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R. Friedl1, W. Klas2,*), T. Rose3, O. Gödje1, M. Preisack1, J.
Tremper4, C.F. Vahl4, K.J Quast5, A. Hannekum1
Dept. of Cardiac Surgery, Univ. Ulm1 and Heidelberg4;
Dept. Databases and Information Systems, Univ. Ulm2;
Research Institute for Applied Knowledge Processing,
Ulm3; ENTEC GmbH, St. Augustin5 (All Germany)
Individualized Learning and Teaching in
Heart Surgery: The Cardio-OP Project
Individualisiertes Lernen und Lehren in der
Herzchirurgie: das Cardio-OP Projekt
Summary
Zusammenfassung
The complexity of cardiac surgery
requires continuous training, education
and information addressing different
individuals: physicians, medical students,
perfusionists and patients. In this paper we
describe the design and prototypical
development of a computer-based,
educational system intended to provide
multiple re-use of multimedia-data in
different instructional sceneries and
flexible composition of content to
different target user groups.
Die Komplexizität der Herzchirurgie
erfordert kontinuierliches Training und
Information für unterschiedliche Personen:
Ärzte, Studenten, Kardiotechniker und
Patienten. In diesem Aufsatz beschreiben
wir die Konzipierung
und die
prototypische
Entwicklung
eines
computer-basierten Ausbildungssystems
welches die multiple Wiederverwendung
von
Multimedia-Daten
in
unterschiedlichen Ausbildungsszenarien
sowie die flexible Komposition von
Inhalten
für
verschiedene
Benutzergruppen zum Ziel hat.
1
Background
Cardiac Surgery is an emerging field in medicine dealing with the operative treatment
of congenital and acquired diseases of the heart and its great vessels. More than 700
000 operations of the open heart are performed worldwide each year in
interdisciplinary high-technical medical units. This discipline is facing a rapid
development of new operative techniques and technologies. The complexity of the
subject requires continuous training, education and information for different usergroups in heart surgery: cardiac surgeons, fellows and surgical residents in their
responsibility to keep up with the state-of-the-art operative techniques as well as other
members of the operation team such as anaesthesiologists and perfusionists.
Furthermore, general practitioners, cardiologists and rehabilitation specialists are very
closely involved in pre-operative diagnosis and post-operative therapy. Students are
frequently joining the operation team during their clerkships, often with tremendous
difficulties in understanding the complex and long-lasting operations. Due to the
limited ischemic time of the heart, surgical procedures are performed under time
pressure, often leaving little room for detailed explanations. Finally, most patients are
seeking very detailed information concerning their disease, the operative therapy and
ual future life.
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Purpose
There is evidence in the literature that efficacy and efficiency of education and
training in different fields of medicine may be improved by the use of multimedia
information systems [1]. In contrast computer-based education programs are facing
some serious disadvantages:
1.
multimedia productions, particularly media recording, media processing and the
authoring process require tremendous financial and time resources [2].
2.
the obtained multimedia data are mostly usable for one specific target user group
in one specific instructional context
3.
computer based learning programs show deficiencies in the support of individual
learning styles and in providing individual information adjusted to the learner‘s
individual needs.
4.
educational multimedia systems often represent pre-packaged and preorchestrated one-shot productions
In this paper we describe the prototypical development of a computer-system,
providing multiple re-use of multimedia-data in different instructional sceneries and
flexible composition of content adapted to different target user groups: students,
physicians, medical teachers and patients.
*)
New affiliation: Institute for Computer Science and Business Informatics, School of
Social and Economic Sciences, University of Vienna, Austria
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System-Overview
An database-driven on-line architecture for multiple re-use and flexible composition
of stored media-items addressing different user groups, on individual levels and in
different educational sceneries has been prototypically established (Fig 1).
The authoring- and production process basically consists of five different steps:
1.
Writing a Digital Storyboard to describe educational content, text-structure,
different knowledge-levels, hypermedia-functions and media intended to use
2.
Media-production and -processing according to the storyboard (see chapter
7). Media-annotation with meta-information using a Annotation Tool and the
Cardio-OP-DataClas (see chapter 6)
3.
Authoring using the authoring system Cardio-OP-Wizard on the basis of the
digital storyboard (see chapter 5). A Media Browser facilitates the databasesearch for corresponding media. It allows to select media components
according to the type of medium and the underlying meta-information based
on the Cardio-OP-DataClas (CDC) (see chapter 6).
4.
The result of each step is stored and computed in terms of data-management
in the repository (see chapter 4).
5.
in the project (see chapter 6). Authoring and presentation of content stored in the
repository is supported by further, specifically developed tools: a Digital Storyboard,
an authoring system (Cardio-OP-Wizard), a Media Browser, an Annotation Tool, and
a Presentation Engine, which can exploit all the features available from the repository.
Digital Storyboard
Text
Media-Production
CardioOP-Wizzards
Video, Graphic, VRML, 3D
Authoring-Tools
Media-Browser
Annotation
Tool
Digital Storyboard
Meta-Data: CDC
Object -Relational Multimedia Repository for Cardiac Surgery
Single
Media
Educational
units
Templates
Metadata
ZyX-Document
Model
Finally a Presentation Engine displays multimedia documents (instructional
applications) to different user-groups by composing media components
according to the authoring process.
Presentation-Engine
4
Repository
The Cardio-OP information system is based on a database system-driven multimedia
repository supporting the following functions: presentation-neutral storage of
multimedia content from the application domain, delivery and presentation of
multimedia material to different locations (e.g. campus, hospital, home), content based
retrieval, re-use and composition of multimedia material for different instructional
settings. The modeling of the multimedia content is based on the ZYX document model
[3] that allows for re-use and presentation-neutral description of the structure and
content of multimedia documents and for the adaptation of content to the user's
interest or technical infrastructure [4].
The ZYX document model model has been implemented as a DataBlade module into
the object-relational database system Informix Dynamic Server/Universal Data Option
[5]. The repository supports fine-grained annotation of single multimedia elements,
fragments, or entire documents, which enables indexing of all content in order to
provide efficient content-based search. It explicitly supports the management and
storage of the CardioOP-DataClas, a domain-specific classification system developed
Operative
Techniques
Leve1-3
l
Case -Based
Teachin
g Level1-3
Physican
s
Student
s
Lecture and
Presentation
Medical teachers
Student
s
Patient
Information
Patients
Fig. 1. Cardio-OP: a database-driven on-line architecture for multimedia
authoring
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Authoring-System
Any multimedia production has to consider the integration and orchestration of
several components ranging from single information items (e.g. video, text) to
learning units and learning courses. Existing authoring tools do not support the
requirements for re-usability, adaptation, and presentation-neutral description of
structure and content of multimedia material and are rather designed to deliver precanned and pre-orchestrated presentations. Multimedia material stored in the
repository, that can be processed and authored in terms of our identified needs (see
purpose) is created by using a specially developed next generation authoring
environment called Cardio-OP-Wizard. It aims at a flexible support for on-line
authoring of multimedia presentations and serves as a connection to the multimedia
repository in order to offer authors all multimedia elements, i.e. complete
presentations, fragments of presentations and individual atomic media objects like
videos and images. The resulting educational modules authored with the Cardio-OPWizard are stored in the repository in a fine-grained structure, such that all the
structural elements and logical components of the presentation are still explicitly
modeled by the repository. This authoring tool allows for the specification of
alternative media elements (i.e. video and an equivalent sequence of images, audio
and an equivalent text) since these alternatives will be used by the system to semiautomatically compile the proper quality of a multimedia presentation to be delivered
to the end users according to their needs.
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CardioOP-DataClas Meta-information
System (CDC)
Knowledge management can be defined as the systematic process of finding,
selecting, organizing, filtering and presenting information in a way that offers guiding
assistance in the process of acquiring, storing and utilizing knowledge. As our
repository serves as a common knowledge base for different user groups and authors it
is designed to support flexible, fine-grained re-use of the multimedia material in
different context and at different locations. Therefore, the Cardio-OP repository
essentially requires the classification and indexing of information items, apart from
the acquisition and storage of multimedia-data. Our analysis of existing medical
classification-systems and thesauri (ICD9, ICD10, SNOMED, MeSH, ICPM,
operation-key 301, PCS, CPT, UMLS, MED, GALEN) showed that these systems do
not provide very detailed content coverage sufficiently satisfying our needs. Similar
results have been described by others [9]. Therefore we started to develop the metainformation system Cardio-OP-DataClas (CDC) indexing the following parameters:
detailed vocabulary of surgical procedures, instruments, materials, anatomy, physioand pathophysiology, etiology, diseases, drugs and terms related to medical
professions; differentiation of a term into the correct medical term, synonyms,
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colloquial terms and other languages; possibility to add comments, multi-linguality;
definite and clear relationship between terms and an underlying numeric key; easy update and technical implementation. The CDC meta-thesaurus currently contains 13000
terms related to cardiac surgery on the basis of a vocabulary editor. It serves as a
controlled, descriptive and evaluative meta-information system associated with our
multimedia-data. The authors use uniform keywords which improves the quality of
knowledge management. The Annotation-Tool is used to add different terms of metainformation to e.g. a video-sequence containing temporal and spatial information on a
surgical procedure, different surgical instruments and anatomical details. The
description of media components covers content- and media-dependent information.
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Media-Processing
Surgical procedures are best visualized using digital video-sequences. However,
operations of the heart are performed under strict time frames leaving little space for
time-consuming exposure of the operating-field to a video recording system. For this
purpose, a remote controlled and mobile video-robot has been developed and installed
in our operation theatre with three degrees of movement and rotation mostly always
finding a recording-corridor between the surgeons' heads. The camera (Panasonic,
3x1/2 CCD) is equipped with a high resolution lens and enables to zoom the small
structures of the heart, i.e. coronary arteries with a diameter of approximately two to
three millimeters in a manner sufficient for teaching purposes. Videos are recorded in
digital video format with a DV-recorder and processed using a video-workstation
equipped with a DV-Master video-card and the Ulead Media-Studio and Adobe
Premiere software into different formats. The system also allows shooting digital
photographs. 3D and 4D animations of the beating heart and feasible surgical
techniques, such as suturing the anastomosis of a coronary artery graft, are developed
using a Silicon-Graphics Workstation and the Soft-Image software. Additionally we
are developing 3D and 4D reconstructions from CT-, MRT- and US-Data using the
Heidelberg Raytracing software, a volume-rendering tool developed at the German
Cancer Research Centre in Heidelberg/Germany specifically for the visualisation of
sectional medical image data [6].
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Instructional Applications
The system contains different instructional applications (Fig. 1) which have been
implemented as first prototypes and which are focusing on aortocoronary bypass
grafting and heart transplantation. Currently the content is being developed.
1.
Mediothek - a kind of multimedia textbook on operative techniques (Fig 2): it is
addressing physicians, students and medical teachers and represents a systematic
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2.
approach to teaching. All important steps of the preoperative evaluation, the
operative procedures and the postoperative care will be interpreted using digital
video, sound, text and virtual animations.
Interactive modules for problem based learning: these applications will aim at the
training of decision making processes in specific clinical situations. They intend
to demonstrate clinical problems and complications and request the user to
develop solution-strategies by interacting with different kinds of question-answer
interactions.
3.
Lecture and presentation: medical teachers will be invited to use the mediamaterial stored in the database for their lectures. According to their instructional
goals this material may be composed on the fly or re-composed to specific
multimedia-presentations for
different target user groups. The resulting
instructional units are intended to be available on-line to the auditorium having
the opportunity to repeat the lecture at home.
4.
Patient information system: the main task of this module will be the information
of the patient (and his relatives) to all aspects of his disease, the operation and the
postoperative course. This module is intended to be available to our patients by
the use of kiosk-systems in cardiology departments (preoperative stay), in cardiac
surgery departments and during the postoperative phase in the rehabilitation
hospitals but also via the Internet. Thus, the system may supplement and
ameliorate the patient’s knowledge throughout the course of his disease in
different medical institutions related to the heart operation but also at home.
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Instructional Design
Principles of cognitive psychology and knowledge management are employed in the
instructional design. Our users may be roughly divided into the professional usergroup (physicians and students) and the patient user-group. This requires a distinction
in terms of program design, functionality and instructional design.
1. Professional user-group: we developed a self-explaining and intuitively usable
human-computer interface. This is an important criterion of non-verbal interaction
with a computer and is regarded as being an important factor of acceptance in
computer-based teaching environments. The program structure and navigational
possibilities support continuous and direct access to all parts of the program.
Hypermedia functions encourage creative and associative learning processes and
support the learner's autonomy. Depending on his interest, the user may jump to other
parts of the program where relationships between technical (surgical) procedures, and
the underlying physio-and pathophysiological principles or diagnostic modalities
become evident. This is important because learning individuals often do not integrate
basic scientific concepts while solving clinical problems. To give the user the best
support to act according to the principles of evidence based medicine the system
Fig. 2. Cardio-OP: Design of the Mediothek on operative techniques
serves also as gateway to other databases as i.e. MEDLINE. Since the hyper-media
architecture allows an arbitrary movement which lacks the linearity of a textbook, we
implemented additional assistance showing the user in which part of the program he
currently stays.
The Mediothek and the module for problem based learning are based on different
instructional levels providing factual knowledge (beginner), procedural knowledge
(advanced) and implicit knowledge (professional), which may be freely selected by
the professional target user groups according to their background-knowledge and
interest. The user has to interact with the problem-based learning module in a way
beyond electronic page turning and following hyperlinks by judging clinical findings,
generating hypotheses and making decisions. The underlying question-answer
complexes are represented by multiple-choice, free-text entry interactions and objectanimations providing intensive feedback.
Space-imagination and the understanding of dynamic processes together with the
capability to interpret visual, acoustic and haptic signals correctly play an important
role in understanding surgical procedures of the heart. In contrast to print-media,
multimedia-systems are capable to simulate such procedures closer to reality by the
employment of video, multidimensional animations and interactive teachingscenarios. The presentation of medical data in a realistic and sequential manner is
intended to provide a high level of authenticity. When knowledge and skills must be
used in real medical life, they should be acquired in an environment as realistic as
possible [10]. To optimize authenticity the case-based teaching modules are planed to
branch into different pathways depending on the user‘s answers and performance.
2. Patient user-group: in contrast, the patient information system will be very easy to
navigate. It will be addressable via the Internet and clinic-based kiosk-systems with
touch screen monitors and large screens therefore specifically satisfying the needs of
disabled and aged people. This module does not intend to replace the traditional and
important physician- patient interaction. However, an adequately informed patient is
able to ask the right questions, to reduce his anxiety and to prepare better for the
operation [7]. The availability of the same system in different medical institutions may
increase the acceptance and frequent use of this tool.
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Conclusion
The demonstrated system reflects a novel integrated approach in terms of information
technology and teaching. We regard it as being important for an effective learning
process that individuals, informing themselves on a specific topic in cardiac surgery,
are supported in their individual learning-styles on individual knowledge-levels. The
demonstrated system may promote these needs in an efficient and economic manner
by its flexible composition, re-use and presentation of multimedia-data. Because the
teaching-applications will provide identical information about a certain subject using
different educational principles it might serve as the basis for a comparable evaluation
to test the effectiveness and efficiency of the different pedagogical approaches while
avoiding frequent confounders [8]. The on-line availability of the system via Internet
allows self-directed learning and information retrieval independently from predefined
locations. In contrast to standard-textbooks and patient information material, with new
releases every 4 to 8 years, the multimedia-repository may provide continuous
availability of actual knowledge and current state-of-the-art developments world-wide.
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the ZYX Data Model for Multimedia Documents and Presentations," in Proc. of
Datenbanksysteme in Buero, Technik und Wissenschaft (BTW99), GI-Fachtagung,
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[6] Meinzer HP, Meetz K, Scheppelmann D, Engelmann U, Baur HJ: The Heidelberg
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34-43
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[9] Chute CG, Cohn SP, Campbell KE, Oliver DE, Campbell JR:.The content coverage of
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Acknowledgement
Partially funded by the German Ministry of Research and Education, grant number
08C58467, in the research program ”From the Scientific and Technical Book to a
Multimedia Knowledge Representation”.
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