2015 Volume 2015 Issue AIMED-001 Pages 09-
To facilitate the meaningful use of medical record and report, we propose a new concept that can enhance expressiveness of structured medical records and reports. A medical record or a report based on the proposed concept is composed of entries and links, while a conventional one is composed of predefined sections, such as "FINDINGS" and "IMPRESSION" or such as "Subjective", "Objective", "Assessment" and "Plan", containing narrative sentences, respectively. Each entry can be an image annotation or a unit of description such as findings of a lesion, a possible diagnosis, or a recommendation. Links express relationships between pairs of entries, such as causation and correspondence. Links are characteristic components of such a record or report, and play an important role to provide a perspective on it. The proposed concept was implemented in a prototype reporting system that can cooperate with a PACS viewer. Using the system, 27 radiologists interpreted 54 CT studies including 27 follow-up ones. After the interpretation, they responded to a questionnaire on the system. According to the response, most of the radiologists thought that the prototype system was superior to conventional ones in many aspects. We believe, the proposed concept will be implemented in many hospital information systems, then play a pivotal role in linking various kinds of medical data among different departments to facilitate big-data utilization.
