an ontology-based system for representation and diagnosis of electrocardiogram (ecg) data

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This reproduction is the best copy available ®

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by

Thidarat Dendamrongvit

A DISSERTATION submitted to Oregon State University

in partial fulfillment of the requirements for the

degree of

Doctor of Philosophy

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APPROVED:

Qvahe wdc

Major Professor, representing Industrial Engineering

pf Se AE

Head of the Department of Industrial and Manufacturing Engineering

Zh, AN Wanei

Dean of fhe Graduate School

I understand that my dissertation will become part of the permanent collection of Oregon State University libraries My signature below authorizes release of my dissertation to any reader upon request

Thidnent Pondarnvangvit

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I would like to thank my advisor, Dr Richard Billo, for his support throughout my work His guidance inspired me to pursue the Ph.D degree I also would like to thank Dr Robert Rucker for his suggestions, Dr Michael Savitt, Dr Kenneth Funk, and Dr Mark Pagell for serving on my committee

I am thankful to the MECOP office and the IME department for my positions as Graduate Research Assistant and Teaching Assistant I have gained invaluable work experience, in which I believe will contribute to my future career

Moreover, I would like to thank the EKG department at Providence St Vincent Medical Center for assisting me during my visits Information about ECG diagnosis from physician Apai Agsarawanich was also very helpful

My sincere appreciation goes to Peerapol Tinnakornsrisuphap for his encouragement through this journey Thanks to my friends for the other activities while in school

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1

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1.1 Research ObjeCtIV€S .Ă LH HH Hàng HH HH rệt 3 1.2 Research ConfriDuftion su nh tưệt 3 LITERATURE REVIEW 11 6

2.1 Electrocardiogram (ECG) DiagnoSIS HH HH 6 2.1.1 Paper Record DDiaðnnOSIS - - án HH nh re 6 2.1.2 Automated ECG Diag'noSIS - Án HH ng re 9 2.2 ECG Standards for Interoperability ó- Ăn H 2.3) ONTOLOGY 13

2.4 Human Factors in Medical Devices and Site Usability - 14

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Page 4.3, Model Developmen HH HH HH Hàn 28 4.3.1 Generation of XML Documents (ECG-XML) from ECG Data 29 4.3.2 Inclusion of Diagnosis in the XML Documents

(ECG-XML~-DIA) HH“ HH TH HH Hung 35 4.3.3 Representation of ECG-XML-DIAG with Graphical and Text

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5 VALIDATION 54

5.1 95a 54

3.1.1 Interoperability Validation - óc HT HH ng te 55 5.1.2 Diagnosis ValidafIOI co HH HT nh ni nh km 55 5.2 _ Experimental Design . - «SH HH HH HT HT tư ng 56

5.2.1 P:.00i)v PT hố 57

5.2.2 Hypotheses and Sample Size Determination «cc.c<«- 58 5.2.3 Sensitivity, Specificity, and Overall Accuracy Calculations 60 5.2.3.1 Sensitivity T€S HH HH HH HH HH HH HH 62 5.2.3.2 Specificify TesSf Ăn HH Hà HH ng 68 5.2.3.3 Overall Accuracy Raf€ SH TH HH HH HH ngà 72 “99 980.3091777 74

6.1 Conclusion from the Objectives and Results -. «- 5< 74 6.2 — Future Research - LH HH HH nh nh HH nà kg 81 6.2.1 Validating the Decision-support System with the Targeted User 81 6.2.2 Increasing the Reliability of the Results by Validating the Accuracy

Rates with More Variety of Data and Sample Size Number 82 6.2.3 Improving the Accuracy ofthe Diagnosis Model - 82 6.2.4 Improving the Methods and Interfaces to Analyze and Present ECG

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Page 6.2.5 Implementing ECG Data Management 5s ccs+ssecS2 83 BIBLIOGRAPHY - TH HH HH HT HH Hàn TH Hà Hà tt 84 APPENDICES SH HH HH ng Hà HH TT TH TH ng 90

APPENDIX A Rules for ECG Diagnosis from HL7 and Existing

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Figure Page

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Figure Page

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Table Page

Table 1: Comparison between the Current System and the Ontology-based

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Figure Page

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A.2 Irregular Atrial Escape Rhythm - 5 Án HH Hi, 93 A.3 Sinus Arrhythmia s2 HH HH TH HH Hi ng 95 A.4 Left Bundle Branch Block s5 S4 tt ng rhnrhnret 97 A.5_ Right Bundle Branch Block - cà HH Tu nHn 99 A.6 Premature Supraventricular Contractions or Premature Atrial Contractions

(9) .ốỐốỐỔỐỔỐ‹ 101 A.7 Frequent PVCs (Premature Ventricular ContractionĐ) ô 102 A.8 Multiformed PVC's (polyformed)

(Premature Ventricular ContracfIOnS) LH nh HH ng ng Hy 103 A.9 PVC’s (Premature Ventricular Contractions) RĐ-on-T «<< ss+sx+2 104 A.10 Junctional Escape BeafS .- HH HH HH HH HH HH net 106 A.I1 Left Ventricular Hypertrophy - - sgk HH HH tp 107 A.12 Right Ventricular Hypertrophy (R.VH]) - ác HH HH ê, 109 A.13 AnterlorF Inf2rCfIOI cà v2 1 Thy ng HT ng tiếp 111 A.14 Inferlor InfarCfiOn - S Ă HT ng ng nh TT ng Hiệp 112

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Figure Page

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Figure

A.36 Trifascicular Block CONN m an One eee eee Eee reece ede ORE SEDER AEE OELOEEDL OEE SE SOE SED ESSERE ORES EEE O RES EEHES

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Electrocardiogram (ECG) Data

1 INTRODUCTION

An electrocardiogram (ECG) is an electrical recording of the activity of the heart and is used to aid the investigation of heart disease The standard 12-lead ECG is a representation of electrical activity of the heart recorded from electrodes on the body surface surrounding the heart Currently, ECG monitoring systems and output data are proprietary products sold by a multitude of different vendors The data are recorded, read, and analyzed by different methods depending on computing platforms and software implementation intricacies Data are not shared among different products, or able to be presented in a ubiquitous manner across heterogeneous computing platforms that do not contain the vendor’s product There is a need to share and integrate ECG data among different devices and systems for various types of uses such as disease diagnosis, administrative processes, and research (European Committee for Standardization, 1993; Health Level Seven, 2004)

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(Health Level Seven, 2004)

Currently, ECG data is interpreted by physicians using paper records and automated ECG devices These ECG devices do not provide complete ECG diagnosis based on the HL7 standard Some of the existing ECG devices do not include automated diagnosis The other devices may have this feature but they diagnose only specific cardiac diseases with the need of proprietary software and platform

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cardiac disease

1.1 Research Objectives

The objectives of the research were:

1 To create an Ontology for representation and diagnosis of ECG data The Ontology encoded in XML provides a machine readable format Thus, ECG data can be shared among different ECG devices and

systems |

2 To create and evaluate a system for ECG measurements and diagnosis based on the HL7 standard The system can be used as a decision support tool for automated ECG diagnosis

1.2 Research Contribution

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among different systems Figure 1 illustrates relationships between the Ontology and multiple systems along with the scope of the research and future domains such as nurses, device suppliers, researchers, and administrative to which the Ontology can be extended

Main Contribution \ “ “Medical Technicians -Physicians

4 Research wg Scope f Device : `, Suppliers „“ DD OPE | SC Researchers

Figure 1: Relationships between Ontology and Different Domains

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This literature review summarizes the research and methods that have been developed in the related fields of this dissertation This chapter is divided into five sections First, a description of electrocardiogram (ECG) diagnosis is presented Research in the field of ECG standards for interoperability and related work are discussed in the second section The third section focuses on the literature about Ontology Human factors concerns for medical devices are described in the forth section The last section provides a summary of the literature review

2.1 Electrocardiogram (ECG) Diagnosis

Two types of ECG diagnosis which are paper record and automated diagnoses are explained in the following sections

2.1.1 Paper Record Diagnosis

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and voltage measures on the ECG paper

Figure 2: ECG Recordings on Paper (adapted from Yanowitz, 2005)

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the time from onset of atrial activation to onset of ventricular activation The QRS complex represents ventricular activation while the QRS duration is the duration of ventricular activation The ST-T wave represents ventricular repolarization The QT interval is the duration of ventricular activation and recovery The U wave represents the time interval after depolarizations in the ventricles, and the start of the next P wave An example of ECG diagnosis of a left bundle branch block, which is a common cardiac disease, is shown in Figure 4

Figure 4: Left Bundle Branch Block (adapted from Yanowitz, 2005)

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Many health care providers now utilize machines and computers to record and diagnose ECG data Useful measurements can be automated to make it more efficient in ECG diagnosis

From the literature, automated interpretation of ECG has been done as decision support for less experienced physicians (Heden et al., 1997) By examining the ECG signal, a number of informative measurements can be derived from the characteristic ECG waveform Most of the research focus has been on developing a method to detect specific ECG measurements for a specific cardiac disease Methods for automated ECG diagnosis are summarized below

Hughes et al., (2004) examined the use of hidden Markov and hidden semi- Markov models for automatically segmenting an ECG waveform into its waveform features They developed an automated system for ECG interval analysis to detect prolongation of the QT interval (Long QT Syndrome) for the diagnosis of abnormal heart rhythm, This research was done to support the study of adverse effects which may be brought by new drugs such as Amiodarone The ECG of the patient was used to provide information about the status of the patient’s heart

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their system performed better than an experienced cardiologist, indicating that the system may be useful as decision support even for the experienced ECG readers

Porela et al (1999) investigated the applicability of computerized electrocardiogram interpretation in classifying patients with suspected acute myocardial infarction They found that computerized analysis of the 12-lead electrocardiogram can increase the consistency and reduce the workload of patient classification They studied ECGs of 311 patients with suspected myocardial infarction and developed a new computerized coding system to detect electrocardiograhic myocardial infarction In their work, the code allows interactive redefinition of criteria to meet user-defined needs However, they concluded because of the weak relationship between elcetrocardiographic and biochemical criteria of myocardial injury, the role of ECG in the diagnostic classification of acute ischemic syndromes should be reevaluated

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existing criteria, the authors claim that the accuracy of their criteria was the highest among those criteria used in a point scoring system including the currently used automated ECG criteria for the diagnosis of RVH

2.2 ECG Standards for Interoperability

Different approaches have been proposed to address the interoperability issue for sharing medical data among different formats and devices The Standard Communications Protocol for Computer-Assisted Electrocardiography (SCP-ECG), which was proposed by the Project Team PT5-007 of CEN/TC 251 in 1993, provides specifications for the interchange format of ECG waveform data, patient information, and measurement results (European Committee for Standardization, 1993) However, the use of this standard was not successful due to some limitations, and therefore was never adopted by ECG product manufacturers The standard leaves too many degrees of freedom in many areas such as details in data format with the result that it is difficult to produce generic SCP-based software (Chiarugi, 2001) Therefore, market-leader manufacturers still prefer a proprietary solution

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administrative information among heterogeneous computer systems The standards enable healthcare information system interoperability and sharing of electronic clinical and relevant data

The Lab Automation Committee, a special interest group of HL7, defines a set of standards for Point-of-Care medical device communication (Lab Automation Committee, 2004) It is intended to provide for open systems communications in healthcare applications between medical devices and patient care information systems for the acute care setting The scope of the standard includes nomenclature architecture and a data dictionary for ECG and other clinical areas such as Vital Signs, Respiratory Measurements, and Common Blood Gas Measurements

This research focuses on the ECG section of the HL7 standard which includes the data dictionary for ECG measurements and enumerations for ECG diagnostics (i.e., abnormal conditions) derived from ECG signals by an ECG machine This HL7 standard was developed based on the SCP-ECG standard and is intended to supersede the previous use of the SCP-ECG

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focuses on only representation of ECG data from a specific database The developed tools cannot be directly applied to ECG data from other sources

2.3 Ontology

Within the domain of Information Systems, an Ontology is “an explicit specification of a conceptualization” (Gruber, 1993), or a document or file that formally defines relations among terms (Berners-Lee et al., 2001) An Ontology offers a shared, structured, and common understanding of some domain or task that can be communicated across people and computers The term Ontology was borrowed from philosophy where it means “Theory of existence” (Mizoguchi and Ikeda, 1996) It is the study of what exists

Research on Ontology has become popular in the Information Systems community Some of the reasons to develop an Ontology are to share a concept of the structure of information among people or software agents and enable reuse of domain knowledge (Musen, 1992; Gruber, 1993) Various applications in Information Systems apply the application of ontologies especially in the area of search and retrieval of information repositories (Guarino, 1998; McGuinness, 1998; Uschold and Jasper, 1999)

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HL7 The Ontology also provides causative relationships among the ECG waveforms, measurements, and diagnostic conditions In turn, the Ontology allows a machine readable format so that ECG diagnosis and data exchange can be done efficiently without the need of proprietary algorithms or software with the result of solving the interoperability issue

2.4 Human Factors in Medical Devices and Site Usability

Human Factors Engineering (HFE), also known as Usability Engineering or Ergonomics is the study of interaction between humans and systems (Murff et al., 2001) Researchers in this area have provided principles concerning device and software program designs that allow for efficient usage (Murff et al., 2001; Sawyer, 1996) According to the United States Food and Drug Administration (FDA), between 1985 and 1989, almost half of all medical devices were recalled because of poor design including problems with software (Food and Drug Administration, 1998) In order to prevent user errors with electronic device, human factors design needs to be considered to ensure patient safety (Sawyer, 1996; Bogner, 1999)

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One of the objectives of this research was to develop a decision aid system for ECG diagnosis Human Factors Engineering was considered in the design process of an efficient system for the users The developed system is intended to provide ECG diagnosis which is medical information through interface via an Internet browser Thus, site usability was also considered as a factor to build a system that meets user requirements and has a user-friendly interface

With respect to site usability, Nielsen (1999) studied a real website and investigated factors that increase site usability Some of these factors include the use of fewer words, making text scannable, and using appropriate words He found that user performance can be improved by using appropriate coding such as headings, bold text, highlighted text, bullet lists, and graphics Other principles for successful web interface design are found in the literature Examples of these principles are simplicity, fast download time, and simple navigation systems

2.5 Summary

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solutions for ECG diagnosis ECG data processes have been done with the need of proprietary software for a particular system It is necessary to standardize the ECG processes for benefits of interoperability for diagnosis of cardiac diseases

HL7 provides a standard for ECG measurements and enumerations (ie., abnormal conditions) Both ECG measurements and enumerations are represented as simple listings with definitions HL7 does not specify relationships between ECG measurements and abnormal conditions Data description for each of these is listed separately without connection between each other In other words, HL7 does not specify which ECG measurement is associated with diagnosis of a particular abnormal condition, and vice versa There is no connection between data descriptions in the standard and actual waveform representation either

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3 PROBLEM STATEMENT

Effective medical systems must have a way of interaction and communication among several agents including physicians, nursing staff, technicians, patients, and computerized systems There is a need to share data in the health care environment There are many types and forms of data that will be used for multiple purposes Medical information should be shared for the purposes of improving the quality of health care and proliferating the results from research Sharing is possible only if interoperability exists

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coordinates directly corresponding to the ECG waveform In essence, there is a conceptual gap between the way ECG data is represented (digital data or waveform) and the HL7 ECG standard measurements and diagnosis (data dictionary)

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4 METHODOLOGY

This chapter describes the methodology to develop an Ontology-based system for representation and diagnosis of ECG data for the purpose of sharing ECG results The following sections explain details of the research approach in steps including use case analysis, ontology creation, and the model development including examples to illustrate the processes

4.1 Use Cases

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4.1.1 Users

The developed system is targeted to the use by medical technicians who do cardiac monitoring and interpret ECGs Information of the ECG interpretation from medical technicians will be forwarded to the physicians who actually do the diagnosis of the patients

4.1.2 Requirements of the System

In the design process of the system, requirements were captured from medical technicians and physicians from the EKG department in a hospital to ensure that the developed system will meet user requirements System requirements are listed as follows:

e ECG data from different ECG devices shall be interpreted without the need of proprietary ECG software Thus, a platform and software-independent system for ECG diagnosis is required

e ECG measurements and diagnosis shall conform to a diagnosis standard e An automated ECG diagnostic system shall be provided with a list of

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In the current system, ECG interpretation is cumbersome because it depends on manufacturer’s software Data cannot be shared among different ECG devices and software Current devices do not have diagnoses conformed to any standard Moreover, the proprietary system can be expensive Table 1 summarizes the advantages that the developed system of Ontology-based will provide over the existing system

Table 1: Comparison between the Current System and the Ontology-based System

Characteristics Current System Ontology-based System

Interoperability

e Proprietary Software and Platform e Data cannot be interpreted on

different computers without proprietary software

e ECG data cannot be transferred (e.g., when patients move, ECG diagnosis history cannot be transferred efficiently.)

¥ Platform and software-independent system for ECG diagnosis in machine readable format

¥ Data from different ECG devices

can be interpreted on different computers

¥ ECG data can be transferred

efficiently (e.g., when patients move, ECG diagnosis history can be transferred electronically without interoperability problem.)

e Various outputs depending on ¥ Measurements and diagnosis

associated with any statement to say how the diagnosis was made Need trained users

e List of diagnosis is not complete and they are not in a standard software language

Standard companies, conform to HL7 standard

e No standard

e Some ECG devices do not provide | “ A decision aid system with automated diagnosis at all They complete diagnosis of cardiac

only provide graphics, and diseases and abnormal conditions

diagnosis is done by physicians based on HL7

¢ Some ECG analysis software ¥ Users can review the associated

packages list a diagnosis measurements according to a

Diagnosis However, the diagnosis is not particular diagnosis

v For less experienced users: provide recommendations for disease diagnosis

¥ For more experienced users: save time spent in reading all the ECGs

Cost

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4.2 Ontology Development and Schema