Consistent and Prioritized Presentation of Surgical Information-Proposal

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1. Proposed Workitem: Consistent and Prioritized Presentation of Surgical Information

  • Proposal Editor: Erik Schreiber,Thomas Neumuth
  • Editor: Erik Schreiber,Stefan Franke
  • Date: 2017-01-11
  • Version: 2017-02-12
  • Domain: Surgery

2. The Problem

With each new assistance functionality introduced in the operating room (OR) – e.g. HIS gateways or vendor-independent inter-device-communication – the amount of available information is growing. Simultaneously, the amount of information that needs to be displayed is increasing. Additionally, information need to be arranged manually on the available OR displays at discretion with no standardized presentation pattern. The unstructured provision of information bears the risk of an information overload and hence delays, complicates or even prevents the spotting of required information. To avoid an information overload, all available information must be prioritized in respect to the current surgical context so that only relevant information can be displayed and changed dynamically. At the same time, indifferent information must be either held back or orchestrated together with other less relevant information (e.g. in the corner of one screen) until they become more relevant. Additionally, a standardized, hardware-independent, ergonomic template is required to assign specific information to designated screens or a designated area of a screen, to allow a consistent vendor independent information presentation across different interventions, intervention types, and across operating rooms.

3. Key Use Case

The proposed integration profile can be applied to any surgical intervention (e.g. Functional Endoscopic Sinus Surgeries, Tympanoplasties, Aortic Valve Replacements or Brain Tumor Removals). During an intervention, all information entities will be arranged on the available displays ordered descending by their priority and category (e.g. Navigation, Vital data, Patient data, etc.). The categories, defined in a template, allow the provision of a consistent presentation of information, no matter what display hardware composition is used.


In the following, the functionality and benefits of CPSI will be illustrated at the example of a Functional Endoscopic Sinus Surgery (FESS), in which an endoscope, a shaver, a suction system, a navigation system, an EHR/PACS viewer and an anesthesia workstation (vital data) will be used. In an integrated OR environment, the usage of these devices and systems can be detected via the OR network (e.g. number of revolutions of the shaver greater than zero). Analyzing the usage data of all available devices and systems, thus allows inferring the current situation in the OR. Alternatively, a workflow information system can be used to determine the current surgical context. The first intervention phase is the preparation phase. During this phase, no surgical instruments will be used. Thus, shaver and suction system will be assessed as irrelevant information entities and will not be displayed. Instead, a high priority is assigned to the EHR/PACS and vital data. As a result, both information entities will be displayed in the center of the surgeon’s field of view (FOV). On first usage of the navigation system, it will be prioritized at the expense of vital data and EHR/PACS viewer that are at this point not necessarily required anymore. However, depending on the underlying template and how much displays are available, both information entities will either be faded out or moved to a minor screen. After finishing the registration, the endoscopic video stream will be an essential information entity for the rest and is shown on the primary screen. This applies anytime during the remaining intervention, as long as neither the navigation nor the EHR/PACS viewer are in use, in which case the respective information is prioritized instead of the endoscopic stream. If the shaver or the suction system is used, the blood pressure becomes an important indicator to detect accidental injuries of vessels. Therefore, the priority of the vital data receives a high priority so that the surgeon is able to track it quickly.

4. Standards and Systems

Involved Systems

  • Any medical OR device/system that needs to visualize information on an external screen
  • Workflow Information System (WIS) - optional
  • OR Display setup

Possibly suitable standards

  • IEEE 11073
  • DICOM (Hanging Protocol)

5. Discussion

To ensure interoperability, data transmission needs to be realized with well-established standards. Since there is no need for new standards, but the usage of existing ones is required, IHE would be a well-suited venue to solve this interoperability problem. Subsequently, an IHE integration profile should be developed to allow easy adoption. Proposed Actors:

  • Prioritizer – This system assigns a priority and a category (which defines the part of the display area the information is assigned to) to each information using for instance a lookup table or conditional statements
  • Display Handler – This system provides information about available displays (resolution, etc.) and their arrangement
  • Layouter – This system uses a predefined template to arrange information at the available displays. If required, it will scale or hide information depending on their category and priority

Open Issues

  • What are suitable forms of representation for information prioritization rules and template data?
  • How to ensure extensibility of the template? How to handle new information categories?
  • How to model the relative positions of the hardware displays to each other?
  • Which standards are best suited?
  • How should the system behave, if there is too much high prioritized information and there is not enough space on the display area for all of them? (Scale down information size? How to determine at what point information becomes unreadable?)
  • How to allow user interaction with the system, if it doesn’t interact as intended?
  • How to handle/prevent single information entities that are stretched over multiple displays
  • Where to draw the line between standardization of the template and customizability by the user