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Data Visualization in Radiation Medicine

Catherine Safiiago

The University of San Diego, Hahn School ofNursing and Health Scierce and

the Betfy and Bob Beyster lnstitute forNursing Research, Advanced Practice, and Simulation

Health Care lnformatics Master's Capstone

December 15,2022

Approved by:

A
Barbara Berkovich, PhD, MA
Capstone Advisor

tafir/zs LL
Date
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Abstract

The Department of Radiation Medicine at a major university hospital is contractually obligated to

provide disease site and treatment completion information on referrals from an external healthcare

provider. This paper presents a process improvement that created efficiencies and better visuals, making

the data interactive and easy to use. With visualizations, trends are easier to spot, so decisions can be

made quickly, capturing any opportunity that may present itself. To complete this project, the purchase

of Tableau was required, and a connection to the existing SQL database to create and present the

requested information. Tableau gives the user multiple ways to present data or share new data not

previously available under the previous process. The cost savings in time over the previous method

makes the purchased software an investment vs. a cost. As the project analyst working on this project, it

allows me more time to analyze other data that can be relevant to stakeholders. Using Tableau to create

interactive visualizations is having “ a picture worth a thousand words”.

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Background

The Department of Radiation Medicine at a major university hospital is

contractually obligated to provide disease site and treatment completion information on

referrals from an external healthcare provider. The department project analyst was tasked

with retrieving data from a SQL database and compiling years' worth of data into

meaningful graphs. The stakeholders from the external healthcare group requested visual

representation as it would be graphically and visually significant to view the rich data. As

Ko and Chang (2017) noted, “Data visualization is an intuitive way for users to easily read

and understand data, especially in big data analyses. It helps to improve the quality of

policies or services by presenting an integrated view and evidence for making healthcare

decisions” (p. 349). The desired outcome is to present the data meaningfully, allowing for

fast decision-making.

Statement of Problem

The original workflow used data from the department database and delivered it in

Excel format, and when the database was initially created, not all ICD-9 codes were listed.

“ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated

with hospital utilization in the United States. The ICD-9 was used to code and classify

mortality data from death certificates until 1999, when the use of ICD-10 for mortality

coding started” (CDC, 2019). There was no indication as to whether a patient had been

treated. The database had to be updated to include ICD-10 and new data indicators. Four

facilities located around the county provide services for this subset of patients. The yearly

average number of patients entered into the database is 2400. Each office is responsible for

entering its facility data. The data had to be manually cleaned to be able to produce any
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meaningful information. The task was time-consuming and inefficient. The graphs in

Excel were passable but needed better optimization. They were not interactive and required

20 charts to individually present the disease site groupings.

Project Purpose

In this project, I aimed to provide an interactive tool that automatically updated

without downloading thousands of lines of data on an Excel sheet. With Tableau, it is now

possible to receive real-time data on one worksheet or dashboard, viewing 1-year, multiple

years, or all years, one disease, or all diseases.

PICOT Question

 Population: Patients referred to Radiation Medicine

 Intervention: Provide a data visualization tool for payor review of radiation

treatment claims

 Comparison: Excel charts upgraded to Tableau interactive visualizations

 Outcome: Interactive and easy-to-use visualizations

 Time: Data available in real-time, anytime

Literature Review

Graphic representation of data can be traced back to 1854 when John Snow

released a map of cholera outbreaks in London (InsightSoftware, 2019). At the beginning

of the 20th century, statisticians wanted exact numbers; they felt that visualizations were

not accurate enough, so visualizations rarely appeared in research (InsightSoftware, 2019).

With the emergence of artificial intelligence and machine learning, visualizations are back

at the forefront, with numerous software applications to generate them.

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The last three decades have seen the field of data visualization explode into

dozens and even hundreds of focus areas. Dashboards and data discovery

tools, scorecard applications, analytics suites, and various other software tools

enable businesses, researchers, and individuals to explore their data in new and

increasingly imaginative ways. (InsightSoftware, 2019)

The graphic representation of data makes it easier to "see" and understand data. “We can easily

distinguish a circle from a rectangle. Data visualization represents the data using shapes,

patterns, or graphs, such as bar graphs, trend or line charts, and heat maps. It helps people to

interpret the data quickly and help them identify specific patterns and trends" (Usharani et al.,

2022). The following review includes discussions on graphic visualization and Tableau.

Ko and Chang (2019) give an example of how to connect a data source. Ko and Chang

explained the different features and have screenshots of the main interface and other graphics

created with data. "By following the procedure described in this paper, it is possible to create a

simple view to explore sample data using Tableau for beginners" (Ko and Chang, 2019, p. 353).

Hoelscher and Mortimer (2018) use a sample business to make a case for using visualizations

and also explain the process of using Tableau "to focus on familiarization with data visualization

software to convey data, results, and insights and apply higher-order thinking" (p. 49). The

authors have a business case with a tutorial to convert business data into meaningful graphic

information. They feel the accounting profession has been only taught accounting and not data

presentation or analytics.

The case was created to provide an introduction to data visualization software and

the basics of data analytics. They emphasize the need for instructional,

educational cases that address emerging technologies and their usage in the
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accounting profession. While few accounting educational case studies have been

developed to focus on data analytics, many focus more on the accounting task and

less specifically on the data visualization software functionality and user

interface. (Hoelscher and Mortimer, 2018, p. 49)

Hoelscher and Mortimer (2018) Demonstrated in their research that using visual information

increased the student's ability to use data analytics and report critical findings. (29.63%

exceeded expectations, 61.73% met expectations, and 8.64% did not meet expectations)

Usharani et al. (2022) made a case in their textbook chapter on healthcare visualization.

They stated that data collection in health industries, such as patient histories, present situation

data, and demographics, helps improve patient care when visualizations are used instead of

presenting providers with raw data. Providers and administrators do not have to spend time

trying to analyze what they are reading. They also claimed that data visualization reduces human

error in interpreting medical test results and can focus on abnormal results instead. The authors

also presented different forms of visuals and how to use them best. They discussed key

performance indicators and how establishing those help the healthcare industry best serve

patients, meet financial metrics and improve patient safety. "The advantages of visualization

help the healthcare industries in many ways to perform their work more simply and effectively"

(Usharani et al., 2022).

Methods

To complete this project, the department acquired a license for Tableau, which was

connected to the SQL database with Radiation Medicine Information Technology

(IT)Department’s permission and assistance. The Referral table was left joined with the Dx

Groups, Sites, and Source1 tables, as shown in Figure 1 Joined Tables. The Source1 table
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contains identifying information for the Sites and DX group tables. Unnecessary columns

were hidden to prevent information overload and to adhere to HIPPA regulations. The

HIPAA Privacy Rule established appropriate safeguards that healthcare providers and

others must achieve to protect the privacy of health information (Office for Civil Rights,

2002).

Once the data were filtered at the data source to the required elements, with IT’s

guidance, I created two calculated fields to produce a 3-column bar chart Shown in Figure

2. The bars display the number of consults, the number of treated patients, and the number

of patients who did not proceed with an intervention. The chart can display all diseases or

be filtered into one disease group. The second filter added to the worksheet sorts the data by

facility. The data are available in real-time as long as the SQL server is active.

Figure 1.

Joined Tables
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Figure 2.

Tableau Consults, Treatments, and No Treatment Bar Chart

Appendix A presents an illustrated workflow of the previous process.  Prior to

implementing Tableau, the process of creating the required graphs took an estimated time of

twelve hours to complete the process. With the implementation of the new, improved

workflow, a notable time-saving was realized; the new process time is approximately 15

minutes. Figure A2 of appendix A illustrates the new workflow. The process is

significantly streamlined and can be easy to follow by anyone.

Results

Using the formula for ROI on time TVC1-TVC2=ROI, where T equals time, V equals

volume, and C equals staff cost, the results for the internal ROI after 3 years is a positive 26%

percentage difference in favor of this project. The cost savings was equal to $2647 after 3 years.

Table 1 Return on Investment illustrates the previous and current investment, cost savings, and
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percentages per year over the lifetime of the current contract. The project cost included a

Tableau developer license at $1200 with a $300-yearly maintenance fee and an hourly employee

rate. The subsequent year’s cost per instance includes the $300 yearly fee.

Table 1

Three Year ROI

Previous Current
Time (hrs) 12 0.25
Volume (report cycle) 2 2
Cost (staff $/hr) 38 38
Cost Yr 1 $912.00 $1,519.00

Time (hrs) 12 0.25
Volume (report cycle) 4 4
Cost (staff $/hr) 40 40
Cost Yr 2 $1,920.00 $340.00

Time (hrs) 12 0.25
Volume (report cycle) 4 4
Cost (staff $/hr) 42 42
Cost Yr 3 2016 342
Total Cost $4,848.00 $2,201.00
Savings $2,647.00 26%

Cost (Software Fees in $) 1500
Cost (Software Fees in $) 300
Cost (Software Fees in $) 300
Investment cost over 3 yrs $ 2,100.00

Discussion

The ultimate goal of this project was to improve communication, reduce the costs of

mandatory contract performance reporting, and create a process that presents a story of changes
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over time and any anomalies where things can be exceptionally different. The ability to add or

change time frames within the visualization is an important improvement. With the previous

process, the work was cumbersome and inefficient. Although this project makes updating and

distributing the visualization efficient, there are drawbacks. If data is entered erroneously, that

data flows through Tableau directly into the visualizations. Eventually, upgrades to the SQL

database will be required to ensure data quality, improve performance and add functionality to

the worksheets in Tableau.

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References

Centers for Disease Control and Prevention. (2021, November). ICD - ICD-9-CM - International

Classification of diseases, ninth revision, clinical modification. Centers for Disease

Control and Prevention. https://www.cdc.gov/nchs/icd/icd9cm.htm

Hoelscher, J., & Mortimer, A. (2018, September). Using Tableau to visualize data and drive

decision-making. Journal of Accounting Education, 44, 49-59.

https://doi.org/10.1016/j.jaccedu.2018.05.002

InsightSoftware. (2019, September). A brief history of data visualization. Retrieved October 26,

2022, from https://www.dundas.com/resources/blogs/introduction-to-business-

intelligence/brief-history-data-visualization

Ko, I., & Chang, H. (2017, October 31). Interactive visualization of healthcare data using

Tableau. Healthcare Informatics Research, 23(4), 349-354.

Office for Civil Rights. (2002, December). 187-what does the HIPAA Privacy Rule do?

HHS.gov. Retrieved November 11, 2022, from https://www.hhs.gov/hipaa/for-

individuals/faq/187/what-does-the-hipaa-privacy-rule-do/

Usharani, S., Bala, P., Rajmohan, R., Pavithra, M., & Kumar, T. (2022). Data visualization for

healthcare. In S. Malik & A. K. Tyagi (Eds.), Intelligent interactive multimedia systems

for e-healthcare applications (1st ed., pp. 3–32). Taylor & Francis
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Appendix A
Workflow Comparison
Figure A1
Previous Workflow
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Figure A2
After Process Improvement
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Appendix B
Gantt Chart
Figure B1
Gantt Task List
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Figure B2
Gantt Chart
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Appendix C
Program Compentencies

Health Science Knowledge and Skills Competency:

The competency was demonstrated through my work in presenting relevant healthcare

data to the stakeholders in a way that made meaningful use of the data.

Leadership and Systems Management Outcome:

The competency was met by managing this project in a timely process, with a spirit of

collaboration with IT.

Systems Design and Management Outcome:

The competency was completed by showing fluency in using Tableau and a SQL

Database to present data in an interactive data visualization.

Data and Knowledge Management Competency:

Data and Knowledge Management was the most important competency completed in this

capstone project, as data had to be managed properly to achieve the intended outcomes of the

project.

Quality and Regulatory Competency:

The quality and regulatory outcomes were achieved by keeping protected information

safe and following HIPPA regulations and the regulations of my employer.

Social Justice and Community Activism:

The competency was demonstrated through the presentation of data that affects the

patients of the stakeholders in the county of San Diego. The data presented revealed the trend in

cancer disease sites for this subset of patients.