1. Authoring And Display Tools For Patient Data Review
Data Visualization
Authoring And Display Tools For Patient Data Review
Jim Ong
Trinka Coster, MD
Kevin Leary, MD
Ida Sim, MD PhD
Stephen Porter, MD
Stottler Henke
Walter Reed Army Institute of Research
Uniformed Services Univ. of the Health Sciences
UC San Francisco School of Medicine
Harvard Medical School
This research was funded in large part by the Office of the Secretary of Defense (OSD) and was managed by the U.S. Army Telemedicine and Advanced Technology Research Center (TATRC).

2. Goal and Assumptions Goal Current state-of-the-art Limitations
Help clinicians review patient data more effectively before, during, and after patient encounters to improve patient care and increase patient safety.
EMRs that employ web application servers, relational databases
Source-oriented queries
Modest use of graphics
Time-consuming and difficult for clinicians to query and mentally integrate patient data from different EMR screens. .
ATA 2007

3. Our Approach Patient Views DataMontage
Dense, graphical displays of subsets of the patient’s medical history that support various clinical perspectives – such as:
medical problem
body system
demographic group
treatment protocol
Modular software toolkit for creating and displaying dense, coordinated timelines and time-series graph displays.
Operates standalone or embedded w/in a desktop, client-server, or web-based system.
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.
ATA 2007

4. View Design Method 1. 2. 3. 4. 5. 6.
Analyzed clinical guidelines to identify relevant patient data, reference values, organization, and presentation
Gathered clinician input, developed strawman designs
Identified data available in clinical database
Developed mockups of initial graphical display design
Elicited clinician feedback and refined view design
Implemented view generation logic
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.
ATA 2007

5. Cardiac View (ICDB) ATA 2007 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
ATA 2007

6. Diabetes View (ICDB) ATA 2007 Reference value Datetime reference line
Non-linear time scale
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.
ATA 2007

7. ATA 2007 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.
ATA 2007

8. DataMontage mockup ATA 2007
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.
ATA 2007

9. 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.
ATA 2007

10. Coordinated Cross-Patient and Single-Patient Views
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11. Coordinated Cross-Patient and Single-Patient Views
ATA 2007

12. DataMontage Editor Overview pane Details pane ATA 2007
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.
Overview pane
Details pane
ATA 2007

13. DataMontage Java API
ATA 2007

14. DataMontage Summary COTS Product Applications Benefits
First production release: 9/04
5/14/07 - version 2.0
Patient Care
Drug Safety
Quality Assurance
Improved patient care
Increased patient safety .
ATA 2007