Br Heart_j 1995;74:559-562

TECHNIQUE

Displaying the long-term progression of patientswith coronary artery disease

C Sherlaw-Johnson, J Mitchard, S Gallivan, D L H Patterson, T Treasure

AbstractCardiac clinicians are often faced withthe problem of trying to assimilatedetails of a patient's long-term history.Case notes are often lengthy, making thisprocess difficult if not impossible in thetime available during an outpatientexamination. A computer system hasbeen developed to assist with this task.This generates a graphical summary ofthe principal features of a patient's long-term progression. It gives an overview ofhow the patient's anginal status haschanged, his or her drug treatment andany surgical interventions. The systemalso allows the clinican to display sum-maries of diagnostic tests carried out.The system can be used to assist clini-

cal management and speed up outpatientexamination. It can also be used to facili-tate case conference sessions and haspotential for being used in medical edu-cation.

(Br HeartJ_ 1995;74:559-562)

Keywords: coronary artery disease, data recording pro-cedures, computer graphics outlining cardiac history.

Clinical OperationalResearch Unit,University College,LondonC Sherlaw-JohnsonJ MitchardS GallivanDepartment ofCardiology,Whittington HospitalNHS Trust, LondonD L H PattersonCardiac Department,St George's Hospital,LondonT TreasureCorrespondence to:Dr C Sherlaw-Johnson,Clinical OperationalResearch Unit, UniversityCollege, London, GowerStreet, London WC1E 6BT.

Accepted for publication6 April 1995

Since 1989 we have been conducting aresearch programme aimed at investigatingthe long-term progression of patients withcoronary artery disease.As part of this research, case notes for all

patients currently attending outpatient clinicsin the cardiac department of the WhittingtonHospital have been scrutinised. The task ofretrospectively extracting information fromsuch notes was found to be very laborious andoften key facts, such as assessment ofpatients' anginal status or their medication,were either not recorded or recorded in a

non-standard fashion making analysis diffi-cult.

Typically, a patient with coronary arterydisease attends outpatients clinics for manyyears. In addition, it is common that suchpatients may have had other referrals to thehospital for the treatment of other conditions.Consequently, the notes for an individualpatient usually comprise a weighty folder con-

taining among other things, hand written his-tories, laboratory test results, discharge

summaries, general practitioners' letters, elec-trocardiogram (ECG) exercise test informa-tion, and summaries of angiograms. There isalso associated correspondence betweenphysicians and surgeons in cases involvingcoronary artery bypass grafting.

In view of the large quantity of informationcontained in a patient's notes it is often diffi-cult to discover how a patient has progressedduring the course of his or her disease. Forexample, trying to find the results of apatient's exercise ECG tests to see whetherexercise tolerance has deteriorated can resultin time-consuming sorting through the notes.Differences between the ways in which clini-cians record information can also make it dif-ficult to interpret what has been happening toa patient. So, for example, trying to find howlong a patient has been treated with /3 block-ers may be hampered if, at some outpatientexaminations, the information has not beenrecorded.The fact that basic information about a

patient's long-term progression can be hard toextract from a set of notes can lead to ineffec-tive use of clinicians' time and a reduction inthe quality of clinical management. In addi-tion, as extracting systematic data from notesabout a single patient is in itself a difficult tasktrying to summarise the progression of groupsof patients, for audit purposes, say, becomesimpractical.

This paper describes data recording proce-dures that have been established at the car-diac department of the Whittington Hospital.They are simple to operate and do not addsubstantially to clinicians' workload.A computer system has been developed to

assist with the analysis of the gathered data.Among other things, this allows a graphicalsummary to be produced outlining the princi-pal features of an individual patient's long-term progression. This gives clinicians animmediate overview of a patient's cardiachistory that is otherwise impractical to obtain.

Data gatheringSince June 1989 data concerning patientswith coronary artery disease have been gath-ered prospectively at the WhittingtonHospital. Information is recorded for everyvisit made to the outpatients clinic, every car-diac investigation and any bypass procedure

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Sherlaw-Johnson, Mitchard, Gallivan, Patterson, Treasure

Figure 1 Data collectionform used duing routineoutpatient examinations.

carried out. Two of the authors JM and CSJ)have also retrospectively collected corre-

sponding data from past case notes for allpatients currently attending cardiac clinics.

Efforts have been made to keep theamount of information recorded as small as

possible to avoid increasing the workload ofthe clinicians. The information noted at eachsession concerns assessments which would, inany case, form part of a routine cardiac exam-

ination. The only additional effort requiredby the clinicians is that they complete a shortchecklist during examinations concerning thestatus of the patient. For example, in the case

of outpatient examinations, the clinician is

a

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Jass

*,-r, a rq',,.., r, e:

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Figure 2 Typical graphical summary of the clinical data recordedfor one patient.

required to record at most 11 items of data.Figure 1 shows the patient status form

completed during an outpatient examination.Before attendance at the clinic such forms are

attached to the patient's notes by clerical staffwho fill in details of the patient's name, hos-pital number, and the date of the examina-tion. During examination the clinicianassesses the patient's class of angina, accord-ing to the Canadian Cardiovascular Societyclassification for angina pectoris (Appendix).The patient's current drug treatment is indi-cated by ticking appropriate boxes on theform, although specific information concern-

ing dose levels and so forth is not included.Patients' smoking habits, their cholesterollevel and whether they have a history ofhypertension or diabetes are also indicated.

Similar data are collected for other investi-gations such as ECG exercise tests and coro-nary angiograms. For patients in whomcoronary artery bypass grafting has takenplace a brief summary of the principal fea-tures of the surgical procedure is alsorecorded.

Information from the forms is entered ontothe department's clinical database system.This has been carried out by one of theresearchers from the team, although thisprocess is soon to be integrated with otherclerical tasks carried out within the depart-ment.

Displaying the progression of anindividual patientThough little information is recorded abouteach patient contact, assimilating the wholeof a patient's history is difficult because of thenumerous examinations that are likely to haveoccurred. To assist this, a computer systemhas been developed that enables clinicians toexamine the progression of a patient sincethey first attended the hospital. The com-

puter system operates on an IBM compatiblemicrocomputer, making use of colour graph-ics facilities.

The computer system allows the clinicianto display patient information at various lev-els of detail. The system has been designed tobe simple to operate and makes use of menudisplays from which the user can choose par-ticular options using cursor controls.When the system is first entered, the user is

presented with a preliminary menu ofoptions. The usual starting option is to selecta patient. This is achieved by either typing inthe hospital number or selecting from a dis-played list of hospital numbers available. Thesystem displays a graphical summary of theselected patient's history.

Figure 2 shows a typical display. The topline of information lists the patient identifica-

tion number, date of birth, and sex. Theremainder of the display summarises the prin-cipal features of the patient's progression as

time charts. Two time axes appear on thebottom of the display, one giving the timesince the patient's first contact with the car-

diac department, the other giving the

Hospital Number Surname Date

d d m m y y

1. CHEST PAINNo angina

Class I angina

Class II angina

Class III angina

Class IV angina

2. MEDICATIONBeta-blockers

Calcium Antagonist

Oral Nitrates

3. SMOKING HABITSNever smoked

Given up

Smokes

4. COEXISTING ILLNESSESDiabetes Mellitus

A History of Hypertension

5. CHOLESTEROLCurrent Cholesterol Level .....

Lipid-Lowering Drugs:

Statins

Fibrates

Other

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Displaying the long-term progression ofpatients with coronary artery disease

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Chest painiWhy sto-ppedE_rG chaness

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Figure 3 Display of exercise electrocardiogram test information.

patient's age in years. Above this, with a gibackground, the presence of coexisting hyptension or diabetes and the patient's smokihistory are displayed. Above these, an indition is given of the classes of drug treatmiprescribed and the time periods involvThe final part of the screen displayspatient's progression. This is indicated b3trace, shown in white, showing the patieranginal status at successive outpatient exarnations, indicated as dots along the traSeveral symbols are used to indicate otlevents or procedures. For example, a

square indicates that the patient suffeimyocardial infarction and a vertical green 1lindicates that coronary artery bypass has beperformed. The number of times that anggraphic catheterisation or ECG exercise teing was carried out is indicated by mnemoicodes.

*;s.h;.?;.,,,i;a

a siaes--3;-; ,:L sr # - ~~~~Cathet-er_Date of catheter

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I;Proximal LAD Octclu(Je*- -, W = \G'bit-w'. i it T(aIProximai RCA .Ite,nosedr

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Figure 4 Display of cardiac angiogram findings.

As can be seen from the example display,this presents a concise summary of a patient'sprogression. In the case shown, the patient

I had an infarction six months after first con-I tact with the cardiac department.

Subsequently, her fairly severe angina failedI to respond to drug treatment. Exercise ECG

and angiographic tests indicated suitability forI coronary artery bypass surgery. This was suc-

cessful in relieving the patient's symptomsand drug treatment was no longer necessary.The patient continues to be followed up.

Considerable detail has been sacrificed tot present information in this way so facilities

have been added enabling the clinician toexamine the patient's clinical history in moredetail. Pressing the 'escape' key of the key-board, causes a menu to be displayed listingitems for which further information can beexamined, including summaries of any car-diac angiograms, ECG exercise tests, choles-terol management, or surgical procedures. Ineach case, the information available takes theform of a brief summary. An example shownin fig 3 gives details of the findings from the

rey patient's exercise ECG test, which in this caseer- indicates ominous ST segment depression. Ifing a patient has had several exercise ECG tests,ca- details of each can be displayed in turn. In aent similar fashion, details of findings fromed. cardiac angiograms can be displayed. If athe coronary bypass procedure has been per-y a formed then principal features of the surgicalit's procedure are available: date of the proce-mi- dure, the types of grafts, and the territoriesLce. grafted (fig 5).herred Discussionred The data collection system that has beenine developed enables long-term informationzen concerning patients with coronary artery dis-,io- ease to be recorded in a systematic fashion.-st- The methods used are simple to implementnic and do not add unduly to the tasks of busy

clinicians. The recorded data comprisesinformation that is readily available as part ofthe routine examination process. The onlynew procedure that has to be adopted is thatclinicians fill in a checklist of their assess-ments for each patient contact. Recordinginformation in such a systematic fashion

I ensures that a uniform record is available ofthe principal features of patient's cardiacstatus for every visit.

* A major advantage of recording informa-* tion in such a systematic fashion is that clini-

cians can examine a patients' long-termprogression. The developed computer systemassists in this objective. The graphical sum-maries give an immediate overview of apatient's history without the necessity of hav-ing to read through and assimilate volumi-nous case notes.

There is considerable potential for usingsuch summary information. Ready access to asummary of a patient's history can clearlyassist clinical management. Such summariescan also have a useful role in case conferencesessions, giving a succinct precis of a patient'spast condition.

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Sherlaw-Johnson, Mitchard, Gallivan, Patterson, Treasure

Nc angina

Glass L _Datec

Glass _

Class 4*E. C".CK:: e r ;,;s :..a an taaq: ,;....::-.t;::i:... tc

\ !ra s fl/ec X :::

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Figure 5 Summary ofa coronary artery bypass procedure.

An important role is envisaged for usingthe results of this work in medical education.A large database of cases has now been com-

piled. This can be used to demonstrate tostudents the large patient-to-patient variationthat exists in the long-term progression ofcoronary artery disease. By using the com-

puter system medical students can browsethrough patient summaries and gain experi-ence of typical cases seen in a specialist car-

diac centre.

There is also the possibility that such sum-maries could be of more direct benefit topatients. During their examination the clini-cian could review their case making directreference to their displayed summary. Theefficacy of different treatments and changesin lifestyle could then be discussed withexamples showing other cases suitablyanonymised. There are plans to give patientsattending the Whittington Hospital a printedversion of their summary charts. The benefitsthat would result from this remain to betested.

AppendixCanadian Cardiovascular Society classification forangina pectoris:

Class I-Ordinary physical activity such as walkingor climbing stairs does not cause angina. Angina withrapid or prolonged exertion at work or recreation.

Class II-Slight limitation of ordinary activity.Walking or climbing stairs rapidly, walking uphill,walking or stair climbing after meals, or in cold, or inwind, or under emotional stress, or only after the fewhours after awakening. Walking more than two blockson the level and climbing more than one flight of stairsat normal pace and in normal conditions.

Class III-Marked limitation of ordinary physicalactivity. Walking more than two blocks on the leveland climbing more than one flight of stairs at normalpace and in normal conditions.

Class IV-Inability to carry on any physical activitywithout discomfort-anginal syndrome may bepresent at rest.

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