This post on my nutrition project using the Board Rounds app appeared on the Penn Medicine blog 12/21/2016.

Harnessing Big Data to Count Calories in the ICU

December 21, 2016

 | by Johanna Harvey

Feeling hungry is a signal from our bodies to our brains that we need fuel to be healthy. But some patients in the intensive care unit (ICU) with traumatic brain injuries or other complications are not able to express or even sense hunger. Often, these patients are connected to tubes that deliver enteral nutrition (EN), a liquid formulation of nutrients delivered to the GI tract.

EN has been shown to have a positive impact on the recovery process, from reducing infections to shortening the length of hospital stays to promoting faster cognitive recovery. But, EN is only beneficial if patients are receiving enough nutrients to counterbalance their energy expenditure – even immobile patients burn calories through normal biological functions like breathing and thinking. However, the average patient only receives about 50 percent of their daily calorie needs, meaning that many patients in the ICU are at risk for malnutrition.  That’s where David Do, MD, a software developer and Neurology resident at Penn, and his fellow researchers come in—they are working on software that will make it easier to track a patient’s nutritional needs and make sure they are getting enough daily calories to help them recover properly.

I sat down with Do to ask him a few questions about the software he is developing and how it will help patients.

Q: Why is nutrition so important for ICU patients?

A: Nutrition is actually a really important part of the recovery process for anyone who is sick. Think about it: even with the common cold, general treatment advice is to rest up and get plenty of food and fluids to help you heal. This is even more important for people who are critically ill and/or in the ICU. 

Patients who are underfed have a higher risk for muscular breakdown and have more trouble fighting off infections. Most of my patients in the Neurointensive Care Unit are in the hospital for a week or longer and in that time it's possible for serious nutrient deficiencies to occur that could ultimately impact the recovery process.

Q:  Why are some ICU patients under-nourished?

A: Normally, our bodies tell us when and how much we need to eat through our sense of hunger. But patients with brain injuries, swallowing malfunctions, or who are on ventilators, can’t tell us when they feel hungry. Instead, they have to rely on clinicians to deliver the right amount of nutrients through feeding tubes.

Q: What challenges to do care teams face when trying to ensure patients receive proper nourishment?

A: Critically ill patients have really complicated medical problems and care teams are often focused on these pressing issues. Unfortunately, sometimes this means that nutrition can fall to the bottom of the list of needs. To make things more complicated, each patient has different needs, meaning they need customized nutrition plans that often require complex calculations. Getting the nutrition levels correct can be challenging for clinicians who are balancing many complicated care needs for several patients. That’s why we created our Enteral Nutrition Calorimeter software—to make it easier for care providers to give patients the nutrients they need to support the recovery process.

Q: How does the software work?

A: This project is really about how we can leverage data that we already have through electronic medical records (EMR) to improve care. In the Calorimeter project, we designed custom monitoring software that tallies the patient’s intake and, based on the nutritional content of the feed, determines how many calories and grams of protein the patient has received. We then estimate each patient’s energy expenditure to determine who received enough. We use this data to provide constant feedback to clinicians by sending automated secure messages to the right person at the right time.

Q: What results have you seen so far?

A: Right now, we are going through the design phase. Our early investigations have helped us map out the obstacles to feeding. We even tried placing a clinician on daily rounds who was dedicated to optimizing nutrition, which improved feeding rates dramatically. While the extra attention may not be sustainable or scalable, we identified several barriers that are addressable through automated methods. We are working on crafting and testing messages to see what makes clinicians respond the most.  

Q: As a resident, how you were supported by Penn faculty to move this project forward?

A: The Neurology faculty have been tremendously supportive of this project, especially the Neurointensive Care faculty who were eager to help design and adopt our solution in their unit. Penn Medicine has become a great environment for interdisciplinary collaborations and innovations, especially for residents. Since I first arrived at Penn more than three and half years ago, I’ve seen a tremendous investment in infrastructure and technology that now allows us to rapidly build and test tech-enabled interventions and applications that will improve patient care. 

Do and his fellow researchers were recently awarded funding for their project through Penn’s Innovation Accelerator Program. Now in its fourth year, the Innovation Accelerator Program from the Penn Medicine Center for Health Care Innovation supports promising ideas from faculty and staff across departments and roles at the University of Pennsylvania Health System in their efforts to develop, test, and implement new approaches to care. This year’s program is co-sponsored by UnitedHealthcare.

The research team includes John Chandler, MD, Neurocritical Care Physician; Joshua Vanderwerf, MD, Neurology Resident; Jennifer McKenna, CNSS, Clinical Dietitian Specialist; Bethany Young, RN, Clinical Nurse Specialist; Susan Kennedy, CNSS, Clinical Dietitian Specialist; Kai Holder, Research Assistant; Davis Hermann, Design Strategist, and Diane Dao, Innovation Intern

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Clinical visualizations - Antiobiotic grid

Physicians need to be able to understand the history of antibiotics given in order to make decisions about broadening antibiotics, narrowing antibiotics, and administering the correct duration of therapy. The standard EMR's medication administration record is not optimized for these needs (Figure 1).

Figure 1: EMR's medication administration record

Problems of the current visual display include

1. Difficult to tell at a glance what antibiotics a patient is currently on
2. Difficult to tell how long a patient has been on antibiotics for
3. The need to scroll
4. Visual sparseness

The first step in our redesign is to use a filter to select the antimicrobials. The second is to reduce the visual sparseness of the grid by grouping by day (Figure 2).

Figure 2

While this view is cleaner than the original, we lost some information about sequence due to grouping--for example, it's not clear what the dose progression of vancomycin has been. To fix this problem, we can create multiple time bins daily, experimenting with three daily time bins (Figure 3) and four daily time bins (Figure 4).

Figure 3: Grouping by up to three time bins daily

Figure 4: Grouping by up to four time bins daily

For the purpose of conveying antibiotic history, three time bins seems to have the best balance of chronology while limiting sparseness. Finally, for visual simplicity, we remove gridlines and lightly shade every other day (Figure 5).

Figure 5: Final design for an antibiotic grid to help make management decisions

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Designing Better Clinical Views

Designers: David Do, Eugene Gitelman, Ian Oppenheim, Jason Maley, and Barry Fuchs

The dashboard concept has been around for a long time, but dashboards still see limited adoption in medicine. Why is that so? How can we be different? By thinking about dashboards firstly through the provider’s eyes, and secondly as a platform, we address several key barriers to adoption:

• Simplicity – in these examples, we allowed ourselves to be inspired by paper notes and diagrams that doctors use. We plot data on trendlines and we can put data side-by-side to examine the interplay of assessments and interventions.
• Designability – A straightforward interface lets providers design and share dashboards. The respiratory dashboard is not only informative but also instructive, training users to dichotomize “oxygenation” and “ventilation”. Other specialists in the hospital may have analogous lessons.
• Tweakability – as we learned in the Carealign process, not all data are of equal importance. The most time consuming part of construction happens after the design, finding the right study names, filtering and “massaging” data (e.g. formatting to fit the fishbones). This dashboard platform lets users make instantaneous adjustments.

Figure 1: Respiratory view is informative and instructive, helping users think about ventilator settings in terms of “Oxygenation” v “Ventilation”.

Figure 2: Each view is designed to answer a particular question. The ID view should contain all the data that an infectious disease specialist uses in order to make an antibiotic decision.

Figure 3: A quick glance at the Quality Indicators view shows patients with foley catheters or indwelling lines

Figure 4: Users can become designers by defining their own views, choosing the types of data to be displayed in each panel

Figure 5: Diabetes views

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Agent - EMR data straight to your phone

Introduction

Agent is a project I am leading at the Hospital of the University of Pennsylvania. Healthcare providers who directly interact with patients can use this app to receive up-to-the-minute results through Push Notifications. 

Aside from streamlining workflow, the Agent platform offers the ability to improve care by delivering targeted notifications based on data. Interventions that would have previously required extensive IT resources to build can now be implemented and tested in a week's time.

Examples of how this can be applied:

• Antibiotics medications often expire without provider awareness, leading to missed doses. Agent alerts providers when it's time to renew a medication.
• Previously there was no automated notification for when patients arrive on the floor. Agent ensure providers are aware so patients can be seen immediately.

The possibilities are limitless. The goal of Agent is to create an environment where people can design, test, and iterate on process improvements. This is where Agile Development meets medicine. 

Agent Landing Page

We needed a way to communicate to administrators the benefits of the new technology to gain support. We also needed a way to onboard beta testers with email confirmation and a survey.

Components

Blog

Multistep sign up process with email confirmation, survey

Technologies

Ruby on Rails
simple-rss gem
CSS
jQuery

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Framework for ICU Dashboards

A project at the Hospital of the University of Pennsylvania

Given the multitude of monitors and ventilators in the ICU, doctors inevitably face a Data Overload problem. These are the sickest patients in the hospital, and clinical decisions often need to be made quickly. Barry Fuchs, the director of the MICU at Hospital of the University of Pennsylvania, asked me to design a dashboard. As he describes it, there should be a series of comprehensive views for each organ system. The Infectious Disease view, for example, should contain precisely the information an infectious disease consultant would use to decide what antibiotics to use. There would be views for a patients cardiopulmonary, hematologic, and neurologic statuses as well.

This problem elucidates a fundamental flaw of EMRs--an organizational scheme carried over from the days when everything was on paper. Even in electronic form, data are often organized the way they were collected rather than the way they will be interpreted, imposing a severe limitation on clinical decision-making. My preliminary designs are below.

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