PROTOTYPE IMPLEMENTATION OF AN EARLYLIFE BIOPROFILING SYSTEM X. Zhao1 , N.Outram1 , K.G. Ros´ en2 and E. Ifeachor1 1
University of Plymouth, UK {xia.zhao2, n.outram, e.ifeachor}@plymouth.ac.uk 2 Neoventa Medical AB and University College Bor˚ as, Sweden
[email protected] Abstract: Many e-healthcare applications have been developed with the aim of providing better healthcare from both clinicians’ and patients’ perspectives. However, it has been shown that it is difficult to build a system that can satisfy end users’ needs because of clinical, engineering and development issues. This paper presents online prototype implementation of an Earlylife Bioprofiling system that introduces clinicians into the development cycle and prompts better end user experience by utilising Rich Internet Application (RIA) technologies using Adobe Flex 2. Keywords: Earlylife Bioprofiling, End user experience, Flex, Java, Fetal Monitoring. INTRODUCTION The Bioprofile is an electronic fingerprint for a given individual. It combines an individuals current and past bio-history and may enable future prognosis and tailored healthcare. It combines clinical data, analysis methods and visualisation to support prediction of future or likely susceptibility to diseases and responses to treatment. Developing a Bioprofile that is of immediate value to end users, such as clinicians, patients and researchers, is difficult for a number of reasons. These include the needs for clinical evidence [1] and consensus, integration of communication between engineers and clinicians throughout the development process and seamless availability of ‘useable’ software tools. Therefore, from the engineering point of view, it is important to build a system which allows non-technical users to easy access as well as brings clinicians into the development process more easily. The new ICT technologies provide such an opportunity and in this paper, we present online prototype implementation of an Earlylife Bioprofiling system that has been built together with the target clinicians and researchers, provides user friendly interface and requires only a web-browser and the Adobe Flash player to access. The reminder of paper is organized as follows. First, we describe the basic concept of Earlylife Bioprofiling and the system conceptual design model. Second, we discuss the implementation details of the prototype including technologies being adopted. Third, the roles of the users in the Earlylife Bioprofiling prototype are illustrated. Then, the testing results and the current system evaluation are discussed. Finally, we describe the future work and conclude this paper.
BASIC CONCEPT OF THE EARLYLIFE BIOPROFILING SYSTEM Earlylife Bioprofiling The Earlylife Bioprofile is the set of information recorded for an individual up to and including the first few weeks in life. It is suggested that events in earlylife can have an impact on childhood development and health in later life. The Barker Hypothesis is an example of this [2]. In summary, the intrauterine conditions that cause changes in fetal growth (rate and pattern) have been subsequently found to have a marked impact on metabolic disorders (obesity, blood pressure, diabetes etc). Injury to the developing brain may have a marked impact on individual development. We are learning to detect when things go wrong by using modern technologies (tissue imaging and Doppler blood flow as examples). This strategy has been successfully applied to the latter stages of pregnancy and the premature baby in particular. Conversely, the technology used during the management of labour itself has not fundamentally changed since the introduction of electronic fetal monitoring in the 1960s. This is despite childbirth still being the one single event in everyones life where they are most likely to sustain a permanent brain injury. As a subproject of BIOPATTERN project (www.biopattern.org), our research is currently focused on this aspect. There are promising techniques that are candidates for inclusion into the Earlylife Bioprofile, but it is virtually impossible to fully evaluate them without complex and expensive clinical trials.
System conceptual design Fig.1 depicts the long term goal of the Earlylife Bioprofiling system. It aims to serve both clinical training and research in prenatal area. There are two main components being proposed in the system: one is the ‘clinical training and certification process’ and the other is the ‘open consensus management system’. The training and certification process contains initial training, continuous training and certification for clinicians. The initial training builds up a user’s knowledge, and provides new terms of references and vocabularies to match the domain of Earlylife Bioprofiling. Online support materials (eLearning Objects, constructivist models etc.) shall be provided. Continuous training and certification periodically provide clinical users with new sce-
Fig. 1: The Earlylife Bioprofiling conceptual design. narios, challenges and clinical features. All trainees are given online feedback that is both intrinsic and extrinsic. The extrinsic feedback is mainly obtained through clinical experts and peers. These can be feedback from a particular question, related materials from the practitioners journal and active links to annotations and events in a case browser. A longer-term aim is to develop authentic simulation models such that users can gain valuable intrinsic feedback (feedback from their immediate environment) through interaction with a simulator. The open consensus management system provides a space for clinicians, researchers and other registered stakeholders to communicate online, exchange experiences and to build a consensus on the best techniques available for Earlylife Bioprofiling. These can include examining the effects of analysis techniques on clinical data, communicating between trainees and clinical experts, discussing the requirements for better system design and evaluating the system for future improvements. IMPLEMENTATION OF THE EARLYLIFE BIOPROFILING PROTOTYPE The Earlylife Bioprofiling application has been developed mainly using open-source technologies. The core ones are: Adobe Flex 2 (including Flex data services and charting) [3]; Java Enterprise Edition 2 (J2EE) [4]; Apache Tomcat [5] web application server with backend database servers. Fig.2 shows the general structure of the current implementation. Flex is adopted for a number of reasons. First, in contrast to traditional HTML-based applications, Flex is used to build Rich Internet Applications (RIA) [6]. It can take advantage of capacities of clients CPUs. Hence, it offers enhanced and real-time user interface options, such as drag and drop, animation, validation, and other rich user interface components found in most familiar desktop operating systems. One of the obvious differences for end users is that they do not need to perform extra mouse clicks / web transactions for updating data. Second, as a RIA approach, Flex can provide great performance benefits. The computing resources of both client and server
Fig. 2: General implementation architecture.
are used more balanced and the free server resource can be used for handle more tasks concurrently. Furthermore, the network traffic will be significantly reduced due to the reduction in client-server transactions. These transactions also use standard HTTP ports, thus avoiding many firewall problems. Third, compared to other RIA approaches such as Java Applets [7] and Ajax [8], Flex offers an excellent and consistent end user experience. It overcomes many installation issues by only requiring the installation of the Adobe Flash Player plug-in that is freely available for most modern web browsers. This is important in a restricted environment such as a hospital. Therefore, end users can access the system within minimum technical effort. Moreover, Flex application is available across multiple platforms [9]. The implementation is based on the common ModelView-Controller (MVC) [10] web application development framework. MVC separates the user interface concerns from the flow of control and the data model. As a result, designers can be mainly responsible for the layout of the web application and programmers can focus on the back-end application logic. Therefore, the MVC approach can support rapid and scalable application development and ease the future maintenance. The open-source Cairngorm Microarchitecture [11], which is a MVC framework for Flex, is used for the prototype implementation. End users can access the user interface through most modern web browsers and the Flash player (v9). Customised Flex Charting Components are used in the implementation to render time-series data, including fetal heart rate (FHR), uterine contraction (UC) and T/QRS ratios. Interaction between client and server are handled by the Cairngorm Controller. The business logic is handled via Java objects and is communicated via Flex Data Service (FDS) [12]. In addition, a set of Java Servlets are developed for handling file uploading and user registration. Java Authentication and Authorization Service (JAAS) [13] is adopted in the user authentication implementation for enhancing user login security. Axis 2 [14] is used to support web services to provide backend access to cross platform software. Two types of databases are used in the system. One is
Fig. 3: A snapshot of the administrator view.
Fig. 4: A snapshot of certification setting view.
document-centric, easy human-readable XML database for storing training and certification question sets. The open source eXist DB [15] is selected in the implementation. The other is traditional data-centric RDBMS for storing the rest of data in the system, such as user and case related data. MySQL [16] is chosen for the implementation and the correspondent connector to Java is used. Additional open-source components, which include Apache Commons FileUpload [17] and JavaMail API [18], are used to handle file uploading from clients to the server and the user registration process.
types of function design. One is case-based questions for user self-testing. The other is certification question banks that can be used by users to assess themselves against different modules and at different levels. In the current implementation, questions are mainly in multiple-choice format, although other modes of input are being developed. Training allows the administrator to add/update questions and add annotation to the feature traces at any point along the time axis. Questions are organized in the list by time order. Meanwhile, markers, which indicate the points where questions appear, are added on the chart. All annotation added by the administrator is viewable by all the users but only editable by the administrator. Certification allows the administrator to build module-based certification question banks. The administrator can set module name, the number of questions in each module and the corresponding passing score. Questions may be added and displayed according to certification modules as shown in Fig.4. One figure is allowed to be uploaded for each question, which helps to assess users in the case-based scenarios. The administrator can then assign users to the modules according to their previous certification results. Registered analysis methods can be made available both for training purposes and as a means of peerevaluation of new analysis techniques. As shown in Fig.5, under Analysis tab, the administrator can register analysis methods (written in Java) against known input and output data types. These settings are stored in the database and provide the means for registered users to select the correct analysis methods for a given data source (as shown in Fig.7).
ROLES OF USERS IN THE EARLYLIFE BIOPROFILING PROTOTYPE The users of the Earlylife Bioprofiling system are divided into one of three categories: administrator, registered user and guest. The roles of each type of user are simply organized in tab navigators. Administrator The administrator may add/accept users into the system, upload cases into the public case library, provide casebased training questions and certification question banks. Fig.3 shows the snapshot of the administrator view and the default view is user management. Users are required to register with the system through email or form and an administrator has to authenticate their application. The system provides an easy filter function that filters users in the system according to different categories such as names, organizations and positions. The administrator can upload cases into the public case library. Those cases are then viewable to all the system users. The features in the uploaded case file are automatically extracted via backend web services and rendered on the charts. The easy managed, semi-transparent clinical data form automatically pops up after the uploading process finishes. It allows the administrator to attach additional Bioprofile information, such maternal data, complications, outcomes measures, mode of delivery, etc. The administrator may update the information at anytime using the “Data form” button. For the clinical training perspective, there are two
Registered user/trainee The registered users can be clinical users or researchers. From the e-learning point of view, these users are mainly trainees, doctors and midwives. Users are provided with three main roles: case browsing, clinical training and trace analysis. The registered user view is navigated through tabs that contain case viewer, basic training materials (currently in PowerPoint format), case-based training, cer-
Fig. 5: The snapshot of analysis setting view.
Fig. 6: The snapshot of the case viewer. tification tests, private case library and analysis. Most case related views are divided into two frames. In the left panel, users can review cases in the tree structure. In the main right area, the selected case data is displayed in FHR, UC, T/QRS and ST morphology charts. All cases from the public library are viewable from the Case Viewer tab as shown in Fig.6. Users may display the charts according to different heart rate and time scale standards. Meanwhile, users may display the series in white background (to rapid scrolling). Under Basic Training tab, users can view PowerPoint training materials being organized into modules with clear descriptions and learning outcome specifications. These materials cover the knowledge of basic physiology, fetal heart rate, fetal ECG and the assessment of the new born. Case-based Training allows users to perform testing on available training cases. A training control is provided to enable users to automatically scroll/pause the traces, change scrolling speed and answer questions in popup windows. Users are given instant feedback for each question they have answered (whether right or wrong). When one case-based test set is completed, users can review their results from the result list or re-take the test according to their needs. Certification Test allows users to perform assessments derived from a large bank questions. Properties, including the number of the questions in each test and pass scores, are predefined by the administrator. Users are given immediate feedback once they submit their tests.
Fig. 7: The snapshot of the sample analysis result. The system records all the certification history for the users. Users can be allowed to re-take the test if they have not passed. Private Cases enables users to upload, annotate and analyse their own cases and clinical data. In the current implementation, these cases can only be viewed by owning users. As a future development, we plan to allow users to make use of their own cases as part of good (reflective) practise and continuous professional training and assessment. The option to share cases in a professional context is being considered. Meanwhile, we are investigating a policy to encrypt data prior to permanentaly storing on the server. Analysis allows users to apply techniques on time series data. Fig.7 depicts the snapshot of a very simple RR transformation analysis to demonstrate the concept. An extra trace of RR is added onto the FHR chart and users may switch them by simply clicking the left vertical axis. Guest The guest view is provided for guest users to explore some basic functions in the system without registration. These functions include a case viewer and basic clinical training materials in PowerPoint format (see Section Registered user/trainee). EVALUATION OF THE EARLYLIFE BIOPROFILING PROTOTYPE The evaluation of the Earlylife Bioprofiling prototype has been carried out with fellow researchers and clinicians from Neoventa Medical AB. The prototype has demonstrated the concept of a ubiquitous web application that supports a much enhanced and useable interface experience using just a web browser, the Adobe Flash Player and a modest internet connection. Use of an RIA framework has been shown to greatly reduce the number of web-based transactions, thus making the application more responsive and useable over a slow internet connection. However, several issues have being highlighted through our initial evaluation study. From the clinical and research perspective, the following aspects need further
improvements. The underlying pedagogy (instructional design) of the training and certification testing need to be critically reviewed. A constructivist model is currently being considered [19]; The interaction between tutors, learners and their peers needs to be developed; standards for (plug-in) analysis techniques needs to be drafted and made available, and examples need to be hosted; on-line trials and community consensus building tools need to be designed and developed. From the technical engineering point of view, the main issues are to effectively handle large data sets and computing requirements. Meanwhile, the prototype needs continuous end users evaluations to improve usability. We plan to utilise the PlymGrid facility at the University of Plymouth to support asynchronous data analysis techniques. CONCLUSION AND FUTURE WORK In this paper, we presented online prototype implementation of the Earlylife Bioprofiling system that introduces clinicians into the development process and can offer better end user experience. We briefly described the concept of Earlylife Bioprofiling and the long term conceptual design model of the system. We mainly presented the implementation of the prototype including the general implementation architecture and the RIA techniques being adopted in the developments. We also gave the detail explanations of roles of the users in the system, which include the administrator, the registered user and the guest user. From the continuous end user testing, we found that the application can be used for effective clinical training and aiding biomedical research. Meanwhile, several issues arise for future development. The future work on implementation will focus on the following issues: (1) Investigating more effective techniques, such as data paging, to render large data sets on the charts. (2) Improving training and certification functions (instructional design) such as the means of training and certification, and communications between learners and trainers. (3) Investigating techniques for large scale data analysis and data mining methods and rendering. (4) Researching on system scalability and security issues. (5) Developing consensus building tools to support new standards in Earlylife Bioprofiling. ACKNOWLEDGMENTS The authors would like to thank Neoventa Medical AB for providing case data and the splitter component, and performing continuous system evaluation. We acknowledge the financial support of the European Commission (The BIOPATTERN project, Contract No. 508803) for part of this work. REFERENCES [1] S.M. Williams, “Putting case based instruction into context: examples from legal and medical educa-
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