1 Health Informatics: Applications, Requirements, and Emerging Research Upkar Varshney Department of CIS Georgia State University E-mail: [email protected].

1

Health Informatics: Applications, Requirements,

and Emerging Research

Upkar VarshneyDepartment of CIS

Georgia State UniversityE-mail: [email protected]

Format of the Tutorial

Health Informatics (HI) Information and Communications

Technologies in Healthcare Specific Examples of Health

Informatics Conclusions and Future

2

Health Informatics (HI)

The intersection of several fields including computer science, healthcare, and business

To provide the needed information anywhere anytime to anyone authorized in prompt, correct and secure ways

Resources, devices and methods to provide healthcare services

Consumer health informatics, nursing health informatics, organizational health informatics, public health informatics, and medical health informatics

3

E-health and Health Informatics

4

Health Informatics

E-health

M-healthEMRand

EHR

Devices

HealthInfo Syst

Telemedicine

Major Goals of HI

Reducing Various Errors in Healthcare Extending the Coverage and Delivery of Healthcare Improving Medication Adherence/Adverse Drug

Events Support Independent Living for the Elderly Improved Decision Making Wellness and Managing Chronic Conditions Improving Efficiencies and Reducing Overall Cost Supporting Patient Empowerment Addressing Limited Human Resources

5

Chronic Diseases

A disease for which there is no cure Managing it well to reduce other complications CDC: Chronic diseases – such as heart disease,

stroke, cancer, diabetes, and arthritis – are among the most common, costly, and preventable of all health problems in the U.S.

Heart disease, cancer and stroke: 50% of all deaths

The four most common reasons: lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption

6

7

Wellness and Proactive Health

People with good health need to maintain it Exercise, stress, food, sleep, weight

People with chronic conditions need to manage it Medications, sleep, weight

Elderly want to live independently Activities of daily living, medications, sleep,

weight, behaviour Use of ICT to enable monitoring and

management of health

IT-based Wellness Management

Various IT/communications technologies for sensors in shoes Internet-aware exercise machines cell-phone based applications for managing

wellness Wellness diary Social networking/group

communications/twitter Suitability/evaluation of technologies Theoretical Support (or lack of suitable

theories)8

Information and Communications Technologies

in Healthcare

Smart computing Wearable computing Sensors RFID Wireless LANs 3G/4G networks Personal area networks

9

10

Quality of data from sensors

HealthDatabases

Networking Infrastructure

Devices

Compressed andProcessed data

Quality of transmitted data

Quality of stored data

Quality of received data

HealthcareDecisionSystems

Quality of healthcaredecisions

Data frommultiple sources

(patients, doctors, labs, pharmacies)

Quality of lifefor the patient

Quality of network control data

Quality of Processed data

Quality of retrieved data

Quality of healthcare services

Quality of service

Quality of integrated data

The Big Picture

11

Improvements with Wireless Technologies

How wireless technologies can help improve healthcare systems worldwide

Wireless technologies can lead to the desired evolution of healthcare system

In general, these technologies can allow information to be available anywhere

any time to anyone who is authorized to access it make the delivery of healthcare services more

efficient reduce the number of tasks that need to be done

by healthcare professionals encourage patients to take better control of their

healthcare needs and life style

Healthcare Quality of Service (H-QoS) and Wireless Requirements

Real-time delivery Cellular/3G/4G

Reliability Challenges for most wireless networks

Wide Coverage Cellular/3G/4G, wireless LANs, satellites, ad hoc

networks Bandwidth

Wireless LANs and 4G networks Location Management

Cellular/3G/4G and wireless LANs Pricing

Wireless LANs 12

13

Suitable Technologies for Healthcare

Suitable technologies for healthcare: implanted (inside body), wearable, portable, and environmental technologies

Implanted technologies: RFID to store information and sensors to measure medical parameters

The wearable technologies: Smart Shirts with sensors designed to wear for extended monitoring of health conditions. Could be washed, ironed and charged for use, and in future, networked with devices and people

The portable devices, such as handheld devices and phones, used in monitoring and recording health conditions

Environmental technologies: computing and communications close to the patients (“Smart” Home)

14

Wireless Technologies in Healthcare

Cellular Networks Wireless LANs Sensors Radio Frequency Identification Bluetooth and ZigBee Satellites Characteristics: Indoor vs outdoor, real time vs

no real-time services, coverage (PANs to WANs), reliability, varying bit rates and levels of location-awareness

15

Sensors & Applications

Small devices with sensing, computation and wireless communications capabilities (not mobile!!)

Sensors measure ambient conditions in their surrounding environment and then transform these into signals (which can be processed to determine the conditions of the “sensed” environment)

Applications Use in wearable, portable and environmental

implementations (Smart Shirt, Smart House, Appliances) Monitoring of vital signs Many more applications with sensor networks (fall

detection with embedded “smart carpet”)

16

Mobile monitoring devices

Implanted, portable, wearable or in the surrounding environment

Devices with sensors to measure a range of vital signs and other parameters for its patient

The devices with intelligence would detect certain conditions by the touch of a user

Many of the smaller medical devices can be integrated in the hand-held/wearable wireless device Pulse-rate, blood pressure, level of alcohol

Specific requirements of vital signs how to measure and process vital signs such as blood

pressure (BP), ElectroCardioGram (ECG), temperature, oxygen saturation

Each of these requires different type of sensor(s) at a certain part of human body

Sensors in Healthcare

17

ECGSensors

SpO2 sensor

Blood pressuresensors

Temperaturesensors

+ Sensors on Neck, Bed, Kitchen,

Appliances, and Bathroom

Sensor locations and user movementReliability of sensorsUnintentional removal of sensorsWear and tear of sensorsSensor-body contact/noiseConnectivity for body area networksFalse positive/false negative

18

D

ECG Signal (60-80/min)

1 beat 240 samples/sec12-36 bits/sample 2.9-8.7 Kbps

Multiplemessagesper minute

Vital SignsSampling rateQuantization Minimum bit rate

Breathing (12-18/min) 1 sample/sec4 bits/sample 4 bps

Body core temperature (97.1-99.1F)1

sample/min16

bits/sample

0.3 bps

Oxygen Saturation (95-99%)1 sample/sec16 bits/sample 16 bps

Blood pressure (Sys<120, Dia<80)

1 sample/minute64 bits/sample 1 bps

19

Radio Frequency Identification (RFID)

Location tracking of Patients and healthcare professionals Supplies, equipments, and blood

Authentication of expensive medications Storage of (compact) information (such as EMR) (Ingestible) RFID on “smart” capsules to

monitor the condition of internal organs (GI tract diseases)

Further Research: Requirements of new applications/bio

compatibility/side effects/long-term use Cost-benefit of RFID deployment

20

Smart House

Assistive environments (for older and/or disabled people) for sensing themselves and their residents

Gator Tech Smart House at University of Florida smart blinds to control ambient light (and privacy) smart bed to monitor sleep patterns smart closet to make clothing suggestions smart mirrors for messages & reminders for

medications smart bathroom with sensors for measurement of

weight, height and temperature, and ECG SmartWave to refuse to heating up the items that you

are not suppose to eat social-distant dining using immersive video smart floor for fall detection

Smart House

21

Smart mail-box

DrivingSimulator

Smart FrontDoor

Smart Mirror& Bathroom

Smart Closet

(Future)

Smart BedSmart

Laundry(Future)

Smart FloorSmartPlugs

Smart Blinds

SmartProjector

HomeSecurityMonitor

Memory Support System

Fall Prevention and Detection Systems

Smart Medication SystemENERGY

AWARE

SYSTEM

Daily Activity Support System (context-aware)

RELIABLE

SYSTEM

Social Interaction/Entertainment System

ALERT&MONITORING

22

Cellular/3G/4G Networks

Offers from about 100 Kbps to 2 Mbps Designed to support multimedia, data, and video Short Messaging Service

stored & delivered in few seconds (not real-time) reminders, or compressed information on patient

General Packet Radio Service (GPRS): 160 Kbps Enhanced Data rate for GSM Evolution (EDGE):384

Kbps 4G (not available in places where patients may live)

but useful for video-oriented healthcare applications Telemedicine, tele-radiology, tele-surgery Video-clips of patients, healthcare professionals

23

Wireless LANs: IEEE 802.11a, 802.11g,

802.11n

802.11a Supports 54 Mbps in 5 GHz band (smallest

range) 802.11g

Supports 54 Mbps in 2.4 GHz band 802.11n

As high as 600 Mbps and up to 70 meters (indoors) and 250 meters (outdoors)

5 GHz and 2.4 GHz both possible Useful for independent homes, assisted

living and nursing homes

Cell Cell

BS/Terminals

User

24

Bluetooth and ZigBee In Healthcare

Bluetooth: Unlikely to be a standalone technology due to short range (10m), limited bit rate (few hundred Kbps) and not more than eight devices in a piconet

The range could be increased by adding Bluetooth adapters in hand-held devices and phones

ZigBee: ad hoc and mesh networking format One of the intended environments is Hospital Care More likely to be a front-end technology and will

require another network to carry monitoring messages to one or more healthcare professionals

Sensors: Bluetooth or ZigBee for communications to other devices or among themselves (sensor networks)

Comparison of Wireless Technologies

25

Wireless Technologies

Coverage Bit rate Cost Number of patients

Suitability

Personal Area Networks (Bluetooth)

Small (about 10meters)

Few hundred Kbps

Low with inexpensive adapters

A few (8 or less active per piconet)

Could work well in conjunction with other wireless networks

Wireless LANs (IEEE 802.11)

Small (about 100 meters)

Several Mbps

Low 10-100 Suitable for homes, assisted living, and nursing homes

Cellular/3G Wide area (nationwide)

Few Kbps to several hundred Kbps

High subscription/usage charges

1000s With commercial traffic, sometimes bandwidth not available

Satellites Wide area Few Kbps to several Mbps

High subscription/usage charges

100s (limited uplink bandwidth)

Primarily outdoor or line-of-sight and may work well as the secondary network

Fixed wireless

Metropolitan Up to several Mbps

High subscription/usage charges

100s (limited to the same general area)

Patient mobility is difficult to support

26

Wearable Computing: Variations

Smart Shirt Networkable

ChargeableWashable

Monitoring of vital signsUser programmablePrivacy support

Context-awareness

27

Vital Signs

Environmental

Variables

Current Activitie

s

Sensory Informatio

n

Prescribed Medicines

Unusual Conditions

ThresholdsRate of ChangePrevious Values

Medicine1, ..NRecent dosesMissed doses

PatientHandicaps

PhysicalCognitiveSensory

SweatPalpitationsBreathing

SittingWalkingRunningSleeping

TemperatureHumidityAir quality

Recent Lab-results

Filtering&

InformationIntegration

Patient’s Medical History

Type of Health

Monitoring

ContextGeneration

and Processing

Patient InfoAnd Context

28

Obtain Vital_signs and thresholds

If Vital_sign<Thres2(low) Emergency Level = HighTransmit Emergency Signal

Yes

No Yes

No

No

YesIf Vital_sign<Thres1(low)

EM-Points = EM-Points + Thres1(low) - Vital_sign)

If RT_CHNGE>RT_THRSLD

EM-Points = EM-Points + POINTS_RT_CHNGE

If CURR_ACTIVITY = RESTING

EM-Points = EM-Points + POINTS_RESTING

No

EM-Points = EM-Points + Thres2(high) - Vital_sign

If Vital_sign<Thres1(high)Yes No

If Vital_sign<Thres2(high)

Yes

Yes

If EM-Points >= EM_Thresh-H

No

YesNo

If EM-Points >= EM_Thresh-MEmergency Level = MediumTransmit Abnormal Signal

Yes

No

If Curr_TM>= RPRT_TM

Transmit Normal Signal

Yes

29

Wireless Networks

Monitoringdevice Healthcare

Professional

Patient Information

Monitoring of Alert Generation

Monitoring of Alert Transmission

Monitoring of Alert Processing

Monitoring of Decisions/updates

Monitoring System

The Monitoring of Monitoring System

Specific Components

EMR/EHR Telemedicine and Health monitoring Medication monitoring and

management Independent Living and Activity of Daily

Life Medical and clinical decision making

30

EMR/EHR

31

Orders for lab tests

Orders for medications

Updated refills

Patient Information

Physician’s notes Test results

Physician

EMR

Source A Source B

Source C

Laboratory

Pharmacy

Hospital

12

3

45

6 7

89

More Research in EMR/EHR

Patient information from multiple sources Verification by patients/healthcare professionals Tagging (source, time)

Use of handheld devices to access EMR Displaying important information first/Cognitive load Viewing part of EMR on small screen vs all on big screen

Reliability of Mobile Infrastructure Coverage, access and delay

Access to EMR in Emergency Use of stored information on patient’s body (RFID/shirt)

32

33

Health Monitoring: Vital Signs and Processing

ECG Signal (60-80/min)

1 beat FECG samples/secBECG bits/sample

Messages

Vital Signs (Nominal Values)

Sampling rateQuantization

Breathing (12-18/min) Fb samples/secBb bits/sample

Body core temperature (97-99 F) FT samples/secBT bits/sample

Oxygen Saturation (95-99%) FSPO2 samples/secBSPO2 bits/sample

Blood pressure (Sys<120, Dia<80)FBP samples/secBBP bits/sample

Fb Bbx

FECG BECGx

FBP BBPx

FSPO2 BSPO2x

FT BTx

34

5.4 Processing of Vital Signs and Parameters.

Vital Sign & Parameters Sampling rate Quantization Total bit rate

Breathing rate 1 sample/sec 4 bits/sample 4 bps

ECG 240 samples/sec 12-36 bits/sample 2.9 to 8.7 Kbps

Blood Pressure 1 sample/minute 64 bits/sample 1 bps

Oxygen Saturation 1 sample/sec 16 bits/sample 16 bps

Core body temperature 1 sample/minute 16 bits/sample 0.3 bps

Transmitting video can add considerable traffic depending on the duration, frequency, resolution, frame rate, and compression

35

Types of Monitoring

Monitoring

Behavior

DementiaDeliriumDisabilityAutism

MedicationsAdherence/abuse

HypertensionDiabetesRheumatoid ArthritisDigestiveRespiratoryCardiovascularNeurologicalRenal

Sleep EatingPattern

Sleep ApneaREMSleep BehaviorSleep WalkingSleep Talking

BingingPurgingAnorexiaBulimiaObesityDiabeticRenalCardiacGeneral Health

36

Threshold-based (multiple vital signs)

Vital-sign(Y)

Vital-sign(X) Vital-sign(Z)

Vital-sign(W)

Inter-relationship amongVital-signs

Emergency Level=Medium

Emergency Level=Medium

Emergency Level=High

Emergency Level=HighThreshold2(Low)

Threshold1(Low)

Threshold1(High)

Threshold2(High)Alerts/Alarm

Alerts/Alarm

Abnormally high (checkfor related problems)

Abnormally low (checkfor related problems)

Normal (but still checkother vital signs)

Emergency Level=Low

37

Cellular/3G/4G for Monitoring

Advantages Real-time Delivery Wide Coverage Bandwidth for WHM Ability to Work with other Wireless Technologies Widely Used Technology Secure Location Management

Limitations Availability and presence of dead-spots Reliability Challenges Lack of Broadcast/Multicast Pricing and the impact of commercial traffic

38

Experience in using Cellular/3G/4G

The cost was a major factor for many users and even some hospitals

The quality was variable (packet loss, delays, disconnections)

Sometimes healthcare professionals were not reachable (coverage, network overload problems)

Patients were not always able to access the network (access and coverage problems)

Sometimes the device battery was a limitation Video quality was variable (bandwidth issues)

39

Wireless LANs for Monitoring

Advantages: Bit Rates Transmission from Patients to AP (access point) Support for Mobile Patients Location Management

Limitations Limited Coverage Security Monitoring Delays Co-located Networks Reliability Multicast

40

Experience in Wireless LANs

The coverage was unpredictable The data speed was variable (monitoring

delays were highly variable) Shared bandwidth Interference in shared unlicensed ISM band

The device could not access the network Reaching to HP was difficult Sometimes video quality was not good

(variable delays)

41

Lack of Medication Adherence

With prescriptions (2010) at 3.5 billion/year, prescription medications a major component of healthcare expenses

From no-use (about one third), infrequent use (about one third), to overuse to abuse (about one third)

The non-adherence leads to 125,000 deaths and $90 billion in additional hospitalization and procedures

People who miss their doses are three times more likely to see doctors again, resulting in further increase in healthcare expenses

About 20% people in US have used prescription drugs for non-medical reasons (prescription drug abuse)

42

Smart Medication Management System

Medication is only dispensed certain doses at certain number of times a day to certain people

SMMS to keep track of the time and the number of times/day a certain medication was taken (also how many times the medication system was attempted to be opened unsuccessfully)

Physicians can check/communicate with SMMS on medication adherence and/or abuse before renewing the prescriptions

SMMS can prepare and transmit short video clips of various actions of the patient

43

MedicationManagement

System

Notification/Alerts

To physicians

To pharmacists

To insurance companies

To designated family members

Satellites

Wireless LANs Wireless LANs

Cellular Networks

Device-NetworksInteraction

WirelessPersonalAreaNetwork

Inter-deviceInteraction

Healthcare Professionals-Patient Interaction

Reminders/alarms

MMS-PatientInteraction

Program/controls

Adherence monitoring

Abuse monitoring

Context-aware Reminders

44

Reminder 1 Reminder 2 Reminder 3

Medication Time

Med ABC (1T)

Med XYZ (2T)

Medication Time

Med ABC (1T)

Med XYZ (2T)

Medication Time

Med ABC (1T)

Med XYZ (2T)

Using SMMS in Multiple Interventions

45

Adherence/side-effects

Report (adherence and patterns of use)

Advice(Scheduling)

Dosing-changes

SmartMedication

Management System

Dispensing of Dose

Sensing of Patient’s actions

Support from family and friends

Context-aware reminder(s)

Support from Healthcare

Professional

Social Support/Motivation

46

The (Seniors or) Elderly

Eligibility for Medicare = 65 = senior citizen/geriatric

“old” (65-85) vs “very old” (85+) 700 million seniors Worldwide (1.3 billion in

2040) US life expectancy=78

People at 65, expected to live another 18.7 years

Women outnumber the man in the elderly population Independent

HouseAssisted Living

Facility

Hospice/Terminal Care Facility

Hospital

Nursing Home

47

Age, Abilities and Deficits in Percentages

AgeSensorimotor and cognitive abilities (average)

Deficit (average)

Technology support needed for daily

activities

60-70 100-90 0-10 Minimal

70-80 70 30 Moderate

80-90 50 50 High

90+ 0-10 90-100 Very high

48

Activities of Daily Living and Falls

ADL includes hygiene, food, social needs, medications, sleep, managing chronic conditions, safety and financial needs (video clips of ADL)

Elderly with increased susceptibility to falls (hours or days before someone finds out)

Health complications due to falls and the delayed response increases the severity of such conditions

Detection of falls an important requirement Automatic detection of falls based on

detection/estimation of posture and pressure on sensor-equipped floors

Visual fall detection along with context information

49

Grand Challenge

A 70 year old widow at home all by herself Mild cognitive impairment, but does most of the

household work on her own Wants to remain as much independent as possible (grown

up children in another state, but call to check if she is fine) Wants to help her friends with similar problems Multiple chronic illnesses requiring multiple medications If not taking medications, her condition may become

acute Partial compliance: one or more side effects A visit from home health nurse once a week Goal to manage chronic conditions and delay her

transition to assisted living/nursing home for 10 years (independence and $500,000 savings in her nursing home expenses)

50

Suitable ICT for the Elderly

Appropriate for sensori-motor and cognitive problems wearable, portable, implanted, and environmental Another classification can be

simple: computers, Internet, websites, cell phones and alarm Intermediate: RFID, emergency alarms, medication and task

reminder systems, fall detection systems Elaborate: Smart Home and all smart devices

Reliable, smart and context-aware, personalized, robust, self-configuring, and no harm to the patients

Cognition, including executive function, decision making and dual-task performance, decline with age (dual-task could lead to increased task complexity, may lead to falls, especially if the home is not well kept)

Some Examples of Current Research

Monitoring and stray prevention system (RFID, GPS, GSM and Geographical Information Systems)

Markov decision processes (MDPs) to provide prompts to a user for guidance through the activity of hand-washing

Wrist-worn integrated health monitoring device (WIHMD) for fall detection, ECG, blood pressure, pulse oximetry, respiration rate, and body temperature

Selective video-clips for automated/human analysis (even remote help based on the context)

51

Medical Decision Making

Complex in terms of number of parameters and variables, outcome possibilities, and information that must be processed

Healthcare professionals need to make these complex decisions with no margins for errors

15% of medical decisions lead to misdiagnosis Cognitive load (Sweller, 1988): Excessive

cognitive load could affect the quality of decision making (medical errors and lower quality of healthcare services) and mobile devices could make it worse

52

Cognitive Load and Decision Making

53

Intrinsic Cognitive Load

ExtraneousCognitive Load

GermaneCognitive Load

Total Cognitive Load

+

Visual Component Quality of

Decision Making

Cognitive Capacity(Working Memory)

Residual Load

AudioComponent

PriorExperiences

Mobile Alert to Healthcare Professional

54

PATIENT-ID = U93

BP = 140/90SPO2 = 99

Temp=98

Medications

Screen 1 Screen 2

Screen N

Pulse = 120

Simple Decision Making

(context-aware system)

55

PATIENT-ID = U93

Do Nothing

Get More Information

Hospitalize

Get More Information

Call a Physician

Hospitalize

Likely condition 1

Likely condition 2

56

Conclusions and Future

Health Informatics is one of the most exciting advances in healthcare and computing

With the increasing cost of healthcare and limited healthcare professionals, health informatics can play a very important role in the future of healthcare

How information can be used most effectively in various healthcare processes (EMR/EHR, health monitoring, medication adherence, and medical decision making)

57

Conclusions and Future

HI can further lead to many important advances in healthcare and technologies Proactive health and wellness management Design and use of medications that are most suited to

individual patients Healthcare systems that are context aware to provide

necessary interventions for health and medications Smart technologies that can sense and support the

needs of elderly in independent living Personalized and intelligent monitoring of patients can

lead to better health outcomes at lower healthcare cost

Questions?

58

For more information:

Pervasive Healthcare Computing

EMR/EHR, Wireless and Health MonitoringVarshney, Upkar 2009 (Hardcover)ISBN: 978-1-4419-

0214-6Springer.com