Keywords |
| Medical education; e-learning; integration; learning management
systems; online education; medical informatics; operating room informatics |
Introduction |
| With the growth in the production of medical devices and the rapid technology
advancement in medicine, operating rooms (ORs) have become more complicated and
require more staff to control the tools and equipments. There are several OR
information systems currently in development or employed in ORs, mostly in an isolated fashion due to the absence of appropriate integration. It is, therefore,
necessary to address the integration concern and to develop strategies for improving
surgical/interventional workflows and data storage and utilization. |
| An OR automation system is a combination of hardware and software designed to
control multiple OR devices via a common interface. OR systems range from the
relatively basic to advanced designs capable of storing and exchanging images and
videos with other systems, which can be controlled by a single person via a simple
interface, e.g., touch-screen or voice commands. This allows surgeons and medical
teams to focus on the patient and procedures rather than diffused dealing with
complicated and unstructured tools and devices. In addition, it offers light control to
adjust suitable illumination for the operation, OR-table control to adjust the position
of the operating table as needed, and the ability to archive and store captured video
and images. Furthermore, the new design of an OR guarantees more free space for
medical staff, efficiency in design and shortened housekeeping time, no cables or
scattered equipment, and real-time collaboration.1,2 |
| In the last two decades, minimally invasive surgery (MIS) has seen a great and solid
rise in popularity resulting in the advancement and evolution of advanced video and
robotics technologies to replace the old open surgical methods.3 MIS procedures offer
the ability to record procedures either fully or partially on tape, multimedia or special
storage servers. |
| Patient medical records (MRs) are an essential element in hospital care. Each record
contains vital patient medical information such as allergies, previous medication,
medication history, discharge reports, radiology images, and other demographic and
medical information, but has little or no detailed information (images, videos, data) on
surgeries and procedures the patient has undergone.4 |
| Medical education and training approaches vary from the traditional with basic
exposure to multi dimensional and interactive approaches including real cases
contained in the MRs. In addition, the MRs are important for medical educational and
training activities. They can be used as medical cases on several educational levels
including undergraduate, graduate, postgraduate, and continuing medical education
(CME). Such medical cases are taught to medical students/doctors as case studies or
as part of the course/degree program.5 Furthermore, research activities have been fully
or partially reliant on data stored in MRs for ages. Retrospective studies and case
studies, in addition to several kinds of research methodologies, are mainly conducted
totally or partially based on data stored in medical records. |
| In addition, the continuous and rapid advancement in information technology and
communications has led to the evolution of e-learning environments. E-learning
systems are educational systems that utilize information and communication
technologies resources such as the Internet, networks, and multimedia applications to
enhance the learning process. In an e-learning environment, the learner is the focus
instead of the material itself. Such an environment allows learners to study at their
own pace according to their capabilities, to communicate with colleagues and teachers
through discussion groups and video conferencing, and to conduct self-assessment
through online evaluations. E-learning environments provide learners with the
flexibility of studying regardless of their location or time zone.5,6 Medical and surgical education is currently searching for new and innovative training tools that
match the sophistication of the new operating methods. In addition, the “To Err is
Human” report published by the Institute of Medicine in the United States and the
“Bristol Case” in the U.K. suggested that better training and objective assessment
would be key strategies in attaining the goal of reducing medical errors. Several
studies and reports have discussed and evaluated virtual reality training in operating
rooms since Satava first proposed training surgical skills in a virtual reality (VR)
environment in the early 1990s.3,7,8 |
| Because of the great importance of e-learning in modern education, and its role in
improving students' performance9, the King Saud University Hospitals (KSUHs) have
begun to implement a modern e-learning system containing state-of-the-art e-learning
components.5,10 |
| In medical education, enabling students to practice medicine, by laying a hand on live
cases and taking part in the examination, procedure and diagnosis processes, is
essential and of great importance to supply them with the necessary skills and
experience to treat their future patients. Traditionally, this was done by organizing
student rounds, where small groups of students observed and examined cases, and
discussed patients’ conditions with their instructors, and by attending educational
surgeries and operating room activities. This traditional approach suffers from the
following disadvantages. |
| • Due to space limitations and convenience in clinics or operating rooms, only a
small number of students can study each case, which means that students can
only be involved in a limited number of cases during their training. This also
applies to the limited number of surgeries and procedures students can
observe. |
| • Students are limited in their ability to examine patient history and radiology
images. Traditional learning enables them to examine only a small subset of
patient data and images, which in turn limits the skills and experience gained
by the students. |
| The benefits of face-to-face learning include direct and immediate response
communication and easy motivation. On the other hand, disadvantages include time
and place constraints, lack of student focus, the fact that the majority of the control
rests with the instructor, and more expense in the delivery.6 To overcome the
disadvantages of traditional teaching activities, KSUHs designed and implemented a
new approach in which traditional teaching is supported by technological tools to
enhance the experience gained by medical students and trainees. The system should
be used to assist and support the current systems and to provide students with tools to
better manage their learning activities and tasks, and assist them in gaining knowledge
and improving their skills. |
| The KSUHs include the College of Medicine, College of Dental Medicine, King
Khaled University Hospital (KKUH), King Abdulaziz University Hospital (KAUH),
and King Fahd Cardiology Center (KFCC). There are over two thousand students
enrolled in these colleges, which employ more than four hundred staff. The technical infrastructure in the KSUHs comprises a 100 Mbps intranet connecting the campus
colleges and the KKUH, and a 32 Mbps microwave link connecting the KAUH
campus. The main functions of the KSUHs are education, research, and providing
medical services to the public. The University academic environment encourages
students to carry out research, and to provide them with the necessary tools and skills
through skill labs, anatomy and physiology software packages, and other applications
and activities. |
| This study discusses the design and approach adopted by the KSUHs to: |
| • implement medical segmentation, tracking and retrieval of patients’ surgical
case data and images with a well structured database design for future retrieval
and utilization of the data; |
| • create an OR educational medical library to be utilized in both educational and
research activities; |
| • provide automated storage and management of data flow before, during and
after an operation, and provide support for surgeons and medical teams to
better control OR tools and instruments. |
System Design |
| The first step in the system design involved building an initial model that takes into
consideration the general OR, medical, and educational requirements. This model
should be dynamic enough to be able to overcome challenges that may appear in the
future. Figure 1 depicts the model used to define the different components of the
system. |
Design considerations |
| The following considerations were incorporated into the system design. |
Data and system considerations |
| The design focused on the best approach to store patient data, images, and videos
generated before (pre-operation), during (intra-operation), and after operations (postoperation)
for future medical consultation and to build up a complete medical case
history from diagnosis to discharge. Data stored during operations comprises mainly
videos and images from laparoscopic devices, hamlet cameras, and radiology and
ultrasound films. The system design allows the recording and forwarding of images
and/or videos to other displays and/or classrooms locally or remotely. The KSUHs
have five operating rooms equipped with up to six cameras in each, as well as
laparoscopic devices, and hamlet cameras. Videos from these cameras are recorded on a SAN storage device; tracking and segmentation of recordings are designed to be
introduced to recorded materials by voice commands or via touch screen commands.
These commands allow the separation of different segments of the operation phases
for searching and retrieval purposes. In addition, commands can be added to tag
certain landmarks or events during the operation. Pre-operation data includes the
diagnosis, radiology films and lab results, in addition to the patient’s demographic
data. Post-operation data includes medical notes, the discharge report, radiological
films, and other examinations. Content of this enormous magnitude recorded during
the operation is expensive in terms of both cost and effort, and requires several
systems and servers with vast storage capacities and sufficient computational
capabilities to keep it safe and secure with the required performance level. |
Space limitation |
| The proposed design considers the restricted space in the OR and available areas for
medical staff movement. The resulting design offers more free space for medical staff,
efficiency in terms of reduced housekeeping time, no cables or scattered equipment,
and real-time collaboration. |
Medical considerations |
| The design allows the surgeon to consult in real-time with remotely located
colleagues, conduct a video conference, and route the operation from various imaging
devices to other output screens. The proposed approach allows the surgeon and
medical team to focus on the patient and procedure rather than dealing with
complicated and unstructured tools and devices. It further offers lighting control to
provide a suitable mixture for the operation and control of the OR table to adjust its
position as needed. |
Educational considerations |
| This design facilitates conducting remote educational sessions utilizing the video
conferencing feature in the design. Instead of having students crowded in the OR to
learn and gain skills, OR videos, audio, images, and data can be simultaneously
routed to various auditoriums and classrooms with commentary by the medical team
and interaction with the audience. Furthermore, cases can be stored either fully or
partially on the video-on-demand servers and can then be accessed by
students/trainees in their own spare time. The approach focuses on designing an OR
educational medical library to be utilized in both educational and research activities.
This would give students and trainees better access to operations and procedures.
Crowding together in the OR with the medical team normally does not provide the
majority of students with a good opportunity to follow and observe the details of the
procedure, besides the other risks associated with such a practice for both students and
patients. In addition, students need to have access to the system from anywhere on the campus as well as from outside the campus through the Internet. Access control
methods were incorporated to prevent unauthorized access, as well as ensuring that
the infrastructure needed is powerful enough to allow students to access the system
reliably and easily. |
General considerations |
| For such a system to be successful, certain general features must be included; that is,
flexibility to adapt the features, capabilities, and goals of the design; ease of use,
which means that medical team members and students/trainees can focus on the
procedures themselves and learners can focus on the material itself, rather than on
how to use the system11; interactivity, whereby learners can interact with each other
and with their teachers and the surgeons through video conferencing and/or discussion
boards; and a solid infrastructure to support the system and provide the learners with
easy and fast access to the system.11,12 The system must utilize the most advanced and
most recent technologies to provide optimal performance. The system must also be
scalable to accommodate any increase in the numbers of students or staff. It must be
expandable, so that new features can be added to further improve the functionality of
the system. The system should have a web-based interface to allow students to access
it using Internet browsers without considering the location of the student. |
| The proposed model design satisfies the medical, technical, and educational
requirements for the approach. It contains the necessary servers and infrastructure to
carry the bandwidth and storage consuming videos, audios, images, and other data. It
is expandable and scalable, adheres to international standards, and can accommodate
new components. It interacts with different hospital systems, picture archiving and
communications systems (PACS), classroom systems, e-learning systems, and lecture
broadcasting. Figure 2 illustrates the system design and the components. |
Discussion and Conclusion |
| The growth in medical device production and utilization, and rapid technology
advancement in medicine, has meant that medical environments and operation rooms
in particular, have become more complicated, requiring more trained and qualified
staff to control the myriad of tools and equipment. In addition, the advances in
information technology and e-learning have prompted medical education institutes to
utilize these technologies to enrich the learning environment and to provide students
with tools and systems to enhance their learning experience. It is believed that
integrating and utilizing hospital information systems and patient data with an elearning
system in educational hospitals is expected to provide better medical training
and educational outcomes.6 |
| A well-designed e-learning environment can motivate students to become more
engaged with the educational material and more content, thereby becoming more
active participants (13). E-learning or interactive learning shifts the focus from a
passive, teacher-centered model to one that is active and learner centered, offering a stronger learning stimulus. Interactivity helps to maintain the learner’s interest and
provides a means for individual practice and reinforcement. Evidence suggests that elearning
is more efficient than the traditional learning approach because learners are
reported to gain knowledge, skills, and attitudes faster. This efficiency is likely to
translate into improved motivation and performance.5,13,14 |
| Interaction plays an important role in medical education. It enhances the students’
capabilities and allows them to get involved in the medical process, as a way of
building skills and gaining experience. This interaction is best applied through a
blended learning approach, where traditional educational methods are supported and
augmented by e-learning tools and resources. The results of previous studies indicate
that students and instructors have a better perception of online, electronic, and
blended learning than fully electronic and distance learning. The OR informatics
approach discussed in this paper is an important component of the blended learning
approach, providing students with an effective, integrated learning environment with
the highest possible quality and accessibility. Blended learning is an approach that
combines both e-learning technologies with traditional instructor-based learning,
where, for example, a lecture or demonstration is supplemented by electronic
tools.8,13,15 |
| Previous studies in both medical and nonmedical settings have consistently
demonstrated that students are satisfied with e-learning.6,12-15 In addition, learners’
satisfaction rates increase with e-learning compared with traditional learning, mainly
due to the perceived ease of use, better access and navigation, interactivity, and userfriendly
interface design.11 In accordance with previous studies and reports, students
themselves do not see e-learning as a replacement for traditional instructor-based
training, but as a means of complementing it, forming part of a blended-learning
strategy.5,12 |
| The proposed design introduces a high level of interactivity further enhancing
learning and training capabilities. It is a student-centered model that uses both
traditional and e-learning systems integrated with hospital systems, patients’ data and
real cases to provide students with interactivity and participation in real life cases and
procedures. Furthermore, it offers students the flexibility they need to learn at their
own pace and according to their needs, while at the same time solving the problem of
lack of space in operating rooms and practical classes.5 |
| This paper discussed a modern approach designed and adopted by the KSUHs that
satisfies the specific requirements of medical education through the integration of
different hospital information systems and e-learning systems in the OR environment.
This blended learning approach is indeed required for the success of e-learning in
medical environments and helps overcome some of the challenges in medical
education. |
| There are several challenges facing the deployment of the OR informatics approach.
Some of these are technical, while others are related to the skills of the doctors, users,
and students. Before research on building the system could begin, it was necessary to
measure the users’ information technology skills to assess their readiness for the new
system. Students were given a questionnaire with a number of questions including
whether they owned a computer, and how they used computers in general.15 The results of this questionnaire showed that although the students had reasonable general
computer skills, they lacked the capability of using these skills in medical education
and research. This confirmed that students required proper training to utilize the
system in the best way, and The College of Medicine was urged to add courses in
medical informatics for the students. When the skills of the staff/doctors were
examined, it was observed that many of them also lacked the necessary skills to use
these systems in the best way.16 The above challenges had to be considered before
implementing a new system. |
| The integration of e-learning into existing medical curricula should be the result of a
well-devised plan. In medical education, an OR informatics approach is even of
greater importance because of its role in overcoming problems such as the lack of
space in operating rooms and critical areas allowing the students to attend procedures
and surgeries without endangering the patients’ safety and security. |
| The proposed OR informatics design where all hospital systems are integrated in a
smart technological environment, supports and augments traditional education by
providing instructors/consultants with easy to use tools enabling them to concentrate
on delivering high quality education/training. At the same time students can obtain a
complete picture of every case they study, increasing the quality of their education
and allowing them to participate fully with the diagnosis and examination procedures. |
| The integration of e-learning into all levels of medical education including CME
should promote a shift toward interactive learning in medical education16, where
educators no longer serve solely as distributors of content, but act more as facilitators
of learning and assessors of competency. With the advancement in information and
communication technologies, the future offers the promise of high-fidelity, highspeed
simulations and personalized instruction using both adaptive and collaborative
learning.14 |
| Furthermore, the e-learning process and methods should be evaluated with respect to
outcomes and efficiency. The evaluation of e-learning should include a peer-review
process and an assessment of outcomes such as learner satisfaction, content, usability,
and demonstration of learning. In addition, faculty skills in creating and delivering elearning
materials and content may differ from those needed for traditional teaching,
which should be commensurate with effort. Moreover, faculty rewards for scholarly
activity must be encouraged and recognized. |
| Sharing content with different institutions in the country, and throughout the world is
an additional dimension for blended learning, electronic content and e-learning
systems.18 This, in turn, should improve the quality of learning in medical institutions.
The expandability feature of the blended approach and e-learning system enables the
addition of new tools or features that may appear to take advantage of the latest
developments in e-learning technology. It is believed that the integration of an elearning
system with traditional classroom teaching is a uniquely applicable
approach.17 The model discussed in this paper is a student-centered blended model
that uses both traditional and e-learning systems to provide students with the
flexibility they need to learn at their own pace and according to their needs, while at
the same time solving problems including lack of space in operating rooms, clinics, and practical classes. The model introduces a high level of interactivity, further
enhancing learning capabilities. |
| Future studies should be planed and conducted to evaluate the utilizations of health
informatics tools in operation rooms. Furthermore safety for both patients and
students should be evaluated with new informatics solutions. |
Acknowledgment |
| The Authors extend their appreciation to the Deanship of Scientific Research at KSU
for funding the work through the research group project No RGP-VPP-058. |
Conflict of Interest |
| None declared. |
 |
| Figure 1: Model used to define the different components of the system |
 |
| Figure 2: System design with main components |
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