Abstract:
A computer-implemented patient information provisioning method is disclosed. The method includes automatically extracting with a computer system, from records maintained for a patient under care in a healthcare facility, information from a electronic medical record; obtaining with the computer system information about a medical ventilator treating the patient; using the information from the electronic medical record and the information about the medical ventilator to determine whether a potentially dangerous condition exists with respect to the ventilator; and electronically alerting a caregiver if it is determined that a potentially dangerous condition exists.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims priority to U.S. Provisional Patent Application Ser. No. 61/161,239 to Ognjen Gajic et al., entitled “Ventilation Monitoring and Control,” and filed Mar. 18, 2009, the contents of each are incorporated herein by reference. 
     
    
     TECHNICAL FIELD 
       [0002]    This document relates to computer-based systems and techniques for monitoring a mechanical ventilator, such as a ventilator serving a patient in an intensive care unit or anywhere in a hospital, so that the ventilator does not harm the patient. 
       BACKGROUND 
       [0003]    Critically ill patients in a hospital are often supported by a mechanical ventilator that assists them in their breathing. The ventilator provides pressurized air that is coordinated with a patient&#39;s natural breathing to help ensure that they obtain sufficient oxygen for normal metabolic activity. 
         [0004]    Such support can be a cornerstone for treatment of problems such as acute lung injury (ALI), and in its more severe form, acute respiratory distress syndrome (ARDS). ALI is caused by problems such as sepsis, pneumonia, and other maladies. ALI is present, on average, in seven percent of ICU admissions and carries an in-hospital mortality rate of 40-50 percent. ALI is generally treated by keeping the PaO2 &gt;60 mmHg, without causing injury to the lungs with excessive O2 or volutrauma. Improperly-provided ventilation may result in ventilator-induced lung injury (VILI). Proper individualized settings for ventilator support may thus be important to prevent the ventilator itself from further damaging a patient&#39;s lung or lungs. However, caregivers frequently fail to recognize ALI/ARDS in patients who have it. 
       SUMMARY 
       [0005]    This document describes systems and techniques that may be used to monitor the effect of a mechanical ventilator on a patient and to alert caregivers when the ventilation is potentially harmful to the patient. The systems and techniques may also be used to change ventilator settings to a more preferred setting. The monitoring may occur by using data feeds from various Electronic Medical Records sources in a hospital, including the hospital laboratory system (e.g., arterial blood gas analysis), natural language processing of diagnostic test reports (e.g., digital chest radiography), nursing observations (e.g., height and gender), and continuous monitoring at the ventilator itself (e.g., tidal volume, mode, and peak and plateau airway pressures). Such external data—i.e., data that is not generated by the ventilation system itself—may provide an indication that the patient is suffering from a lung injury, and that ventilation on the patient should occur at different levels than for a patient who does not have a lung injury. 
         [0006]    In certain implementations, such systems and technique may provide one or more advantages. For example, patient care and safety may be improved when a system can monitor the patient automatically, and can do so using information that is not available from the ventilator itself. Also, where the system is connected to a communication system, a caregiver can be alerted and can address any dangerous situations that may arise. The alerts may be made judiciously, however, so that a caregiver will understand that the alerts are important when they are given. In addition, the alerts may be textual and contain information (e.g., including information about the patient&#39;s current condition), rather than simply being alarms, so that a caregiver can more readily understand the problem and quickly respond to it. Also, certain levels of follow-up may be provided, such as by recommending a change in treatment to a caregiver, or even making certain changes automatically where those changes have been determined to be helpful and safe. In this manner, patients having ALI and other problems may be protected from further damage to their lungs, and may receive superior care at a lower cost to the healthcare system. 
         [0007]    In one implementation, a computer-implemented information presentation method is disclosed. The method comprises automatically extracting with a computer system, from records maintained for a patient under care in a healthcare facility, information from a electronic medical record; obtaining with the computer system information about a medical ventilator treating the patient; using the information from the electronic medical record and the information about the medical ventilator to determine whether a potentially dangerous condition exists with respect to the ventilator; and electronically alerting a caregiver if it is determined that a potentially dangerous condition exists. The information from the electronic medical record can comprise data from an arterial blood gas analysis. The method can also include obtaining with the computer system textual information from a medical report for the patient and using the textual information to determine whether a potentially dangerous condition exists with respect to the ventilator. 
         [0008]    In some aspects, the information about the medical ventilator comprises information about a measured peak pressure or set tidal volume for the ventilator. Also, a potential dangerous condition can be determined to exist if the information from the electronic medical record indicates an arterial blood gas level of PaO2/FIO2&lt;approximately 300, and the measured peak pressure is above about 35 mm H20 or the measured set tidal volume is above about 8 mL/kg predicted body weight (PBW). In addition, electronically alerting a caregiver can comprise providing an electronic messaging service with a description of an alerting condition of the patient, and information identifying the patient. Moreover, the method can include blocking alerting of the caregiver if the caregiver has previously been notified about the patient a predetermined number of times in a predetermined time period. 
         [0009]    In another implementation, a computer system is disclosed that includes a medical ventilator for providing mechanical ventilation to a patient, one or more processors, memory, and one or more programs. The programs are stored in the memory and are configured to be executed by the one or more processors. They include instructions for automatically extracting, from records maintained for the patient, information from an electronic medical record; instructions for obtaining with the computer system information about the medical ventilator; instructions for using the information from the electronic medical record and the information about the medical ventilator to determine whether a potentially dangerous condition exists with respect to the ventilator; and instructions for electronically alerting a caregiver if it is determined that a potentially dangerous condition exists. 
         [0010]    In yet another implementations, a computer-implemented patient information presentation system is disclosed. The system comprises one or more mechanical ventilators for treating patients in a healthcare facility; an interface operating on a computer processor system programmed to obtain data about operating parameters of the one or more ventilators and data from a central electronic medical records system operated by the healthcare facility; an electronic patient evaluator to use the data about the operating parameters of the one or more ventilators and the data from the central electronic medical records system to identify the presence of a potentially dangerous condition exists with respect to one or more ventilators; and an alert module to provide, for transmission to one or more caregivers, a notification of the identified dangerous condition. 
         [0011]    In another implementation, a computer-implemented patient information presentation system is disclosed that comprises one or more mechanical ventilators for treating patients in a healthcare facility and an interface operating on a computer processor system programmed to obtain data about operating parameters of the one or more ventilators and data from a central electronic medical records system operated by the healthcare facility. The system also includes means for identifying presence of a potentially dangerous condition from the data about operating parameters and the data from a central electronic medical records system, and an alert module to provide, for transmission to one or more caregivers, a notification of the identified dangerous condition. 
         [0012]    The details of one or more embodiments are set forth in the accompanying drawings and the description below. Other features and advantages will be apparent from the description and drawings, and from the claims. 
     
    
     
       DESCRIPTION OF DRAWINGS 
         [0013]      FIG. 1  is a conceptual flow diagram showing the processing of patient-related information into a clinical decision in aid of the patient. 
           [0014]      FIG. 2A  is a block diagram showing processing of various patient-related data in order to generate an alert for a caregiver. 
           [0015]      FIG. 2B  is a schematic diagram of a computer system for alerting caregivers about ventilation problems with patients in a healthcare facility. 
           [0016]      FIGS. 3A and 3B  are a flow chart of a process for determining whether to alert a caregiver about a ventilated patient. 
           [0017]      FIG. 4  shows an example of a generic computer device and a generic mobile computer device, which may be used with the techniques described here. 
       
    
    
       [0018]    Like reference symbols in the various drawings indicate like elements. 
       DETAILED DESCRIPTION 
       [0019]    This document describes systems and techniques for identifying problematic operating conditions for a mechanical patient ventilator. The systems and techniques take into account data apart from the ventilator itself or currently-measured real-time patient data. Rather, the systems and techniques can combine ventilator data or real-time patient data, with historical patient data that is stored in an electronic medical record (EMR) system. In this manner, customizable “smart alarms” may be developed for notifying medical personnel when a potentially dangerous condition arises with a ventilator. Such alarms may take into account data such as laboratory results in an EMR (e.g., arterial blood gas analysis), natural language processing of diagnostic test reports (e.g., digital chest radiography), nursing observations (e.g., height and gender), and continuous monitoring at the ventilator itself (e.g., tidal volume, mode, and peak and plateau airway pressures). 
         [0020]    In one example, when a patient who meets diagnostic criteria for ALI is ventilated with potentially injurious ventilator settings for one hour or longer, a respiratory therapist or other on-call caregiver receives a message, such as on a display pager or notification in an EMR, about the potential for injurious ventilation. The message may be suppressed if other warnings have previously been sent to the same caregiver about the same patient, in recent history, lest the caregiver not give full attention to the message. 
         [0021]      FIG. 1  is a conceptual flow diagram showing the processing of patient-related information into a clinical decision in aid of the patient. In the figure, a patient information system  100  is shown as providing information about a patient to a caregiver  108 . The patient is connected to a ventilator  102  and thus may be an ICU patient in relatively serious condition. The ventilator  102  includes electronic components for controlling the ventilator options and for identifying certain parameters associated with the ventilator  102 , such as volume and pressure of air supplied to the patient by the ventilator  102 . 
         [0022]    Certain of such parameters may be read by an alerting system  104  that is in electrical or other such communication with the ventilator  102 . The alerting system  104  may be a computer-implemented system that is programmed to gather patient-related information from multiple sources, including the controller for the ventilator  102 , and to apply rules to such gathered data in order to determine whether a potentially dangerous situation exists for the patient. The alerting system  104  in this example also acquires information from an electronic medical record (EMR) system. Such gathering of information by the alerting system may occur periodically according to a clock associated with the alerting system  104 , or it may occur in response to a patient-related event, such as a substantial change in ventilator parameter readings being provided to the alerting system  104  from the ventilator  102 . 
         [0023]    The information extracted by the alerting system  104  from the EMR system  106  can take a variety of forms. For example, laboratory results can be associated with certain conditions of the patient, and can be used to determine a user&#39;s response to the ventilator  102 , and by extension, the condition of the patient with respect to ALI. Also, text in medical records can be identified and read by the system  100 , and can be used to make matches to predetermined words. 
         [0024]    The alerting system  104  is shown as sending communications to a caregiver  108 . The communications may take a variety of familiar forms such as pager messages in text, or standard text messages, among other possibilities (e.g., data to be displayed in an app on a smart phone carried by the caregiver  108 ). The caregiver  108  may then read those messages, which, based on a determination made by the alerting system, will indicate that a dangerous condition may exist. The caregiver  108  may then return to the patient&#39;s room, review the ventilator and its parameters in more detail, and change those parameters to ensure the patient&#39;s safety. The caregiver  108  can also call into an ICU and direct another caregiver to modify a course of treatment for the patient. 
         [0025]    Also, modification of the ventilator&#39;s operation can be achieved automatically rather than manually, and is shown in the figure by an arrow leading back from the alerting system  104  to the ventilator  102 . For example, the alerting system may determine that the ventilator  102  setpoint for a particular parameter is at a potentially unsafe level, and may provide a new setpoint that the ventilator  102  may subsequently follow, at least until caregiver  108  can turn their attention to the ventilator  102  and manually override whatever setpoint has been automatically selected. Limitations may also be provided so that only setpoints previously determined to be safe under all conditions will be selected by the alerting system  104 . 
         [0026]      FIG. 2A  is a block diagram showing processing of various patient-related data in order to generate an alert for a caregiver. Such processing occurs by use of an alerting system  200 . The alerting system  200  may include a data extractor  202  and contact management system  206  that are added to an existing electronic medical record system so as to provide alerting functionality. The existing system may include a variety of institutional databases  208  that may take a variety of forms, and may be used by a healthcare institution in its ordinary course of business. Such databases could range from EMR databases of various types, to accounting databases and databases used to assist caregivers with making diagnoses. The existing system may also include a data warehouse  204 , which may be provided with read access to various portions of the institutional databases  208  and may be employed to extract information from the institutional databases  208  and reformat and store the data where it can be queried and otherwise manipulated more readily. 
         [0027]    The data extractor  202  may then be triggered by an internal clock on a periodic basis to extract data from the data warehouse  204 , where the relevant data, in this example, relates to conditions of patients in a healthcare system who are currently on ventilators. Two particular pieces of data are gathered in this instance. First, information from a laboratory report on the patient&#39;s arterial blood gas level may be retrieved and identified. In particular, blood gas levels of PaO2/FiO2 below a certain level, such as about 300, may indicate that the patient suffers from ALI (box  210 ). Second, information from a patient&#39;s chest radiograph report may be obtained from the patient&#39;s medical records (box  212 ). Textual annotations in the report may be extracted, either by simple parsing from an electronic record or by OCR, and a search may be made for certain trigger terms such as (“bilateral” and “infiltrate”) or “edema”—terms that indicate that the patient may have lung damage indicative of ALI. 
         [0028]    The data extractor  202  may also at this point identify real-time or near real-time data form the patient&#39;s ventilator that indicates the current setting for the ventilator in terms of pressure and/or volume (box  214 ). The data extractor  202  may then apply one or more rules to the extracted data to make a determination about whether a dangerous condition is likely to exist for the patient. In this example, the determination is made if the arterial blood gas data shows PaO2/FiO2 &lt;300 (or less than about 300), the chest radiograph mentions the terms quoted above, and the peak pressure on the ventilator is over 35 mm of H 2 O or the set tidal volume is greater than 8 mL/kg PBW (predicted body weight) or a similar amount to also indicate a problematic and potentially dangerous ventilator setting. 
         [0029]    If the data extractor  202  makes a determination that a potentially dangerous condition exists, it may send a signal to a contact management system  206 , which may be a system that prepares and routes a variety of messages to mobile devices  216  of caregivers in the system  200 . Such preparation and routing, in this example, may include an initial determination by the system  200  of the caregiver that is currently responsible for respiration of the patient, such as an on-call respiratory therapist assigned to an ICU where the patient is stationed. The preparation may further include the generation of a message whose text indicates an identity of the patient, either directly (by name) or indirectly (by location in the ICU) and the nature of the condition that triggered the notification. 
         [0030]    In certain circumstances, the generation of an alerting message may be blocked or delayed. Typically, such action may occur to prevent the generation of false positive reports that would result in caregivers having less respect for the system  200 , and in the quality of care for patients declining. For example, the system  200  may require that an alerting condition be present for a certain number of cycles of the system  200 , such as over a period of several hours. Also, the system  200  may limit the number of notifications that a particular caregiver receives, so that the caregiver is not being bombarded with notifications about a particular patient, and is rendered unable to determine which are serious and which are not. 
         [0031]    In this manner, the system  200  can automatically identify potential dangerous conditions for a patient on a defibrillator even if no caregiver has yet to make a determination that the patient has ALI or is likely to have ALI. The system  200  can also generate an alert that is custom, in that it can be transmitted remotely to a caregiver using whatever messaging technology the caregiver prefers (e.g., smart phone, text pager, etc.) and can give information about the nature of the alert. In addition, it can manage the number and type of message that is delivered so that the overall operation of system  200  is not overly intrusive to caregivers. As a result, the care of a patient may be improved. 
         [0032]      FIG. 2B  is a schematic diagram of a computer system  220  for alerting caregivers about ventilation problems with patients in a healthcare facility. In general, the system  220  may comprise all or a portion of system  200  in certain implementations—though more detail is shown in this figure for certain portions of system  300 . 
         [0033]    The system  300  generally includes an alerting computer system  222  which may be made up of one or more computer servers programmed with computer code to analyze various scattered data in a healthcare system so as to generate an alert that a dangerous condition may exist for one or more patients who are using ventilators in the system. The computer system  222  may capture its data from a number of ventilators  230  via a data aggregation unit  228 . The unit  228  may include a database that stores and manages various parameters concerning ventilators that are operating in one or more ICU&#39;s in a healthcare system, including ventilator setpoints and readings (e.g., respiration rate, oxygen content, etc.) taken by the various ventilators. The unit  228  may also include an interface that operates according to a known API so that data about the ventilators can be communicated to the computer system  222  in a predefined manner. 
         [0034]    The computer system  222  may also gather data from a data warehouse  224 , which may take a variety of forms, and is generally designed to be a centralized location where data about a healthcare system may be easily accessed and manipulated. The warehouse  224  may in turn query a data system  226  for the entire healthcare system. The data system  226  is shown here as a rack of servers to indicate that the data system  226  will typically involve a number of different servers scattered across a campus or larger network of healthcare facilities, though the particular physical form of any of the computer systems or sub-systems shown here is not critical and can take any appropriate form. 
         [0035]    The system  222  includes a variety of components that allow it to obtain data relating to ventilator patients and to generate alerts in appropriate circumstances. An interface  232  is provided so that system  222  can query unit  228 , data warehouse  224 , and other appropriate data stores to obtain information that can be used to determine the condition of a patient or patients. Such data may be used by a patient evaluator, in combination with patient evaluation rules  238  that are stored by the system  222 , to determine whether a patient could be in a potentially dangerous condition. Patient data  240  may also be stored and used by the patient evaluator  234 , such as identification information for the patient, the ICU in which they are staying, etc. Example rules are discussed above and below in more detail. 
         [0036]    An alert module  236  may be notified by the patient evaluator  234  when a potentially dangerous condition is determined to exist. The alert module  236  may then gather information about the patient and the alerting condition, and may prepare a message (box  246 ) to be sent to an appropriate caregiver. The system  222  may also generate information in addition to individual alerts. For example, patient reports (box  242 ) may be generated for administrators who query the system  222 , and such reports may indicate the number of times an alert has been generated for a particular patient and the nature of the alerts. Such a query may be made by an administrator trying to determine whether alerts have been acted on appropriately, or by a caregiver from the patient&#39;s room, to determine how long an alerting condition has existing, in determining a proper remedial plan of care for the patient. Also, more general ICU reports (box  244 ) may be generated, and may show an administrator a compilation of alert activity for one or more ICU&#39;s, which may assist the administrator in staffing caregivers or determining whether appropriate ICU care is being provided. 
         [0037]      FIGS. 3A and 3B  are a flow chart of a process for determining whether to alert a caregiver about a ventilated patient. The process begins at box  302  where data concerning one or more patients currently on ventilators is gathered. Such readings may occur periodically, such as every 5 minutes, every 15 minutes, every half hour, or every hour. Certain of the readings may be updated more often than are other readings that are expected to change less over time. For example, real-time readings from a ventilator may be made frequently, whereas queries made of medical records such as lab results may be made less frequently. 
         [0038]    At box  304 , the arterial blood gas level for a patient is determined from an EMR reading. If the PaO2/FiO2 level is below 300, no alert is generated, and the process stops for that patient until the next round of data gathering. Likewise, if no textual terms on a chest x-ray report indicate the presence of infiltrates, the process ends for the patient in the current cycle. Similarly, at box  308 , if the patient is not on a ventilator, the process stops for the cycle, and if the patient is younger than 16, the process also stops. Similarly, the process stops if the patient is not on ICU monitoring (box  312 ). Each of these determinations may be conducted in different appropriate orders, and would ordinarily be conducted so that a minimal number of determinations are needed. 
         [0039]    The process then makes particular individualized determinations about the patient&#39;s current ventilator treatment. First, if the patient&#39;s Paw is over 35 mm H 2 O, a provisional determination to generate an alert is made, and the process moves to  FIG. 3B . The provisional determination to trigger an alarm may also depend on a determination that the triggering conditions has existed for more than a certain number of measuring cycles, such as 4 sequential cycles over an hour on a 15 minute repeating schedule. By requiring multiple consistent readings in a row, the process can avoid generating false positive results. Such limits may also be applied for a certain period, such as over the first three days of mechanical ventilation for a patient. In addition, weaning modes of mechanical ventilations such as pressure support, may also be eliminated to minimize the impact of artificial values (e.g., high airway pressure due to cough or patient manipulation). 
         [0040]    If the Paw is not over 35, then the patient&#39;s predicted body weight (PBW) is calculated according to the equations shown in boxes  318  (if the patient is male) or  320  (if the patient is female). The delivered tidal volume for the patient is then determined at box  322 , and a determination is made at box  324  of whether the tidal volume is greater than 8 ml/kq of PBW. If the volume does not exceed that amount, the process ends for the current cycle for the patient. If the volume does exceed that amount, then a provisional determination to generate an alert is made and the process moves to  FIG. 3B . 
         [0041]    In  FIG. 3B , determinations are made with respect to whether a provisional determination to generate an alert should result in an actual alert being generated. In particular, it may not be helpful to patients to generate an alert every time the numbers above indicate that a potentially dangerous (e.g., potentially injurious) condition exists, because over alerting is known not to result in improved care. Thus, at box  326 , the patient&#39;s location is checked, and a contact identifier for a caregiver is determined at box  328 . The contact identifier may be a pager or e-mail or text message in EMR address for whatever caregiver is currently on call for the ICU where the patient is staying. Two determinations are then made that may result in the notification (e.g., in the form of a text page), a determination is made whether a recent page has been given to the caregiver or provide (box  330 ). If a recent alert was given, and the ventilator settings were not changed, it may indicate that the provider responded to the alert but decided to leave the ventilator in its existing state. Such a provider may not wish to be alerted again in a short time period. If so, the alert is held for a predetermined time period or until the patient is located in the same ICU as the caregiver (box  334 ) (so as to minimize the time that the caregiver will have to take away from other important work in order to answer the alert). 
         [0042]    Second, a determination is made whether multiple pages above a certain number have been made to the caregiver about the patient in a certain prior time period leading up to the current time (box  332 ). Again, if so, the page or other form of notification may be held up or delayed. If neither limiting condition exists, the alert may be provided to the relevant caregiver (box  334 ), and data stores that track the number of alerts that have been given can be incremented with time-stamped entries so that the determinations of boxes  330  and  332  may be accurately made in futures rounds of the process. 
       Example 1 
       [0043]    A ten-month study was conducted on 5118 patient admissions at an intensive care unit in a large healthcare system. Subjects were included if they were on a ventilator. Patients were excluded if they were under 16 years old, did not provide research authorization, were ventilated less than 12 hours or less than 49 PEEP measurements, were readmitted to the hospital during the study period, or were already being ventilated when the study began. The prevalence of ALI was 10% among 2944 patients receiving invasive ventilation during the study period. The system sent 69 alerts for 56 patients. Of the alerts, 14 were false positives (25%), seven resulted in decreased tidal volume (12%), five resulted in a changed mode of ventilation (9%), six resulted in increased sedation or neuromuscular blockage (11%), and twenty-four resulted in no intervention (43%). 
         [0044]    Analysis indicated that 6.1% of patients has median Ppl&gt;30 before the intervention and 5.65% had it after. The analysis also showed that 3.57% of the patients had median Vt &gt;8 mL·kg PBW before intervention, and 8.04% had it after. 
       Example 2 
       [0045]    A study of a cohort of 485 consecutively admitted critically ill patients in a medical ICU of a tertiary center was conducted (less  38  patients who denied research authorization). A system for reviewing a near-real time copy of the patient medical record was used in combination with readings from a ventilator to generate an electronic alert. Reports from emergency portable chest radiographs were consulted for data concerning patient lung condition. 
         [0046]    ALI was defined according to standard consensus conference criteria. See Bernard GR., et al., Am J. Respiratory Critical Care Medicine 149, pages 818-24 (1994) An electronic alert was triggered by a combination of observations within a 24 hour period: (1) qualifying arterial blood gas analysis: the ratio of partial pressure of oxygen over inspired oxygen concentration (PaO2/FiO2)&lt;300, and (2) qualifying chest radiograph report: free text Boolean query containing trigger words: (“bilateral” AND “infiltrate”) OR “edema.” 
         [0047]    From the 485 consecutive patients, 54 patients were identified with ALI (11%). Sensitivity and specificity of the alert was determined against a gold standard of prospective assessment by a trained study coordinator who was blinded to the alert. The alert generated good sensitivity, 93% (95% CI  90  to  95 ) and specificity, 90% (95% CI  87  to  92 ), with a positive predictive value of 53% (95% CI  49  to  58 ) and a negative predictive value of 99% (95% CI  98  to  100 ). Likelihood ratio for positive result was 9.07 and for negative −0.08. The main reasons for false positives were cardiogenic pulmonary edema and atelectasis. The alert identified patients with ALI within twenty-four hours from the onset in all cases. 
         [0048]      FIG. 4  shows an example of a generic computer device  400  and a generic mobile computer device  450 , which may be used with the techniques described here. Computing device  400  is intended to represent various forms of digital computers, such as laptops, desktops, workstations, personal digital assistants, servers, blade servers, mainframes, and other appropriate computers. Computing device  450  is intended to represent various forms of mobile devices, such as personal digital assistants, cellular telephones, smartphones, and other similar computing devices. The components shown here, their connections and relationships, and their functions, are meant to be exemplary only, and are not meant to limit implementations of the inventions described and/or claimed in this document. 
         [0049]    Computing device  400  includes a processor  402 , memory  404 , a storage device  406 , a high-speed interface  408  connecting to memory  404  and high-speed expansion ports  410 , and a low speed interface  412  connecting to low speed bus  414  and storage device  406 . Each of the components  402 ,  404 ,  406 ,  408 ,  410 , and  412 , are interconnected using various busses, and may be mounted on a common motherboard or in other manners as appropriate. The processor  402  can process instructions for execution within the computing device  400 , including instructions stored in the memory  404  or on the storage device  406  to display graphical information for a GUI on an external input/output device, such as display  416  coupled to high speed interface  408 . In other implementations, multiple processors and/or multiple buses may be used, as appropriate, along with multiple memories and types of memory. Also, multiple computing devices  400  may be connected, with each device providing portions of the necessary operations (e.g., as a server bank, a group of blade servers, or a multi-processor system). 
         [0050]    The memory  404  stores information within the computing device  400 . In one implementation, the memory  404  is a volatile memory unit or units. In another implementation, the memory  404  is a non-volatile memory unit or units. The memory  404  may also be another form of computer-readable medium, such as a magnetic or optical disk. 
         [0051]    The storage device  406  is capable of providing mass storage for the computing device  400 . In one implementation, the storage device  406  may be or contain a computer-readable medium, such as a floppy disk device, a hard disk device, an optical disk device, or a tape device, a flash memory or other similar solid state memory device, or an array of devices, including devices in a storage area network or other configurations. A computer program product can be tangibly embodied in an information carrier. The computer program product may also contain instructions that, when executed, perform one or more methods, such as those described above. The information carrier is a computer- or machine-readable medium, such as the memory  404 , the storage device  406 , memory on processor  402 , or a propagated signal. 
         [0052]    The high speed controller  408  manages bandwidth-intensive operations for the computing device  400 , while the low speed controller  412  manages lower bandwidth-intensive operations. Such allocation of functions is exemplary only. In one implementation, the high-speed controller  408  is coupled to memory  404 , display  416  (e.g., through a graphics processor or accelerator), and to high-speed expansion ports  410 , which may accept various expansion cards (not shown). In the implementation, low-speed controller  412  is coupled to storage device  406  and low-speed expansion port  414 . The low-speed expansion port, which may include various communication ports (e.g., USB, Bluetooth, Ethernet, wireless Ethernet) may be coupled to one or more input/output devices, such as a keyboard, a pointing device, a scanner, or a networking device such as a switch or router, e.g., through a network adapter. 
         [0053]    The computing device  400  may be implemented in a number of different forms, as shown in the figure. For example, it may be implemented as a standard server  420 , or multiple times in a group of such servers. It may also be implemented as part of a rack server system  424 . In addition, it may be implemented in a personal computer such as a laptop computer  422 . Alternatively, components from computing device  400  may be combined with other components in a mobile device (not shown), such as device  450 . Each of such devices may contain one or more of computing device  400 ,  450 , and an entire system may be made up of multiple computing devices  400 ,  450  communicating with each other. 
         [0054]    Computing device  450  includes a processor  452 , memory  464 , an input/output device such as a display  454 , a communication interface  466 , and a transceiver  468 , among other components. The device  450  may also be provided with a storage device, such as a microdrive or other device, to provide additional storage. Each of the components  450 ,  452 ,  464 ,  454 ,  466 , and  468 , are interconnected using various buses, and several of the components may be mounted on a common motherboard or in other manners as appropriate. 
         [0055]    The processor  452  can execute instructions within the computing device  450 , including instructions stored in the memory  464 . The processor may be implemented as a chipset of chips that include separate and multiple analog and digital processors. The processor may provide, for example, for coordination of the other components of the device  450 , such as control of user interfaces, applications run by device  450 , and wireless communication by device  450 . 
         [0056]    Processor  452  may communicate with a user through control interface  458  and display interface  456  coupled to a display  454 . The display  454  may be, for example, a TFT LCD (Thin-Film-Transistor Liquid Crystal Display) or an OLED (Organic Light Emitting Diode) display, or other appropriate display technology. The display interface  456  may comprise appropriate circuitry for driving the display  454  to present graphical and other information to a user. The control interface  458  may receive commands from a user and convert them for submission to the processor  452 . In addition, an external interface  462  may be provide in communication with processor  452 , so as to enable near area communication of device  450  with other devices. External interface  462  may provide, for example, for wired communication in some implementations, or for wireless communication in other implementations, and multiple interfaces may also be used. 
         [0057]    The memory  464  stores information within the computing device  450 . The memory  464  can be implemented as one or more of a computer-readable medium or media, a volatile memory unit or units, or a non-volatile memory unit or units. Expansion memory  474  may also be provided and connected to device  450  through expansion interface  472 , which may include, for example, a SIMM (Single In Line Memory Module) card interface. Such expansion memory  474  may provide extra storage space for device  450 , or may also store applications or other information for device  450 . Specifically, expansion memory  474  may include instructions to carry out or supplement the processes described above, and may include secure information also. Thus, for example, expansion memory  474  may be provide as a security module for device  450 , and may be programmed with instructions that permit secure use of device  450 . In addition, secure applications may be provided via the SIMM cards, along with additional information, such as placing identifying information on the SIMM card in a non-hackable manner. 
         [0058]    The memory may include, for example, flash memory and/or NVRAM memory, as discussed below. In one implementation, a computer program product is tangibly embodied in an information carrier. The computer program product contains instructions that, when executed, perform one or more methods, such as those described above. The information carrier is a computer- or machine-readable medium, such as the memory  464 , expansion memory  474 , memory on processor  452 , or a propagated signal that may be received, for example, over transceiver  468  or external interface  462 . 
         [0059]    Device  450  may communicate wirelessly through communication interface  466 , which may include digital signal processing circuitry where necessary. Communication interface  466  may provide for communications under various modes or protocols, such as GSM voice calls, SMS, EMS, or MMS messaging, CDMA, TDMA, PDC, WCDMA, CDMA2000, or GPRS, among others. Such communication may occur, for example, through radio-frequency transceiver  468 . In addition, short-range communication may occur, such as using a Bluetooth, WiFi, or other such transceiver (not shown). In addition, GPS (Global Positioning System) receiver module  470  may provide additional navigation- and location-related wireless data to device  450 , which may be used as appropriate by applications running on device  450 . 
         [0060]    Device  450  may also communicate audibly using audio codec  460 , which may receive spoken information from a user and convert it to usable digital information. Audio codec  460  may likewise generate audible sound for a user, such as through a speaker, e.g., in a handset of device  450 . Such sound may include sound from voice telephone calls, may include recorded sound (e.g., voice messages, music files, etc.) and may also include sound generated by applications operating on device  450 . 
         [0061]    The computing device  450  may be implemented in a number of different forms, as shown in the figure. For example, it may be implemented as a cellular telephone  480 . It may also be implemented as part of a smartphone  482 , personal digital assistant, or other similar mobile device. 
         [0062]    Various implementations of the systems and techniques described here can be realized in digital electronic circuitry, integrated circuitry, specially designed ASICs (application specific integrated circuits), computer hardware, firmware, software, and/or combinations thereof. These various implementations can include implementation in one or more computer programs that are executable and/or interpretable on a programmable system including at least one programmable processor, which may be special or general purpose, coupled to receive data and instructions from, and to transmit data and instructions to, a storage system, at least one input device, and at least one output device. 
         [0063]    These computer programs (also known as programs, software, software applications or code) include machine instructions for a programmable processor, and can be implemented in a high-level procedural and/or object-oriented programming language, and/or in assembly/machine language. As used herein, the terms “machine-readable medium” “computer-readable medium” refers to any computer program product, apparatus and/or device (e.g., magnetic discs, optical disks, memory, Programmable Logic Devices (PLDs)) used to provide machine instructions and/or data to a programmable processor, including a machine-readable medium that receives machine instructions as a machine-readable signal. The term “machine-readable signal” refers to any signal used to provide machine instructions and/or data to a programmable processor. 
         [0064]    To provide for interaction with a user, the systems and techniques described here can be implemented on a computer having a display device (e.g., a CRT (cathode ray tube) or LCD (liquid crystal display) monitor) for displaying information to the user and a keyboard and a pointing device (e.g., a mouse or a trackball) by which the user can provide input to the computer. Other kinds of devices can be used to provide for interaction with a user as well; for example, feedback provided to the user can be any form of sensory feedback (e.g., visual feedback, auditory feedback, or tactile feedback); and input from the user can be received in any form, including acoustic, speech, or tactile input. 
         [0065]    The systems and techniques described here can be implemented in a computing system that includes a back end component (e.g., as a data server), or that includes a middleware component (e.g., an application server), or that includes a front end component (e.g., a client computer having a graphical user interface or a Web browser through which a user can interact with an implementation of the systems and techniques described here), or any combination of such back end, middleware, or front end components. The components of the system can be interconnected by any form or medium of digital data communication (e.g., a communication network). Examples of communication networks include a local area network (“LAN”), a wide area network (“WAN”), and the Internet. 
         [0066]    The computing system can include clients and servers. A client and server are generally remote from each other and typically interact through a communication network. The relationship of client and server arises by virtue of computer programs running on the respective computers and having a client-server relationship to each other. 
         [0067]      FIG. 8  is a block diagram of a patient monitoring system. The system  800  may involve a number of networked computers and computer systems. The system  800  is shown for convenience here as being centered around a patient monitor system  808 . The patient monitor system  808  extracts data from a number of data stores  802 - 804  and groups and formats the data for convenient display, such as in the manners discussed above. The data stores  802 - 804  may include, for example, data reflecting real time information about a patient (e.g., vital signs) as well as centrally stored electronic medical record information, among other things. Particular types of data are discussed with respect to  FIG. 2  above. 
         [0068]    A data extractor  810  may be programmed to identify and retrieve relevant data from the data stores  802 - 804 . The extractor  810  may be programmed to implement heuristic rules that were determined by observing or surveying experienced caregivers with respect to the data points that they most often consult during particular phases of a patient&#39;s stay in a facility, such as in an ICU. A grouper  812  takes the particular data values retrieved by the extractor  810  and organizes the data into relevant groups, such as by organ type as discussed above. The extractor  810  or grouper  812  may also generate derivative data using one or more extracted data points. 
         [0069]    A display formatter  816  provides for the generation of data for displaying patient information. The display formatter  816  may, for example, generate icons and arrange the icons and textual patient information provided by the extractor  810  and/or grouper  812  for display on a patient monitor  818 . The particular display may vary, in certain implementations, based on the identity of the particular caregiver who is observing the monitor  818  or the class into which the caregiver falls (e.g., the caregivers particular job title, such as physician, nurse, attending physician, etc.). 
         [0070]    The identity of the caregiver may be discerned by a caregiver identifier  814  that is in communication with a sensor  820 . The sensor  820  may take a variety of forms such as an RFID sensor that obtains identifying information from an RFID chip in an identification badge worn by a caregiver when the caregiver is in proximity to the monitor  818  and thus in proximity to the sensor  820 . The sensor  820  may also include a biometric sensor, such as a fingerprint reader. The caregiver may provide identifying information by other sensing mechanisms also, such as logging into a clinical system in various familiar manners. Each of these sensed objects may be considered to be a beacon that provides identifying information about the caregiver. 
         [0071]    The identifying information may include a ID number such as form an RFID chip or bar code in or on an ID badge. The number may be returned by the sensor, and turned into a separate ID number by the caregiver identifier  814 , such as the caregiver&#39;s employee number. The display formatter may then user the latter ID number to access a data store that stores formatting information for a display that is unique to the particular caregiver. The monitor  818  may thus, in this manner, provide for a display that is formatted in a manner that matches the job title of the caregiver (attending physicians may need information that is slightly different than that needed by nurses) or matches the actual caregiver (certain physicians may be more efficient if data is presented to them in a customized manner). 
         [0072]    A number of embodiments have been described. Nevertheless, it will be understood that various modifications may be made without departing from the spirit and scope of the invention. For example, much of this document has been described with respect to ICU monitoring with attending physicians, but other forms of patient monitoring and reporting may also be addressed. 
         [0073]    In addition, the logic flows depicted in the figures do not require the particular order shown, or sequential order, to achieve desirable results. In addition, other steps may be provided, or steps may be eliminated, from the described flows, and other components may be added to, or removed from, the described systems. Accordingly, other embodiments are within the scope of the following claims.