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Configurable Clinical Summary

Primary mentor

Nyoman Ribeka

Backup mentor

Saptarshi Purkayastha

Assigned to

 

Abstract

Background
During the implementation, the implementation team, which consists of the Doctors also, soon realized that, due to the flexibility in the HTMLForms and Concept Dictionary, any type of data can be captured very effectively using multiple modularized forms. But, as the patient data entered using multiple forms will span across multiple encounters, a Consultant Doctor needs to look up each of the forms to get an idea of the Patients medical condition. The Doctor has only few minutes to go over each patient record in an already crowded public health domain. It will increase the Doctors work several fold. As a result, it seems, currently in several OpenMRS implementations there is a tendency of creating one long form with multiple sections and data is entered retroactively for a period of time, so that the patient record is viewed at once.
We are proposing a Patient Clinical Summary Module to be developed in this project
a) To realize the true potential of encounter concept, so that a Patients medical history is time-stamped and b) the data entry is easier with multiple form based encounter
As OpenMRS implementation can be very different from one site to another, so the Patient Clinical Summary View will be different from one implementation to another. So, it is important that the Clinical Summary need to be configured based on concept dictionary and encounters chosen.

Project Champions

Implementation: MissionArogya - ArogyaNet

Rajib Sengupta 

Objectives

A. Clinical Summary Template function :
Users (Doctors) should be able to select concepts to define the template for a clinical summary.
It can be implemented as
a) Tag in HTMLForm (example: A tag to display a table of lab results)
b) A wizard like tool , where the user can choose the different concepts and ordering of the concepts in the form
c) An ideal solution will be to have a WYSIWYG editor, which combines the wizard concept as well as the formatting concept

Optional
The doctor may decide to include specific "Encounters" that are important to create a final template of clinical summary
The doctor may save this template , so that it can be used by other doctors.
(I am not sure if these nice to have can be implemented easily)

Some specific Requirements (from Joaquin):

1. There should be a button to print the summary which shows just the summary and not the entire page
2. Should be able to show observations that have been entered for the patient
a. Can choose whether it's the first or last chronologically, the lowest or highest, or all, as is done in the reporting and reporting compatibilty module
3. Should be able to select to view or not view the last 5 to 10 encounters a. Should be able to select how many are displayed b. Should have an option to choose if the encounter name is a link that takes you to the form
4. Should be able to place graphs of any numeric concept as in the Graphics tab in the Patient Page
5. Should be able to show patient flags (https://modules.openmrs.org/modules/view.jsp?module=patientflags)
6. Should be able to select to show which program the patient is in (as in the Description tab in the Patient page)
7. This should be an additional tab in the patient page, and not a link in the patient summary as in the current Patient Summary Module
8. There should be a default view which should be able to be set depending on the user's role, though if the user has the modify clinical summary privilege they should be able to change it. This change should only affect their view.
a. If the user is able to edit the clinical summary, they should also be able to save it in a template which another user can upload to their page to have the same view. This assumes that it would be a system with the same data dictionary

Mockup:

https://wiki.openmrs.org/display/~jibesh/Home

Extra Credit

Resources

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11 Comments

  1. I think the first step towards making a better configurable clinical summary system is creating a modular model the represent the patient summary itself. I'm carving the initial model right now and we're planning to have a design call on this one soonish.

    With a modular model, we can pipe down this model and use multiple type of viewer to see the patient summary itself. We can send them to an android phone or tablet, or patient dashboard or even print out a paper summary :)

    1. Great point Nyoman. 

      I understand the technical satisfaction of creating a module which is portable across devices/platforms. But the most important thing will be that the end user (ideally Doctor,  or the implementer who have some idea of  HTML) can easily configure it and change it . Two  points to keep in mind is, 1) the concepts in the clinical summary will be different (A oncologist will like to see the ECOG performance score right up at the top of the summary while other doctor's will not be interested at all) 2)  and/or it may be based on specific encounter, specifically the very first encounter which covers several important historical information that will be different for different type of group of doctor's but they are under the same hospital, thus using the same openmrs instance.

      The idea is the doctor (non-technical users) can decide what data of patients (in openMRS termionology which concepts in specific encounter) will show up in the patient summary. It will be ideal, if one doctor can configure this and save/share it as a template which can be used by other doctors. In several proprietary EMR software this is a basic feature.

      Here is what I discussed with Darius in earlier emails which might be helpful in further design discussions

      ===========================


      From: Darius Jazayeri <djazayeri+pih@GMAIL.COM>
      To: openmrs-devel-l@LISTSERV.IUPUI.EDU 
      Sent: Wednesday, February 29, 2012 10:19 AM
      Subject: Re: [OPENMRS-DEV] Couple of GSOC 2012 Project ideas

      Hi Rajib,The idea is that in HTML Form Entry you can create custom tags, and those tags are backed by java code, which can hit the database.
      One point of the project would be to describe several useful widgets for summaries, that are generic enough to let people define things in the way they want.
      -Darius

      On Wed, Feb 29, 2012 at 7:03 AM, Rajib Sengupta <rajibs123@yahoo.com> wrote:

      Darius,
       
      If it is easy to develop in HTMLForm entry (or something similar) that will be awesome. 
       
      I understand that it will not be encounter based and as such the tag will need a qualifier to go back few recent encounters to limit the scope, as you mentioned here
          <labResultTable conceptIds="123,234,345" withinDays="180" maxResults="5"/>
       
      I don't want to make it complex, but is there any way to make it a little flexible , so that, the doctor may be able to see few of the initial encounter of the patient in the summary along with the recent ones.
      Ideal would have been if the doctor can specify a date range in the HTMLForm and that brings up the summary. Something like this:
        <labResultTable conceptIds="123,234,345" startdate="start_date_variable" endDate="endDate_variable"/>
      But I think, from the HTMLForm entry  we cannot do a database lookup - correct?
       
      So, something like this will be also useful where we can hardcode the number of initialencounter as a qualifier :
       
         For the initialencounters: <labResultTable conceptIds="123,234,345" initialEnounters="2"/>
         For the recent encounters: <labResultTable conceptIds="123,234,345" withinDays="180" maxResults="5"/>
       
      Sorry for ranting on.. but as Saptarshi and you have pointed out, I also believe, this feature will be a great addition for openMRS
       
      Thanks for all the help
      Rajib
       From: Saptarshi Purkayastha <sunbiz@GMAIL.COM>
      To: openmrs-devel-l@LISTSERV.IUPUI.EDU 
      Sent: Wednesday, February 29, 2012 2:08 AM
      Subject: Re: [OPENMRS-DEV] Couple of GSOC 2012 Project ideas
      yes, that will be really useful... and if you say it is quite straightforward to implement, then this is awesome!!I thought it will be tough to implement these.
      Image upload/download, Better skip-logic in HTMLFormEntry and this will really be great...
      ---Regards,Saptarshi PURKAYASTHAMy Tech Blog:  http://sunnytalkstech.blogspot.comYou Live by CHOICE, Not by CHANCEOn 29 February 2012 12:02, Darius Jazayeri <djazayeri+pih@gmail.com> wrote:
      What I mean is: what if the HTML Form Entry infrastructure were broadened, or we wrote some similar code from scratch, which was not encounter-based, but let you do something like this:<html>
      <h1><lookup code="patient.name"/></h1>
      <showIfAny cssClass="alert" calculations="LateCD4,NeedsCXR,FallingWeight"/>
      <div style="float: right; border: 1px black solid">
          Recent Labs
          <labResultTable conceptIds="123,234,345" withinDays="180" maxResults="5"/>
      </div>
      Etc.
       </html>
      I.e. something "just like HTML Form Entry" (it could even be HTML Form Entry) with an extra set of custom tags, or groovy functions, or whatever, that provide you some common things you'd want to show on a summary sheet. (And of course the ability to save that summary definition to the database.)
      I feel like that would be quite straightforward to implement, and provide a lot of bang-for-the-buck.-DariusOn Tue, Feb 28, 2012 at 9:16 PM, Saptarshi Purkayastha <sunbiz@gmail.com> wrote:
      I think the clinical summary module is useful, but is very hard for someone new.A WYSIWYG editor for the clinical summary module will be very useful.
      With the HTMLFormEntry it means we are able to use only summary from one encounter, which is not the case in our requirement
      What we are looking for is creating a summary of multiple encounters and showing the summary across a period of time for a patient. A BIRT report is fairly useful to do that, but the clinical summary module demo shown by Win a few days back was nice... If only it was easier to make those for non-developer.
      ---Regards,Saptarshi PURKAYASTHAMy Tech Blog:  http://sunnytalkstech.blogspot.comYou Live by CHOICE, Not by CHANCEOn 29 February 2012 05:55, Darius Jazayeri <djazayeri+pih@gmail.com> wrote:Hi Rajib,For project #2, are you thinking of something that assumes a similar level of knowledge to HTML Form Entry? For example, if HTML Form Entry had 10 new tags that let you do things like display a table of lab results, would that be enough? Or are you envisioning something with a WYSIWYG editor, or at least some wizard-like tool to let non-html-aware clinicians create their own summaries?-Darius

  2. A couple of questions come up for me.

    1. Will this use or replace the patient summary module (https://modules.openmrs.org/modules/view.jsp?module=patientsummary), if so I think it should be explicitly stated.

    2. I'm assuming that this would be an additional tab on the patient page where the data would be shown and not a link in another tab like it was for the patient summary module. 

    3. An option for the WYSIWYG editor could be the xforms module which already has the editor.

  3. Adding to Joaquin's comment, I have worked with one of the GSOC student who proposed for this project, to create a mockup from an implementation perspective  - This is just one way of getting it done end to end in a 3 months time frame.  As a result, my proposed solution is, option b: A wizard like tool , where the users can choose the different data elements

    Configurable Patient Summary Mockup

    The idea is as following:

    1. In the Admin page there should be an option to create new templates for patient summary

    2. The templates should be easily created using a wizard (Not via HTMLForm entry tag - too complex for users. WYSIWYG editor would have been ideal , but I think it will be very time consuming and an end product may not get created)

    3. The template should be saved so that it can be used by all

  4. Building on Rajib Sir's comments

    I went through the discussion and Sir I think this might help. 

    I have previously worked on a Blood bank project and it works similar lines. I had used WYSIWYG editor - CKEditor for the purpose of creating configurable html forms . Its integration is quite easy so I believe it shouldn't take much time. Also its fairly simple to use.

    We can manage forms from the admin panel as well configure templates using the editor. The template is saved and can be viewed by all with permission.

    I have linked screen shots of the working module below

    Manage Page >  CK Editor View Forms -> Use Forms

  5. Also, found this patient dashboard module on the HISP india repository, which might be of use.  There's no documentation, so I don't know exactly what it is

    https://github.com/hispindia/patient-dashboard

  6. I've worked with HISP India before, as far I know there is no formal documentation of the above module but I have the user manual with screen shots.

    Patient Dashboard.pdf

    1. Thanks Apurv. Can I post this as a new page on the OpenMRS wiki?  I think it might be helpful to others.

  7. Here are some high level requirements
    Should be an additional tab in the patient page
    Show observations that have been entered for this patient
    Should be able to choose whether the last or first chornologically, highest or lowest value, or all for a specific date range or x days/months
    Limit to the last x number of observations where x is an integer
    Should be able to show the last encounters entered (show form name)   
    should be able to choose how many previous encounters   
    should choose whether the form is shown as a link to go to it
    Show and place graphs of observations that are numeric   
    Show alerts from patient flags (https://modules.openmrs.org/modules/view.jsp?module=patientflags)
    Show the programs the programs patient is in as in the description tab in the patient page
    Easily configure the layout of the different elements, could use HTML Form Entry or XForms or something else
    Though this is configurable by every user, there should be a default template that should apply to new users   
    this should be configurable per role
    (Secondary) User should be able to export design as a file and others should be able to upload it   
    this assumes that they are using the same concept dictionary
    Here are some high level requirements (with minor edits made)

    1. Should be an additional tab in the patient page
    2. Show observations that have been entered for this patient
    3. Should be able to choose whether the last or first chronologically, highest or lowest value, or all for a specific date range or x days/months
      1. Limit to the last x number of observations where x is an integer
    4. Should be able to show the last encounters entered (show form name)   
      1. should be able to choose how many previous encounters   
      2. should choose whether the form is shown as a link to go to it
    5. Show and place graphs of observations that are numeric   
    6. Show alerts from patient flags (https://modules.openmrs.org/modules/view.jsp?module=patientflags)
    7. Show the programs the patient is in as in the description tab in the patient page
    8. Easily configure the layout of the different elements, could use HTML Form Entry or XForms or something else
    9. Though this is configurable by every user, there should be a default template that should apply to new users   
      1. this should be configurable per role
    10. (Secondary) User should be able to export design as a file and others should be able to upload it   
      1. this assumes that they are using the same concept dictionary
    1. 8. Easily configure the layout of the different elements, could use HTML Form Entry or XForms or something else

      +1 for this.

      This is just based on our own needs: but I think "customizability" is highly desirable for this sort of project. It would be great to be able to separate summary data out into different sections, sub-sections, etc. using different layouts throughout.

      I'm not sure what the plans are for the wizard designer, but only worry would be that it could limit the user in the sort of summaries that can be created. Sometimes having that power available with working directly with say an HTML form and then having a developer design the template, could be better. The reason is that might not always be the end user designing the summary, but rather developers/implementers who would like to make project/domain specific summaries and release those to the end users.