COMPUTER PROCESSING OF NEURORADIOLOGICAL REPORTS. AN INTRODUCTION TO THE APPLICATION OF THE VARIABLE-FIELD-LENGTH FORMAT AND MEDTRAN.

Abstract

Advances in the application of computer technology to medicine have been proceeding at an ever-increasing rate (2–6, 12–18, 21). This report deals with a technic that the authors have recently applied to radiology. The method combines routine dictation and typing of patients' radiological reports utilizing a special, commercially available typewriter. This typewriter will simultaneously prepare the material in the form of hard copy for routine use, and punch paper tape which is in machine language for computer input, storage, and analysis. The procedure was adapted from a previously described program of computer processing of neurological and neurosurgical case summaries (10, 11). The technic is now being routinely applied to neuroradiology reports of special procedures such as pneumoencephalography, ventriculography, angiography, and myelography performed at University Hospital and Bellevue Hospital of the New York University Medical Center. The purpose of adopting this process is to take full advantage of the high-speed digital computer so that the data in the reports may be utilized in various types of research. These include statistical studies of records, correlation of radiological findings with clinical and laboratory data, and retrieval of reports for follow-up patient care. Method The main purpose of the technic described is to produce readable hard copies of the report for the chart, files, administrative needs, etc., and simultaneously have the report produced in the form of machine language so that it can be placed in a computer for storage and appropriate analysis. This is accomplished in such a manner as to encroach as little as possible on the physician's time and effort while he dictates his routine radiology report. The method of accomplishing this has been previously described in detail elsewhere (10, 11), but a synopsis will be presented here. (a) Dictation: All reports are dictated according to a rigid format in fixed sequence which is modified to the needs of the radiologist. The formats contain two sections. The first is termed the fixed-field for statistical and identifying data, i.e., name of patient, age, hospital, ward, date of procedure, etc. (Tables I to III). The second section, termed the variable-field, contains the description of the procedure and the radiographic findings. The variable-field is in the form of first, second, and third order paragraphs (Tables II and III). The amount of verbal and numerical data that can be placed in this section is virtually unlimited. The first and second order paragraphs are coded for computer identification, while the third order paragraphs contain the data of the report.