Towards a structure of the Knowledge Domain for Augmented Surgery with an ontological approach

1. Towards a structure of the Knowledge Domain for Augmented Surgery with an ontological approach MD. Banihachemi Jean-Jacques Urgences, Service de Chirurgie Orthopédique et de traumatologie du Sport Hôpital Sud – C.H.U. de Grenoble Avenue de Kimberley B.P. 338 38434 Echirolles Cedex jjbanihachemi@chu-grenoble.fr Buffalo Nov.24.2008

2. SUMMARY • Presentation • Work • Conclusion

3. LES ALPES

4. HOPITAL SUD

5. Hôpital Universitaire de Grenoble / France • UJF, a university open to the world and society • TIMC-IMAG Laboratory : (Techniques for biomedical engineering and complexity management – informatics, mathematics and applications – Grenoble )

6. Why This Subject • Emergency Doctor : Cross view of all the medical specialties • New specialty : • SYmu : Systéme multimedia des urgences: (WO/2005/059802) SYSTEM AND METHOD FOR PROCESSING INFORMATION RELATING TO MEDICAL HOSPITAL CONSULTATIONS

7. Master : Robot-Based Tele-Echography II - A Comparative Study The aim of this clinical trial is to evaluate the concordance of diagnosis of injuries in thoracoabdominal trauma using two different echographic methods. The first method is a robot-based tele-echography performed by radiologists in a remote location. The second is bedside echography performed by emergency physicians according to the FAST (Focussed Assessment by Sonography of Trauma) examination.

8.  GMCAO - (J. Troccaz): Biomechanical modelling, image processing, data fusion and robotics for computer-assisted medical interventions. •  ThEMAS - (J.L. Bosson) : Epidemiology and clinical research methodology •  OSIRIS- (M. Simonet): Ontologies, Knowledge and Data: from Modelling to Representation and Exploitation. Application to Intelligent Information Systems in the Health domain

9. CAMI Computer Assisted Medical Interventions • The ultimate objective of the Computer-Aided Medical Interventions (CAMI) research group is clinical: the purpose is to assist the physician or surgeon in the successful execution of diagnostic or therapeutic gestures by minimizing invasiveness whilst improving accuracy

10. THE PROBLEM • Augmented Surgery • Around for more than 25 years • Examples • Orthopilot (B-Braun-Aesculap) • CT-Free Vector Vision ( BrainLAB) • Stryker Knee Trac • Navitrack (Zimmer) • FluoroKnee System (Smith et Nephew et Medtronic)

11. Evaluation of quality of existing & new devices Major Challenge • What is Quality? • General Medical Field : World Health Organization : W.H.O. • garantir à chaque patient l’assortiment d’actes diagnostiques et thérapeutiques lui assurant le meilleur résultat en termes de santé, conformément à l’état de la science médicale, au meilleur coût pour le meilleur résultat, au moindre risque iatrogénique, pour sa plus grande satisfaction en termes de procédures et de contacts humains à l’intérieur du système de soins • Pharmacology : AFSSAPS (French National Authority for Health) • Expected Medical Service (EMS) • Delivered Medical Service (DMS) • Augmented Surgery • EMS: what is EMS in this context? • DMS: what is DMS in this context? • Other notions

12. Quality in Augmented Surgery • EMS : To be defined • DMS : To be defined EMS and DMS rely on various notions: • Inventory of notions related to Quality • Structuring Final Objective : Build an Information System for the actual Evaluation of EMS and DMS.

13. Conceptual Structuring of the Domain • Ontological approach • Identify Concepts & Relations related to Quality in Augmented Surgery • Name • Define • Structure • Conceptual structuring ~Conceptual Schema, Terminology, Ontology • Objective: Information System for Quality Evaluation • Conceptual Schema: support to database design • Terminology: standard vocabulary of the domain • Ontology: ultimately …

14. The TEAM / ACTORS • Builders team • an emergency doctor with expertise in medical new technologies Jean-Jacques Banihachemi, MD • an engineer-doctor with expertise in Augmented Surgery Alexandre Moreau-Gaudry, MD-PhD, head of the CIC-IT • a researcher with expertise in the ontological domain Michel Simonet, PhD • a researcher with expertise in Information System design Ana Simonet, PhD • Role • Identify and structure concepts • Represent the conceptual structure

15. THE TEAM / ACTORS • Users team • Several internationally-published orthopedic surgeons • SARAGAGLIA. D., MD-PHD • MERLOZ. P., MD-PHD • PLAWESKI. S, MD • …… • French Public Health doctors who are experts in the domain of Augmented Surgery • CINQUIN. P., MD-PHD • BOSSON. J-L., MD-PHD • …… • Role • Validate Concepts and their structuring

16. MATERIAL • Expert knowledge • Bibliographical Texts • valgus osteotomies • anterior cruciate ligament surgery • total knee replacement • Case report Form • “Medico-economical Evaluation of Surgical navigation in treating insufficiencies of anterior cruciate ligament surgery of the knee” • National multi-centric study

17. Case Report Form Texts from the Bibliography terms terms concepts concepts Organization of concepts by Builder team Ontological Framework concepts terms Expert Knowledge

18. METHODOLOGY • Identify Concepts • Acquisition from experts • Brain storming  terms • Grouping equivalent terms  concepts • Extraction from texts • Manual extraction ( Excel file) • Selection and grouping of terms • Identify Relations • «Structuring» sessions  Fragments of a conceptual structure

19. Brain Storming Prototype/ non prototype Supplier Prospective trial Retrospective trial Publications Functional index Methodology CE Mark 1 2A 2B 3 reanimation – necessity precaution Purchase price Class Number of user sites Number of operators Number of patients operated on Number of lawsuits Software Observation notebook Evolution OPERATING PRACTITIONER Surgeon, neuro-surgeon / orthopedic-surgeon Radiologist Emergency Doctor Gastroenterologist Countries where it is used GDP Big Mac Index IS-A IS-A indicators TRAINING for surgeons NON OPERATING PERSONNEL Anesthetist Paramedic MEDICAL DEVICE furtive Operating procedure Endoscope robot Navigation station (ACL) Anatomical zones  FMA Ergonomics interface METHODOLOGIE D’EVALUATION Age, weight, height, gender, BMI Antecedents Quality of life Patient expectations • Criteria • individuals / society (political) • scientific / medico / economic • - cost–benefit ratio EVALUATION PATIENT EXPERIENCE MEDICO-ECONOMIC EVALUATION SCIENTIFIC EVALUATION RESEARCH TRAINING COURSE PATIENT Cumberland (CAIT) Functional score Number of lost working days Number of days in the hospital Number of re-hospitalizations Device dangerous not dangerous SOCIOLOGY Quality score DISSEMINATION COMMUNITY

20. Pathology = surgical indication Genu varum arthrosique • Mechanical Axis • Définition axe mécanique • Qu’est-ce que c’est? • Définition modalité d’évaluation • - Comment? • Pathological Evaluation • Axe mécanique préopératoire • Pre-operative Planning • simuler sur la radiographie l’ouverture souhaitée pour obtenir bon axe mécanique • Clinical trial methodology • Rétrospectif • Comparaison, • Significativité • méthodologie etc. Surgical treatment Ostéotomie de valgisation Surgeon • Surgical treatment indications • A° > 15° => ostéotomie tibiale d’ouverture • interne fixée • Cale phosphate TriCa • Plaque T • A° < 15° => ostéotomie tibiale • (ouverture interne) • ostéotomie fémorale • (ouverture externe) • Quality • Définition des critères • évaluation des différents critères • résultats obtenus • DMS • 1 - Surgeon • Per-opératoire, à M3 • 182° < Axe mécanique post op < 186° • Facilité d’évaluation etc… • 2 - Patient • Score fonctionnel • Douleur • Autre… • 3 – In terms of Public Health • évaluation médico-économique • f (patients, matériels, etc.…) • 4 – Society dimension • Others … EMS 182° < Axe mécanique < 186° Facilité d’évaluation : ergonomie, etc... Formation 1 - Surgeon 2 - Patient Score fonctionnel 3 - In terms of Public Health 4 – Society dimension New technology Dispositif médical Conceptual fragment

21. Temps consommé (temps additionnel) • Perception • Raisonnement • Action • Détermination objective de la laxité et son importance • Positionnement le plus isométrique du transplant • Rapprochement de la stabilité originale de l’articulation • précision Conceptual Fragment definition Robot-assisted surgery Quality • Encombrement • Cout • Mécanique • Ultrasonique • Magnétique ou électromagnétique • optique infra rouge +++ Diminution de l’anisométrie Positionnement optimale des tunnels osseux Navigation Précis fiable System Objective Anatomy LCA • Planifier • réaliser Definition CAMI Physiopathologie Practical 3 generations Background Clinique: Lachman + Pivot Shift • Grenoble TIMC • Neuro chirurgie • ORL • Chirurgie du genou 1992: 1er Prototype • Positionnement • Calibrage et évaluation • Planification et navigation • Bone morphing • Robot Doc: prototype industriel • Visée pédiculaire dans la chirurgie du rachis • Logiciel applicatif : Navitrack, ototrak, orthopilot, surgetics, surgigate Radiographie: Telos

22. Brain Storming • Extraction from Texts Fragments of a conceptual schema “How to arrive to a conceptual Schema?” Expert in Information System Design Top Layer of Conceptual Schema

23. TOP LAYER Case 1,1 EMS Pathology Checkup Used for Medical Device concerns Intervention 1,* 0,* 0,* Uses recommended for 1,1 Patient Anatomic Zone 1,* Place Team 1,1 1,*

24. RESULTS • Three major concepts were identified and support our modelization  • Medical Device • Intervention • Case • EMS : Linked to the Medical Device • DMS : • relates to experience with users • evaluated a posteriori, possibly over a long period • refers to several elementary ontology fragments (FMA, ontology of Medical Devices, …) • Top layer of a conceptual schema (next slide)

25. Conceptual diagram of an Information system 1,1 EMS Thesaurus Place of intervention Medical Device Patient 1,1 myCode 1 0,* num lastName firstName birthDate address myPat 1,1 DMS 0,* myIlls 1,1 0,* 0,1 ? SURGEON NURSE 1,* Intervention 1,1 Pathology 1* date funcCheckupBefore funcCheckupAfter noDaysHospBefore noDaysHospAfter id startDate Symptoms handicaps 1,1 0,* Physical therapist follow-up Anatomic Zone FMA Unit Cost 1,1 1,1 1,1 LocTeam Phys.Ther. nurse 1,1 Observation Start Date 0,* 0,* Team 0,1 0,* 1,* Members Patient Checkup(Post-operative) Patient Checkup (Quantified, Preoperative) 0,1 pain Functional Score Substitution Criteria …. pain Functional Score Substitution Criteria …. 1,* 1,* Surgeon NURSE ??? ADELI UNITCOST UNITCOST

26. CONCLUSION The ontological structuration work : Formalize the notion of Expected Medical Service (EMS) and Delivered Medical Service (DMS) Key to quality for Augmented Surgery Ontological framework : a priceless aid Support for the design of an Information System

27. Perspective • Support • Teaching • Medical research (data) • Medical economics • Patient’s choice • Standard for Quality in Augmented Surgery • Towards an Ontology of Quality? • Out of reach of our group alone •  Ontological material