Converting Paper to DigitalConverting Paper to Digital

Carolinas Health Informatics ProgramCarolinas Health Informatics Program

Practicum ProjectPracticum Project

John HoranJohn Horan

CarolinasCarolinas Comfort Scale Comfort ScalePresentation OutlinePresentation Outline

Introduction of the Carolinas Comfort Scale (CCS)

Project Scope and RequirementsResearch and DevelopmentApplication DemonstrationPotential Impact of ApplicationQuestions and General Discussion

• CCS is survey used to help physicians and patients assess Quality of Life both pre and post hernia repair with mesh

• Developed by physicians and researchers from Carolinas Laparoscopic and Advanced Surgery Program (CLASP)

• CLASP has become a leader in minimally invasive surgery by focusing on Patient Care, Research, and Education.

What is it?

• Developed by comparing Carolina Comfort Scale results against the SF-36 questionnaire which is considered the gold standard for measuring Quality of Life for patients who have undergone hernia repair surgery

• Results of the study published in the Journal of American College of Surgeons http://www.ncbi.nlm.nih.gov/pubmed/18387468

• CCS was found to better assess the quality of life and satisfaction of patients who have undergone surgical hernia repair better than the generic SF-36.

How it was developed

Carolinas Comfort ScaleCarolinas Comfort Scale

The CCS survey is currently used by surgeons in 19 US states, 39 Countries, and has been translated into multiple languages.

CSS Usage

Carolinas Comfort ScaleCarolinas Comfort ScaleA physician from the United Kingdom will use the CCS in Nottingham City Hospital which covers 64 general practices and provides care to 330,000 patients annually. The CCS will be used as a support tool for screening eligibility for inguinal hernia repair surgery funded by the Nottingham City Hospital.

French physicians will launch a researchtrial using the CCS involving 30 university hospitalteams in France. The study is sponsored by the French government.

Carolinas Comfort ScaleCarolinas Comfort ScaleCurrent Workflow of Data Collection

Carolinas Comfort ScaleCarolinas Comfort Scale

• Patients fill out the paper based survey

• Question responses are scored using an algorithm developed by CLASP surgeons and researchers that score five endpoints

• Activity, Sensation, Pain, Movements and the Total Score.

How the Survey Works

Carolinas Comfort ScaleCarolinas Comfort ScalePrimary Endpoint #1: Activity ScoreCompare mean/median scores for each of the 23 questionnaire items (1a, 1b, 2a,2b, 2c, etc) for lightweight vs. heavyweight mesh. This will provide a summary forall of the 23 questions for each comparative group.PROC SORT data= CCS.Responses; by CURRENTMESHTYPE; RUN;PROC MEANS NOPRINT data= CCS.Responses;VAR q1a q1b q2a q2b q2c q3a q3b q3c q4a q4b q4c q5a q5b q5c q6a q6bq6c q7a q7b q7c q8a q8b q8c;OUTPUT OUT=CCS.AvgAll MEAN=m1-m23;by CURRENTMESHTYPE ;RUN ;Primary Endpoint #2: Sensation ScoreBroader Endpoint #2: Compare mean/median scores for sensation collapsed acrossactivity (1a, 2a, 3a, 4a, 5a, 6a, 7a, 8a) for symptomatic vs. non-symptomatic patients.This will provide a report that specifically focuses in on the sensation of mesh postimplantation pertaining to a specific activity for each comparative group.PROC SORT data= CCS.Responses; by SYMPTOMATIC; RUN;PROC MEANS NOPRINT data= CCS.Responses;VAR q1a q2a q3a q4a q5a q6a q7a q8a;OUTPUT OUT=CCS.AvgSensation MEAN=m1-m8;BY SYMPTOMATIC;RUN;Primary Endpoint #3: Pain ScoreBroader Endpoint #3: Compare mean/median scores for pain collapsed acrossactivity (1b, 2b, 3b, 4b, 5b, 6b, 7b, 8b) for symptomatic vs. non-symptomaticpatients. This will provide a report that details the level of pain that is experiencedby the patients pertaining to a specific activity either pre or post-operatively foreach comparative group.PROC SORT data= CCS.Responses; by SYMPTOMATIC; RUN;PROC MEANS NOPRINT data= CCS.Responses;VAR q1b q2b q3b q4b q5b q6b q7b q8b;OUTPUT OUT=CCS.AvgPAIN MEAN=m1-m8;BY SYMPTOMATIC;WHERE FOLLOWUPTIMEPOINT = ‘PREOP’;RUN; 7Primary Endpoint #4: Movement ScoreCompare mean/median scores for movement collapsed across activity (2c, 3c, 4c,5c, 6c, 7c, 8c) for symptomatic vs. non-symptomatic patients. This will provide areport that details movement limitations either pre or post-operatively for eachcomparative group.

SAS Scoring Algorithm SamplePROC SORT data= CCS.Responses; by SYMPTOMATIC; RUN;PROC MEANS NOPRINT data= CCS.Responses;VAR q2c q3c q4c q5c q6c q7c q8c;OUTPUT OUT=CCS.AvgMOVEMENT MEAN=m1-m7;BY SYMPTOMATIC;WHERE FOLLOWUPTIMEPOINT = ‘POSTOP’;RUN;Primary Endpoint #5: Total ScoreCompare mean/median scores for QOL scores collapsed acrosspain/sensation/movement & activity for symptomatic vs. non-symptomaticpatients. This will provide an overall report based on the mean for all 23questionnaire items./*Combine result data files from examples #2, #3 and #4. This combination representsall scores collapsed across pain/sensation/movement.*/PROC APPEND BASE=ccs.avgSENSATION DATA=ccs.avgPAIN FORCE; run;PROC APPEND BASE=ccs.avgSENSATION DATA=ccs.avgMOVEMENT FORCE;run;PROC MEANS NOPRINT data= CCS.avgSENSATION;VAR m1 m2 m3 m4 m5 m6 m7 m8;OUTPUT OUT=CCS.QOLall MEAN=m1-m23;by SYMPTOMATIC; RUN ;Compare mean/median scores for QOL scores collapsed acrosspain/sensation/movement & activity for symptomatic vs. non-symptomaticpatients. This will provide an overall report based on the mean for all 23questionnaire items using the Wilcoxon signed-rank test.PROC APPEND BASE=ccs.avgSENSATION DATA=ccs.avgPAIN FORCE; run;PROC APPEND BASE=ccs.avgSENSATION DATA=ccs.avgMOVEMENT FORCE;run;DATA CCCS.meanALL;SET CCS.avgSENSATION;RUN;PROC NPAR1WAY WILCOXON data=ccs.meanALL;8CLASS SYMPTOMATIC;VAR m1 m2 m3 m4 m5 m6 m7 m8;OUTPUT OUT = CCS.wilcoxonresults;RUN;PROC SORT data=ccs.wilcoxonresults; by SYMPTOMATIC; RUN;PROC MEANS

• An electronic version of the CCS survey• Electronic version of survey needs to be easily

distributed to current and future users on a variety of platforms

• To minimize risk survey needs to function as a standalone application so CLASP does not take on the risk or expense of data collection and data management.

• Current users need to have the ability to print PDF versions of the completed survey with results and have the ability to export data for patient records and further analysis.

What CLASP wanted

• Security of patient information• Data collection and storage• Branding of application to bring recognition to the

research and work that CLASP has done to create the Carolina Comfort Scale

• Ability to control the use and monitor usage of the application

• Ability to update application as future changes are developed

Additional Considerations

• Decrease turn around time of data analysis• Make data collection and sharing easier• Create application that would require very little if any

additional support• Make application and results generation easy to use

and export for current users

Additional Considerations Continued

• Research into existing tools and solutions• REDCap• Survey Monkey• WebSurvey Toolbox

• To meet customer requirements separate versions of the electronic survey would have to be developed for each platform using several different tools• Android: Android SDK or Eclipse• Apple: XCODE• Web: Eclipse, Netbeans, etc.

• Development costs and management would be expensive and time consuming if separate platform development was undertaken

Development options

CarolinasCarolinas Comfort Scale Comfort Scale

A solution exists to meet all the A solution exists to meet all the

needs!needs!

• Adobe leader in development of Rich Internet Applications

• Using Adobe’s development tools applications can be developed and then distributed to a variety of platforms

Carolinas Comfort ScaleCarolinas Comfort ScaleAdobe workflow for application development

Carolinas Comfort ScaleCarolinas Comfort Scale• Is Flash a good choice for

development of this application?• Benefits of Adobe Flash vs. HTML5

• Popularity: estimated that world wide over 90% of internet users have Flash installed on their desktop computers

• Many users find it to be easier to use than other development options that exist with HTML5

• Drawbacks of using Flash• Not support on Apple devices,

however Adobe provides several tools to convert flash based application for use on IOS

vs.vs.

Application DevelopmentApplication Development

• A tested and successful design already existed in the paper format of the survey

• Screen elements were designed in Photoshop and then imported into Adobe Catalyst. In Catalyst the screen elements were given functionality and page transitions were defined

• The project was then imported into Flash builder where additional functionality was added and it was then compiled for testing on the Blackberry Playbook and Adobe Air platforms

• The customer was sent an Adobe Air version of the prototype application to evauluate and additional edits to the screen layout were made

• The Adobe Air and Playbook tablet prototype was then demonstrated before the Department of Minimally Invasive Surgery at there monthly team meeting

Carolinas Comfort ScaleCarolinas Comfort ScaleProposed workflow for application data

collection and analysis

Carolina Comfort ScaleCarolina Comfort ScaleApplication Demonstration

Results Results

• Response to the application was very positive• When prompted for feedback on the application the only

question was could it have the ability to export the data. I had missed demonstrating the data export screen in my presentation

• When scoring the paper survey the algorithm has to take into account that patients may neglect to answer a question or that they may select more than one choice for a question. These issues can be prevented in the application by limiting question responses to one selection and by requiring that users answer each question before the results are generated.

• Converting the survey to electronic forms give the customer multiple options for distribution and the ability to manage their intellectual property

Results Continued Results Continued

• Use of the application would allow Physicians to have immediate result that that they could share with their patients

• Provides patients with additional information• Streamlines the workflow of data collection and analysis• Provides an example of how other paper based surveys and

forms can be converted into applications in a cost effective manner

• Next steps develop the full scoring and export functionality into the application

Questions Questions