Low-cost comprehensive data system for cardiac patients

August 5, 2017 | Autor: Libardo Melendez | Categoria: Information Systems, Humans, Office Management, Coronary heart disease, Medical Records
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Catheterization and Cardiovascular Diagnosis 5: 347-355 (1979)

Low-Cost Comprehensive Data System for Cardiac Patients Libardo J. Melendez, MD, FRCP (c), and A. Craig MacDonald, MD, FRCP (C) Functional systems to collect, store and retrleve cllnlcal, hernodynamic, and angiographlc information are needed to serve cllnical research and quality control In the cardiac laboratory. Computers are Ideally sulted for this application, but high investment and maintenance costs are a barrler for their wider use. A low-cost data processlng and procedure reporting system was developed using a programmable calculator, a floppy dlsk drlve, and a printer. Files have been started on 750 consecutive adult patients undergoing cardiac catheterizatlon and angiography. Each file contains a cllnlcal proflle (CP), angiographic interpretation (Al), and hernodynamicdata. CP and Al are coded accordlng to a data basedefinition appropriate for patlent care (procedurereport) and researchanalysis. Data input is simplified by the use of multiple-choice forms and prompts appearlng on the calculator alphanumeric display. One floppy disk may hold 400 patlent files. Immediateaccess to stored Information for cross reference, computations, and statistlcal work is possible in all patients, a patient category, or an indivldual case. Stored items may be retrieved in coded form for analysis or translated Into sentences to generate a multiplecopy procedure report. Follow-up lnformatlon may be subsequently addedto the patient file. Operation requires mlnlmal training and little expertise in computer technology. Key words: patlent data system, coded patient file, computers In cardiology, computer-assisted report

INTRODUCTION

The advent of aortocoronary bypass surgery led to a considerable increase in the number of cardiac catheterizations and angiographic procedures performed in patients with coronary artery disease. Many of the questions that remain to be

From the Dlvlslon of Cardiology and the Department of Diagnostlc Radiology, Victoria Hospital Corporation, London, Ontario, Canada. Reprint requests to: Dr. L.J. Melendez, Victoria Hospital Corporation, 391 South Street, London, Ontario, Canada N6A 4G5. Received March 19, 1979; revision accepted July 17, 1979.

009&6569/79/0504-0347W2.00 0 1979 Alan R. Liss, Inc.

348

Melendez and MacDonald

answered on the natural history of this disease as influenced by various medical and surgical approaches call for careful analysis of clinical, hemodynamic, and angiographic information. Functional systems to collect, store, and retrieve this information are needed; computers are ideally suited for this application. Although important work has been done in this area, notably that of the American Heart Association committee for grading coronary artery disease', many cardiovascular laboratories may not have a large computer system readily availablez3. The purpose of this report is to describe the development of a comprehensive, yet economical, data system for clinical, hemodynamic, angiographic, and surgical/ medical follow-up information in patients investigated for ischemic heart disease. The characteristics of such a system were defined as follows: 1) It should be possible to store and retrieve relevant clinical, hemodynamic, angiographic, and medical/surgical follow-up information. 2) Information input should be as simple as possible to avoid errors and assure compliance of all physicians and surgeons involved. 3) Stored information should be immediately available in an intelligible format to be used as a procedure report for the patient's records. 4) Initial and maintenance costs should be low.

The major obstacles that we encountered with commercially available systems were high initial investment or maintenance cost and lack of storage and reporting capabilities for clinical, angiographic, and medical/surgical follow-up information. Although the system that we describe here does not have on-line handling of hemodynamic data, it provides both an immediately available printed procedure report and ample capability for storage and retrieval of patient files. Its cost is less than a third of the computerized cardiac catheterization system produced by the same manufacturer. SYSTEM DEVELOPMENT

We have met our requirements with a system that uses a programmable calculator as the central processing unit, magnetic floppy disks for mass storage, and a printer (Fig. 1). Stored items may be retrieved to generate a multiple-copy procedure report or individually accessed for research purposes. The equipment chosen for this project was a 15036 byte read/write memory programmable calculator coupled io a line printer and a floppy disk drive.* The calculator is provided with a small alphanumeric display and a tape cartridge. The former obviates the need for a television screen, and the latter serves as a convenient storage for the software of the system. Information to be stored is collected with the use of multiple-choiceforms. Figure 2 shows coded multiple-choice forms used for patient profile and catheterization procedures. The items included in the multiple-choice forms represent the essential data base definition that we have found of practical use in our laboratory. Hemodynamic data are read from pressure recordings and entered on the form. No computations (cardiac index, vascular resistances, etc.) are necessary, since they 'Hewlett Packard 9825A calculator. 9871A printer, and 9885M disk drive.

Data System for Cardiac Patients

349

Fig. 1. System hardware. Left: programmable calculator and floppy disk drive. Right: printer with

multiple-copy z-folded paper.

are automatically performed when the procedure report is generated. Completion of the entry forms is simple and takes only a few minutes. A similar multiple-choice coded form is used for angiographic information (Fig. 3). This includes quantitative or qualitative left ventricular global contractility and segmental wall motion characteristics, and status of the great vessels, valves, and coronary arteries. Segment division for the left ventricle and the coronary arteries follows the guidelines of the American Heart Association’. Each coronary artery segment is qualified as normal, partially obstructed, or occluded. Partial obstruction is further qualified as diffuse, segmental, single, or multiple, with or without collateral circulation to the distal vessel. The degree of lumen diameter reduction is quantified in percentile terms1. Storage of information is accomplished by running programs stored in the tape cartridge. The basic program permits entry of patient identification, numeric data, and coded information, with the help of prompts shown on the calculator’s alphanumeric display. For purposes of quality control at input, each code entry is automatically double-checked by searching a master code-and-phrase bank (stored in the cartridge), and numeric data are range-checked. A 1,008byte file, assigned to each case on the flexible disk, holds identification, coded entries from the patient’s profile, hemodynamic data, and coded angiographic interpretation. Since each floppy disk has a storage capability of 468,480 bytes, over 450 patient files can be kept in a single disk.

ISTABLE )UNSTABLE

U011 Uo2(

A

(please print)

T STATUS AT END 0 F PROCEDURE

W

0 0 0 ADDITIONAL COMMENTS

)RIGHT HEART FROM ARM )RIGHT HEART FROM GROIN )LEFT HEART FROM A M )LEFT HEART FROM GROIN )TRANSSEPTAL ICOP, THERCU)DILUTION )COP. FICK IROUTINE ANGIOS (LV, AO, CA) 1 LEFT VENTRICULOGRAM )AORTOGRAM )CORONARY ARTERIOGRAMS )BY-PASS INJECTION )RIGHT SIDE INJECTION 1 ILEOFEUORAL ARTERIOGRAM )OTHER

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PATIENT

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DATE :

CODED CATHETERIZATION REPORT

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VICTORIA HOSPITAL CORPORATION, LONDON, ONTARIO CARDIAC CATHETERIZATION LABORATORY

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(relevant information only)

INONE )NITROGLYCERINE: TABLETS/WEEK IPROPRANOLOL: TOTAL DAILY DOSE= )LONG ACTING VASODILATORS ) DIGOXIN DIURETICS ) INSULIN )ORAL ANTICOAGULANTS ANTIARRHYTHMIC DRUGS I ANTIHYPERTENSIVE DRUGS

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Fig. 2. Multiple-choiceform utilizedfor patient data entry. A. Clinical profile. 6. Cardiac catherization procedure.

please see reverse

0 0 NEGATIVE 0 INCONCLUSIVE 0 NOT AVAILABLE

ISYSTEMIC HYPERTENSION )SMOKING HABIT: CIGARETTES/DAY)FAMILY HISTORY OF IHD IHYPERLIPIDEMIA. Type )DIABETES MELLITUS IOBESITY lOEL-;ONTRACEPTIVES POSITIVE ITREADMILL TEST

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AGE CARDIOLOGIST

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DIVISION OF CARDIOLOGY

VICTORIA HOSPITAL CORPORATION

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Fig. 3. Entry forms for coded angiograrn report. Interpreter circles selected codes (left) or boxed alphanumeric characters (right).

GAN

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Prolapsing Mitral Valve

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Melendez and MacDonald

Retrieval of information is accomplished by reading the patient’s file on to the calculator. Codes and numeric data may then be printed as such or decoded into intelligible phrases to generate a multiple-copy procedure report (Fig. 4). Decoding is accomplished with the use of a code-and-phrase bank stored in the tape cartridge. For instance, code “SO1 ,” corresponding to profile item “chronic stable angina pectoris” (Fig. 2), extracts the expression “chronic stable angina pectoris” from the phrase bank and directs it to the appropriate category location on the procedure report, in this case “clinical cardiac diagnosis.” Data entry and procedure report generation takes less than five minutes per case. Operative and follow-up information is entered and retrieved in a similar manner. EXPERIENCE WITH THE SYSTEM

The system was implemented in our institution on February 14, 1978. Over 750 patient files have been started at the time of drafting this manuscript. Following each cardiac catheterization, parts I and I1 of the procedure report (Fig. 4) are generated; they are reviewed and signed by the cardiologist. When coded angiographic interpretation is entered the basic patient file is completed and part 111of the procedure report (Fig. 4) is generated. Patients undergoing surgery or entered on a follow-up protocol have sub-files started that use the same identification items through recalling them from the basic file. The two major advantages provided by the system have been the easy access to stored information, either for clinical reviews or when retrieving results of past investigations in individual cases, and the immediate availability of the procedure report, printed in a multiple-copy format and available upon completion of cardiac catheterization. The latter avoids reporting delays and helps communication among clinicians, radiologists, and surgeons. The “off-line” entry of hemodynamic data has not been, in our experience, a disadvantage. We believe that computer handling of hemodynamic data should complement rather than substitute the clinician’s intervention, this being particularly desirable in academic institutions. Mathematical computations are performed by the program, using the well-known algorithms for body surface area, cardiac index, vascular resistances, stroke index, work index, etc. The system is particularly useful for clinical research. Codes and/or numeric data may be cross-referenced to select patient population subsets, and this allows easy review of clinical, hemodynamic, angiographic, and operative experience in any given patient category or in all cases in file. Programming the calculator requires a minimum of expertise that may be acquired with the use of a training tape cartridge and instruction manuals. The daily routines for data input and procedure report generation have been performed by a medical secretary with no previous experience in computer technology. Maintenance requirements have been minimal. Difficulties encountered have included the following. I ) A few cases require more elaborate description than what is allowed by the coded entries. This difficulty has been overcome by the entry of additional noncoded information to suit the needs of particular cases. 2) The vast majority of procedures in our laboratory are performed on adult patients with ischemic, valvular, or myocardial disease. This data system is not

Data System for Cardiac Patients

355

suitable for the more complex hemodynamic and angiographic findings in patients with congenital heart disease. 3) Inaccurate entry of information on check-mark forms is a potential source of error in any computer assisted system4. The best approach for its solution has been the responsible filling of the forms by the physician or surgeon in charge of the procedure. Unsupervised delegation of this responsibility to inexperienced trainees must be avoided. CONCLUSIONS

Based on our experience with the system described in this report, we believe that similar systems may be economically developed in other cardiovascular laboratories for the dual purpose of storing and reporting patient information. Although we have used a programmable calculator or “desk-top computer,” similar objectives may be met with some of the newer, low-priced microcomputers. The multiple-choice forms used to collect information constitute, in fact, a data base definition for the system, susceptible to be expanded or condensed according to the needs of each laboratory. Information derived from hemodynamic and angiographic procedures and from patient follow-up becomes immediately accessible, a definite advantage both in patient management and in clinical investigation. REFERENCES 1. Report of the Ad Hoc Committee for Grading Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association: A reporting system on patients evaluated for coronary artery disease. Circulation 51:4, 5-40, 1975. 2. Gensini GG: Methods of data collection, storage, analysis and reporting. In: “Coronary Arteriography.” Mount Kisco, New York: Futura Publishing Company, Inc., 1975; pp 131-156. 3. Institute of Electrical and Electronic Engineers Incorporated Computer Society: “Computers in

Cardiology.” IEEE Computer Society, 1975. 4. MacGregor DC, Dovvey HD, et al: Computer-assisted reporting system for the follow-up of patients

with prosthetic heart valves. Am J Cardiol 42:444-452, 1978.

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