[Standardized findings in echocardiography using WWW: EchoBefundSystem].
As a non-invasive imaging system, ultrasound echocardiography has a very high impact on modern diagnosis and is widely used in clinical routine but without any structured and standardized documentation of the results. Thus, quality management (QM), statistics and comparison of the results are difficult. Therefore, a working group of the German Cardiac Society issued a consensus proposal. For evaluation and wide public distribution, we have developed the first internet-based application covering the full proposal: EchoBefundSystem. The EchoBefundSystem is a web based client-server application for standardized documentation of echocardiography results right at the workplace. The software leads the examiner by means of a user interface design and stored medical knowledge. The level of detail is scaled automatically to the ongoing examination. Every day clinical routine is performed on only two pages, one for general patient data and a second one covering the complete minimal data set called "minimum finding" in the standard. As the examiner discovers more and more special findings or might even enter a complete medical study, the interface offers more and more fields and checkboxes. One data set can contain up to 600 values and findings. The structured user interface reflects the organ structure as well as examination methods familiar to the examiner. Automatically calculated fields speed up the examination. Judgements, diagnoses, values and ranges are interrelated. If there is a difference between the entered data and the medical knowledge base, a warning will be issued but the doctor's decision is authoritative. Some values may be gathered by different methods and even different units are converted automatically. The final doctor's letter is generated automatically in clear text but still editable and can be given out to the patient right after the examination without any further delay. Beside the minimal data set, all abnormal findings will appear and findings will be summarized wherever possible. The report is intended for the referring general practitioner, your own documentation, expert witness as well as clinical studies. Interested examiners may test the full version online at http://echo.ma.uni-heidelberg.de
Schweikart
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DFKI GmbH Erwin-Schrödinger-Str. Geb. 57 67663 Kaiserslautern. schweik@dfki-uni.kl.de bzw Oliver.Schweikart@web.de
Metzger
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D003196:Computer Graphics; D003936:Diagnosis, Computer-Assisted; D004282:Documentation; D004452:Echocardiography / Q000295:instrumentation / Q000592:standards*; D006801:Humans; D020407:Internet; D016347:Medical Records Systems, Computerized; D008955:Models, Cardiovascular; D014584:User-Computer Interface
Standardisierte Befunderfassung in der Echokardiographie mittels WWW: EchoBefundSystem.