SoftServe sets up its Research and Development Department in 2008…
This is continuation of Mobile EMR, Part III.
It happened to be possible to fit more information to the single pager! We’ve extended EKG slightly, reworked LABs results, reworked measurements (charts) and inserted a genogram. Probably the genogram brings majority of new information in comparison to other updates.
Right now the concept of mobile EMR looks this way…
Initially the charts of measured values have been from dots. Recent analysis and reviews tended to connect the dots, but things are not so straightforward… There could be kind of sparkline for the current period (7-10 days). Applicability of sparkline technique to represent data from the entire last year is suspicious. Furthermore, if more data is available from the past, then it will be a mess rather than a visualization, because there is so narrow space allocated for old data. Sure, the section of the chart could be wider, but does it worth it?
What is most informative from the past periods? Anomalies, such as low and high values, especially in comparison with current values. Hence we’ve left old data as dots, previous year data as dots, and made current short period as line chart. We’ve added min/max points to ease the analysis of the data for MD.
Having genogram on the default screen seems very useful. User testing needed to test the concept on real genograms, to check the sizes of genograms used most frequently. Anyhow, it is always possible to show part of the genogram as expanded diagram, while keep some parts collapsed. The genogram could be interactive. When MD clicks on it, she gets to the new screen totally devoted to the genogram with all detailed attributes present. Editing could be possible too. While default screen should represent such view onto the genogram that relates to the current or potential diagnosis the patient has.
In the future the space allocated for the genogram could be increased, based on the speed of evolution of genetic-based treatments. May be visualization of personal genotyping will be put onto the home screen very soon. There are companies providing such service and keeping such data (e.g. 23andme). Eventually all electronic data will be integrated, hence MDs will be able to see patients genotyped data from EMR app on the tablet.
This is mid term future. DNA sequencing is still a long process today. But we’ve got the technology how to deliver DNA sequence information onto the tablet. The technology is similar to BigImage(tm). Predefined levels of information deliver could be defined, such as genes, exoms and finally entire genotype. For sure additional layers overlays will be needed to simplify visual perception and navigation thru the genetic information. So technology should be advanced with that respect.
We’ve met with Mr.Tufte and demo’ed this EMR concept. He played with it for a while and suggested list of improvements, from his point of view.
Edward Tufte insists that sparklines work better than dots. It is OK that sparklines will be of different sizes. It is natural that each measurement has its own normal range. Initially we tried to switch the charts to the lines, but then we rolled back. Seems that we should make this feature configurable, and use sparklines by default. But if some MD wants dots, she can manually switch it in app settings.
Partially our EMR concept has been switched to sparklines – for display of Vital Signs. Below is a snapshot:
One more thing related to the Vital Signs, we did great by separating on the widget on top, and grouping them together. It adds much value, because they are related to each other. It is important to see what happened to them at each moment. Our approach, based on user testing, appeared to be a winning one!
Current use of the space could be improved even more. First reason is that biggest value of that research was keeping ‘All Information’ on single screen. Human eye recognizes perfectly which type of information is needed. All space is tessellated into multiple locuses of attention. Then human eye locks the desired locus and then focuses within that locus. Second reason is iPad resolution. We can squeeze more from retina resolution without degradation of usability (like size of labels and numbers). It is possible to scale to the newspaper typography on iPad, hence fit more information into the screen estate.
This confirms the modern trend to genetics and genetic engineering. Genogram is a special type of diagram, visualizing patient’s family relationships and medical history. In medicine, medical genograms provide a quick and useful context in which to evaluate an individual’s health risks. Many new treatments are tailored by genotype of the patients. E.g. Steve Jobs’s cancer was periodically sequenced and brand new proteins where applied, to prevent disease spread. All cells are built from the proteins, reading other proteins as instructions. This is true for the cancer cells. Thus if they read instructions from fake proteins, then they can not build themselves properly. We like this idea immediately, because its value is instant and big, its importance is as high as allergy. Below is sample genogram, using special markers for genetically influenced diseases.
There are other cosmetic observations which will be improved shortly. We continue usability testing with medical doctors. More to come. It could be Mobile EMR on iPhone. Stay tuned.
UPDATE: Continued on Mobile EMR, Part IV.
On 27th of August I’ve published Mobile EMR, Part I. This post is a continuation.
The main output from initial implementation was feedback from users. They just needed even more information. We initially considered mEMR and All Information vs. Big Data. But it happened that some important information was missing from the concept relied on Powsner/Tufte research. Hence we have added more information and now ready to show the results of our research.
First of all, data is still slightly out of sync, so please be tolerant. It is mechanical piece of work and will be resolved as soon as we integrate with hospital’s backend. The charts on the default screen will show the data most suitable for the each diagnosis. This will be covered in Part III when we are ready with data.
Second, quick introduction for redesign of the initial concept. Vital Signs had to go together, because they deliver synergetically more information when seen relatively to each other. Vital Signs are required for all diagnosis. Hence we have designed a special kind of chart for vital signs and hosted it on top of the iPad. Medications happened to be extremely important, so that physician instantly see what meds are used right now, reaction of vital signs, diagnosis and allergy, and significant events. All other charts are specific to the diagnosis and physician should be able to drag’n’drop them as she needs. It is obvious that diabetes is cured differently than Alzheimer. Only one chart has its dedicated place there – EKG. Partially, EKG is connected to the vital signs, but historically (and technically too) the EKG chart is complemently different and should be rendered separately. Below is a snapshot of the new default screen:
Most important notes are filtered as Significant Events and could be viewed exclusively. Actually default screen can start with Significant Events. We just don’t have much data for today’s demo. Below is a screenshot with Significant Events for the same patient.
Charts are configurable like apps on iPad. You tap and hold the one, then move to the desired place and release it. All other charts are ordered automatically around it. This is very useful for the physician to work as she prefers. It’s a good opportunity to configure the sets according to diagnosis. Actually we embedded pre-sets, because it is obvious that hypertension disease is cured differently than cut wound. Screenshot below shows some basic charts, but we are working on its usability. More about that in Part III some time.
According to Inverted Pyramid , default screen is a cap of the information mountain. When many are hyping around Big Data, we move forward with All Information. Data is a low-level atoms. Users need information from the data. Our mEMR default screen delivers much information. It can deliver all information. It is up to MD to configure the charts that are most informative in her context. MD can dig for additional information on demand. Labs are available on separate view, groupped into the panels. Images (x-rays) are available on separate view too. MD can click onto the tab IMAGERY and switch to the view with image thumbnails, which correspond to MRIs, radiology/x-ray and other types of medical imagery. Clicking on any thumbnail leads to the image zoomed to the entire iPad screen estate. The image becomes zoomable and draggable. We use our BigImage(tm) IP to empower image delivery of any size to any front end. The interaction with the image is according to Apple HIG standard.
I don’t put here a snapshot of the scan. because it looks like standard full screen picture. Additional description and demo of the BigImage(tm) technology is available at SoftServe site http://bigimage.softserveinc.com. If new labs or new PACS are available, then they are pushed to the home screen as red notifications on the tab label (like on MEASUREMENTS tab above) so that physician can notice and click to see them. It is common scenario if some complicated lab required, e.g. tissue research for cancer.
Labs are shown in tabular form. This was confirmed by user testing. We have grouped the labs by the corresponding panels (logical sets of measurements). It is possible to order labs by date in ascending (chronological) and descending (most recent result is first) orders. Snapshot below shows labs in chronological order. Physician can swipe the table to the left (and then right) to see older results.
Editing is possible via long tap of the widget, until corresponding widget goes into the edit mode. Quick single click will return the widget to preview mode. MD can edit (edit existing, delete existing and assign new) medications, enter significant sign, notes. Audit is automatic, according to HIPAA, time and identity is captured and stored together with edited data.
Continued in Mobile EMR, Part III.
At SoftServe we do some researches, I’m in charge of them. This time I’d like to describe one of our researches. It is called Mobile EMR. EMR stands for Electronic Medical Record. This research is intended to find what will hospitals, agencies, practitioners will use tomorrow. Mobile EMR aka mEMR is a hot intersection of booming Mobility, Big Data, Touch Interface, Cloud trends. Today we research it, tomorrow they will use it. SoftServe works with multiple ISVs which build solutions for hospitals, agencies, hence we have influence on evolution of medical solutions.
Part I will be about how we started and what we get up to date, with conclusion for next steps, which will be described later in Part II.
It has started some time ago during UX research for medical data visualization. Then famous government initiative has been launched to transfer healthcare industry to EMR. Mixing that soup we figured out that it is possible to propose really new concept for the EMR for physicians. We found research by Seth M. Powsner and Edward R. Tufte, “Graphical Summary of Patient Status” published in far 1994. They work at Yale University. One of them is MD, another is PhD in statistics and guru of presenting data. It was oriented onto All Data paradigm that Mr.Tufte loves. I love it too. I love the idea of having All Data on single pager. As soon as Apple released iPad we understood that it is perfect one pager to put the EMR onto. In 2011 I attended E.Tufte one-day course, and found a moment to speak about healthcare data visualization. Mr.Tufte confirmed there was nothing done in the industry still! He pointed to the printed copy of mentioned research and proposed to implement it. After that we had one more face-to-face contact with Mr.Tufte on that research, we god some additional clarifications and recommendations (mainly related to low level details such as sparklines). Below is a snapshot of the proposed visualization by Powsner/Tufte:
All Data has to be handled by special kind of chart, that shows three periods of data. Rightmost biggest part shows week or 10 days, middle narrow part shows previous year, and leftmost part shows all possible data prior to last year. Having such data presentation we are capable to display all anomalies and trends for the whole period that has data logs.
We were aware there was web implementation. It was 100 percent copy of the research (charts part of it). Below is a screenshot from the browser:
We took our Mobile IP and SDK (such as authentication, cache, cryptography etc reusable blocks; Big Image(tm), SaaS SDK) and built first app for iPad. Obviously we lacked deep domain knowledge, hence first version is not perfect. But idea was to do technology feasibility rather than ready-made solution (because we work with healthcare ISVs who keep deep domain expertise). There were few cycles for visualization and layout of the charts and other UI elements. As a result, we got this “first version”:
All remarks and proposed improvements will be listed herein a bit later! Right now I’d like to show few more screenshots what we have got. Physicians identify the patients by MRN or by name, if the patient stays at the hospital for some time. Hence, we introduced two-way patient identification: via My Patients list, and via wristband/MRN scan. Below are screenshots: My Patients and Wristband/MRN Scan. First one is My Patients:
This one is Wristband/MRN Scan:
“First Version” has been shown to MD from New York large hospital. Impressions were mixed :-O
In general – idea of such mEMR is good. But using it with its current data is not so valuable. I’ve got recommendation for data presentation improvements. They are listed in unsorted order below. The format is the following: subheader represents an issue or proposal for improvement. The text after it describe reasoning and clarifies details.
In the left top corner next to the photo we show basic patient information. It happened that both DOB and age is required simultaneously. Year serves as additional identification for multiple Johm Smiths. Ok, the information about age should be like 56 y.o. F, where F stands for female. M stands for male. Sex must follow the age, and must be encoded into single letter F or M. It should be next to the patient name. DOB should be on second line. Look below:
Photo John Smith 62 y.o. M
In the right top corner we shown Discharged. It happened that nobody cares about discharge, while everybody needs Admitted. Hence, right below the MRN we have to add new line. MRN and Admitted record must be kept together. Look below:
Those requirements are related to the integrity of the data, what is kept with what. There is no requirements to UI layout. Current layout was confirmed as good.
There is a widely used abbreviation for diagnoses. It is OK to use smth like HTN and MDs will understand it. Writing Depression is also good, but often names are long and abbreviation works better. Important information that is mission in our “first version” is Allergy. It is “the must” that complements the diagnosis. We have to allocate some space below Diagnosis and specify there Allergy. If Allergy is present, then it must be very contrast, may be highlighted in red. Look below:
Allergy: Aspirin (rash)
The patient can be currently on some medications. They must be listed on top of our single pager. Current Medication is such important as Diagnosis. We can specify it as a simple list of what the patient takes. Look below:
Metoprolol 50 daily [sorry, I can’t put units here right now]
Norvase 5 mg daily
Paroxetine 20 mg daily
Medication can be labeled as Meds. It should be in the upper area of the screen, as well as improved User Info and Diagnosis. Other info such as hospitalization and clinic visits should be kept within the upper area of the screen. Later sections describe the middle area of the screen.
I will provide typical medications for those 4 diagnosis: HTN, CAD/HLD, CHF, Asthma. Please update patients data to those 4 diagnosis only. This is our restriction for demo purposes. Medications will take max 4 lines on text, each line up to 25-30 chars.
We shown then as separate charts: chart per temperature, chart per pressure, chart per heart rate. It sucks. The reason is that it does not represent information. What MDs see as information from vital signs? The relation between all signs together! Hence we must pack all 5 vistal signs into single chart so that all peaks or dropdowns are visible relatively to each other. The labeling for vital signs is the following: t for temperature, HR for heart rate, BP for blood pressure, RR for respiratory, SpO2 for something I don’t remember right now. The order of vital signs should be as listed with t on top and SpO2 at the bottom. Chart should be from sparklines, not for dots. All mins and maxs should be visualized properly. Now I understood what Mr.Tufte explained to our UX designer about use of sparklines. We though it was for all charts, but it happened it is only for vital signs. Look here for visualization spec. The chart with vital signs must be on top. Let’s keep it alwas in left top corner. If there is insufficient space, stretch it to the width of two charts.
They suck. Usually doctors put a lot of secondary info there. Hence there is no place for such irrelevant notes on the Home Screen. All doctors need is an entry point into the Notes. Doctors read them on demand. As a secondary screen opened intentionally. Implement it if possible.
Those are important! Significant Event is some even that is related to the life of the patient. E.g. patient fall and got head injury. In other words, non-typical events according to the diagnosis. If vomiting is common for that diagnosis, then vomiting is not a significant event, hence not worth big attention.
Probably we can redesign the right pane to show Medication on top, then Significant Events on top and in the middle, and has Notes as entry point at the bottom. If Medication takes too much space, then we can group it with Vital Signs (increased horizontally chart) and keep them together on top as a separate section. All other charts and Significant Events should be below them. Personally I like first alternative better – to use current right pane for both Medications and Significant Events.
Electrocardiology is “the must” on home screen. Add it as a separate chart, as in Tufte’s research and in web demo (see links above). It is OK to keep EKG on same place, hence keep it hear Vital Signs for example, at same horizontal level.
This is a section of all scans. MDs call them interchangeably Imaging and Radiolody. They have it as secondary information. Hence we have to put probably 1 or 2 images on the Home Screen, but implement separate screen with thumbnails to all imagery available for that patient. For our demo we can keep few images on Home Page, then we will see. But they (images) should be organised in some group labelled as Imaging.
Our “first version” doesn’t have Labs data at all. How Labs look like? It is a list of text and numbers. Furthermore, MDs get used to the order how to read the labs (BTW I confirm the same for vital signs). E.g. Labs called Hepatic Panel is shown as a sequence of AST, ALT, Alkaline Phosph. Labs called Coagulation is shown as PT, PTT, INR. It is common that Labs list contains 5+ sets of results (named as Panel here). Superscripts are used to represent K+, Na+, Cl-, CO3-, Ca2+ and so on.
We can allocate the space at the bottom of the Home Screen to visualize Labs and Imaging. Labs should grab more space than Imaging. As I’ve told, having 2 thumbnails as an entry point to Big Image is sufficient. Then physician should click either title Imaging or “…” next to the title, to get to the separate screen with all other images. Re Labs, they could be shown in tab format. Look below:
date1 date2 date3
Erythr. 4.5 4.3 2.8
HGB 140 138 100
It could be useful to have layout presets for chronic diseases like Diabetes etc.
Continued on Mobile EMR, Part II.