1(#total) CS5038 The Electronic Society Lecture 9: eHealth Lecture Outline The Future of Healthcare - The banking metaphor Existing Health on the Web eHealth.

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CS5038 The Electronic SocietyLecture 9: eHealthLecture Outline

• The Future of Healthcare - The banking metaphor• Existing Health on the Web• eHealth - terminology• Transmural Care• Electronic Medical Records (EMR)• Medical Records - Access• Clinical Decision Support Systems • Telemedicine - Case Studies• eHealth Standards • eHealth / eScience : Cancer Diagnosis• Benefits of eHealth• Medical Errors• Why is eHealth Adopted Slowly?• New sources of "health"

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eHealth - The Future of Healthcare The banking metaphor

Most transactions carried out by the customer

Centralisation of specialist services

Decentralisation of non-specialist services

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Existing Health on the Web

Estimated to be ~20,000 health websites1

Used by 98 million adults2

75% of people who have web accessaverage of 3.3 times per month

More than consult doctors each day3

7M e-patients/day on the net; 2-3M patients see a doctor

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Existing Health on the Web

Access to accurate information can lead tomore knowledgable, empowered, less anxious

patientsmore participatory health decisionsbetter care as patient and doctor become partners

Mis-information can lead to confused and angry patientsbad decisions, mis-placed hope, worse care, harm

Privacy violations can cause emotional and economic damage

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eHealth“Healthcare which is supported by electronic

processes”

Other terms:Healthcare informatics or Health Information

Technology (HIT)Medical Information Systems (MIS)Biomedical informatics (also includes Bioinformatics:

gene sequencing etc.)

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eHealth“Healthcare which is supported by electronic processes”

eHealth includes: Electronic Medical Records: easy communication of patient data between different

healthcare professionals (GPs, specialists, care team, pharmacy) Telemedicine: do not require a patient and specialist in same physical location.

Decision support systems in healthcare Data can be analysed to provide alerts, reminders and real-time decision aids

Evidence Based Medicine: The application of the scientific method to medical practice Check if diagnosis is in line with scientific research. Data can be kept up-to-date.

Citizen-oriented Information Provision: for both healthy individuals and patients Specialist-oriented Information Provision: best practice guidelines from latest

medical journals. Virtual healthcare teams: collaborate and share information on patients through

digital equipment (for transmural care).

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Transmural Care

Transmural: Care should not stop at the walls of the hospital Both intra- and extra-mural, thus ‘transmural care’. Care before, during and after the hospital stay. Cooperation and coordination among local practitioner,

hospital, home care and rehabilitation centres Patient part of an agreed programme - protocols and

standards.

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Electronic Medical Records (EMR)(also called Electronic Health Record (EHR))

Access of patient data by clinical staff at any given location Accurate and complete claims processing by insurance

companies Building automated checks for drug and allergy interactions Clinical notes Prescriptions Scheduling Sending and viewing labs

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Electronic Medical Records (EMR)(also called Electronic Health Record (EHR))

NHS project in UK: One of the largest projects in the world for a countrywide EMR Goal: 60,000,000 patients with centralised EMR by 2010.

Two types of record: “Born digital" record : information originally entered in

electronic format “Digital format” record : originally produced in a hardcopy form

(x-ray film, photographs, etc.), scanned or imaged and converted to a digital form.

Also: Personal Health Record (PHR) - stored and maintained by the patient.

Issue: Home computer vulnerable to attack

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Electronic Medical Records (EMR)

Maintaining Records May be required many years after a patient’s death

Insurance claims or murder investigation Investigate illnesses within a community

• industrial or environmental disease

• doctors committing murders

need for periodic conversion and migration to ensure the formats they were captured in remain accessible

Media degrades Media becomes obsolete protection of privacy is a major concern - need privacy and

security policies

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Electronic Medical Records (EMR)Abuses Outsourcing of transcription and storage: Could violate

patient-physician confidentiality Governments may refuse to disclose records of military

personnel used as experimental subjects. http://www.guardian.co.uk/military/story/

0,11816,1331784,00.html

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Medical Records - AccessLaws governing access to medical records:

In the UK: Data Protection Acts & Freedom of Information Act 2000

Patients or their representatives have the right to a copy of their record. Except:• where information breaches confidentiality

(e.g. information from another family member or where a patient has asked for information not to be disclosed to third parties)

• where information would be harmful to patient's well-being (e.g. some psychiatric assessments).

Patients have the right to check for any errors in their record and insist that amendments be made if required.

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Medical Records - AccessLaws governing access to medical records:

In the US: Only patient and health care providers directly involved in delivering care

have the right to view the record. Patient may grant consent for any person to evaluate the record. Special Situations.

Capacity

• When a patient does not have capacity, a legal guardian is designated Medical emergency involving a non-communicative patient

• Consent is assumed unless written documentation has been drafted previously

Research, auditing, and evaluation

• Individuals involved in research have access. They are not allowed access to identifying information.

Risk of death or harm

• Information can be shared without permission if failure to do so would result in death or harm.

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Clinical Decision Support Systems Software to aid clinical decision-making; characteristics of patient

are matched to knowledge base, recommendations are presented to the clinician/patient

(Sim et al, JAMIA, 2001)

Objectives: Diagnostic support Drug dosing Preventive care reminders Disease management (diabetes, hypertension, AIDS, asthma) Test ordering, drug prescription

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Clinical Decision Support Systems

Methods:

rule-based, bayesian network, neural network, fuzzy logic, genetic algorithms, case-based reasoning, etc.

Forward reasoning (data-driven) use if sparse data start with data, execute applicable rules, see if new

conclusions trigger other rules: if high WBC AND cough AND fever AND etc. =>

pneumonia if pneumonia => give antibiotics, etc.

Backward reasoning (goal-driven) use if lots of data start with “goal rule,” determine whether goal rule is true by

evaluating the truth of each necessary premise patient with lots of findings and symptoms is this lupus? => are 4 or more relevant criteria satisfied?

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Telemedicine “The delivery of medicine at a distance.”

Two basic forms: Live telemedicine - videoconference link Store-and-forward telemedicine - transmit for assessment

offlineTypical Telemedicine interaction: store and forward followed by

live interaction.

Data types text (e.g. patient's notes) image (e.g. x-ray) Telemedicine often relies on images (still or

moving)

Equipment general purpose (e.g. PCs) specialist (e.g. electronic stethoscope)

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Telemedicine (contd.) “The delivery of medicine at a distance.”

Telemedicine most useful when Specialist services are in very high demand or Patients are extremely isolated (Antarctica or remote

communities in Australia, Africa and Alaska)

Home care is often delivered by telemedicine Automatic monitoring and pill dispensing etc.

Telesurgery may also be considered as a subset of telemedicine.

Patient operated on by remotely controlled robotic arms etc.

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Telemedicine - Case Study8 Cornwall hospitals - Minor Injury Units:

replacing "unviable" accident & emergency departments nurse led

Before: No access to specialist consultants Long wait for GP to be called in

After: Linked to specialist consultant in Royal Cornwall Hospital Recorded sessions useful for training nurses and for audit Cornwall Healthcare Trust expects to save £100,000 a year

http://www.bthealth.com/casestdy/cstudy/case11.htm

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Telemedicine - Case StudyNHS Direct

http://www.nhsdirect.nhs.uk/

Biggest telemedicine project in the worldMainly telephone service Expanding to:

Web Online diagnosis for common conditions Health encyclopaedia My NHS healthspace (personal info portal): news,

reminders, knowledge Digital TV

More information on Telemedicine: www.teis.nhs.uk

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eHealth Standards Not-for-profit organisations involved in the standardization

process American Society for Testing and Materials (ASTM), Health Level 7 (HL7) Healthcare Information and Management Systems Society

(HIMSS) CEN (European Committee for Standardisation) ISO TC215

Controlled medical vocabularies: Standardized Nomenclature of Medicine, Clinical Terms

(SNOMED-CT) Logical Observation Identifiers Names and Codes (LOINC) OpenGALEN Common Reference Model

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eHealth / eScience : Cancer DiagnosisTelemedicine on the Grid Multi-site videoconferencing Real-time delivery of microscope imagery Communication and archiving of radiological

images Supports multi-disciplinary meetings for the

review of cancer diagnoses and treatment. Remote access to computational medical

simulations of tumours and other cancer-related problems

Data-mining of patient record databases Improved clinical decision making.

Currently clinicians travel large distances

Grid technology can provide access to appropriate clinical information and images across the network.

More Information:

http://www.escience.cam.ac.uk/projects/telemed/

http://www.rcuk.ac.uk/escience/examplesh.asp

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Benefits of eHealthReduced record keeping expensesMore accurate data

No poor handwriting problemsAutomated sharing among patients and provider

Empower the patient to manage their own health - via Internet information and decision support tools

Reduced office visits to get resultsAvoidance of duplicating testsAutomatic summarisation/graphical displays of

context-relevant information to the physician

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Benefits of eHealth (contd.)

Decision Support Tools -> Improved decisions Remote access to data - e.g. ill while travelling Improved workflows Decreased risk of malpractice suits Ability to mine large record databases

Research causes of disease Assess effectiveness of treatment programmes/drugs Monitor outbreaks of diseases Easier to conduct clinical trials and rapidly incorporate

research results in decision support tools

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Medical Errors

Human Errors:IOM Report, 199944,000 to 98,000 die in US annually from medical

errors at 44,000, would rank as 8th leading cause of

death• car accidents: 43,458• breast cancer: 42,297• AIDS: 16,516

7000 deaths from medication errors alone

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Medical Errors

Does Software Help?

Therac-25Radiation therapy machineAt least six known accidents between 1985 and 1987Patients were given massive overdoses of radiationAt least five patients died of the overdosesCauses: both organisational and technical

100 medical software recalls annually, 40 for software errors

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Inte

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f IT

Inte

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f IT

IT as a gadgetTrojan horse: networks, …Full Integration of IT into Business (Organisational, Legal) Re-engineering of the system

19801980 19901990 20002000 Jean-Claude HealyJean-Claude HealyMay 2000May 2000

Manufacturing

Business Services(Banks)

Public Services(Health…)

Why is eHealth Adopted Slowly?

2005 - WRONG!2005 - WRONG!

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Why is eHealth Adopted Slowly? Lags behind other industries by 10-15 years Complex regulations - e.g.

Patient records Privacy laws

Lack of interoperability/standards Doctors reject IT systems

Risks Potential for errors due to software bugs Highly coupled systems - greater risk of catastrophe Decision support systems could lead to mass produced

mistakes Privacy - data vulnerable to attack

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Why is eHealth Adopted Slowly?

Many projects have been abandoned after massive investmentReport by Standish Group (‘95):

$250 billion each year on 175,000 IT projects 31% projects cancelled before completion = $81

billion for canceled projects 53% of projects cost 190% of estimated costs

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New sources of "health" 1

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New sources of "health" 2

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New sources of "health" 3

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eHealth - Busan, S Korea

Medical Tourism2 hours by air for 2 billion people

1% with disposable income = 20 millionCardiac - Cancer - Mental HealthCosts can be competitivePopular tourist resort for families

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SummaryThe Future of Healthcare - The banking metaphorExisting Health on the WebeHealth - terminologyTransmural CareElectronic Medical Records (EMR)Medical Records - AccessClinical Decision Support Systems Telemedicine - Case StudieseHealth Standards eHealth / eScience : Cancer DiagnosisBenefits of eHealthMedical ErrorsWhy is eHealth Adopted Slowly?New sources of "health"