An Intelligent Patient Data Review Assistant (IPDRA) AMIA Medinfo 2004 Jim Ong, MS LTC Trinka Coster, MD Matthew Medlock, MD LTC Joseph Parker, MD Jane Dowling, MS Stephen Porter, MD Seth Powsner, MD Ida Sim, MD PhD Stottler Henke Walter Reed Army Institute of Research Uniformed Services Univ. of the Health Sciences Walter Reed Army Medical Center NYU Medical Center Harvard Medical School Yale University School of Medicine UC San Francisco School of Medicine This research was funded by the U.S. Department of Defense.

IPDRA Mission Help clinicians review patient data more effectively before, during, and after patient encounters Current state-of-the-art Limitations Web application server Relational database Source-oriented queries Modest use of graphics Time-consuming to query related patient data from different parts of the database Hard to mentally integrate data spanning multiple pages and data sources . AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

IPDRA Approach Patient data views Information-dense displays Visual view authoring Testing and debugging Present integrated, clinically-meaningful subsets of each patient’s records (by problem, body system, demographic). Compact, coordinated timelines and time-series graphs with traditional text, tables. Users specify view logic by drawing and configuring hierarchical flow charts. Desktop application lets users test and debug view definitions and upload them to the server. Patient data views - Each view facilitates rapid data review and support best clinical practices via effective integration and presentation of a clinically-meaningful subset of the patient’s data. For example, a view could present patient data from the perspective of a particular medical problem, body system, or demographic group. Longer term, IPDRA will automatically select relevant views for each encounter, based on current complaint, patient history, clinician specialty and preferences, visit type Information-dense graphics – Multivariate graphical displays enable clinicians to see patterns and trends spanning diverse clinical data (e.g., clinical events, labs, meds). Mouse rollover, popup windows, and web navigation provide quick access to additional details and related information. Our graphical displays are inspired by (but extend) prior work by Plaisant and Schneiderman, Powsner and Tufte, Pharmaceutical Product Development. Extensions include combining time-series and timeline graphs within a single coordinated display, full web support (graphs can be rendered by Java applet in browser or by Java web server, add’l info referenced by web URL can be accessed by clicking on datapoints.) Web access – web browser accesses views generated by IPDRA web application server. Visual view authoring – View logic defines the database retrievals, data transformations, and data presentation needed to generate each view. IPDRA applies and extends SimBionic, a tool for authoring complex logic visually by drawing flow-charts and finite-state machines that can be run within Java and C++ programs. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

Key Questions Effectiveness Feasibility How should we design patient views to enable effective and efficient data review by clinicians? What software tools and processes can enable practical design and development of large libraries of views? AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

Cardiac View (ICDB) Module Graph Reference ranges Show/hide module roll over  short text notes mouse click  html detail In this example, there are five modules labeled Vitals, Events, Studies, Lab Tests, and Medications (medications not shown) that contain vertically-stacked timelines. Symbols show measurements and events associated with points in time. Symbol size, shape, and color helps encode qualitative attributes and highlight significant data points. You can show or hide each module by clicking on the triangle next to the module’s label. This feature is useful when there are many graphs and timelines that cannot be shown all at once. When you click on a graph, a red vertical line is displayed in all graphs to help you compare data points at the time. Timeline high in normal range AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

Diabetes View (ICDB) Datetime reference line Reference value In most graphs in this graph set that display a single clinical variable, a circle shows a value in normal range, an upward triangle shows a high value, and a downward triangle shows a low value. Blue lines show target values, and blue, yellow, and red regions show variable ranges for increasing levels of severity. Glucose Tolerance – (this example graph set contains no glucose tolerance data). Circles show normal range values for glucose at 2 hrs. Upward triangles show high values. The yellow region indicates Impaired Glucose Tolerance, and the red region indicates diagnosis for diabetes. Plus signs and crosses show glucose at 1 hr and 3 hrs, respectively. Glycosylated Hemoglobin – the green region shows the normal range. BP – Normal systolic and diastolic BP values are shown as plus signs and crosses, respectively. High values are shown as upward triangles. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

Selecting a time-stamped note draws a datetime reference line Normal range / grid lines These time series graphs show normal ranges for each variable using grid lines that partially span the height of each graph. The timelines at the bottom of the graph container show periods of drug intake. When users click on a note in the right part of the display, the note is highlighted in red, and a vertical highlight line is displayed in all graphs to show the date of the note in relation to the data points and time intervals. This example is inspired by the psychiatric patient summary designed by Powsner and Tufte. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

Hypertension View (ICDB) The design of this hypertension view was guided by patient data review recommendations specified by the JNC7 draft guidelines. The initial subview within this view shows blood pressure and heart rate. The blue region indicates Stage 1 hypertension. Yellow and red regions indicate Stage 2 and Stage 3 hypertension, respectively. Filled symbols indicate blood pressure measurements that exceed the threshold for Stage 1 hypertension. These time series graphs are vertically aligned with timelines that show medications over time. Other subviews show physical exam data, risk factors, related problems, and lab data relevant to hypertension. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

DataMontage mockup This mockup of a pediatric weight chart shows reference ranges that change over time. Colored regions represents percentile ranges. The blue reference line indicates median weight vs. age. Reference ranges for boys are shown at left, girls on the right. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

IPDRA Architecture View Authoring View Generation View authoring tool (SimBionic) View test/debug application or Web application server View logic specifications SimBionic run-time system Primitive functions: query database DataMontage API generate HTML, XML The View Authoring tool is based on the SimBionic authoring tool. It lets view designers draw flow charts to create View Logic Specifications. The IPDRA Web Application Server and the IPDRA View Test/Debug Application are two programs that generate views. Both programs embed the SimBionic run-time system to run view logic specifications that generate views by calling “predicates” (functions that return values) and “actions” (functions that don’t return values) to query the database, transform the retrieved data, and generate HTML and XML files that comprise the generated view. The user views the generated view using a Java-enabled web browser. Java applets enable highly interactive graphical displays that use tooltips and mouse interactivity to provide additional information on demand. View designers use the IPDRA View Test/Debug Application to test and debug view specifications. This Application lets view designers execute the view one step at a time to verify the correctness of the view’s logic. End users access the IPDRA Web Application Server from their web browser to generate views using view specifications that have been validated. Object templates (DataMontage XML, HTML, SQL queries) View files: HTML, XML DoD Clinical database (ICDB, M2, CHCS II) AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

IPDRA View Authoring Tool (SimBionic) Flow-chart drawing area Catalog of flow charts, primitive functions, variables The data retrieval, transformation, and presentation logic of each view is specified by drawing flow charts. Each rectangular nodes specifies calculations and actions. Each oval node specifies conditions that control which path within the flow chart is taken. A node can call a lower-level flow-chart, so complex view logic can be decomposed into multiple flow charts, organized in a hierarchy. Additional optional info – The green node indicates the flow chart’s “entry” node – execution of the flow chart starts at the green node. A red node indicates a “final” node. Execution of the flow chart ends at the red node. The “Catalog” pane on the left side of this window displays objects that comprise the view definitions, such as flow charts, functions that can be called by the flow charts, and global variables. These objects can be grouped within folders. A step-by-step debugger lets users execute views, step-by-step, to verify the correctness of each view. AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant

IPDRA Status Prototyped IPDRA view server and test/debug application Developed initial set of views using ICDB Evaluation and refinement of views planned for fall 2004 using DoD M2 clinical database IPDRA subsystems released as products Java SimBionic visual authoring tool (Feb 2004) DataMontage graph library (Sept 2004) AMIA MedInfo 2004 - An Intelligent Patient Data Review Assistant