT) video monitors and even holographic displays are commonly used as the interface to virtual worlds in nonimmersive simulators.

7.3.3Comparison of Immersive and Nonimmersive Simulators

Both immersive and non-immersive simulators carry specific advantages and disadvantages. Of course, the type of simulator environment that is best for a particular application will depend on multiple factors, including task characteristics, user characteristics, design constraints imposed by human sensory and motor physiology, multimodal interaction, cost, and the potential need for visual, auditory, and haptic components.

The level of detail of the anatomical model and the degree of interactivity will vary based on the goals of the simulator. Low levels of detail may be appropriate for simple tasks focusing on developing better eye-hand coordination, whereas higher degrees of image fidelity may be warranted when the task requires the subject to develop enhanced spatial awareness or situational awareness skills.

Interactivity is undoubtedly one of the real strengths and centerpieces of the simulator. The teaching tool’s power relates directly to the level of interactivity. Greater levels of interactivity will support increasingly more powerful teaching tools. Ideally, the simulator would be capable of matching the level of detail with the desired degree of interactivity to produce the most effective transfer of training for a given skill level. At the upper end, an increase in simulated detail and interactivity demands increased processing power, which even at today’s computational rates is still the rate-limiting step.

These constraints are reflected in the performance of the simulator’s latency and frame refresh rates. Latency is a measure of the interval between the instant when the user initiates an action and the instant when the computer registers the action. Short latency intervals avoid user-induced errors that occur when the user overcompensates or undercompensates for a given action because of the delay between the initiation of the action and the apparent result. Frame-refresh rate is the number of frames that the computer can generate in a given amount of time on the display system. A rate of 30 frames per second (fps) is considered ‘‘real time,’’ since the eye does not distinguish one frame from the next. As a result, all simulation systems strive to achieve this level of performance [2].

7.3.4 Haptic Sensations

Creating three-dimensional graphics and adding sound to the virtual environments have been the focus of the majority of the VR systems. The physical aspects of exploration and interaction have been largely ignored [3]. The task of developing technologies that generating sophisticated haptic (i.e., tactile, force, and proprioceptive) sensations is one of the most difficult challenges that re-