# Patent

## Title
Gesture-based communication and reporting system

## Abstract

The present invention relates to a gesture-based reporting method and system, including a critical results reporting pathway, which is used to communicate critical findings to users according to predetermined methods (i.e., e-mail, facsimile, etc.), and create an electronic auditing trail to document receipt, understanding, bi-directional queries, and track clinical outcomes. Based on a predetermined rule set, predetermined data elements within the structured database could trigger the critical results reporting pathway. There is a quality assurance component to the invention, such that technical deficiencies in an imaging quality can be noted, analyzed, and tracked. There is a workflow and data analysis portion to the invention, wherein workflow is enhanced, and structured data is mapped to a standardized lexicon, such that data mining can be performed. Thus, the present invention extends beyond reporting alone and is a tool to facilitate electronic communication, consultation, education/training, and data mining for quality assurance.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
The present application is a continuation-in-part of U.S. patent application Ser. No. 11/176,427, filed Jul. 8, 2005 now U.S. Pat. No. 7,421,647, which claims priority from U.S. Patent Provisional Application No. 60/586,415, filed Jul. 9, 2004, the contents of which are herein incorporated by reference in their entirety.


BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention relates to an image reporting method and system, and more particularly, to methods of communication using a gesture-, symbol- or icon-based method and system of reporting findings in a radiological environment.
2. Detailed Description of the Relevant Art
The image reporting methods and systems used in the medical field, particularly radiology, has involved radiologists making notes or marks with wax crayon on x-ray film, the marks which are erasable, inconsistent, and not reproducible. However, it has taken days for a typist and the radiologist to generate reports using this technique, and if a large volume of reports are generated, this technique has not been timely or accurate.
Another image reporting method which is used conventionally, involves a radiologist dictating a report into a microphone after reviewing and interpreting findings contained within a medical image. The dictated report is then transcribed by either a typist, or by a computer using speech recognition software.
In either approach, the input is speech generated, which is then converted into a text report. However, the drawback of this approach is a potential lack of accuracy due to the problems in the inscription of varying speech patterns.
Further, traditional reporting strategies require the user to divert attention from the image in order to perform ancillary tasks such as image navigation, processing, manipulation, and reporting (most commonly using a computer keyboard or mouse as the input device). Further, timely reporting of critical results, has not always been achieved in the present system.
Thus, a method and system which performs all of these tasks in a timely and accurate fashion, and which can combine any of these tasks for efficiency purposes, is desired.
SUMMARY OF THE INVENTION
The present invention relates to a gesture-based reporting system and method, which includes a client computer or workstation with high-resolution image displaying device, and an input device which is a programmable stylus or electronic pen, where the individual concepts (i.e., radiological findings) contained within the report are defined by a series of symbols, icons, or gestures, which are drawn directly onto the image displayed on the image displaying device, by the radiologist, using the programmable stylus.
The symbols, such as checkmarks, dots, etc., are gestures or symbols which are predetermined to mean certain information. The gestures or symbols used, utilize an economy of symbols that are diverse in nature and have broad based appeal to the population of end users. At the same time, they can be made applicable to a variety of different specific situations, modalities, pathologies, etc., in order to interpret the imaging study.
Therefore, unlike a traditional text report (where the image and text report are distinct and separate from one another), the informational content contained within the image and the gesture-based report are inseparable. Instead of translating a finding or concept (i.e., an enlarged heart in a radiological application) from the image into text, the concept is retained directly within the image. This avoids the potential clerical and cognitive error, which can occur in the translational process from image to text.
By coupling imaging data, findings, and the report into one dataset, the present invention offers a unique ability to incorporate specialized decision support tools directly into the image and report simultaneously. Using a standardized and universally accepted gesture language, potential misperceptions are alleviated, and language barriers are no longer a problem.
The computer program that implements the gesture-based reporting, can perform the function of storing the image with the gestures thereon. Further, the gesture language used to map to specific findings and concepts are recognized by the gesture recognition software program, and these findings and concepts can be translated into a report using the gestures. Still further, the type of image would also be recognized by the computer program, and the computer program would be able to generate an image and place the symbols onto the selected image in the appropriate areas. Thus, the present invention works bi-directionally.
The bi-directional nature of the present invention allows for a traditional prose report to be converted into a gesture report, using natural language processing (NLP) to convert prose into symbols. This could be performed in a retrospective fashion to convert historical prose reports into gesture-based reports—providing direct comparison of reports between different users in a standardized reporting format.
In another embodiment consistent with the present invention, detailed and descriptive information (relative to the described finding) can be provided by incorporating additional modifying terms and descriptors into the gesture language, in a highly structured and organized fashion. These modifiers and descriptors force the user to identify and quantify his analysis in pre-defined and limited terms, obviating the uncertainty of the traditional prose format which may be flowery, lengthy, and unclear as to the significance and exact findings being described.
The reporting format of the gesture-based reporting method and system supplements the traditional text reports, and can add more flexibility to the user. Thus, the various reports generated can be electively turned on or off by the user of the system, and can include: 1) gestures or symbols alone embedded on the image, which map to specific findings and concepts, according to the present invention; 2) an itemized list of findings (and modifying terms associated with each finding), in a structured, text format; and 3) a traditional text report with the findings translated into prose format using natural language processing (NLP) tools.
The gesture-based report and the gesture-embedded images or “key images”, can then be auto-routed to the referring clinician using a pre-defined communication protocol.
The advantages of using gesture-based reporting when compared to conventional reporting schemes, include the important advantage that the user never takes their eye off the target image, thereby maintaining continuous contact with the object of focus. This offers a number of theoretical advantages in eye tracking, workflow, and diagnostic accuracy.
In one embodiment consistent with the present invention, the present invention may utilize an input device such as a programmable stylus, which can perform ancillary tasks such as image navigation, processing, manipulation, and reporting, using the stylus as a combined input and navigational device. This programmable stylus can not only be used to draw symbols onto the image, but can also accomplish other tasks intrinsic to the image display, navigation, interpretation, and reporting processes that are superior to using traditional computer keyboard or mouse methods. This would allow image navigation and display to be a continuous process, whereby the user never takes their eyes off the image—enhancing productivity and workflow, and also improving the image perceptual process.
The creation of structured reporting using a standardized gesture language allows for the creation of a referenceable database, which can be queried by the user for research purposes. This creates a valuable resource for practice management, clinical research, quality assurance, or utilization review.
In another embodiment consistent with the present invention, interactive consultation can be performed, with the end-user having the ability to “turn on and turn off” the embedded gestures or symbols, such that the combined image/report provides becomes an electronic consultative tool between two users. This improves on the present methods where users have to move from the images (and the findings contained within them) to the report, which are decoupled and separate from one another.
In another embodiment consistent with the present invention, neural networks can be used to more accurately define image interpretation where users are inconsistent in the results of their analysis.
Further, with gesture-based reporting, varying overlays or tiers of reports can be provided, which can show either different findings over time, or different aspects of the findings, thereby providing as much information to a user as possible in one image.
Still further, the present invention includes a critical results reporting pathway, which is triggered by report creation, examination order, report review by predetermined personnel, or the use of critical data elements in the report. In this critical results reporting pathway, referring clinicians are identified, notified, and their acknowledgements and review of the reports, as well as any communications and electronic consultations, are recorded and audited for an outcomes analysis.
In yet another embodiment, the gesture-based report includes a number of multi-tiered data elements that can be accessed either manually or in an automated fashion by the program of the present invention, the latter predetermined in accordance with each individual end-user's unique profile.
In yet another embodiment, layered or multi-tiered structured data which can be incorporated into the report by the program of the present invention, can also be used to facilitate manual or computer program-generated directives. These directives can take a number of different forms and include electronically derived (program-derived) queries of EMR data, consultations, and communication. The resulting gesture-based reporting program-driven communication pathways can be used to communicate critical findings to users according to predetermined methods (i.e., e-mail, facsimile, etc.), and create an electronic auditing trail to document receipt, understanding, bi-directional queries, and track clinical outcomes, which are stored in the database. Based on a rule set created by any of the aforementioned parties, any one of predetermined data elements within the structured database could trigger the critical results reporting pathway by the program. Once this pathway is activated by the program of the present invention, a predetermined chain of events takes place, all of which are program-driven steps.
In yet another embodiment, while most “critical results” reporting is commonly thought of as originating from the interpreting radiologist, “critical results” can also be initiated by the clinician. Thus, a consultant can review an imaging exam and may wish to alert a radiologist of “outside” imaging data. The present invention provides reporting pathways such that this is accomplished in a timely manner.
In yet another embodiment, the gesture-based reporting apparatus and system has a quality assurance component. Thus, technical deficiencies in image quality (e.g., motion artifact), can be noted and tracked. Further, technical deficiencies in image quality with uncertain etiology and significance, can be noted and analyzed.
In yet another embodiment, gesture-based reporting can be used for quality assurance (QA) purposes, by noting image artifacts which are interpreted as representative of pathology, and providing follow-up recommendations. The issues and recommendations can be used in the future for technologist/radiologist education and training.
Thus, one can see that gesture-based reporting becomes a mechanism that extends beyond reporting alone and can be a tool to facilitate electronic communication, consultation, education/training, and data mining for quality assurance.
In yet another embodiment, the gesture-based reporting apparatus and method can be used to assist in workflow. In the same manner in which QA data can be input (using gesture-based reporting) and integrated directly with the imaging dataset, workflow can be directed using gesture-based reporting to provide electronic instructions to the program of the present invention to drive the various computer program functions a user goes through in the course of the human-computer interaction.
In yet another embodiment, gesture-based reporting is used in data analysis. The creation of structured data mapped to a standardized lexicon is the central theme of gesture-based reporting, with the multiple data elements recorded extending across a broad spectrum including (but not limited to) pathologic and descriptive findings contained within the medical imaging dataset (e.g., CT scan), technical data related to image acquisition and processing, clinical data related to the individual patient medical and surgical history (as well as the specific signs and symptoms prompting the exam being performed), decision support data (e.g., CAD, textual and morphologic analysis, anatomic localization), historical imaging data, consultative information, genomics and proteinomics, and patient-specific demographics. Once these various structured data elements are mapped to a standardized and universal lexicon, data mining can be performed by the program of the present invention by having the end-user enter in specific search criteria and/or data elements of interest and the database will be automatically queried by the program. The resulting data analysis can then be integrated into the imaging report/patient folder through an electronic link presented by the program that can be accessed in a manner similar to an electronic spreadsheet with multiple individual tabs corresponding to different data categories. These structured data elements can be accessed manually (by manually searching the database), by opening up the respective tabs (using the electronic stylus), or by entering in a graphical symbol language that specifies the specific data element in question.
There has thus been outlined, some features consistent with the present invention in order that the detailed description thereof that follows may be better understood, and in order that the present contribution to the art may be better appreciated. There are, of course, additional features consistent with the present invention that will be described below and which will form the subject matter of the claims appended hereto.
In this respect, before explaining at least one embodiment consistent with the present invention in detail, it is to be understood that the invention is not limited in its application to the details of construction and to the arrangements of the components set forth in the following description or illustrated in the drawings. Methods and apparatuses consistent with the present invention are capable of other embodiments and of being practiced and carried out in various ways. Also, it is to be understood that the phraseology and terminology employed herein, as well as the abstract included below, are for the purpose of description and should not be regarded as limiting.
As such, those skilled in the art will appreciate that the conception upon which this disclosure is based may readily be utilized as a basis for the designing of other structures, methods and systems for carrying out the several purposes of the present invention. It is important, therefore, that the claims be regarded as including such equivalent constructions insofar as they do not depart from the spirit and scope of the methods and apparatuses consistent with the present invention.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic showing the gesture-based reporting method and system according to one embodiment consistent with the present invention.
FIG. 2 is a flowchart showing the gesture-based reporting method according to one embodiment consistent with the present invention.
FIG. 3 is a depiction of a chest computed tomography (CT) of a person, showing gestures and modifiers on the image according to one embodiment consistent with the gesture-based reporting method and system of the present invention.
FIG. 4 is a flowchart showing the bi-directional electronic consultation embodiment of the gesture-based reporting method and system of the present invention.
FIG. 5 is a flowchart showing the critical results reporting pathway according to one embodiment consistent with the present invention.
FIG. 6 is a flowchart which continues the critical results reporting pathway of FIG. 5.
FIG. 7 is a flowchart which continues the critical results reporting pathway of FIG. 6.
FIG. 8 is a flowchart showing the electronic consultation method according to one embodiment consistent with the present invention.
FIG. 9 is a flowchart showing the imaging examination method and reporting method according to one embodiment consistent with the present invention.
FIG. 10 is a flowchart showing the QA features according to one embodiment consistent with the present invention.



DETAILED DESCRIPTION OF THE INVENTION
The present invention relates to an alternative approach to creating an image-based report. Applications of this gesture-based (or symbol-based or icon-based) reporting can be utilized for any type of image-reporting that would benefit from a “shorthand” that is accurate and descriptive, such as in the fields of medicine (i.e., radiology), landscaping, architecture, etc.
However, the medical (i.e., radiology) application will be the exemplary embodiment as discussed below. In the exemplary radiological application, the present invention includes a computer-implemented method and computer system function to create a database of gesture-embedded image reports from which text reports can be generated and from which data mining and other analyses can be conducted.
Although the method and system of the present invention is described as being directed to the analysis of digital images, the present invention can also be adapted for use with analog images such as conventional x-ray films, photographs, or paper-based images.
In the exemplary embodiment of medical (radiological) applications, the reporting system 100 of the present invention (see FIG. 1) is also designed to interface with existing information systems such as a Hospital Information System (HIS) 10, a Radiology Information System (RIS) 20, a Picture Archiving and Communication System (PACS) 30, and to conform with the relevant standards, such as the Digital Imaging and Communications in Medicine (DICOM) standard, DICOM Structured Reporting (SR) standard, or the Radiological Society of North America's Integrating the Healthcare Enterprise (IHE) initiative.
Thus, bi-directional communication between the gesture-based reporting system 100 of the present invention and the information systems, such as the HIS 10, RIS 20, and PACS 30, etc., allows the reporting system 100 to retrieve information from these systems and update information therein and provide the desired report generated by the reporting system 100.
The reporting system 100 of the present invention (see FIG. 1) includes a client computer 101, such as a PC, which may or not be interfaced or integrated with the PACS 30, and includes an imaging display device 102 capable of providing high resolution of digital images in 2-D or 3-D, for example. However, if the image resolution can be sufficiently high, the client may be a mobile terminal, such as a mobile computing device, or a mobile data organizer (PDA), operated by the user accessing the program remotely from the client (see FIG. 2).
Methods and systems consistent with the present invention are carried out by providing an input means 104 (see FIG. 1), or user selection means, including hot clickable icons etc., or selection buttons, in a menu, dialog box, or a roll-down window of an interface provided at the client 101, and the user may input commands through a programmable stylus, keyboard, mouse, speech processing means, laser pointer, touch screen, or other input means 104.
The input or selection means 104 may be constituted by a dedicated piece of hardware or its functions may be executed by code instructions executed on the client processor 106, involving the display unit 102 for displaying the selection window and a stylus or keyboard for entering a selection, for example.
However, input of the gestures, symbols, or icons, by a user would preferably be accomplished using a multi-functional, programmable stylus 104, which can not only be used to draw symbols onto the image, but can also accomplish other tasks intrinsic to the image display, navigation, interpretation, and reporting processes that are superior to using traditional computer keyboard or mouse methods (both within the PACS and Electronic Medical Report (EMR)).
The client 101 typically includes a processor 106 as a client data processing means, the processor including a central processing unit (CPU) 107 or parallel processor and an input/output (I/O) interface 108, a memory 109 with a program 110 having a data structure 111, all connected by a bus 112. Further, the client 101 would include an input device or means 104, a display 102, and may also include one or more secondary storage devices 113. The bus 112 may be internal to the client 101 and may include an adapter to a keyboard or input device 104 or may include external connections.
The imaging display device 102 for the present invention is a high resolution touch screen computer monitor, which would allow images, such as x-rays, to be readable and for the gestures or symbols to be applied easily and accurately. Alternatively, the imaging display device 102 can be other touch sensitive devices including tablet, pocket PC, and plasma screens. The touch screen would be pressure sensitive and responsive to the input of the stylus 104 which would be used to draw the gestures or symbols of the present invention, directly onto the image displaying device 102.
In addition, high resolution goggles may be used to provide end users with the ability to review images without the physical constraints of an external computer. For example, a surgeon wearing specialized high resolution goggles to display the cross-sectional radiological image of a brain tumor in 3-D format, would be able to note the gestures on the image highlighting the pathology in question and reporting pertinent characteristics (i.e., anatomic localization, size, etc.), to serve as a guide during surgery. These goggles are used for image-guided surgery and gesture-based reporting would serve to provide consultation on pertinent findings during the course of surgery.
In another example, an internal medicine physician could use these specialized goggles outside the hospital, to review images with embedded gestures or symbols. The images could be downloaded using wireless technology and displayed on the goggles, thereby eliminating the need for a computer screen for image display.
Note that with respect to the client system 101, the graphics user interface is a client application written to run on existing computer operating systems which may be ported to other personal computer (PC) software, personal digital assistants (PDAs), and cell phones, and any other digital device that has a screen or visual component and appropriate storage capability.
The processor 106 at the client 101 may be internal or external thereto, and executes a program 110 adapted to predetermined operations. The processor 106 has access to the memory 109 in which may be stored at least one sequence of code instructions comprising the program 110 and the data structure 111 for performing predetermined operations. The memory 109 and program 110 may be located within the client 101 or external thereto.
Note that at times the system of the present invention is described as performing a certain function. However, one of ordinary skill in the art would know that the program 110 is what is performing the function rather than the entity of the system itself.
The program 110 which runs the gesture-based reporting method and system of the present invention can include a separate program code for performing a desired operation, or may be a plurality of modules performing sub-operations of an operation, or may be part of a single module of a larger program 110 providing the operation.
The processor 106 may be adapted to access and/or execute a plurality of programs 110 corresponding to a plurality of operations. An operation rendered by the program 110 may be, for example, supporting the user interface, data mining functions, performing e-mail applications, etc.
The data structure 111 may include a plurality of entries, each entry including at least a first storage area that stores the databases or libraries of gesture symbols, or image files, for example.
The storage device 113 stores at least one data file, such as image files, text files, data files, audio, video files, etc., in providing a particular operation. The data storage device as storage means 113, may for example, be a database, including a distributed database connected via a network, for example. The database can be a computer searchable database and may be a relational database. The storage device may be connected to the server 120 and/or the client 101, either directly or through a communication network, such as a LAN or WAN. An internal storage device 113, or an external storage device 114 is optional, and data may also be received via a network and directly processed.
In methods and system consistent with the present invention, the client 101 may be connected to other clients 101 or servers 120, including administration, billing or other systems, via a communication link 116 as a client communication means, using a communication end port specified by an address or a port, and the communication link 116 may include a mobile communication link, a switched circuit communication link, or may involve a network of data processing devices such as a LAN, WAN, the Internet, or combinations thereof. In particular, the communication link may be to e-mail systems, fax, telephone, wireless communications systems such as pagers and cell phones, wireless PDA's and other communication systems.
The communication link 116 may be an adapter unit capable to execute various communications protocols in order to establish and maintain communication with the server 120, for example. The communication link 116 may be constituted by a specialized piece of hardware or may be realized by a general CPU executing corresponding program instructions. The communication link 116 may be at least partially included in the processor 106 executing corresponding program instructions.
In one embodiment consistent with the present invention, if a server 120 is used in a non-distributed environment, the server 120 would include a processor 121 having a CPU 122 or parallel processor which is a server data processing means, and an I/O interface 123, but may also be constituted by a distributed CPU 122 including a plurality of individual processors 121 on one or a plurality of machines. The processor 121 of the server 120 may be a general data processing unit, but preferably a data processing unit with large resources (i.e., high processing capabilities and a large memory for storing large amounts of data).
The server 120 also includes a memory 124 with program 125 having a data structure 126 all connected by a bus 127. The bus 127 or similar connection line can also consist of external connections, if the server 120 is constituted by a distributed system. The server processor 121 may have access to a storage device 128 for storing preferably large numbers of programs for providing various operations to the users.
The data structure 126 may include a plurality of entries, each entry including at least a first storage area which stores image files, for example, but may also have alternative embodiments including that associated with other stored information as one of ordinary skill in the art would appreciate.
The server 120 may be a single unit or may be a distributed system of a plurality of servers 120 or data processing units, and may be shared by multiple users in direct or indirect connection to each other. The server 120 performs at least one server program for a desired operation, which is required in serving a request from the client 101.
The communication link 129 from the server 120 is preferably adapted to communicate with a plurality of clients.
The present invention is implemented in software which can be provided in a client and server environment, or in a distributed system over a computerized network across a number of client systems. Thus, in the present invention, a particular operation may be performed either at the client or the server, at the edge of a network or at the center, or both. Therefore, at either the client or the server, or both, corresponding programs for a desired operation/service are available.
In a client-server environment, at least one client and at least one server are each connected to a network 220 such as a Local Area Network (LAN), Wide Area Network (WAN), and/or the Internet, over a communication link 116, 129. Further, even though the systems HIS 10 and RIS 20, and PACS 30 (if separate) are shown as directly connected to the client 101, it is known that these systems could be connected to the client over a LAN, WAN, and/or the Internet via communication links. Interaction with users may be through secure and non-secure internet connectivity. Thus, the steps in the methods consistent with the present invention are carried out at the client or at the server, or at both, the server (if used) being accessible by the client over for example, the Internet using a browser application or the like.
The client system 101 may include communications via a wireless service connection. The server system 120 may include communications with network/security features, via a wireless server, which connects to, for example, voice recognition. However, one of ordinary skill in the art would know that other systems may be included.
In another embodiment consistent with the present invention, the client system may be a basic system, and the server may include all of the components necessary to support the software platform of the present invention. Further, the present client-server system may be arranged such that the client system can operate independently of the server system, but that the server system can be optionally connected. In the former situation, additional modules would instead be connected to the client system. In another embodiment consistent with the present invention, the client system and server system can be disposed in one system, rather being separated into two systems.
Although the above physical architecture has been described above as client-side or server-side components, one of ordinary skill in the art would know that the above components of the physical architecture may be in either client or server, or in a distributed environment.
Further, although the above-described features and processing operations may be realized by dedicated hardware, or may be realized as programs including code instructions executed on data processing units, it is further possible that parts of the above sequence of operations are carried out in hardware, whereas other of the above processing operations are carried out using software.
The underlying technology allows for replication to various other sites. Each new site can maintain “state” with its neighbors so that in the event of a catastrophic failure, other server systems can continue to keep the application running, and allow the system to load-balance the application geographically as required.
Further, although aspects of one implementation of the present invention are described as being stored in memory, one of ordinary skill in the art will appreciate that all or part of the methods and systems consistent with the present invention may be stored on or read from other computer-readable media, such as secondary storage devices, like hard disks, floppy disks, CD-ROM, a carrier wave received from a network such as the Internet, or other forms of ROM or RAM either currently known or later developed. Further, although specific components of the system have been described, one skilled in the art will appreciate that the system suitable for use with the methods and systems consistent with the present invention, may contain additional or different components.
Accordingly, in one embodiment consistent with the present invention, the gesture-based reporting system 100 and method as used in an exemplary radiology method and system, includes a client computer 101 with image displaying device 102, and an input device 104 which is a programmable stylus. The programmable stylus 104 is used as input means, and can not only be used to draw symbols onto the image, but can also accomplish other tasks intrinsic to the image display, navigation, interpretation, and reporting processes of the present invention.
Thus, the radiologist turns on the client computer system 101, which may be a stand-alone PC, or part of or connected to a client workstation known in the radiological field as the PACS workstation 30. In this exemplary embodiment, the client computer 101 is the PACS 30, and some or all of the present invention, with respect to imaging display device 102, computer memory 109 and program 110 etc., is contained within the PACS 30 instead of being provided separately.
Thus, the user logs onto the PACS system 30 once the client 101 is operational. The computer program 110 will then offer the user a menu in step 200, and the radiologist can then select, and the program 110 will open up in step 201, the worklist folder listing image files available for analysis, from the menu offered.
In step 202, the radiologist can select and the computer program 110 will load the imaging study (i.e., patient data) selected in step 201, including but not limited to image data corresponding to radiological examinations of patients from the PACS 30, and additional information, including but not limited to laboratory data, pathology reports from the Electronic Medical Record (EMR), patient demographics, and billing, from data storage 113, onto the display 102. Note that the PACS 30 stores information according to existing standards such as DICOM. The data from the PACS 30 is stored in an examination image storage device 114, 128 for example, where it can be accessed via the client computer 101 for display on the image displaying device 102. Alternatively, the reporting system 100 can directly access the PACS images in storage 113 without the need for an intermediate storage device 114 or 128, for example.
The selected imaging study, including all of the associated unread (or read) examination files for that patient, is displayed by the computer program 110 on the client 101. The study can be organized by the computer program 110 by DICOM series prior to display.
When the study only contains a few images (radiography or mammography), the radiologist reviews the images in a static fashion. If the imaging study contains many images (CT, MRI), the images are reviewed in a dynamic fashion using a cine format (which is akin to a movie where the images rapidly scroll up and down in a sequential fashion).
In step 203, the radiologist selects the desired image display format (static or dynamic) and begins reviewing the images. When the radiologist observes a pertinent finding, the specific image of interest is denoted (using the stylus 104) and marked as a “key image” using an appropriate gesture or symbol on the image (see FIG. 3). The radiologist draws the pre-defined symbol over the finding of record, based on an established gesture language, to create an “embedded” image.
The gestures or symbols (see Table 1), such as checkmarks, dots, etc., are gestures or symbols which are predetermined to mean a certain type of pathology. The gestures or symbols used utilize an economy of symbols that are diverse in nature and have broad based appeal to the heterogeneous population of end users (i.e., radiologists). At the same time, they are applicable to all imaging modalities, anatomic regions, and different types of pathology that the radiologists are asked to interpret in imaging studies.
For example, as shown in Table 1, a check mark can be used to show a “normal” image, an “S” shaped line through the long axis of the spine to show scoliosis, three dots forming a triangle to show airspace disease, three horizontally-oriented tacked lines to show interstitial disease, etc. However, it would be obvious to one of ordinary skill in the art that various different gestures, symbols or icons could be used to identify differing conditions and diseases, these gestures or symbols which would be taught to the radiologist beforehand, either in a text, or which may be provided in a tutorial on the client computer 101.
After the radiologist defines the primary finding, modifiers may be recorded on the image using the stylus 104 by the radiologist, also using pre-defined symbols and icons, an example of which are shown in Table 2. The modifying terms and descriptors force the radiologist to identify and quantify his analysis in pre-defined and limited terms, obviating the uncertainty of the traditional prose format which may be flowery, lengthy, and unclear as to the clinical significance and exact etiology of the findings being described.
For example, when the radiologist wants to specify the anatomic location of the lung nodule, he/she can, for example, “click” on the designated icon for “anatomy”, and localizes the area of interest on the corresponding three-dimensional anatomic map using the stylus 104. These modifying gestures or symbols provide additional information regarding size, morphology, clinical significance, and diagnosis (see Table 2 and FIG. 3); although one of ordinary skill in the art would know that other symbols other than the ones shown, can be used for these and any other terms.
After completion of image review and interpretation, the radiologist can then sign the gesture-embedded image by electronically placing his/her initials (using the stylus 104) on the image, for example in the lower right hand corner of one of the key images.
The image with the gestures and/or for the modifiers recorded thereon, can be saved on the client computer 101 in step 204.
After being instructed to “save”, the computer program 110 will correlate the gesture or modifier recorded on the image, to a database 113, 114 or 128 for example, of gestures which provide the text for the correlation of the gesture or modifier, in step 205. The program 110 will then update the display 104 to show the text correlating to the gesture or modifier, next to the gesture or modifier symbol in step 206. The computer program 110 will offer confirmation and verification of the gestures or modifiers to be saved, by flashing the corresponding text for the entered gesture or symbol at the location of the gesture in step 207.
If the computer program misinterprets the gesture or symbol entered, and the text for the gesture or symbol is incorrect, the radiologist will place an “X”, for example, over the gesture or symbol (for “delete”), and the computer program 110 in step 208, will erase or delete the text and/or the gesture or symbol for the image and the corresponding report related to that gesture.
The radiologist then re-enters the gesture-based symbol as in step 204, and repeats the process, eventually confirming the gesture when visualizing the correct corresponding text. The computer program 110 will confirm the text as correct in step 209, and then save the gesture-embedded image in step 210.
The “saved” annotated “key images” are stored separately in the database or archive 113, 114 or 128, for example, in addition to the comprehensive imaging dataset. These “key images” with the embedded gesture-based symbols can also be electronically sent directly to the referring clinician (based on a pre-defined communication protocol, such as e-mail, etc.) in step 211.
Once the image/report has been signed off and saved, the computer program 110 then brings up the radiology worklist folder and the radiologist can then click on a new image file and repeat the above process.
In another embodiment consistent with the present invention, if the radiologist is correlating with an historical comparison study and notices some previously reported findings remain, he/she can pull up a previous image, then either redraw the appropriate gestures or symbols or re-propagate gestures or symbols from the prior study by dragging the gestures over to the new study using the stylus 104. Thus, the computer program 110 will allow the movement of gestures from one image to another, in a similar fashion to a “copy” or “cut and paste” function in word processing.
In another embodiment consistent with the present invention, to facilitate the interpretation process, the radiologist can utilize automated decision support by clicking on the corresponding icon with the stylus 104. Examples of automated decision support include temporal subtraction (where changes over time are noted), computer-aided detection (CAD) (which detects pre-defined pathologies), computer-generated measurements and differential diagnosis (which provides a list of potential pathologies depending on the radiological findings). These automated decision support systems can provide findings which can be recorded onto the image in gestures, by the radiologist, or automatically translated into gestures, depending on how the automated decision support system works and can be integrated into the gesture-based reporting method and system of the present invention.
For example, a radiologist interpreting a chest CT for the presence of lung cancer can utilize computer-aided detection (CAD) software to assist in the interpretation process. In one embodiment consistent with the present invention, the CAD findings can be superimposed onto the image by the computer program 110 using a different color/format relative to the gesture-based reporting symbols. This allows for the clinician or radiologist to essentially “turn on and off” gesture-based reporting and CAD at their discretion. Images can be viewed with or without these “layers of data” and the entire dataset is permanently archived/stored in a collective fashion by the program 110.
In generating a report from the gesture-based reporting method and system, digital ink technology (i.e., electronically creating symbols and translating them into text) and specialized recognition software to translate the gestures or symbols used to map to specific radiological findings and concepts into an itemized text report, would be provided. The program 110 containing this recognition and report generation software is provided in the computer program 110 and in one embodiment consistent with the present invention, possibly integrated with the PACS which is responsible for image display, distribution, and storage (of both medical images and reports). Natural language processing (NLP) would provide the intelligence to convert the gestures and itemized text into a standard prose format.
Once the gesture-based symbols are embedded on the image, the report may be generated in at least three formats, as desired. In one embodiment consistent with the present invention, the reports generated using gesture based reporting formats can each be electively turned on or off by the user of the system, and include:
1) gestures or symbols alone embedded on the image, which map to specific findings and concepts, as in the present invention; or
2) an itemized list of findings (and modifying terms associated with each finding), in a structured, text format; or
3) a traditional text report with the findings translated into prose format using natural language processing (NLP) tools.
However, unlike the traditional reports, the creation of structured reporting using a standardized gesture language allows for the creation of a referenceable database (for example, storage 114), which can be queried for clinical and research purposes.
Therefore, unlike a traditional text report (where the image and text report are distinct and separate from one another), the informational content contained within the image and the gesture-based report are inseparable. Instead of translating a finding or concept (i.e., enlarged heart) from the image into text, the concept is retained directly within the image. This avoids the potential clerical and cognitive error, which can occur in the translational process from image to text.
Thus, by coupling imaging data, findings, and the report into one dataset, the present invention offers a unique ability to incorporate specialized decision support tools directly into the image and report simultaneously. For example, with traditional prose reporting, a great deal of ambiguity is introduced through the use of synonyms, which are commonly used to describe similar (but sometimes different) concepts. The clinical may have different clinical perceptions of the synonymous terms “infiltrate”, “airspace disease”, “consolidation” and “pneumonia”. Using a standardized and universally accepted gesture language, these potential misperceptions are alleviated, and language barriers are no longer a problem.
Thus, in the aforementioned reference to “infiltrate”, in one embodiment consistent with the present invention, the user can use the universal symbol for the finding and query the report database for all patients who had this reported finding between specific dates of time or who fulfilled certain demographic or clinical profiles. This creates a valuable resource for practice management, clinical research, quality assurance, or utilization review.
In addition, in one embodiment consistent with the present invention, a report can be used to generate an image which shows the specific findings detailed in the report. For example, the type of x-ray (i.e., chest, etc.) would be recognized by the computer program 110, and the computer program 110 would be able to generate an x-ray and place the gestures or symbols onto the selected film in the appropriate areas using a report as a basis. Thus, the present invention works bi-directionally.
The bi-directional nature of the present invention allows for a traditional prose report to be converted into a gesture report, using natural language processing (NLP) to convert prose into symbols. This could be performed in a retrospective fashion to convert historical prose reports into gesture-based reports—providing direct comparison of reports between different users in a standardized reporting format.
In another embodiment consistent with the present invention, interactive consultation can be conducted with the clinician. By embedding the findings directly into the medical image as in the present invention, and providing the end-user with the ability to “turn on and turn off” these embedded symbols, the combined image/report provides becomes an electronic consultative tool.
For example, in step 300 (see FIG. 4), the computer program 110 saves an embedded image that was interpreted by a radiologist who had reviewed a chest CT exam as previously described in FIG. 2, and who had made the following findings by embedding the appropriate gestures or symbols and modifiers onto the “key images”.
1. Pulmonary embolism
2. Pneumonia
3. Pleural effusion
4. Hilar lymphadenopathy
When the clinician calls up the CT for review on the client computer 101, the computer program 110, in step 301, presents the user with the option to review the study in its entirety (from beginning to end, consisting of 600 individual images), or to review “key images” only (consisting of 4 images).
If the user elects to view “key images” only, the computer program 110 then presents the user in step 302 with the 4 “key images” in a pre-selected format based on the user preference. For clinician A, for example, this consists of all 4 images displayed on a single display or monitor 102 using a 4:1 display format, for example. For Clinician B, for example, the 4 individual images are displayed individually using a 1:1 display format, for example, with the clinician being able to navigate between images using the input device 104 of their own preference (i.e., stylus, track ball, mouse).
When the clinician highlights the first “key image” (once again using their desired input device 104), the computer program 110 presents the user with the option to review the image in, for example, three ways in step 303:
1. Image without symbols
2. Image with symbols (static mode)
3. Image with symbols (dynamic mode)
Note that in one embodiment consistent with the present invention, the clinician's individual preference can already be established in the computer program 110 as a default and incorporated into the computer sign-on process, but the clinician has the ability to override the program 110 default at any point in time. In addition, the clinician can toggle between the various options “on the fly” by activating the appropriate icon for that viewing mode manually, for example.
If, for example, the clinician has selected option 3 (image display with symbols using dynamic mode) as a default, the computer program 110 will present the highlighted “key image” with a sequential display of embedded symbols in step 304, in the exact order that the radiologist recorded them during interpretation. This in effect becomes an active movie, where the end-user views the entire interpretation process from beginning to end (and can control the speed, based on their preference).
In the example of the CT case, the first highlighted “key image” chosen by the clinician shows the pulmonary embolism in the exact viewing state that the radiologist was using at the time of symbol application. This entails a number of pre-selected variables including but not limited to, for example, the specific window/level setting employed, the magnification factor, the specific processing algorithm employed, the specific anatomic orientation (sagittal, axial, coronal), and any 3-D volume rendering used. In one embodiment consistent with the present invention, the pre-selected variables can be chosen prior to highlighting the key image by the user. The highlighting of the key image in step 305 creates a “short cut” for the clinician to avoid the time consuming process of image manipulation and allows the clinician to review the image in a manner identical to the interpreting radiologist.
The clinician then passively views the electronic consultation as gestures or symbols are automatically applied by the computer program 110 in step 305. In addition to the gestures or symbols themselves, the computer program 110 shows the clinician the corresponding text as each symbol is recognized by the computer program 110 gesture recognition software. This in effect has the advantage of creating an educational tool for gesture or symbol recognition for the clinician, being able to actively associate each applied gesture with its corresponding text.
After the gesture or symbol for pulmonary embolism is applied by the computer program 110, the clinician then sees the various modifying symbols applied by the program 110, which describe, for example, size (i.e., in linear or volumetric measurements), anatomic location (i.e., 2.sup.nd order branch of the right upper lobe pulmonary artery), internal composition (i.e., non-calcified and occlusive), clinical significance (i.e., extremely high), and diagnostic level of confidence (i.e., high). Note that the gestures can be shown as being applied in the order that they were recorded, or can be shown all at once, depending on user selection.
In another embodiment consistent with the present invention, after completion of the entire sequence of symbol application (which typically takes 5-10 seconds) by the computer program 110, the clinician can then opt to view “additional data” by clicking an education icon “on” in step 306. The computer program 110 then presents the clinician with a number of resources including, for example, journal articles, web links, teaching file cases of related cases; using a search engine that search the databases based on the pre-defined user preferences.
Another option presented to the clinician by the computer program 110 in step 307 of one embodiment of the present invention, is the application of decision support tools (i.e., image processing, CAD, segmentation, differential diagnosis) which are, for example, customized to the reported findings and clinical indication, as well as the clinician's pre-determined preferences, as noted above.
If the clinician opts not to review “additional data” then the electronic consultation of this image is terminated by the computer program in step 308, and the second highlighted “key image” is presented by the computer program in step 309, in this exemplary case, demonstrating the finding of pneumonia within the superior segment of the right lower lobe, which has decreased in overall volume by 20%, when compared with the comparison CT exam performed 5 days earlier.
This sequence by the computer program 110 is relatively short (approximately 5-10 seconds), and the computer program 110 follows with the presentation of the third and fourth highlighted “key images”, after which, the electronic consultation is ended.
The entire sequence of events would take a short period of time—about 1-3 minutes, depending upon the options employed by the clinician. At any time during the consultation, the clinician can highlight a specific image or data point (using the stylus 104) and the program 110 will “save it” to be electronically sent to its own imaging folder, which can be accessed by predetermined factors, such as, for example, disease state, radiological finding, patient name, modality, etc.
The electronic consultation using the gesture-based reporting of the present invention is bidirectional in nature and the computer program 110 allows for the same sequence to be reviewed in reverse order, with the clinician doing the reporting first. In this exemplary instance, a clinician (i.e., ER physician) has reviewed the chest radiograph first (i.e., at 1:30 am) and recorded his/her preliminary interpretation using the appropriate gesture language. For example, the clinician has recorded the following symbols (in sequential order):
1. Density, poorly defined, right lower lobe, of uncertain clinical significance
2. Cardiomegaly, mild, minimal acute clinical significance
3. Degenerative changes, mid-thoracic spine, no acute clinical significance
In this example, the radiologist interprets the same study at, for example, 8:00 am and reviews the ER physician's interpretation (which takes only a few seconds—i.e., 5-10 seconds) using the gesture-based reporting method. Additional data obtained by an automated search on the EMR states the patient's WBC count is normal and no fever is present.
In addition, in this example, the patient's imaging file includes a CT exam performed one year earlier which showed, for example, a similar poorly defined density, superior segment of right lower lobe, with differential diagnosis listing pneumonia, aspiration, and cancer (in sequential order of statistical likelihood).
When correlating these different modalities (of the same anatomic region), the radiologist can conclude that, for example, the chronicity of the finding, interval increase in size, and lack of supportive data to suggest an inflammatory process make carcinoma the primary concern. The corresponding gestures or symbols employed by the radiologist when entering the gestures onto the image using the gesture-based reporting method, denote the following data (in order of application), for example:
1. Density, poorly defined, superior segment right lower lobe, moderate increase in size compared with prior chest CT of Apr. 30, 2004, primary diagnosis carcinoma, high clinical significance, follow-up recommendations: chest CT and oncologic consultation.
2. Cardiomegaly; no changes from preliminary interpretation.
3. Degenerative changes in thoracic spine; no changes from preliminary interpretation.
During the course of the radiologist's review and interpretation, the radiologist can elect to confirm “as is” the findings of cardiomegaly and degenerative changes initially made by the ER physician. This can be done, for example, by placing a “check mark” gesture over the corresponding symbols entered by the ER physician. The radiologist can then modify the gestures or symbols denoting the poorly defined right lower lobe density and then place the image/report in a high priority queue with instructions to electronically page the ER physician for “stat image consultation”.
The ER physician can then receive the stat page with the corresponding patient and image/report information. The ER physician can then in turn review the radiologist's interpretation/electronic consultation and return an electronic text message (i.e., high priority) to the radiologist stating they received the consultation, agreed with the interpretation, and have ordered the recommended CT and oncologic consultation.
Of course, an interactive consultation can be initiated if the clinician reviews an image and thinks they see something that the interpreting radiologist missed. In that case, the clinician can record the appropriate gesture (using their own unique color or other identifying format) and electronically send the image to the interpreting radiologist for clarification. By either typing a text message or simply placing a question mark next to the newly added symbol, the radiologist recognizes the clinician's query and can modify the image, and re-send it back to the clinician. This electronic consultation can then be stored in the patient's imaging folder for future reference. All correspondence can take the form of gesture language and be recorded as an additional “layer” of imaging data.
When this image/report is subsequently reviewed by a consulting oncologist, for example, 3 hours later, the oncologist will be able to review any portion or all of the findings made, interpretation, and consultation that ensued. If the oncologist elects to review “all findings”, the computer program 110 will present the findings with the initial ER physician's gesture-based report (color coded in a particular color, such as blue, for example), followed by the radiologist's gesture-based report (color coded in a different color, such as red, for example). The oncologist can add any additional findings to the image or incorporate additional clinical/historical data as well.
In this particular example, the oncologist identifies rib destruction (i.e., 4.sup.th right posterior rib, mild in severity, uncertain diagnostic confidence, high clinical significance). This “questionable discrepancy” is identified by the computer program 110 when inputted by the oncologist and the computer program 110 electronically sends the report to the interpreting radiologist, where it enters a “discrepancy queue” based on this identification.
The radiologist then reviews the oncologist's findings and will send the oncologist a text message, for example, acknowledging the additional findings made, which will be better evaluated on the ordered chest CT. This correspondence (in any format desired, including audio file) may be attached to the image (under the consultation tab, for example) so that the radiologist interpreting the upcoming chest CT will have direct access to the imaging findings and clinical notes of all three physicians involved in the chest radiograph.
These three physicians will in turn automatically receive the chest gesture-based report (with key annotated images) by electronic message. The entire process is easy to accomplish and takes very little time. In fact, the time required for each physician to review their counterpart's findings, enter modification, and initiate the communication protocol should be less than 3 minutes, for example.
In another embodiment, the electronic consultation is used in an electronic image workflow method and system, including an electronic auditing function that captures user actions performed during imaging interpretation, as described in copending U.S. patent application Ser. No. 11/586,580, filed Oct. 26, 2006, the contents of which are herein incorporated by reference. It is important to note that all electronic consultations are recorded as structured data elements within the gesture-based database 113 by the program 110 (with each gesture-based data element being assigned to the authoring clinician or radiologist).
In another embodiment consistent with the present invention, the unique signature of the user can be used to define certain privileges in image reporting. This would provide the capability for “second opinions”, consultations, and queries, where some users could actively change or delete gestures of other users (i.e., radiologists being able to change or delete gestures of referring clinicians).
For example, a radiology subspecialist may be asked by a primary radiologist, referring clinician, or patient, to review the image and render a “second opinion” or consultation. The consulting radiologist would add or delete gestures to the original report. in doing so, alterations (in the form of gestures or symbols) would be recorded by the program 110 in a different color or other format, so that the user could recognize the distinct nature of the reports of the primary consulting radiologists. Each “individual” report could be selected or activated on an individual basis, with the “final” version of the report (as stored in the imaging archive) recording all versions. When a referring clinician wishes to review an image/report, the program 110 would ask them to select which report to use as the default.
Using this same concept, in another embodiment consistent with the present invention, a clinician could record their own interpreted image findings within their own patient records. An oncologist, for example, may wish to record additional findings not mentioned by the interpreting radiologist. The oncologist would record additional symbols or gestures on the corresponding images and “save” those annotated images as “key images” which go into the patient's oncology folder. These images are then reviewed at the time of the patient's next visit or treatment. When the patient has a follow-up imaging exam (to measure the response to treatment), the annotated images are pulled up (as selected by the oncologist as his/her default), when a query is rendered by the oncologist. The computer (using artificial intelligence as a form of decision support), recognizes the gestures or symbols by the oncologist and highlights the same anatomic region and imaging features on the follow-up exam. This allows the oncologist to serially track imaging findings using their own embedded gestures.
In another embodiment consistent with the present invention, a multi-tiered approach can be taken to the analysis of some radiological data—i.e., mammography. In this embodiment, the RIS and modality would provide the first two tiers of information, whereas the third and fourth tiers would be entered by the radiologist. Further, if NLP were added to the equation, the prior image/report could be pre-screened for pertinent data and presented to the radiologist at the time of interpretation in manner similar to a CAD overlay.
The individual tiers in this embodiment, could be incorporated similar to an Excel spreadsheet, where the user would click on specific tabs of interest. When the “tier 1” tab is clicked, the individual data contained within this tier (i.e., Background Data, such as historical data, clinical indications, historical comparisons), is displayed, along with the ability to directly view the linked historical images. When the “tier 2” tab is activated, the individual data (i.e., Technological Aspects, such as QA descriptors, technique, breast density, and localizing markers), is displayed. This allows the individual radiologist or clinician to customize their viewing protocols as a standard default. All the data is embedded or linked within the image but what is displayed is at the discretion of the individual end user.
“Tier 3” would contain the imaging findings of the radiologist according to the methods and system of the present invention as described above, and “tier 4” is the interpretation, such as the clinical significance of the findings, follow-up recommendations, and confidence in diagnosis. Comparison studies and reports can be electronically linked, and if interpreted using gesture-based reporting, temporal subtraction may be a useful tool over designated areas of pathology.
In other embodiments consistent with the present invention, the following modifications can be made, either in the specific manner that the gesture-based reporting is undertaken, the ancillary technologies used, or the output generated.
For example, potential modifications other than a different input device 104, or a different display device 102, as noted above, would include different gesture or symbol language than identified in the Tables. For example, users will have the capabilities of creating their own unique gestures and symbols, which can in turn be mapped back to the standardized language using translational software. In addition to the proposed graphical language, an alpha numeric symbology could also accomplish the same task, but would be limited by language differences among international users.
As previously mentioned a different output (i.e., report) can be used. The output generated could be customized to the specific preferences of the user. In addition to the graphical display of the images with superimposed gesture-based reporting symbols, the gestures could be mapped to an XML schema with the EMR storing these gestures in a raw format.
Further, there are additional applications of gesture-based reporting outside of Medical Imaging. Gesture-based reporting becomes a viable reporting alternative anywhere the data is presented or recorded in the form of a graphic, diagram, or picture. Medical images are recorded in a number of non-imaging disciplines including (but not limited to) endoscopy, cardiology, opthalmology, bronchoscopy, dermatology, and colonoscopy. The images obtained are currently stored in the EMR and could easily be used to generate a report using symbols.
For example, the cardiologist performing a coronary angiogram could use gestures or symbols embedded onto the image to describe vascular stenoses (severity, location, clinical significance) and proposed treatment options; all using gesture language. The same cardiologist could also report functional abnormalities (such as cardiac wall motion abnormalities) using gesture language, which could be more easily conveyed than traditional prose reporting.
The ability to identify findings and track interval change electronically (using decision support) is extremely valuable in disciplines such as dermatology, where diagnosis and patient management is largely based on visual input. A dermatologist taking a photograph of a multi-focal rash could use temporal subtraction technology to quantify interval change in number, size, and geographic distribution of the dermatologic condition. Gesture-based reporting could use the gesture or symbol language to identify and describe the pertinent findings and the computer program, could, on follow-up examination, automatically highlight the previously identified areas of abnormality and perform sequential quantitative and qualitative comparison. This allows gesture-based reporting to become a valuable resource for both diagnosis and treatment.
Medical photographs are commonly taken with the operating room to illustrate pathology and these photographs could be easily used in a similar manner. The surgeon would simply superimpose gestures over the area of pathology and use the functionality of the computer workstation to provide magnification and image processing to enhance areas of concern. The anatomic relationship of the area of pathology to surrounding normal tissue and organs is best depicted using medical photography and gesture-based reporting becomes the logical means of reporting.
In addition to the “macroscopic” photos taken intra-operatively, “microscopic” photos are commonly used by pathologists and would be well suited for gesture-based reporting. In pathology, the boundaries between normal and abnormal cells is especially critical and text reports are difficult to communicate these subtleties. A magnification view of a specially stained microscopic specimen would both delineate these boundaries between normal and abnormal and specifically identify abnormal cells. The specific abnormalities of these individual cells can be highlighted and reported using gesture-based symbols, which again would be standardized. This would be beneficial in pathology where consultations with “outside experts” are frequently sought. The ability to electronically transmit the micro and macroscopic images with highlighted findings using a standardized gesture or symbol language is particularly appealing.
Further, a variety of medical notes currently written in text format could be easily converted to gesture-based reporting format, using gestures superimposed upon diagrams. For instance, a physician recording a history and physical could use symbols superimposed upon computer generated diagrams of each respective organ system to record pertinent findings and the associated modifying terms and concepts previously described. The same principles can be applied to procedure notes, consultations, and progress notes.
Another category of medical reports for gesture-based reporting application are existing tests displayed in graphical representation (EEG, EMG, EKG). The neurologist interpreting an EEG could highlight “key portions” of the graphical display that correspond to abnormal findings and annotate these findings using gesture-based reporting. These key portions of the graphical analysis highlighted are then stored by the computer program separate from the comprehensive dataset and used for detailed comparison on follow-up exams. The same applications of decision support can be used in conjunction with gesture-based reporting for interpretation and reporting.
A number of non-medical applications would be well suited for gesture-based reporting, which include anything that is predicated upon pictorial or graphical representation. A policeman or insurance adjustor investigating a traffic accident can use graphical representation of the accident scene, automobiles, and ensuing damage through a series of photographs and diagrams which can in turn be annotated with gestures or symbols for reporting. Similar applications can be used for engineering, design, and architectural professionals.
In order to address these divergent needs and expectations of generalists and specialists in the medical profession, a two-tiered gesture-based reporting language can be used with equal proficiency among general radiologists and subspecialty radiologists. The basic set of gestures or symbols (see Tables 1-2) would be applicable to a number of commonly observed radiological findings, and be common to all imaging modalities and anatomic regions. The specialized set of gesture-based reporting symbols would be more granular in nature and specialized to different organ systems and imaging modalities. Lack of knowledge of the specialized set of symbols would not preclude one's ability to use gesture-based reporting methods and systems as illustrated below.
In this example, two different radiologists are using gesture-based reporting in the interpretation of a brain CT in, for example, an 8-year old boy with vomiting and headaches. The general radiologist identifies a mass in the posterior fossa of the brain and highlights the “key images”. While going through the gesture-based reporting process of describing the unidentified mass, the radiologist describes it with the following descriptors: mass, poorly defined, cerebellum, minimal mass effect, high clinical significance, uncertain etiology, follow-up recommendation for MRI.
The neuroradiologist interpreting the same study also uses gesture-based reporting but describes the mass in slightly different terms: mass, cerebellar vermis, well defined associated hydrocephalous, internal cystic change and calcification, high clinical significance, medulloblastoma, neurosurgical consultation.
Using decision support and additional information obtained from the EMR, the computer program 110 of the present invention, using neural networks that are preprogrammed into the software, will ask the general radiologist a few targeted questions for improved characterization. The program 110 first asks the radiologist to localize the mass using the anatomic map. In doing so, a corresponding reference brain CT is brought up by the program 110, and the radiologist places his/her stylus over the exact area of the mass in question. The computer program 110 then clarifies the anatomic location as “cerebellar vermis” and displays this description for the user.
The second question the computer program 110 asks is, “is there associated hydrocephalous?” The radiologist reviews the images and answers “yes”. The third question posed by the computer program 110 is “does this mass contain any internal calcification, hemorrhage, or cystic change?”. The radiologist points the stylus 104 over both cystic change and calcification to denote its presence. The computer 110 (using neural networks) identifies the mass in question as a medulloblastoma and presents the radiologist with teaching file cases from an electronic database.
When asked by the computer program 110 if these images correspond to the clinical entity in question, the radiologist answers “yes” and enters this as the presumptive diagnosis with a “high degree of clinical confidence”.
The end result is the gesture-based language used to describe the mass is almost identical in the final report for both radiologists. The path in which they took may have been slightly different, but the end result and corresponding report is similar. In addition to incorporating decision support into the gesture-based reporting interpretation process, educational feedback on the gesture or symbol language is also provided to end users for continued learning.
The learning process for use of the gesture-based reporting method and system is also bidirectional in nature. The end user must learn the gesture or symbol language and descriptive methodology while the computer program 110 learns to accurately comprehend the gestures or symbols uniquely created by each end user. This process of iterative learning by the computer program 110 in gesture recognition is similar to that currently employed with speech recognition technology. In one example consistent with the present invention, when the radiologist recognizes the computer program 110 has incorrectly identified the symbol entered, he/she clicks on the “learning icon”. The computer program 110 than asks for the end user to draw the desired symbol three times and asks the user to map it to the corresponding text.
In one embodiment consistent with the present invention, the computer program 110 also tracks the frequency with which each individual gesture or symbol is used by each radiologist and creates a statistical profile of most commonly used gestures or symbols. Collectively this allows the computer program 110 to enhance its accuracy in gesture recognition.
End user education can be provided through a number of means including, for example, on-line learning which teaches the radiologist commonly used gestures or symbols and how to create user-specific symbols. The computer program 110 may also provide a library of standardized gestures or symbols (with corresponding text) that can be used by “touching and dragging” the desired gesture or symbol to the image, using the stylus 104. Since not all concepts may be able to be described by gestures alone, for these instances an alternative input (speech or pull-down menus) can be included in the reporting system 100.
In another embodiment, in addition to the specific concept that the symbol is mapped to (e.g., mass), a series of modifying and descriptive data is created by the program 110, which provides greater detailed information for the user regarding that particular finding. For example, data elements contained within the gesture-based report include findings (e.g., mass, nodule, calcifications), modifiers (e.g., temporal change, clinical significance, follow-up recommendations), descriptors (e.g., size, morphology, density), diagnosis (e.g., pathologic diagnosis, differential diagnosis, degree of certainty), and directives (e.g., search for laboratory data, initiate consultation, assign to teaching file). For example, in the case of a mass located on a chest CT exam, the end-user may want to attach the following data to the mass symbol in gesture symbology: 1) Anatomic region: right upper lobe, 2) Temporal change: new, 3) Clinical significance: high, 4) Follow-up recommendations: biopsy, 5) Morphology: ovoid, 6) Margins: spiculated, 7) Density: soft tissue (60 H.U.), 8) Size: 3.5 cm, 9) Differential diagnosis: neoplasm (primary vs. metastatic).
As stated above, in addition to graphical symbols (i.e., gesture-based symbols), a number of other different input methods can be employed to denote this additional data, which can be graphical or textual in nature. Alpha-numerics are one option (e.g., “RUL” for right upper lobe, “Bx” for biopsy), while an alternative mechanism would be context-specific computerized data (e.g., the program 110 provides pull-down menus which are mapped to a context-specific ontology for each individual finding/symbol). Many of these descriptors/modifiers can be derived automatically by the program 110 from computerized decision support tools (e.g., temporal change, morphology, size, density, differential diagnosis). The end-user would simply identify the finding from the imaging data, denote its epicenter or borders (using an electronic stylus 104), and the program 110 would perform these additional functions.
Regardless of whether this supporting data is derived from the end-user (manual) or the computer program 110 (automated), as stated above, the end result is the accumulation of multiple finding-specific data which is “attached” to each individual symbol. This supporting data can be accessed in a number of ways—one of which would simply be to place the input device 104 (e.g., electronic stylus) directly over the symbol and the associated data elements would be displayed by the program 110. Using graphical symbols as an alternative to textual data, an alternative mechanism of displaying these modifiers/descriptors would be to incorporate additional symbols in a designated area (e.g., periphery of the primary symbol) which can be “turned on” and “turned off” by the program 110 through simple input commands (e.g., double click, increased pressure of stylus 104).
In another embodiment, another mechanism for integrating these descriptors/modifiers would be to add visual or auditory data to the primary symbols (e.g., blue color for findings with “high” clinical significance, blinking symbol when an additional imaging/clinical test is recommended), which are implemented by the program. This collective data (primary symbol, modifying/descriptive data) is mapped to a standardized lexicon by the program 110, which stores structured data elements in a database 113 (i.e., ontology), that is both context and user-specific. This provides a mechanism for automated data mining (of both the symbols and the textual data associated with symbols) by the program 110, so that the data elements contained within the image (e.g., embedded symbols) can be automatically queried for clinical analyses by the program 110.
As an example, an end-user may want to search the electronic database 113 for information associated with a specific finding (e.g., mass). The end-user can identify the specific database 113 of interest (e.g., one that is radiologist-specific), to determine what data is associated with this finding. In this representative analysis, the searcher may be performing a quality assurance (QA) function to identify the frequency and specificity with which the radiologist in question identifies the anatomic location of all masses for a specific type of exam (e.g., CT) and anatomic region (e.g., thorax). The database 113 could be queried by the program 110 by the user simply inputting the database symbol (e.g., mass) and selecting from a pre-defined list presented by the program 110 if analyses or manually inputting the analysis to be performed. Because all data is directly mapped to the symbols themselves by the program 110, any query of the databases 113 can be done by the program 110 by the user activating the symbol of choice, selecting the analysis in question, and selecting the corresponding database 113.
Thus, the gesture-based report includes a number of multi-tiered data elements that can be accessed either manually or in an automated fashion by the program 110, the latter predetermined in accordance with each individual end-user's unique profile.
In one example of a breast imaging report from a mammogram, one can see that different data elements within the multi-tiered report are of specific importance to different user groups. Examples of these occupational differences are as follows: 1) background data may be of critical importance to the technologist performing the exam; 2) technical aspects may be of importance to the medical physicist analyzing quality assurance (QA) and quality control (QC); 3) imaging findings of importance to the clinician who is charged with directing clinical management of the patient; and 4) decision support and interpretation data important to the radiologist tasked with rendering a diagnosis.
To further the above example, in one scenario, a radiologist interpreting a mammogram identifies a mass at the 9 o'clock position of the breast and determines this has increased in size when compared to the historical comparison mammogram performed one year earlier. He/she also has determined that the identified mass is of high clinical significance (requiring immediate action), and recommends that a biopsy be performed to exclude malignancy. These modifiers can be “attached” to the symbol for mass by “attaching” the corresponding symbols (e.g., up arrow for “increased”, circle with the numeral 9 inside for 9 o'clock position, letters “Bx” (for example, for biopsy recommended) to the primary finding. Alternatively, the author can “attach” the modifier data elements to the “finding” (i.e., mass), by selecting pre-defined data elements from a structured text list (e.g., clinical significance numerical grading scale), which can be automatically provided based on a context or user-specific rule set.
Some of this accompanying data can also be automatically derived by computer-based decision support, such as descriptive information assessing size, density, and morphology. Once the reader has identified a “mass” on a mammographic study, he/she can direct the program 110 to perform an automated analysis of size, density, morphology and “attach” this program 110 or manually derived analysis to the “finding”.
These various data elements can be subsequently viewed asynchronously by highlighting the specific finding in question (e.g., placing an electronic cursor over the “mass”) and the program 110 then provides the accompanying data for review. In the present example, a clinician reviewing the mammographic report may see a symbol for “mass” displayed on the image. By highlighting the mass symbol, the accompanying modifier and descriptive data is presented to the clinician. In this manner, the reader of the report can selectively review which data are of importance to him and ignore those data elements of lesser importance.
In another example, a surgeon who is reviewing the mammogram has created a profile that requests that the program 110 alert him only to findings that reach a specific clinical significance threshold, which are then shown in an “active” form. When the surgeon logs onto the computer (PACS or EMR), his/her profile is applied to the imaging database 113 by the program 110 automatically. When the surgeon proceeds to review the mammogram on his patient, only those findings that are identified by the program 110 as having a critical significance score exceeding that specific threshold are shown. As a result, the calcifications (that are unchanged from prior studies) and of low clinical significance are not shown, whereas the mass of high clinical significance (and requiring biopsy) is shown. This in effect creates user and context-specific filters that can make some findings “active” and other findings “inactive” according to the predefined user profiles and rule sets created. If, however, the surgeon elects to view “all findings”, then the program 110 would activate all findings and display them for review.
An alternative scenario would be where an end-user informs the program 110 to activate only “new” or “changed” findings. In this scenario, other findings identified as “stable” or “unchanged” would not be presented as “active” symbols.
An oncologist following a cancer patient with known metastatic disease, who is currently undergoing chemotherapy, requires detailed knowledge of both treatment response as well as detailed quantitative measurements (to determine tumor burden). For that specific patient profile (documented cancer, receiving treatment), the oncologist may set the program 110 to show only those findings pertinent to the cancer, along with the detailed size/volume measurements from both current and prior studies. In this scenario, when the oncologist highlights the finding in question (mass), they would be presented with the accompanying serial quantitative data measurements, along with calculated percentages of interval size change. In the case of an untreated tumor, the program 110 could also present the oncologist with a computer-derived doubling time, based on serial quantitative measurements in an untreated patient.
In another embodiment, layered or multi-tiered structured data which can be incorporated into the report by the program 110, can also be used to facilitate manual or computer program-generated directives. These directives can take a number of different forms and include electronically derived (program-derived) queries of EMR data, consultations, and communication. The resulting gesture-based reporting program-driven communication pathways can be used to communicate critical findings to users according to predetermined methods (i.e., e-mail, facsimile, etc.), and create an electronic auditing trail to document receipt, understanding, bi-directional queries, and track clinical outcomes, which are stored in the database 113. In order to illustrate how this would work a number of examples are provided below.
In a first example, a radiologist identifies suspicious microcalcifications on a screening mammography. In creating the gesture-based report, the radiologist identifies microcalcifications at the 3 o'clock position of the left breast, which were not present on the comparison study done 2 years earlier. The additional modifier and descriptive data entered into the report by the user using gestures or text, describe these microcalcifications as pleomorphic in morphology, clustered in distribution, of high clinical significance, suspicious for malignancy, and the radiologist marks the report with a recommendation for biopsy, using gestures or text. All of these data elements are directly integrated from gestures or text into the text report by the program 110 and are accessible to an observer whenever the gesture-based microcalcifications symbol is highlighted.
In one embodiment, the program 110 includes an automated critical results pathway which can be automatically triggered by the radiologist creating the report, the referring clinician ordering the exam, the radiology department chairman, or the hospital administration reviewing the medical history. The structured data elements contained within the report include a number of “critical” data elements (any one of which could automatically trigger the program 110 to initiate the critical results pathway) including: a) microcalcifications, clustered, b) microcalcifications, pleomorphic, c) high clinical significance, d) suspicious for malignancy, and, e) biopsy recommended.
Based on a rule set created by any of the aforementioned parties, any one of these data elements within the structured database 113 could trigger the critical results reporting pathway by the program 110 in step 400 (see FIG. 5). Once this pathway is activated by the program 110, the following chain of events takes place, all of which are program-driven steps.
The referring clinician of record is identified from the exam order by the program in step 401.
The referring clinician is notified according to his/her profile and preferred method of communication (i.e., e-mail, pager, facsimile, according to order of preference, etc.) by the program in step 402. For example, in this exemplary case, the referring clinician has requested notification via an e-mail alert. While the critical finding (e.g., mass) is still in “ongoing communication status”, the gesture-based symbol will be color coded (e.g., yellow) in a manner to reflect incomplete communication between the referring clinician and the original clinician. The color coding of this finding will change as different steps in the communication pathway take place.
In the e-mail alert a “high priority, non-emergent” status is assigned by the program 110 in step 403. Other alert statuses could be “medium priority” or “low priority”, for example.
The transmission is time-stamped and recorded in the gesture-based structured report database 113 by the program 110 in step 404, and the clinician's acknowledgement of receipt by PDA is time-stamped and recorded in step 405, and linked by the program 110 in step 406 to the finding (microcalcifications), modifier (high clinical significance), and descriptor (pleomorphic) used to initiate the critical results pathway.
A pre-defined time period defines how much time is allowed to transpire before a follow-up communication or secondary communication protocol is initiated by the program 110, and this is dependent upon the clinical severity of the finding in question, along with the follow-up recommendations. In this particular example, where the finding in question is not immediately life threatening, a predetermined time period is allowed to elapse before the secondary communication protocol is initiated by the program 110 in step 407. If all the predetermined communication protocols expire without documented communication, then a communication chain outside of the referring clinician is begun, with the “back up” physician of record being notified by the program 110 in step 408. If the back-up physician cannot be reached in the pre-defined communication protocol, then a third physician is notified by the program 110 (e.g., ER physician, medical department chief, chief of staff).
Since the status is assigned “high priority, non-emergent” in this example, the clinician elects to continue seeing patients and to review the report data in a few hours.
At hourly intervals, e-mail reminders are sent by the program 110 in step 409 to the clinician according to the predetermined communication protocol since he has not actively reviewed the critical report. Each e-mail receipt is acknowledged by the clinician, with receipts are time-stamped and recorded by the program 110 in step 405.
After the second alert, the clinician decides to review the data at his office computer. Using the link provided by the program 110, he opens up the gesture-based or text report on his patient in step 410. When opening up the report, an electronic auditing tool is activated by the program 110, that records all computer interactions.
The critical finding (microcalcifications) is highlighted in blinking format by the program 110, signifying its “high priority” status.
The clinician then activates the microcalcifications gesture-based symbol (i.e., 3 small dots in the shape of a triangle) in step 412, and the accompanying modifier and descriptor data is displayed by the program 110 in step 413.
As part of the “automated critical results pathway” method, the program 110 then presents a message box asking the clinician in step 415 to check off all the data received. Thus, the program 110 initiates a series of documented communications to take place, each of which is recorded by the program 110 in step 415 within the communication and reporting databases 113. These include the following data elements: 1) receipt of the emergent notification, 2) review of the gesture-based data, 3) acknowledgment of understanding the nature of the abnormality in question, and follow-up recommendations, 5) bidirectional communication/consultation between radiologist and clinician, 6) additional clinical/imaging data relevant to the case, and 7) follow-up actions initiated.
The clinician then reviews the gesture-based data, and acknowledges his understanding of the issues, by placing check marks next to “high priority”, “suspicious for malignancy”, and “biopsy recommended” tabs, which are recorded by the program 110. The clinician can use an electronic auditing tool such as that disclosed in co-pending U.S. patent application Ser. No. 11/586,580, filed Oct. 26, 2006, the contents of which are herein incorporated by reference in their entirety.
In addition to recording these responses within the gesture-based structured database 113, the program 110 presents the clinician with a list of automated options in step 416, that include the following: a) a radiologist consultation, b) an automated ordering of additional imaging exam or procedure, c) a clinician consultation, d) an automated notification of patient, and e) an automated ordering of clinical/lab testing.
The clinician the chooses the options he/she prefers, by checking off the options for “additional imaging exam/procedure” and “automated patient notification”, which the program 110 records in step 417.
The program 110 then presents the clinician with a context-specific imaging order list in step 418, and the clinician selects stereotactic biopsy, for example, which order the program 110 acknowledges in step 419.
In step 420, the program 110 then sends a separate e-mail confirmation to the clinician once the stereotactic biopsy has been scheduled.
In step 421, the program 110 generates a letter (also sent via e-mail) to the patient, attached to a modified gesture-based report (in keeping with the “patient” version of the gesture-based report), informing the patient that a high priority finding was identified on her mammogram and her physician has requested a biopsy.
In step 422, the patient acknowledges receipt of the letter which is recorded by the program 110, and the program 110 provides the patient with scheduling options for the proposed biopsy in step 423.
In this example, the patient declines immediate scheduling of the biopsy pending discussion with her physician, which is recorded by the program 110 in step 424.
In step 425, the clinician is in turn sent an e-mail alert by the program 110 notifying him of the patient receipt of the report and request to defer biopsy pending communication with the clinician.
In step 426, the clinician acknowledges receipt of this information, and requests a follow-up e-mail in 24 hours by the program 110 as to the status in step 427.
The clinician may then, for example, telephone the patient, and after in-depth discussion, it is mutually decided to proceed with the biopsy.
When the follow-up e-mail arrives in 24 hours, as sent by the program 110 in step 427, the clinician responds with a request to formally schedule the biopsy, which is recorded by the program 110 in step 428, and forwarded to the appropriate scheduling personnel in step 429.
The patient is e-mailed the scheduling by the program 110 in step 430, and now requests scheduling of the biopsy. She then selects an appointment for the biopsy, which is recorded by the program 110 in step 431. The program 110 provides instructions for the procedure along with confirmation to the patient in step 432.
After the appointment has been scheduled, confirmation e-mails are sent to the clinician, the radiologist generating the original report, and the doctor who is scheduled to perform the biopsy, in step 433.
All correspondence and acknowledgment of receipt is recorded in the gesture-based structured database 113 by the program 110 in step 434.
Once the biopsy has been completed, the results are entered and stored in the gesture-based report in step 500 (see FIG. 8), and the specimen is submitted to Pathology, along with the gesture-based report in step 501.
Before issuing the final pathology report, the pathologist reviews the gesture-based report/images from both the original mammogram and biopsy specimen. If any questions were to arise, the pathologist could electronically consult with the radiologist in step 502 as described previously, using the gesture-based report/images.
After the pathology report has been finalized, electronic copies of the report are sent by the program 110 in step 503, to the radiologist reading the original mammogram (and recommending biopsy), the clinician, the radiologist performing the biopsy, and the patient.
The pathology report data is in turn entered and recorded into the gesture-based structured reporting database 113, in step 504, and the program 110 automatically calculates the interpreting radiologist's report accuracy in step 505 by comparing the present findings against aggregate findings stored in the database 113 which are normally found for this diagnosis.
The program 110 then issues an immediate report to the radiologist/pathologist for correction in step 506, and also issues quarterly reports quantifying report accuracy (positive predictive value, negative predictive value, sensitivity, specificity) in step 507, which are electronically sent to each radiologist or pathologist based on a radiology/pathology correlation.
In another embodiment, while most “critical results” reporting is commonly thought of as originating from the interpreting radiologist, “critical results” can also be initiated by the clinician. In an example of this embodiment, a consultant can review an imaging exam and may wish to alert a radiologist of “outside” imaging data.
In such an example, the consulting clinician reviewing the gesture-based report, may identify a finding that is either overlooked or misinterpreted and desire to report this to the radiologist, for a possible addendum to the gesture-based report. Another scenario may occur when an outside imaging study has been performed, which contains valuable data not available to the radiologist at the time of initial interpretation. In either case, this example of “critical results reporting” entails communication and documented receipt between the clinician and radiologist, with integration of “new” data into the original gesture-based report, thereby creating a longitudinal gesture-based report that integrates metachronous data.
In one example, the consulting clinician (in this case, a gastroenterologist) has been consulted to see a patient with anemia and unexplained weight loss. While reviewing the patient's medical records and interviewing the patient, the consulting clinician has learned that the patient has had a recent abdominal CT exam at the host institution, along with an earlier barium enema (BE), performed at a nearby hospital. The gesture-based report from the recent abdominal CT exam disclosed a nonspecific liver lesion (2 cm, hypodense, uncertain clinical significance, probably benign, no recommended follow-up). The outside BE identified a 3 cm mass in the cecum, suspicious for malignancy, with recommendation for colonoscopy.
In reviewing the abdominal CT exam, the consulting clinician believes he can retrospectively visualize the cecal mass in question. He decides to notify the radiologist who originally interpreted the CT scan, and by doing so determine whether the liver lesion described in the original report may be of greater clinical significance. The consulting clinician then initiates an electronic consultation with the radiologist in the following manner.
The consulting clinician logs onto the PACS and retrieves the CT scan in question in step 600 (see FIG. 9). The consulting clinician selects the image in step 601, that he believes shows a mass in the cecum that was not originally reported, and then in step 602, uses the electronic stylus (or other input device 104) to highlight the mass in question.
In a manner identical to that of a radiologist interpreting an exam and generating a gesture-based report, the consulting clinician enters a “mass” symbol over the region of interest and adds additional modifiers (i.e., 3 cm, suspicious for malignancy, biopsy recommended), which are received by the program 110 in step 603.
The consulting clinician then annotates the image with gestures and/or additional text, “outside BE reported 3 cm cecal mass”, and saves the annotated image in step 604.
The consulting clinician then invokes the “critical results” function (using the corresponding symbol provided by the program 110) in step 605, and selects the “radiologist communication” option. With the radiologist communication option, the electronic critical results pathway is initiated by the program 110 and the program 110 sends an alert to the radiologist of a critical results finding, in the predetermined preferred manner as discussed above. Because the radiologist is already signed onto the PACS, when the communication pathway is initiated by the program 110, the email message, in this case, is sent directly to him at his workstation by the program 110.
The radiologist opens up the corresponding application link provided by the program, and reviews the gesture-based report issued by the consulting clinician along with his own original gesture-based report.
If desired, the clinician can elect to open a radiologist consultation by responding to a program 110 displayed prompt. At this point in time, the clinician and radiologist are electronically linked to the same gesture-based reporting dataset and either party can communicate with the other using either data input (using an electronic stylus 104, for example) or speech input (with a recorded audio file). If additional clinical or imaging data is provided to the users, this is stored in the gesture-based reporting database 113 and assigned to the authoring end-user. In this particular example, the referring physician may provide additional clinical data (history of documented renal cell carcinoma 2 years ago) through text using the electronic stylus 104 in step 606. This “free text” is then converted to “structured text” by the program 110 using a natural language processing (NLP) software program, and then entered into the structured text/gesture-based reporting database 113 in step 607.
After reviewing the imaging data, the radiologist opts to amend his original CT report in 2 ways: a) adding the finding of cecal mass, and b) editing the modifiers associated with the reported liver lesion to reflect the possibility of metastasis from cecal carcinoma (high clinical significance, biopsy recommended).
The edited information (as well as the electronic communication generated by the consulting clinician) is all recorded in the gesture-based structured database 113 by the program 110 in step 608.
Whenever the CT exam is reviewed going forward, the “initial” and “subsequent” gesture-based data will be incorporated into the “most recent” gesture-based report by the program 110 in step 609, thereby illustrating the longitudinal (and dynamic) nature of the gesture-based report.
The amended gesture-based report is electronically transferred to all individuals who had previously accessed the CT report by the program 110 in step 610, with the amended data highlighted by the program 110 to reflect the changes made.
Based on the amendments made, both the original referring clinician and the consulting clinician are electronically notified of the recommendation for biopsy (of both the cecal and liver lesions) by the program 110, and the acknowledgements are recorded as in step 415 (see FIG. 6), and prompted by the program 110 in step 416 with the following options: a) request for radiologist consultation; b) automated ordering of additional imaging exam or procedure; c) request for clinician consultation; d) automated notification of patient; e) automated ordering of clinical/lab testing; and f) selection by the consulting clinician of the automated ordering of a liver biopsy.
In this case, the clinicians schedule the patient for option f), the liver biopsy. The authoring clinician's input is recorded in step 417 and the order for the patient is automatically sent to the computerized physician order entry (CPOE) system by the program 110 in step 418, as well as recorded in the gesture-based reporting and communication databases by the program 110 in step 419, etc., as in FIGS. 6-7.
Following performance of the liver biopsy on the patient, the pathology results are entered into the database 113, as in FIG. 8, and stored in step 500, and electronically sent to the radiologist, the consulting clinician, and the primary clinician in step 501. The program 110 then correlates the pathology data with the structured data within the gesture-based database 113, and stores the revised report in step 504, etc.
In another, more emergent example, a chest radiograph is reviewed by the radiologist who determines the patient has a life-threatening pneumothorax (i.e., collapsed lung). As soon as the radiologist observes the finding in question, he/she can manually generate a critical results communication pathway by simply inputting the critical results symbol (e.g., symbol for poison or alpha-numeric symbol “CR”). By instantly invoking the critical results communication pathway a “high alert” status is initiated which elevates the communication protocol to ensure communication is received within 5 minutes, for example. In addition to notification of the referring clinician, the radiologist can elect to notify other clinicians (e.g., surgeon on call, ER physician) by simply inputting the respective initials of the physician to be contacted, for example. The electronic communication protocol confirms receipt of the requested clinician(s) and displays the name/s of the additional clinician(s) to be contacted, which can be confirmed by the radiologist by placing a check mark next to the computer program-generated name. Once the communication takes place, the same process takes place with electronic acknowledgment of receipt, confirmation of understanding, recording of all consultations (each individual author's input is recorded using gesture-based reporting and their own unique identifier), and tracking of clinical and imaging follow-up. Another important feature of the gesture-based reporting critical communication pathway is that all critical communications are flagged in the database 113 for subsequent outcomes analysis in step 507. All individuals participating in the communication protocol will be sent pertinent follow-up/clinical outcomes analysis data by the program 110, which is also incorporated into a quality assurance scorecard database(s) 113 in step 509.
In another embodiment, the gesture-based reporting apparatus and system has a quality assurance component. In one example, a radiologist reviews an imaging exam (e.g., CT scan) and wants to record a technical deficiency in image quality (e.g., motion artifact). Using gesture-based reporting, the radiologist could record the quality assurance (QA) symbol, followed by a symbol for motion, which in turn can be followed by a symbol for the desired action to be taken (e.g., repeat image acquisition), which is received by the program 110 in step 600. As previously stated, the symbol sets used can be graphical in nature (e.g., ∞) or consist of alpha-numerics (e.g., Q1). Regardless of the input language used, the output is a standardized lexicon that creates structured universal data that in turn can be longitudinally tracked and analyzed (i.e., data mining) by the program 110 in step 606.
Another example includes a technologist who identifies a technical deficiency in image quality upon image acquisition, but is uncertain as to its etiology and significance. Using gesture-based reporting, the technologist can mark the artifact in question and simultaneously transfer this data to a number of different sources for review and analysis. Specifically, in this representative example, a nuclear medicine scan is being acquired by the technologist who identifies an area within the image devoid of uptake (i.e., cold spot), and is concerned that this may be the result of technical malfunction (i.e., detector drop-out), as opposed to underlying pathology. While the imaging data is being acquired, the technologist can identify the area in question in step 600, and using gesture-based reporting, can query different sources for real-time assistance in step 601. The technologist may simultaneously query, for example, the interpreting radiologist, medical physicist, and nuclear medicine provider. The gesture-based reporting mark-up is received by all three parties in step 602 who can respond to the initial inquiry with recommendations (also entered using gesture-based reporting), for appropriate action to be taken. The radiologist may instruct the technologist (using gesture-based reporting input) to repeat the image acquisition using a different gamma camera (i.e., acquisition device) in step 603. The physicist may identify the abnormality as a signal drop-out from a faulty detector and refer the technologist (again through use of gesture-based reporting and web-based links) to another quality control (QC) test for more detailed analysis. The vendor (through remote on-line access, for example) may be able to run a series of remote testing and identify the specific defect and link/integrate this testing data to the original image in step 603 (again using gesture-based reporting layered data inputs), and simultaneously send this imaging/QC data with gesture-based reporting inputs to both the technologist and a local technician for on-site repair in step 604. Once the detector defect has been fixed, a phantom test image can be obtained, labeled with gesture-based reporting inputs, and integrated into the original imaging dataset in step 605 to document the original QA deficiency, date/time of all QA correspondence, follow-up interventions, and the QC phantom image documenting task completion. In this manner, gesture-based reporting facilitates a QA/QC audit trail with combined imaging data, consultations, and interventions all recorded using GBR inputs in step 606.
Another example of how gesture-based reporting can be used for QA purposes can be illustrated with a digital screening mammographic exam. As is customary with screening mammography, the exam is interpreted at a time distinct and separate from the image acquisition (typically the next day). When the radiologist reviews the images, he/she notices that a cassette artifact on one of the mammographic views created the false impression of pathologic microcalcifications. The technologist misinterpreted the artifact as focal pathology and marked up the image (using gesture-based reporting) as having microcalifications. The radiologist who later interprets the images, sees the technologist mark-up and realizes that in actuality the area in question actually is the result of cassette artifact and not representative of pathology. The radiologist then enters gesture-based reporting input (with additional descriptive information that specifies the specific artifact in question) for artifact onto the pertinent image, along with the recommendation (again using gesture-based reporting input data) that the specific CR mammographic cassette used for the image acquisition be cleaned and re-imaged to ensure the artifact has been removed. At the same time, this gesture-based reporting-integrated imaging data is sent to the chief technologist (who is tasked with overseeing mammography QA/QC), and it is also sent to the technologist who initially acquired the image (and misinterpreted the abnormality as underlying pathology), thereby creating an educational tool (using gesture-based reporting) that links imaging and QA data with user-feedback. The radiologist also sends the annotated gesture-based reporting mammographic image to the mammography QA database, so that it can be used in the future for technologist/radiologist education and training. Thus, one can see that gesture-based reporting becomes a mechanism that extends beyond reporting alone and can be a tool to facilitate electronic communication, consultation, education/training, and data mining for quality assurance.
In another embodiment, the gesture-based reporting apparatus and method can be used to assist in workflow. In the same manner in which QA data can be input (using gesture-based reporting) and integrated directly with the imaging dataset, workflow can be directed using gesture-based reporting to provide electronic instructions to the program 110 to drive the various computer program 110 functions a user goes through in the course of the human-computer interaction.
In the example of a radiologist tasked with interpretation of a medical imaging study (e.g., CT angiography of the thorax (CTA) for the evaluation of pulmonary embolism), a number of different workflow steps are required which include the following steps: 1) image display, 2) clinical data access (from the EMR), tools, 6) image processing and segmentation, 7) decision support, 8) reporting, and 9) communication.
In conventional use, the user utilizes a conventional input device (e.g., mouse or keyboard) to interact with the graphical user interface (UI). This typically consists of the user clicking on a computer icon or an item from a worklist displayed by the program 110. An alternative to this conventional input would be use of gesture-based reporting to drive workflow commands, through the use of a symbolic or alpha-numeric symbol workflow language (which would be a logical extension of the gesture-based reporting concept—only that the language would track to a standardized lexicon for workflow, as opposed to the reporting language previously described).
In this representative example, the radiologist tasked with interpreting the chest CTA would direct the human-computer program 110 interactions with a standardized “gesture-based reporting” workflow language using the electronic stylus for manual input (or alternatively speech commands, which propagate the corresponding symbol language onto the computer screen and image being evaluated). The radiologist can direct program 110 actions by simply drawing the workflow symbols directly onto the image being evaluated to perform the various steps, each of which would be recorded in the workflow database 113 by the program 110 (for future analysis, such as creation of automated workflow templates using an electronic auditing tool as previously disclosed) through the standardized workflow symbols and corresponding structured text.
In this example, the radiologist may direct the program 110 to apply multi-planar 2-D and 3-D reconstructions, using the corresponding gesture-based reporting symbol. The radiologist may then invoke the magnification tool by inputting a separate symbol, and later open up a computer-aided detection (CAD) computer program through another gesture-based reporting symbol. He/she can even specify which CAD program to use (in the event that multiple CAD programs are available, such as disclosed in co-pending U.S. patent application Ser. No. 12/000,932, filed Dec. 19, 2007, the contents of which are herein incorporated by reference in its entirety), by using pre-defined symbol language (e.g., CAD1, CAD 4, CAD PE, etc.).
In the event the radiologist identifies an important image with pertinent findings (e.g., pulmonary embolism), he/she may annotate that “key” image using the gesture-based reporting symbol language, and subsequently direct further action using the gesture-based reporting workflow language. In this example, the radiologist may direct that the “key” image be simultaneously downloaded into an electronic teaching file database (e.g., by using the symbol “TF”) as well as a separate image folder to be sent to the referring clinician (e.g., by using the symbol “KI” followed by the clinician's initials, for example). The program 110 recognizes the symbol input as “Key Image” and then automatically directs the annotated image to the referring clinician who has been identified by either their initials or another identifier. In this manner, the concept of using a symbol language that tracks to a standardized lexicon is expanded to go beyond reporting applications, and be used in an analogous method for workflow.
In another embodiment, gesture-based reporting is used in data analysis. The creation of structured data mapped to a standardized lexicon is the central theme of gesture-based reporting, with the multiple data elements recorded extending across a broad spectrum including (but not limited to) pathologic and descriptive findings contained within the medical imaging dataset (e.g., CT scan), technical data related to image acquisition and processing, clinical data related to the individual patient medical and surgical history (as well as the specific signs and symptoms prompting the exam being performed), decision support data (e.g., CAD, textual and morphologic analysis, anatomic localization), historical imaging data, consultative information, genomics and proteinomics, and patient-specific demographics. Once these various structured data elements are mapped to a standardized and universal lexicon, data mining can be performed by the program 110 by having the end-user enter in specific search criteria and/or data elements of interest and the database 113 will be automatically queried by the program 110. The resulting data analysis can then be integrated into the imaging report/patient folder through an electronic link presented by the program 110 that can be accessed in a manner similar to an electronic spreadsheet with multiple individual tabs corresponding to different data categories. These structured data elements can be accessed manually (by manually searching the database 113), by opening up the respective tabs (using the electronic stylus 104), or by entering in a graphical symbol language that specifies the specific data element in question.
As an example, the radiologist interpreting an abdominal CT exam for evaluation of suspected bowel obstruction may want to determine what prior abdominal surgeries the patient has had, which may place the patient at increased risk for small bowel obstruction (due to post-operative adhesions). The radiologist can manually search the patient EMR for prior surgical data, click on the “historical clinical data” tab presented by the program 110 within the comprehensive structured database 113, or use gesture-based reporting to automate the search process. This last option can be performed several ways—the simplest way would be to enter the symbol for “surgical history”, which could consist of an alpha-numeric symbol (e.g., SH) or a graphical symbol (e.g., scalpel), for example. The database 113 would be automatically queried by the program 110 which would respond with a list of structured data elements related to all prior surgical procedures. This would include all prior surgical procedures such as tonsillectomy, skin biopsy, dilation and curettage, partial colectomy, cholecystectomy, septoplasty, fixation of femoral fracture, and craniotomy. If the radiologist wanted to create a more specific search of relevant surgical history, he/she may enter the same symbol language to query previous surgery, followed by the clinical indication (SBO). In this case, the program 110 filters out all extraneous surgeries not relevant to the specified clinical indication and creates a more targeted, context-specific data search which provides the radiologist with the more relevant surgical history of partial colectomy and cholecystectomy. This in effect creates a mechanism for searching the structured databases 113 using gesture-based reporting graphical inputs, thereby obviating the need for a manual (time intensive) search.
In another example, the radiologist identifies a nonspecific soft tissue mass within the abdomen that has the appearance of a malignancy. The radiologist seeks to identify genetic risk factors of the patient, in hopes of creating an accurate differential diagnosis. After reporting the specific characteristics of the mass in question using gesture-based reporting, the radiologist can query the database 113 for determining a computerized differential diagnosis based on the described imaging features (e.g., anatomic location, size, morphology, density). Based on these specific data inputs, the program 110 can derive a differential diagnosis based on imaging criteria cross-referenced with the pathology database 113. This list may consist of six different neoplastic entities, for example.
The radiologist then elects to further refine the computer program-generated differential diagnosis (which was created by the program 110 based on the radiologist gesture-based reporting data), by entering in the symbol for genomics/proteinomics (which could consist of a graphical representation of a double helix or alpha-numeric “GP”). This graphical input command would then direct the program 110 to correlate the patient-specific genomic data with the differential diagnosis and create a more refined differential diagnosis with probability statistics (based on the genetic predisposition of the patient). In this manner, gesture-based reporting creates a mechanism to direct targeted mining of the structured databases 113 using a number of different search criteria, all of which can be denoted through a graphical input language. The search data can in turn be recorded within the gesture-based report through linking these different layers of data through a tabular format (similar to an electronic spreadsheet), which can be opened at the discretion of each end-user.
It should be emphasized that the above-described embodiments of the invention are merely possible examples of implementations set forth for a clear understanding of the principles of the invention. Variations and modifications may be made to the above-described embodiments of the invention without departing from the spirit and principles of the invention. All such modifications and variations are intended to be included herein within the scope of the invention and protected by the following claims.

## Claims

1. A computer implemented-method of implementing a critical results reporting pathway, comprising:
initiating a critical results reporting pathway in a computer system, upon a critical data element being identified by said computer system in a report created at a client computer of said computer system, or upon entry into the computer system of an examination order at a client computer of said computer system;
identifying a user who entered said examination order or said report and notifying said user of initiation of said critical results reporting pathway via a predetermined electronic communication method predetermined by said user;
receiving acknowledgement from said user of said notification via said predetermined electronic communication method, and linking said acknowledgement to a medical finding in said examination order or said report in a database;
activating an electronic auditing tool and tracking all actions, using said computer system, which are performed by said user upon review of said report or said examination order at said client computer of said computer system, said actions which include documenting said user's review of said report or said examination order;
presenting to said user automated medical options from said database, using said computer system, said medical options which include consultations, additional examinations or procedures;
receiving a selection from said user of at least one of said medical options;
presenting said user with a list of context-specific options, generated based upon said selected at least one medical option;
receiving a selection from said user of one of said context-specific options; and
implementing said user's selected context-specific option.

2. The method of claim 1, further comprising:
assigning a priority status using said computer system, to notification of said user of said initiation of said critical results reporting pathway.

3. The method of claim 2, wherein said notification of said user and receipt by said user of said acknowledgement of said user are time-stamped and recorded by said computer system.

4. The method of claim 3, wherein said acknowledgement is linked by said computer system, to a medical finding, modifier, or descriptor, in said report.

5. The method of claim 4, further comprising:
allowing a second predetermined time period to run, using said computer system, before electronically notifying said user again when acknowledgement is not received by said computer system, within a first time period.

6. The method of claim 5, further comprising:
notifying said patient of said medical finding in said report via a predetermined electronic communication;
scheduling said context-specific option as an additional examination or procedure, using said computer system; and
confirming, using said computer system, said scheduling of said additional examination or procedure to said user via said predetermined electronic communication.

7. The method of claim 5, further comprising:
wherein said procedure is scheduled by said user, using said computer system, only after receipt of approval by said patient.

8. The method of claim 1, further comprising:
storing results of said procedure in a database, using said computer system.

9. The method of claim 8, further comprising:
conducting an electronic consultation, using said computer system, between users at a plurality of client computers, regarding said results of said additional examination or procedure.

10. The method of claim 9, further comprising:
preparing and storing a report in a database of said computer system, and
electronically forwarding said report to predetermined users, using said computer system.

11. The method of claim 10, further comprising:
performing an automated comparison of findings in said report with findings in said database, using said computer system.

12. The method of claim 11, further comprising:
issuing reports on report accuracy, using said computer system.

13. The method of claim 12, further comprising:
informing said user of said report accuracy for correcting said report, using said computer system.

14. The method of claim 8, further comprising:
searching said database, using said computer system, in accordance with pre-defined user preferences.

15. The method of claim 10, further comprising:
cross-referencing imaging criteria obtained from an examination procedure, with pathology data stored in said database; and
deriving a differential diagnosis, using said computer system, based on said cross-reference.

16. The method of claim 12, further comprising:
performing an automated outcomes analysis of said database, and forwarding said analysis to predetermined users, using said computer system.

17. The method of claim 1, further comprising:
highlighting critical findings in said report, using said computer system.

18. The method of claim 1, further comprising:
utilizing gesture-based or symbol-based reporting, of a gesture-based reporting method, to create said report, using said computer system.

19. The method of claim 18, further comprising:
generating an image, using said computer system, which shows specific findings in said report, wherein said specific findings are shown using gestures or symbols of a gesture-based reporting method, on said image.

20. The method of claim 19, further comprising:
converting prose reports into gesture-based reports, using said computer system; and
comparing reports between different users in a standardized reporting format.

21. The method of claim 20, further comprising:
tracking a frequency, using said computer system, of each individual gesture or symbol used with said gesture-based reporting method, by said user, to create a statistical profile of commonly used gestures or symbols.

22. The method of claim 18, further comprising:
creating a structured database, mapping to a standardized lexicon, where multiple data elements include at least one of: pathologic and descriptive findings contained within a medical imaging dataset, technical data related to imaging acquisition and processing, clinical data related to individual patient medical and surgical history, decision support data, historical imaging data, consultative information, genomics and proteinomics, or patient-specific demographics.

23. The method of claim 22, further comprising:
creating direct targeted data mining of said structured database, using said computer system, utilizing a plurality of search criteria which can be denoted through inputted gestures or symbols of a gesture-based reporting method.

24. The method of claim 18, further comprising:
driving workflow commands, using said computer system, through a use of symbolic or alpha-numeric workflow language tracked to a standardized lexicon for workflow.

25. The method of claim 1, further comprising:
displaying on a display, resources for said user generated by said computer system, including at least one of journal articles, web links, and teaching file cases.

26. A computer system to implement a critical results reporting pathway, comprising:
at least one memory containing at least one program for performing the steps of:
initiating a critical results reporting pathway in a computer system, upon a critical data element being identified by said computer system in a report created at a client computer of said computer system, or upon entry into the computer system of an examination order at a client computer of said computer system;
identifying a user who entered said examination order or said report and notifying said user of initiation of said critical results reporting pathway via a predetermined electronic communication method predetermined by said user;
receiving acknowledgement from said user of said notification via said predetermined electronic communication method, and linking said acknowledgement to a medical finding in said examination order or said report in a database;
activating an electronic auditing tool and tracking all actions, using said computer system, which are performed by said user upon review of said report or said examination order at said client computer of said computer system, said actions which include documenting said user's review of said report or said examination order;
presenting to said user automated medical options from said database, using said computer system, said medical options which include consultations, additional examinations or procedures;
receiving a selection from said user of at least one of said medical options;
presenting said user with a list of context-specific options, generated based upon said selected at least one medical option;
receiving a selection from said user of one of said context-specific options; and
implementing said user's selected context-specific option.

27. A non-transitory computer-readable medium whose contents cause a computer system to implement a critical results reporting pathway, the computer system having a program comprising the steps of:
initiating a critical results reporting pathway in a computer system, upon a critical data element being identified by said computer system in a report created at a client computer of said computer system, or upon entry into the computer system of an examination order at a client computer of said computer system;
identifying a user who entered said examination order or said report and notifying said user of initiation of said critical results reporting pathway via a predetermined electronic communication method predetermined by said user;
receiving acknowledgement from said user of said notification via said predetermined electronic communication method, and linking said acknowledgement to a medical finding in said examination order or said report in a database;
activating an electronic auditing tool and tracking all actions, using said computer system, which are performed by said user upon review of said report or said examination order at said client computer of said computer system, said actions which include documenting said user's review of said report or said examination order;
presenting to said user automated medical options from said database, using said computer system, said medical options which include consultations, additional examinations or procedures;
receiving a selection from said user of at least one of said medical options;
presenting said user with a list of context-specific options, generated based upon said selected at least one medical option;
receiving a selection from said user of one of said context-specific options; and
implementing said user's selected context-specific option.