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Web based aphasia test using service oriented architecture (SOA)

Based on an aphasia test for Spanish speakers which analyze the patient's basic resources of verbal communication, a web-enabled software was developed to automate its execution. A clinical database was designed as a complement, in order to evaluate the antecedents (risk factors, pharmacological and medical backgrounds, neurological or psychiatric symptoms, brain injury -anatomical and physiological characteristics, etc) which are necessary to carry out a multi-factor statistical analysis in different samples of patients. The automated test was developed following service oriented architecture and implemented in a web site which contains a tests suite, which would allow both integrating the aphasia test with other neuropsychological instruments and increasing the available site information for scientific research. The test design, the database and the study of its psychometric properties (validity, reliability and objectivity) were made in conjunction with neuropsychological researchers, who participate actively in the software design, based on the patients or other subjects of investigation feedback.


Introduction
The French doctor Armand Trousseau first used the word aphasia in 1864 to designate the lack of language communication. This pathological state was defined as the complete or partial loss of language communication faculty, with conservation of the intelligence and the integrity of the phonation organs. The aphasia can be described as an affection that decreases the language capacity due to injuries in the cerebral cortical areas of language or in its conduction pathways. The expressive aphasia primarily affects the spoken language, whereas the receptive aphasia primarily affects the language interpretation [1]. The aphasias which abruptly occurred are generally produced by head traumas or cerebrovascular accidents, which generate circumscribed injuries caused by embolisms or thrombosis. Brain tumours, infections, such as encephalitis, and degenerative disorders or dementias, such as the Alzheimer disease, can also be cause of aphasia.
Nowadays, all the available aphasia tests, brief or comprehensive, manual or computerized, permanently incorporate the clinical diagnosis as the main output thus translating or classifying the test results into a predefined syndromes typology. Consequently, the current instruments are both constructed and validated based on this typology. The originality of the present project consists not only in the free distribution of a more agile, operative and objective instrument for the evaluation of this complex language pathology but also in the attempt of constructing a quantitative pattern related to the obtained responses independent of one predetermined typology. By following this approach, profile comparisons between the pattern above mentioned with different neuropsychological or clinical instruments can be made. Nevertheless that predefined and hypothetical typology emerges from the present theory is taking into account because it constitutes an indispensable research component for conceptual purposes and also provides the necessary arguments for test clinical interpretation and application. In other words, the present project does not intend to replace the theoretical and technical perspective of the professionals involved, but also simply complement it.
The aphasia test automation responds to one of the most important argentinean scientific and technological priorities since it attempts: a) to get evidence based diagnoses, b) to construct a database to obtain more effective interdisciplinary research in the human neurosciences, and c) to develop integration policies for different and distant regions of the country.
To design the test automation, a service oriented architecture (SOA) was chosen. SOA is a software architecture that integrates the different functional units from an application, named services, through well defined interfaces between them. The interfaces are neutral and independent of the hardware platform, operating system or programming language in which the service is implemented. They allow these services to be developed using a wide variety of technologies and to interact with others in a uniform and universal approach [3]. Many of the SOA concepts are not totally new, nevertheless a characteristic that differentiate to SOA from other past similar architectures is the wide acceptance of the XML (extensible markup language) like a common language for data description and interchange, and the existence of a large number of standards with sufficient adoption from all the technology suppliers. This guarantees high interoperability level between different applications, avoiding specialized code development (named glue-code) to connect software modules or components.

Tests design
An original aphasia test was initially constructed using paper. It consists of a series conformed by 72 commands to be answered by the aphasic patient, and includes the necessary instructions and requirements for a correct execution.
The test items were chosen, predominantly, from a neuropsychological tests suite for spanish speakers developed by its author [4], which was validated with brain damaged patients, as an innovative approach for the spanish speakers scope.
This test was designed with own objectives, that is, independently from other brief evaluations for aphasics available in the market and with the purpose of being administered only by people with important linguistic impairment. By means of this technique, the patient performance on a series of tasks involving knowledge and basic abilities for verbal communication is explored while the patient is cognitively stimulated. The test is offered for translation and scientific research, which has already begun to be carried out with people of different Argentina regions.

Software design
To improve the benefits of a service oriented architecture, a standard definition for the interfaces was made to invoke each service, to allow reusability in different application modules. This interface definition, not strongly bound to a particular implementation, is known like weak connection between services ("loose coupling"). The benefits of a weakly connected system consist of its agility and capacity to adapt itself to changes in the software components that constitute the application.
Otherwise, the strong connection ("tight coupling") means that the different application components have much dependency among them for their execution, which does not allow the components reusability in a separate way, since any modification to one of its components ends up affecting to the others [3].
The systems or applications having only a web service interface without a service oriented design are a clear example about the services non-reusability. The SOA intention is to separate the application from the way in which its components (services) are implemented. This is based on a design principle called "separation of concerns". The advantage of this separation is to allow implementation changes for the components without affecting the applications and, vice versa, modify applications reusing the same components [3].
Unlike the traditional software components, the services have characteristics that facilitate their adoption as part of a service oriented architecture. One of these qualities is the complete autonomy respect to other services, this implies that each service is responsible for its own domain, it means a specific function or a group of related functions. These services can be classified in verticals and horizontals, according to the capacity in the defined architecture. The verticals are based on the application context like aphasia test functionalities, and their scope is limited to a specific domain, for example the service responsible to make the test results interpretation. The horizontal services are based in the system infrastructure and they are acceded by services from different application layers. They are not limited to a particular domain, for example the authentication service, which provides security in all application layers.
This service based design proposal has as objective the application units creation with a well defined purpose, weak connection and isolated to each other, using a standard communication mechanism. The software and hardware infrastructure necessary to implement this application is conformed by an application server, a web server and a database organized according to security policies implemented in the university network, as described in the Figure 1.

Development
The application development was performed using an iterative and incremental process, it means that the project scope was divided in smaller subprojects handled individually for time and resources allocation. Each subproject had its own lifecycle and the necessary autonomy, to generate a tested deliverable ready to be implemented; providing the basis for another subproject or being a component ready for deployment in the execution runtime if it has not dependencies.
The identified subprojects were: Most of the item scores are associated to the number of attempts needed by the patient to get the correct answer, having a maximum of three attempts per item. During the interview, the evaluator considers the following aspects that will conform the COMPLEMENTARY CONDUCTAL EVALUATION: • General aspect. domain model was created to reflect the test main objects in a high abstraction level. After this model construction, activity and sequence diagrams were developed to validate and decompose the identified objects from the previous step. Both diagrams allowed a valid design model definition, using it as a input to start with each module codification. For the application development an own n-layers development framework was employed; it is based on Java EE [5] implementing software patterns [6] used in previous web applications deployments in our site as shown in the Figure 2. For this project it was necessary to incorporate one module in the framework above mentioned to facilitate the web services implementation for the developers. This module has functions such as interface definition, data transformation and message generation following the W3C (World Wide Web Consortium -http://www.w3.org/) specifications. Following the objective related to enable the automated test execution without a Internet connection, a complementary application was designed having the same screen as the web version, to avoid a double learning process by the doctors interested in its implementation. The Figure 3 shows an screenshot for this application. This complementary software has additional screens for modifications, deletions and queries to the tests saved locally. This information is saved using a local text file and it can be sent to the web site as an input for the statistics database running on it. This information upload can be made by e-mail or from the web site, the site has an option to allow this upload for authenticated users. The application also has an option to export the local text file contents to a spreadsheet, facilitating its reusability in statistic or data analysis applications. Regarding its distribution an executable file is delivered including a user manual with detailed instructions for a correct installation and use. For this operation, the user needs to use the same user/password combination used to log into the web site.
To collaborate with the results analysis, a screen was implemented to visualize an interpretation guideline based on an exploratory response weighting as shown in the Figure 4, which reflects the different patient impairment levels, according to the correct responses percentage achieved in each items subset associated to the neuropsychological functions explored by the test: • RED -0% to 33%: Severely affected function.
• GREEN -67% to 100%: Slightly affected function to normal performance. A key generation algorithm was implemented with the objective to identify in unique form each test in the web site, including those from the complementary application which runs without internet connection.

Conclusions
The present project brought to the university community a suitable methodology to implement a service oriented architecture using software patterns, based on a real life application case. Some presentations were made about this methodology and the acquired knowledge is used as a subject on the courses included in the system engineering career. Additionally, a new service integration layer was added to our development framework, based on a java classes collection which provides a simple interface for web services implementation, hiding the complexities related to this technology for the developer.
Regarding the test execution result transference, the Cordoba Hospital Neurosurgery Service and the Philosophy and Humanities Faculty-Research Center of the National University of Cordoba are using the test in an experimental way having the paper version replacement as objective. The automation provides greater precision and speed in the results calculations for the different groups of subjects studied; avoiding the manual register of each interviewer answer for later processing.
Any health institution (public or private) with a service of Neurology or Psychology is a potential user of this development. The automated aphasia test is available in the following web site: http://neurotests.frc.utn.edu.ar. Additionally, the site provide the aphasia test in a pdf format in english or spanish to be used manually, as well as theoretical sources, development framework details and a demo to know the test functionality. In order to use the test with all the functionalities enabled or to download the complementary application to be used without internet connection is necessary to send an e-mail to nsvigliecca@hotmail.com. Dr. Vigliecca will contact to the interested ones to provide more details about the test objectives and finally give a username and password so they can be authenticated in the web site. Thanks to this project, the authors are working in different commissions for an initiative organized by the Dirección Nacional de Programas y Proyectos Especiales (DNPyPE) member ot the Secretaría de Ciencia, Tecnología e Innovación Productiva (SECyT), to advance in the telemedicine instrumentation in Argentina based on a government policy establishment. As consequence of these commissions work, the authors are working on the message format and security, to be conform with the law established by the argentine legislation, according to these laws promulgation: Personal Data Protection (Id 25326), Digital Signature (Id 25506) and Information Confidentiality (Id 24766).
At this moment, this project complements to other denominated "Cognitive and behavioral models of evaluation for clinical and experimental research in neuropsychology and psychopharmacology" from the CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas), and represents an interaction model with health professionals and computer science engineers.