Watermark Medical Interpreting Physician Access Manual 1
Table of Contents Chapter 1: Getting Connected... 3 Chapter 2: Inspecting and Editing a Sleep Study... 6 A. Inspecting a Study... 6 B. Opening a Sleep Record (Editing the RAW data)... 7 C. Automated Identification of Apnea/Hypopnea Events (A/H)... 10 D. Automatic Exclusion of Time in Bed (TIB)... 10 E. Setting Start and Stop Times and Baseline SpO2... 11 F. Editing Events in Detail... 11 G. Adding Comments to the Report... 13 H. Retrieving Released Reports... 16 Chapter 3: Global Text Override... 17 A. Setting up Global Text Override... 17 2
Chapter 1: Getting Connected A. Connecting to the Sleep Study Portal Please log onto our website www.watermarkmedical.com using Internet Explorer Only. You will be directed to the Watermark Medical web site where you can click on the Sign In tab in the upper right corner to access the Sleep Study Portal. 3
1. At the Sleep Study Portal login screen type in your username and password. The password field is case sensitive. Click on Log In. 2. Once logged in you will see Interpretation at the top of the menu. Click on Interpretation to expand the menu, then click Interpretation Queue : 4
3. From the Interpretation Queue main menu, click on Search to bring up the studies that are currently pending in your interpretation queue. You may search by the default date range or select to search by a specific name or status type. Highlight a study by clicking on it. Right-clicking the highlighted study will bring up the menu options. 4. Check your pop-up blocker settings before proceeding to the next section. Click on Tools, Pop-up Blocker, Pop-up Blocker Settings, and add the following site: https://portal.watermarkmedical.com ** If you only see the option for Turn Pop-up Blocker On then you don t need to change your settings. Internet Explorer v9 users will need to select: Tools, Internet Options, Privacy, Pop-up Blocker, Pop-up Blocker Settings to add the site listed above. 5
Chapter 2: Inspecting and Editing a Sleep Study A. Inspecting a Study 1. Prior to making edits to the study, you may wish to become familiar with the subject s data. Right-click on the study to get a menu (or click on the icon) with the following view only options: View Report - Review the results from the most recently generated report for the subject. View QA Summary and Predicted Risk Review Patient Survey information. View Report History View in reverse chronological order all reports generated for this study. View Sleep Study - View only mode for observing raw data associated with study. 6
B. Opening a Sleep Record (Editing the RAW data) 1. To begin making edits to the study raw data, right-click the subject name and select Interpret Study. 2. The data will begin to download to the local computer. 3. This process requires a current version of JAVA in order to view the raw data. If the process hangs or gives you a white screen with a red X in the upper left corner, you will need to navigate to this link to download the current JAVA update: http://www.java.com/en/download/index.jsp. Click on the Free JAVA Download icon, save the file to your desktop and then execute the file by double-clicking on it to run. 7
4. Once the raw data is loaded to the screen you will be able to make edits. The time scale for the data is defaulted to 10 minutes. You may change the time scale by clicking on the drop-down arrow in the upper right. If the selected study consists of multiple nights selector buttons will appear that, when clicked, change the actively edited night. The actively edited night is represented by red text in the button, and by default a multi-night study will be set for editing Night 1. 5. A number of methods are available to scroll through the file. Icons in the bottom left and right corners of the screen shift the file: Backward half time scale Backward one time scale Forward half time scale Forward one time scale Backward to start of the file Forward to end of the file Pg Up: Backwards one screen length Pg Dn: Forward one screen length Left-click and drag the Pointer at the bottom of the screen to move anywhere in the file. 6. Mouse function within the edit screen is as follows: Left-clicking on an event gives you information about that event. 8
Highlighting a section of data by left-clicking and dragging your mouse gives you a full edit menu. Right-clicking on a specific event gives you an abbreviated edit menu. 7. To increase the amplitude of a signal: Move the mouse pointer over the + symbol until it turns yellow, then left-click to increase the signal amplitude. Move the mouse pointer over the - symbol until it turns yellow, then left-click to decrease the signal amplitude. 9
8. To save edits click on the Save button in the menu bar. You will not be permitted to save the edits until both nights of data have been viewed in a multi-night study. Once you save your edits, the study is permanently assigned to you as the Interpreting Physician. On accounts with multiple interpreting physicians assigned, this will prevent other physicians from viewing this study in the Interpretation Queue. A prompt will appear advising you that the study is being placed in the status of Interpretation Processing while a new report is being generated. During this time the study is locked. ** If you receive a "com.sum.xml.internal.ws.client transport exception: server sent HTTP status code 400. Bad request" error while trying to save, a JAVA update is needed for your computer. Please reference Step 3 listed above for instructions on how to update. 9. To cancel edits without generating a new report, click on the Cancel button in the menu bar. Note that all edits will be lost upon cancellation. Cancelling edits will leave the study unassigned to an Interpreting Physician. If multiple physicians are assigned to an account, this study will still be available to other physicians in the Interpretation Queue. C. Automated Identification of Apnea/Hypopnea Events (A/H) The automated algorithms utilize pattern recognition of individual signal characteristics to define apnea and hypopnea (A/H) events. A/H events are marked and annotated in the Time in Bed (TIB) channel. For each event the first letter identifies an apnea (A) or hypopnea (H), followed by an indicator of the depth of the desaturation (i.e., 4%, 3%, 1% or 0%). If a snoring sound, head movement or pulse rate arousal is recognized in the arousal window (which is linked to the recovery of the airflow and/or the nadir of the desaturation) then an A will be appended to the annotation (i.e., H4A, H1A, etc). D. Automatic Exclusion of Time in Bed (TIB) The web editor automatically inserts Exclude from Time in Bed (ExTIB) stripes in the TIB channel to reject A/H events and SpO2 that are likely caused by artifact. 1. ExTIB stripes that should be adjusted for each study include: a. ExTIB Start First 15 minutes of the study. The end of this stripe can be adjusted by placing the cursor in an alternative start point, right-clicking and selecting Set Start of TIB Time. Note that the new TIB Time is applied only to the currently-active night (as denoted by red text in the 10
Night selector button). Changing the start TIB time for another night requires selection of that night with the night selector button. b. ExTIB Stop The last 3 minutes of the study. The end of this stripe can be adjusted by placing the cursor in an alternative end point, right-clicking and selecting Set Stop of TIB Time. Note that the new TIB Time is applied only to the currently-active night (as denoted by red text in the Night selector button). Changing the stop TIB time for another night requires selection of that night with the night selector button. 2. ExTIB stripes are automatically inserted but can be extracted: a. ExTIB Movement Gross head movement likely to cause artifact. To remove this stripe, place the cursor over the stripe, right-click and select Reject Auto Scoring. b. ExTIB Upright Any period when the subject is detected as having his/her head upright. E. Setting Start and Stop Times and Baseline SpO2 1. After the file opens, place the mouse at the point that you wish to set the start of the active night (night 1 by default). Right click and select Set Start of TIB Time. 2. A baseline SpO2 stripe will automatically be inserted in the region of the ExTIB Start stripe (beginning 30s into the record). The lighter colored regions in the stripe contain artifact or desaturations and are not included in the baseline SpO2 calculation. The calculated value that will appear on the report is presented along the stripe. 3. To insert an alternative Baseline SpO2 stripe, left click and drag to highlight a region for the desired baseline SpO2 stripe. Release the left mouse button, and select Add Baseline SpO2. The baseline SpO2 stripe will appear. Figure: This image shows a sample TIB section with a Start TIB stripe (bottom, red) and corresponding Baseline SPO2 stripe (top pink, red). The baseline SPO2 value (97.2) is calculated and displayed automatically when the TIB stripe is created. Note that the baseline stripe begins 30s into the record. 4. Place the mouse at the point that you wish to set the end of study. Right click and select Set Stop TIB Time. F. Editing Events in Detail 1. There are a number of options available to accept or reject auto-scored events: a. Reject Auto Scoring of apnea/hypopnea (A/H) event: Place the cursor over an A/H event, rightclick and select Reject Auto Scoring A/H. An X will be placed over the A/H stripe and the name will be changed to Tech. b. Reject Auto Scoring of ExTIB event: Place the cursor over an ExTIB stripe, right-click and select Reject Auto Scoring ExTIB. An X will be placed over the ExTIB stripe and all A/H events above the ExTIB stripe will revert to the A/H annotation. If multiple ExTIB stripes overlap, you will need to reject each stripe individually. c. Reject Auto Scoring of Low SpO2: Place the cursor over the low SpO2 stripe, right-click and select Reject Auto Scoring. An X will be placed over the low SpO2 stripe and this period will be included in the hypoxemia statistics. A/H events may change as a result of allowing the SpO2 for definition of obstructive events. d. Delete Tech Scoring of an A/H event: Place the cursor on a previously edited A/H event, rightclick and select Delete Tech Scoring A/H. The stripe annotation will revert to the auto-scored 11
status and the event will be counted in the AHI. e. Delete Tech Scoring of an ExTIB event: Place the cursor a previously edited ExTIB event, right click and select Delete Tech Scoring. The X will disappear in the ExTIB stripe, and the A/H stripes above the ExTIB will revert to the auto-scored status (e.g., X with Auto). f. Accepting A/H Events: Place the cursor over the A/H stripe, right-click and select Accept for AHI Or Accept for RDI. The X will disappear and the stripe will be named Tech. 2. Adding New Events: Press and hold the left mouse button, then move the mouse to the left or right to create a yellow region the length corresponding to the desired stripe. Release the left mouse button and select one of the following options. a. ExTIB Awake Inserts a stripe that corresponds to patient information provided in the Sleep Log. b. ExTIB Tech Excludes all data from any region not otherwise excluded but which should be. c. Accept A/H, Exclude SpO2 Use when the relative change in the SpO2 is acceptable for identifying sleep disordered breathing but the absolute value of the SpO2 appears low. This feature excludes the SpO2 for use in hypoxemia statistics but accepts all A/H events under the stripe. d. Tech Exclude SpO2 Inserts a stripe that will exclude the region of SpO2 from the hypoxemia calculation. A/H events that require desaturations will not be called. f. Tech Exclude Snoring Inserts a stripe that will exclude snoring sound arousals and quantification of snoring during periods visually identified with background noise. e. Add A/H Tech Inserts either a Tech A or Tech H with the manually selected level of desaturation for the hypopnea. 3. Marking Central Events: Central events can be detected based on the alignment of the nadir of a desaturation event and minimum airflow and the effort signal. a. To convert an existing A/H event to a central event, use the Convert Central function place the cursor on the A/H event, right click and select Convert Central. b. To convert a region of A/H events for conversion to central events, press and hold the left mouse, then move the mouse to the left or right to create a yellow region the length corresponding to the desired region. Release the left mouse button and select Convert to Central. 12
G. Adding Comments to the Report 1. After saving your changes under Interpret Study the file will go to a status of Interpretation Processing and no menu options are available. During this time a new report is being generated with your saved changes. When the new report generation is complete the study status will go to Interpretation Complete and you are able to right-click (or click on the icon) and select Review Sign Release Study to make text edits to the report. To refresh your screen with the new status click on the Search button. 2. In edit mode a screen will appear with the most current version of the report at the top with tabs at the bottom that correspond to each section of the report. The auto-generated text from the report is populated on each tab. 13
3. To begin making edits to the text of the report click on the appropriate tab and then click in the box Replace Standard Message to put a check mark in the box. You will be prompted to confirm that you want to change the auto-generated text by clicking on OK. 4. Edits are made by typing text directly into the selected tab or by creating and selecting Predefined Comments. You will only have the option to use Predefined Comments when the Replace Standard Message box is checked. Click on the link Predefined Comments on the lower left. This will open the link in the top section of the window. 5. To add a predefined comment click on the plus sign. Type in the text of the comment. Apply a code to the comment. Select the tabs where you would like to view the comment. Click on Save. 14
6. To select a predefined comment, highlight the comment and click the Copy Comment icon. You will be prompted to Allow Access to the computer clipboard. Paste the comment to the text box on the tab by right-clicking and selecting Paste, or by using CTRL-V to paste the text at the desired location. Exit Predefined Comments by clicking on the red X icon. 7. When text edits are completed. You will need to sign the report. Click on the Diplomat Statement tab to create your custom statement that is applied with your signature. Click on Change Diplomat Statement to begin edits. Click on Save when completed. Once saved, this will be the default statement until new edits are saved. Place a check in the Sign Report box by clicking in the box. Click on Generate Report to complete your edits. 8. Once the report is generated you now have the option to Release Report. You will not get this option if the report is not signed, there must be a check in the Sign Report box. Once the report is released it will be removed from the Interpretation queue list. Click on OK to continue: 15
H. Retrieving Released Reports 1. All reports that are interpreted and released are available in view only mode for reference purposes through the web portal. From the main menu, highlight Released. Place a check in the date range field by clicking in the box. Click on Search to pull up the available reports. You may also search by the other available search options such as patient name or device serial number. 2. Click on the study to highlight and right-click (or click on the icon) to get the available view options for the study. There is also an option to Re-Interpret My Study which will allow you to pull the study back to the Interpretation Pending queue and make new edits. 16
Chapter 3: Global Text Override A. Setting up Global Text Override The Global Text Override feature allows an interpreting physician (IP) to override the system standard generated text based on severity. You cannot change the format of the report, however you can create standard statements of text that you will not have to edit each time you interpret a sleep study. The feature requires the role of ReportTextOverride to be assigned to the user. The role is not a default assigned role; it must be requested through technical support. 1. From the Utilities menu, select Custom HST Report Text. From this screen the IP can do a global override for any of the text sections on the first page of the HST Report. 2. Select the text section to override by clicking on the tabs at the top. For example, click on Treatment Considerations. If no override is specified for a text section or severity the auto generated text will continue to be displayed. 17
3. The system allows a custom message for each severity level. Select the appropriate severity tab, click on Override Text and then type your message. Repeat this step for each severity level. If you don t include a specific severity, reports with that severity will continue to show the default system text. Once all overrides are completed, click on Save. 4. The severity levels are determined based on the following rules which you can see by clicking Help. 5. Once completed return to the Interpretation Queue, highlight the desired study and select to Review Sign Release Study. A message will prompt that the system generated text is being overwritten, click on OK. 18
6. The Replace Standard Message check box is automatically checked and the text is replaced with the specified custom text. The Report above still shows the original system-generated text and if preferred, just un-check the Replace Standard Message box. Once any additional changes are made the interpreting physician should follow the normal sign and generate report steps to complete the process. 19