7Breaths is born

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Respiratory rate needs to be measured over one minute?

A fundamental part of medical practice is the measurement of primary physiology. For centuries heart and respiratory rates have been calculated to help identify disease and demonstrate response to treatment. However confidential enquiries, internal reviews and other studies frequently show that observations are poorly taken. This in part has lead to an inexorable rise in early warning scores and system to identify acute illness. A potential barrier to the recording of observations, whether by doctor, nurse or other health professional is the time taken to measure them. Traditionally a minute has been the gold standard in order to ensure reliability. Studies have supported the 60s approach (Simoes 1999) but with increasing pressures on health services and rapid advances in easy to access technologies the time has come for a review. Can you help?

Take part in a large scale observational trial using your smartphone

This idea was first in my previous post here, tweeted and published on the NHS Hackday googlegroup . This idea was quickly picked up by Neville Dastur, a Consultant Vascular Surgeon, software developer and owner of Clinical Software Solutions Ltd and 7breaths was born.

What are we going to do with the data?

The data will be openly available to data analysts and mathematicians to attempt to generate an algorithm that can be used in future version of 7breaths that will automatically report the respiratory rate once the software is ‘confident’ that it is able to predict within set level of confidence what the respiratory would be at 1 min.

We envision that this will take into consideration

  • Inter-breath duration
  • Variability and pattern of the Inter-breath duration

Why bother with this?

Ultimately this is a demonstration of the power of open source, collaborative healthcare innovation. While it is a bit of fun there is a real possibility that new methods to improve the accuracy of RR measurement and that can also save time could transpire. It’s also a demonstration that a simple piece of software may enable an economical way of gathering data at the point of care that does not require any form of duplication of efforts.

Want to take part?

Download the App

google-play app-store

Register

When you first download the app, you have the option of registering the software. We would encourage this as it would allow us to acknowledge your contribution and also provides a degree of provenance for the data collected.

Start collecting data

When you are next counting a patient’s respiratory rate, use 7breaths instead. At the end of one minute it will report the respiratory rate and it will give you an option of sending the data to us. That’s it!

Who’s behind 7 breaths?

Damian Roland – Paediatrican (@damian_roland)
Wai Keong Keong – Haematology Registrar (@wai2k) <- ME
Neville Dastur – Vascular Surgeon (Clinical Software Solutions) <- He built the app! (Sourcecode on GitHub)

Staff Administration System (SAS): A Vital Missing Piece in Hospital IT systems

Reflect on the current state of affairs

  1. Patient
    Who is the junior doctor looking after me at this moment in time? Who is my nurse? Who is my Physio?
  2. Radiologist
    I am reporting a CT Scan on Mr Some Body. There is something not right here, I need to speak to the doctors looking at this patient now. Who is it? How I can make contact?
  3. Haematologist
    I have some really abnormal blood results for Mr Some Body. I need to tell someone in charge of this patient’s care, but I do not know who it is? The contact number on the form is not working.
  4. GP
    I have a vital piece of information I need communicate to the doctors looking after my patient, but I don’t even know where to start.
  5. Nurse
    I need a doctor to see this patient as she is in pain. Doctors change around all the time and it’s 530pm already, who should I call?
  6. Patient relative
    I want to tell the physiotherapist something really important about my dad to help discharge. I do not know who to get in touch with.
  7. Ward Junior Doctor
    I want whoever is taking over my shift to be notified if a patient does not get a CT Scan by 10pm. It is 6pm and I’m going home now.
  8. Site Manager
    I wonder what medical and nursing levels are tonight.
  9. Director of Operations and Workforce
    I wonder if we are deploying the right skill mix of doctors, nurses, physics, occupational therapists. Are we matching the clinical services to clinical need?
  10. Medical and Nursing Directors
    I really need to understand if we are providing safe enough levels of care in our hospital all the time. I need live up-to-date information. I hear concerns all the time but I do not have any data to backup it up to guide decision-making and strategy.
  11. Chief Executive and Financial Director
    The Workforce is our most valuable and expensive resource and patients are the focus of our organisation. I have never had an objective way to bring these two together.

This is a problem

Speak to any nurse, ward doctor, lab technicians, GP or patient (or relative). This is a problem. I have been to 4 NHS Hackdays now and spoken to others attending other health IT events and the following are recurring themes.

  • Bleep Bleep – The problem with intra-hospital communication between professionals
  • Patient Lists – Making Information to the right person as the right time and keeping track of patients
  • Notifications – Making sure important information get to the right person
  • Task Management Software – Making sure things get done 24 hours a day
  • Rota Management Software – Management staffing, leave, ensuring the right skill mix
  • Medical and Nursing Handover Software – Making sure things get done and right information gets transferred (I actually see this as an amalgamation of patient list + task management software)

SAS – The Vital piece of IT infrastructure that is missing

Imagine a hospital EPR running without a PAS (patient administration system) system.

That’s essentially the situation now with managing staff in hospitals. Let’s call this system the Staff Administration System (SAS) for now; I know this is not a great name!

Like a PAS, SAS will form the backbone to any application that requires coordination or communication between staff. For example, a lab system will just have to send a message out a notification application that says, ‘please inform the junior doctor looking after a particular patient about this result.’ The notification system will then query the SAS to find out the right person(s) to send the notification on.

It will be system to let’s every other system know, who is on duty and when, what their grade and skill sets are. For example a rota management system will use data from this system to ensure that there is someone on duty on all time that can perform a cardiac pacemaker or chest drain in an emergency out of hours situation.

Without a SAS every piece of software that does any form of staff management will require its own database that is not coordinated with any other. This is not sustainable nor safe in the long run.

It is not just about the IT

A SAS is not going improve the care coordination for people do not change the way they work. A SAS will require people to login to work and logoff. It will require staff nurses to assign themselves to a particular patient. It requires teams to clearly define their roles and ensure that it is recorded electronically.

Imagine what things could be like

  1. Patient
    Who is the junior doctor looking after me at this moment in time? Who is my nurse? Who is my Physio?
    > I can just look this up on my Patient Information System. It is reassuring to know the names and faces of the people overseeing my care.
  2. Radiologist
    I am reporting a CT Scan on Mr Some Body. There is something not right here, I need to speak to the doctors looking at this patient now. Who is it? How I can make contact?
    > I’ll just click this button on my radiology information system and it will contact the doctor in charge of the patient now and we are connected!
  3. Haematologist
    I have some really abnormal blood results for Mr Some Body. I need to tell someone in charge of this patient’s care, but I do not know who it is? The contact number on the form is not working.
    > Same as no.2
  4. GP
    I have a vital piece of information I need communicate to the doctors looking after my patient, but I don’t even know where to start.
    > I can just login into my portal in my local hospital and click contact the team 
  5. Nurse
    I need a doctor to see this patient as she is in pain. Doctors change around all the time and it’s 530pm already, who should I call?
    > I just click ‘contact the doctor’. 
  6. Patient relative
    I want to tell the physiotherapist something really important about my dad to help discharge. I do not know who to get in touch with.
    > Log in to Patient Portal.. Contact my physiotherapist… Done
  7. Ward Junior Doctor
    I want whoever is taking over my shift to be notified if a patient does not get a CT Scan by 10pm. It is 6pm and I’m going home now.
    > Add a task linked to the patient record to send a notification to the whoever the looking after that patient at 10pm. 
  8. Site Manager
    I wonder what medical and nursing levels are tonight.
    > Let me just look at the dashboard to see the live staffing levels linked to live patient levels.
  9. Director of Operations and Workforce
    I wonder if we are deploying the right skill mix of doctors, nurses, physics, occupational therapists. Are we matching the clinical services to clinical need?
    > Another dashboard? 
  10. Medical and Nursing Directors
    I really need to understand if we are providing safe enough levels of care in our hospital all the time. I need live up-to-date information. I hear concerns all the time but I do not have any data to backup it up to guide decision-making and strategy.
    > I can finally target the training requirements of my staff. I can finally have some data on staffing that I can link to patient level data to try to understand the link between patient care and staffing. This was not possible before.
  11. Chief Executive and Financial Director
    The Workforce is our most valuable and expensive resource and patients are the focus of our organisation. I have never had an objective way to bring these two together.
    > We are not going to able to increase efficiency and quality without changing the way we work. We need to re-design pathways of care and get people working better together as a time. I want to use IT to make this happen. Current IT system don’t understand or manage our most expensive and valuable resource. 

This must happen

IT is only an enabler of new innovative processes for care delivery. Healthcare staff are the key and most important components to these processes. He can we design patient pathways and have no way of digitally representing the staff members that are key components of that pathway. Without this, how can we move forward?

What can YOU do about it?

  1. NHS Trusts. Build your own and share it – Currently NHS England are making funds for projects just like this. I ask that you run it as an open source project and share your learnings and code with others. Make sure you truly understand the care delivery process and reflect it in the design and data structure.
  2. Software Vendors: Build it, make sure it is interoperable with open APIs. Run it as an open source project. Sell it as a service. This will encourage uptake and constant improve to it. Partner with an NHS Trust and work together and access the £260 million fund.

Let me know what you think. Are people addressing this already?

Creative Commons Licence
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.

VitalVis – Re-imagining the Observation Chart for the Digital Age [NHS Hackday 4 – London Edition]

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For NHS Hackday 4 – London Edition. I wanted to work on a design hack to solve the following challenge.

How to display 5 days worth of patient bedside observation data on a small smartphone sized screen.

Digital collection of routine observations (Blood pressure, Heart Rate, Respiratory Rate, Oxygen Saturations and Temperature) is becoming more common place in the acute hospital setting. The advantages of automated calculation of Early Warning Scores (EWS) and automated notifications to the clinical team and Patient At Risk Team (and related early intervention teams) are undeniable.

However, displaying of a large amount of patient observations to allow comparison of trends in a small smartphone sized screen remains problematic. Doctors are very used looking at patterns and trends very quickly. The way this is represented on smartphone sized screens currently makes this difficult.

iPods

The example above is taken from a leading provider of bedside observations systems. As you can see, the number of observations is quite limited and getting previous observations require a significant amount of scrolling and does not allow direct comparison with the current set of observations. This is a significant disadvantage compared to paper.

Inspired by Edward Tufte

Inspired by the father of data visualisation, Edward Tufte and his paper co-authored by Seth Powsner article (“Graphical Summary of Patient Status”, The Lancet 344 (August 6, 1994), 386-389), the Superteam (see below) produced the following solution:-

Iphone5 with VitalVisThis design shows:-

  • A total of 5 days of observational data:- The last 24 hours is shown in the right half where as the previous 4 days is shown on the left hand side of the screen.
  • The right  area of the screen shows the most recent set of observations
  • Horizontal Gray bars demonstrate ‘safe ranges’
  • Numbers incorporated in the middle divider helps orientates viewer

Principles of the design:-

  • Minimal use of colours
  • Maximising the data-to-ink (pixel ratio)
  • Variable X-axis with emphasise on the last 24 hours
  • Use of dots or lines to represent trends instead of ‘artificial’ lines
  • Relies of the natural ability of the human mind to quickly process large amount of information using pattern recognition

This also allows:-

  • In a larger screen like a tablet or computer monitor, this allows one to view observations from multiple patients at the same time, allowing a quick overview of multiple patients
  • Incorporation into a patient dashboard

The technical implementation

To turn this idea into reality, we were fortunate to have anonymised real patient level data collected by Wardware provided by Rob Dyke (@robdykedotcom) of Taxtix4 in the form of an mySQL database. In the short amount of time available to create the, the Superteam managed to create a webapp that can query this database and display it on a webpage. The technology stack: Python, Django, Mathlib library. Screenshot below. [30/05/2013: An updated version 48 hours post hackday could be found here ]

ScreenShot_01

To my knowledge this is the 1st ever project at any of the previous NHS Hackday to use actual patient data. I strongly believe that one cannot build good systems without using realistic data.

The Superteam

This project would not be possible without the skills, professionalism and dedication of the following amazing people:-

  • Martin Green – Radiation Physicist and Coder
  • Alan Beebe – Coder
  • Chris Pritchard (@chriscpritchard) – Student paramedic and Coder
  • Ayesha Garrett (@londonlime) – Designer
  • Amanda (@complexitytamer) – User Experience Designer
  • Wai Keong Wong (@wai2k) – Haematologist <- ME!

Collaborate and other Resources

The code if available on GitHub

Presentation is available on SlideShare

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Why NHS hospitals don’t utilise modern telecommunication technologies. A response to Prof Jonathan Kay, CCIO, NHS Commissioning Board

Professor Jonathan Kay, CCIO for the NHS Commissioning Boards asks on this NHS Hackday Google Group thread:  why so few NHS hospitals utilise modern telecommunication technologies such as the mobile phone, SMS to improve communications within and between medical teams.

Below are my observations:-

  • Communication and care coordination within the hospital is not on the radar on most hospital’s IM&T strategy: PAS, PACS, Electronic Prescribing, Clinical Correspondence (incl. discharge summaries), Clinical Notation (incl. Bedside observations) are.
  • Internal referrals and internal communication is often a problem for junior doctors and nurses on the frontline, who often do not have a seat at the table when it comes to influencing organisational strategy. We are the silent and transitionary workforce (junior docs).
  • Revolutionising communication requires investment on new platforms such as smartphones and other mobiles devices and staff skilled to manage their deployment on a large scale. (I’m not referring to Blackberrys that are relatively simple).
  • Due to points above there aren’t many people selling solutions. Those that exist require both a hardware and software investment. And often, the hardware is tied to the software instead of treating the hardware as a platform, a general purpose computer, that enables all sorts of other possibilities. Examples of this includes things like Wardware, VitalPAC, and various handover software.

I’m waiting for a forward thinking organisation to tackle the issues of intra-hospital communication head-on to solve the bleep bleep (pagers), patient list and guidelines at point-of-care problem that have been discussed in great detail on the NHS Hackday Google Group and on a series of podcast that a few of us junior doctors record: http://thedigitaldoc.co.uk/podcasts

In conclusion, the people that decides how the money is spent is blind to the problem -> resources are not allocated -> No one  steps forward to offer solutions.

Crowdsourced wisdom for performing medical procedures (not surgery!) safer, better and more humanely

Dear all,

I’m a haematologist and one of the procedures that that I perform often for diagnostic purposes is called the Bone Marrow Aspirate and Trephine Procedure

I think that it is fair to say that this procedure is notorious for being rather uncomfortable and painful.

However, in the last 4 months having performed probably 80 of these and trying out variations of different techniques, I’m convinced that if done properly this procedure does not have to be painful and anxiety provoking.

There are two main goals of this procedure:-

  1. Ensure that the patient is as comfortable as possible
  2. Ensure that adequate specimens are obtained to enable accurate and reliable diagnosis

It has occurred to me that every haematologist have their own tips and tricks on how to achieve both goals. Some of these wisdom has been passed down from others, others from personal insight and some are derived from solid scientific principles.

I’m very keen to create an online site for us to share tips and tricks on different stages of this procedure.

I’m of the opinion that as doctors (I’m not referring to surgeons) we are generally very poorly taught about doing procedures. The mantra of see one, do one, teach one prevails. So, it is often the least experienced being taught how to do a procedure by the second least experience person. Indeed, even though I have performed bone marrow biopsies for 5 years, last week was the only time a consultant actually watched me do one and it was only because it was his/her private patient and not to teach me!

So, how would a crowdsourced medical procedure (not major surgery!) resource look like? Wiki-style? Discussion thread style? Hybrid of both? Stackoverflow style? I think that if we built something useful, there may be funding from some charities.

The web is full of tutorials and youtube videos but this is not what I’m looking for.

Too many people are having procedures done in suboptimal ways. I’ve seen too many patients traumatised by poor technique. I will be the first to admit that over the years I have been guilty of the same.

Who wants to have a go at this at NHS Hackday Oxford?

Some resources to start you off:

Notes from Patients Site re: Bone Marrow Aspirate and Trephine
http://csn.cancer.org/node/162494

Youtube Video of the Procedure from the University of Leicester
http://www.youtube.com/watch?v=svTQ-zJHY9M

Contribute to the discussion for at the NHS Hackday Google Group:
https://groups.google.com/forum/?fromgroups=#!topic/nhshackday/kz7k9po4oGk