Methods Inf Med 1994; 33(05): 479-487
DOI: 10.1055/s-0038-1635051
Original Article
Schattauer GmbH

A Unified Approach to the Design of Clinical Reporting Systems

A. Gouveia-Oliveira
1   Department of Biomathematics, Faculty of Medicine, University of Lisbon, Portugal
,
N. C. Salgado
2   CISED Informatica, Lisbon, Portugal
,
A. P. Azevedo
2   CISED Informatica, Lisbon, Portugal
,
L. Lopes
3   Companhia IBM Portuguesa SA, Lisbon, Portugal
,
V. D. Raposo
2   CISED Informatica, Lisbon, Portugal
,
I. Almeida
2   CISED Informatica, Lisbon, Portugal
,
E. Galvão de Melo
1   Department of Biomathematics, Faculty of Medicine, University of Lisbon, Portugal
› Author Affiliations
Further Information

Publication History

Publication Date:
12 February 2018 (online)

Abstract:

Computer-based Clinical Reporting Systems (CRS) for diagnostic departments that use structured data entry have a number of functional and structural affinities suggesting that a common software architecture for CRS may be defined. Such an architecture should allow easy expandability and reusability of a CRS. We report the development methodology and the architecture of SISCOPE, a CRS originally designed for gastrointestinal endoscopy that is expandable and reusable. Its main components are a patient database, a knowledge base, a reports base, and screen and reporting engines. The knowledge base contains the description of the controlled vocabulary and all the information necessary to control the menu system, and is easily accessed and modified with a conventional text editor. The structure of the controlled vocabulary is formally presented as an entity-relationship diagram. The screen engine drives a dynamic user interface and the reporting engine automatically creates a medical report; both engines operate by following a set of rules and the information contained in the knowledge base. Clinical experience has shown this architecture to be highly flexible and to allow frequent modifications of both the vocabulary and the menu system. This structure provided increased collaboration among development teams, insulating the domain expert from the details of the database, and enabling him to modify the system as necessary and to test the changes immediately. The system has also been reused in several different domains.

 
  • REFERENCES

  • 1 Bernauer J. A controlled vocabulary framework for report generation in bone-scintigra-phy. In: Miller RA. ed. Proc Annu Symp Comput Appl Med Care. New York: IEEE Comput Soc Press; 1990: 195-9.
  • 2 Haug PJ, Ranum DL, Frederick PR. Computerized extraction of coded findings from free-text radiology reports. Work in progress. Radiology 1990; 174: 543-8.
  • 3 McDonald CJ, Tierney WM. Computer-stored medical records. Their future role in medical practice. JAMA 1988; 251: 3433-40.
  • 4 Friedman C, Alderson PO, Austin JHM, Cimino JJ, Johnson SB. A general natural-language processor for clinical radiology. J Amer Med Inform Assoc 1994; 02: 161-74.
  • 5 Kuhn K, Zemmler T, Reichert M, Heinlein C, Roesner D. Structured data collection and knowledge-based user guidance for abdominal ultrasound reporting. In: Safran C. ed. Proc Annu Symp Comput Appl Med Care. New York: McGraw Hill; 1993: 311-5.
  • 6 Bernauer J. Conceptual graphs as an operational model for descriptive findings. In: Frisse ME. ed. Proc Annu Symp Comput Appl Med Care. New York: McGraw Hill; 1992: 214-8.
  • 7 Venables CW. An overview of computerized endoscopy record systems. In: Vicary FR. ed. Computers in Gastroenterology. Heidelberg: Springer Verlag; 1988: 29-38.
  • 8 Gouveia-Oliveira A, Raposo VD, Azevedo AP. et al. SISCOPE: a multiuser information system for gastrointestinal endoscopy. Endoscopy 1991; 23: 272-7.
  • 9 Maratka Z. Terminology, Definitions and Diagnostic Criteria in Digestive Endoscopy. 2nd ed.).. Bad Homburg: Normed Verlag; 1989
  • 10 Gouveia-Oliveira A, Raposo VD, Salgado NC. et al. Modification of the OMED nomenclature: a systems approach based on the SISCOPE data model. Endoscopy 1992; 24 (Suppl. 02) 457-60.
  • 11 Rozen P, Levy E. Data management in a gastroenterology endoscopy service: initial experience using a minicomputer. Front Gastrointest Res 1984; 07: 96-109.
  • 12 Zimmerman J, Shapiro E, Porath Y, Rach-milewitz D. Computer application in a gastrointestinal endoscopy unit. Endoscopy 1985; 17: 207-9.
  • 13 Gouveia-Oliveira A, Raposo VD, Salgado NC, Almeida I, Nobre-Leitão C, de Melo FG. Longitudinal comparative study on the influence of computers on reporting of clinical data. Endoscopy 1991; 23: 334-7.
  • 14 Sowa JF. Conceptual Structures. Reading, MA: Addison-Wesley; 1984
  • 15 Chen PPS. The entity-relationship model: towards a unified view of data. ACM Trans Database Syst 1976; 9-36.
  • 16 Martin J. Information Engineering. A Trilogy (3 Vols). Englewood Cliffs, NJ: Prentice-Hall; 1989
  • 17 Pryor AT. Current state of computer-based patient record systems. In: Ball MJ, Collen MF. eds. Aspects of the Computer-based Patient Record. New York: Springer-Verlag; 1992: 67-82.
  • 18 De Dombal FT. Organization of data input -The importance of rapid/high quality data collection. Endoscopy 1992; 24 (Suppl. 02) 445-56.
  • 19 Musen MA. Dimensions of knowledge sharing and reuse. Comput Biomed Res 1992; 25: 435-67.
  • 20 Kuhn K, Gauss W, Wechsler JG. et al. Structured reporting of medical findings: evaluation of a system in gastroenterology. Meth Inf Med 1992; 31: 268-74.
  • 21 Ohmann C, Thon K, Stöltzing H. et al. The personal computer as an aid to documentation of upper gastrointestinal endoscopy. Theor Surg 1986; 01: 69-83.
  • 22 Zingmond D, Lenert LA. Monitoring free-text data using medical language processing. Comput Biomed Res 1993; 26: 467-81.
  • 23 Friedman C, Cimino JJ, Johnson SB. A conceptual model for clinical radiology reports. In: Safran C. ed. Proc Arum Symp Comput Appl Med Care. New York: McGraw Hill; 1993: 829-33.
  • 24 Johnson SB, Gottfried M. Sublanguage analysis as a basis for a controlled medical vocabulary. In: Kingsland LC. ed. Proc Annu Symp Comput Appl Med Care. New York: IEEE Comput Soc Press; 1989: 519-23.
  • 25 Cimino JJ, Clayton PD, Hripcsak G, Johnson SB. Knowledge-based approaches to the maintenance of a large controlled medical terminology. J Amer Med Inform Assoc 1994; 01: 35-50.
  • 26 Johnson SB, Cimino JJ, Friedman C, Hripcsak G, Clayton PD. Using metadata to integrate knowledge in a clinical information system. In: Miller RA. ed. Proc Annu Symp Comput Appl Med Care. New York: IEEE Comput Soc Press; 1990: 340-4.
  • 27 Jean FC, Thelliez T, Mascart JJ, Degoulet P. Object-oriented information system in the HELIOS medical software engineering environment. In: Frisse ME. ed. Proc Annu Symp Comput Appl Med Care. New York: McGraw Hill; 1992: 595-9.
  • 28 Meyer B. Object-oriented Software Construction. London: Prentice-Hall; 1988