The file formats shown in Figure 5.5 should facilitate the advances in linking documents and pointing to components within them. OSML style sheets will produce a page layout that allows strong internationalisation capabilities. The ‘Namespace in XML’ recommendations published by the World Wide Web Committee (108) (W3C) have been adopted. This includes the capability for the file structure to be moved easily between servers without requiring editing of inter-document hypertext links. This is particularly important in the context of enterprises such as VOEU, which will necessitate the use of mirror sites, some of which will need to represent the data in different languages.
OSML will allow the integration of tools for searching databases that may be incorporated into all levels of training environments. The authors perceive the adoption of this language will assist the seamless integration of information technologies into the operating theatre environment and, as with all XML applications, OSML will be excellent for adaptation of the teaching material for handheld devices, hence increasing accessibility.
Early work on the Exeter Virtual Orthopaedic University (113) based upon HTML has demonstrated the potential for Java-based integration of the declarative learning material for either Intranet or Internet distribution, and the control of local simulation systems for surgical training using such a system. The future development of OSML will incorporate these underlying principles, though it will still require the activation of dedicated scripts to interact with the simulation systems (Figure 5.6).
Conclusions drawn from the development of OSML: The OSML provides a flexible language upon which to base media archives and communication for the evolving virtual university. The ‘bottom line’ is a robust document-handling process that supports peer-reviewed secure and appropriate placement of documents. The consortium of partners ensured that the following milestones were met by achieving the deliverables expanded below:
Pathology <PATH>
User Classes <USER>
Orthopaedic Surgical Markup (OSML) e.g. VOEU XML Schema Other <OTHER> Operative <Op> Type <TYPE> Other Medical <**ML> Generic Surgical <GSML> HCML Anatomy <ANAT> Demographics <Demo> File (.html) Physiology <PHYS> Masterclass <MC> Higher <HST> Basic <BST> Course Work <Course>
Examinations <Exam> Imaging <Imag> Logbook <Log>
Figure 5.6 Using a schema to link mark up languages by .xml to .html resources that can be presented to different users (Colours assist in highlighting the hierarchy, with
1. OSML DTDs. DTDs were adopted for a working model of document development (These were later converted to Schemas).
2. OSML documents.Inclusion of the standard file formats into the DTD/schema ensures that the surgical knowledge base is accessible via the Visual Integrator. In the later versions, a schema writer was added that allows users to prepare more trials using variations upon the schemas but accommodating all the variables the users wish to employ. OSML file extensions will allow for the tailoring of specific courses to meet the needs of individuals, which are expanded upon in the pedagogy section of chapter 9. 3. OSML editor and uploading process. The aim of this was to progressively enhance the collection and preparation of educational material by knowledge workers (particularly Surgical Specialists). The process of automation of OSML Tag generation should facilitate the preparation of future modules. In the case of the developed uploading process, a metadata header was added to an MS Word™document so as not to alienate the medical profession who, as seen in Chapter 8, are familiar with this software package. The editor will ultimately become part of the fully integrated toolkit for users, probably managed entirely as a web service, but this is at present solely a dissemination and exploitation plan. Richard Lawley (SOTON) built the current (working) system.
4. OSML browser/viewer. For the prototype of the VOEU Visual Integrator, the IAM group Virtual University systems adopt the current generation HTML browser (Microsoft™ Internet Explorer v5.5 or above). Browser plug-ins have been used to provide appropriate functionality for specific file types. The aim ultimately is to be able to provide a bundled package that is downloadable so that end-users can automatically upload a suitable browser plug-in kit for the development of future Virtual University content. The planned features of OSML include:
Multiple Applications for Multimedia components – this should release the educational content from the delivery media.
Integration of Multilingual Systems – an enhancement of the visual integrator.
Narrowcasting potential for dedicated operator skill levels in surgery and computing
Reduced centralized server storage and data management costs via a distributed architecture
Ability to handle declarative and procedural material through ease of database access
Surgical Log cross-checking for error correction
Authentication and peer review ratification
Integration of surgical and medical coding for clinical management – conforming to the proposed HL7 standards where possible.
The disadvantage of such a system may lie in the need to ensure acceptance of the specification that will necessitate the formal review process of the ISO. This may delay the implementation initially, but is ultimately a vital step in the maturation of OSML v1.0 fromde factostandard to a ratified one.
5.10 Summary
This chapter addressed the issues of accommodating surgical and educational factors in a tutorial system for surgical training. The feasibility aspects are more important than the operational aspects here. Reference to standard models for User Interface (UI) design includes the use of ‘frames and style sheets’. It includes analysis of user-centred design and its significance to providing interfaces dedicated to surgical users. The interfaces dictate Staff Training Protocols, so that setting up new systems will require training of the staff to an adequate standard to operate the User Interfaces (UIs). Virtual environments used for training will need to meet a standard that provide both an adequate training environment, and also an adequate testing environment. The EVW prototype 3 trials have been prepared to do this.
Surgical simulation is still in its infancy. So too is its relationship to the evolving Virtual Orthopaedic European University (VOEU) Project. Simulation and other such surgical systems will benefit training through Inter-Active Learning, and certain sub- skills of surgery explored in the SOTON Simulation are incorporated into a broader educational package that realistically maps the roles of the training surgeon in accordance with their ‘educational ontology’. This is to determine the capabilities of the Surgical Skills Simulation, through psychomotor performance vs. skills Levels testing.
The tasks of the EVW prototype 3 trials, based upon the EVW prototype 1 simulation trial results, support a training deficiency diagnostic approach and indication of the information-processing and psychomotor skills systems failures. Ultimately the simulations may then be developed, based upon accurate quantitative information
regarding surgical performance metrics. This depends upon the tasks demanded of the University of Southampton simulator by the trainees in the EVW prototype 3 trials.
Such core tutorial skills to be trained focus upon identification of structures whilst navigating through a three-dimensional, ‘7 degree-of-freedom’ space, and analysis at this stage of development is based upon user questionnaires that are aimed at the evaluation of the broad spectrum of surgical simulators. This is a subjective analysis of the system by trainees but still represents a basic evidence base upon which to build.
The comments recorded by the user group in the 1st EVW prototype simulation are part of a process of evaluation evolution. The 1st EVW prototype simulation trial results led to further design team group discussions. The results suggested that such browser-based interfaces are to be built into educational environments to assist the control of training simulators, and so this approach has henceforth been adopted. The EVW prototype 2 trial of the 2nd generation systems did not proceed and so plans were established to create a further prototype incorporating the principles learned inthe 1st and 2ndprototype simulationfor the final trial of this thesis.
The UI Design Strategy evolved also. By way of reference to standard models for User Interface (UI) design, this section included the analysis of user-centred design and its significance to providing interfaces dedicated to surgical users. This is essential for developing interfaces for surgeons. A key part of the usability trials of future surgical educational systems is the assessment of the interface and its integration into such systems.
A core design principle is the separation of structure and content. This is in part to ensure that the demands made upon the user are achievable. Once established, the interfaces will dictate staff training protocols as users will be obliged to adopt such systems. The content should be able to be transferred from system to system – by virtue of being contained in ‘learning objects’ categorised by specific metadata.
Usually, the system internals are designed first (entities, events, functions, etc) and the detailed user interface added later. Modelling users and their tasks, environment, and usability requirements earlier in the development makes it possible to develop an abstract definition of how the user thinks of the system (Users' Conceptual Model). For the Surgical Simulator Shoulder Arthroscopy Tutorial the software application allows the user to adopt a user-centred perspective upon the environment. This will facilitate integration of learning experience with previous clinical experience.
The research therefore led to the development of tools for Visual Integration. This supports the basic user profile. Ultimately the development of the spectrum of devices that can process and deliver data to users via a shared User Interface will convey a uniform application environment in the domain of healthcare information assimilation, analysis, and delivery. An XML proto-standard originally referred to as Orthopaedic Surgical Mark-up Language (OSML) was structured to support this principle. This has now for the most part been succeeded by the development of XML schemas to support the data structure of specific functions of the system.
Users are banded into groups of stakeholders, including basic surgical trainees (BST) and higher surgical trainees (HST). These are the target groups for the trials of the demonstration prototypes. The system also caters for providers such as editors who contribute material e.g. surgical knowledge engineers, surgical curriculum developers, and surgical researchers. This ensures that the experiments can control the stratification of user experience and thus the validity of comparison of different user groups. With such an underlying architecture developed, the next chapter goes on to describe the discrete tools within the shared working environment.