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e-Health

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e-Health

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  1. e-Health Jim Hunter

  2. Outline • What is e-Health? • Stuart ScottGP/Clinical Director e-Health NHS GrampianTuesday 5th December • e-Health research at Aberdeen

  3. e-Health - Definitions • EUThe use of modern information and communication technologies to meet needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers. • World Health Organisation (WHO): • eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research.

  4. NHS – Connecting for Health • National Programme for Information Technology (2002-2010) • CRS: "a secure, shared national Care Records Service for England". Designed to replace existing electronic and paper based systems for all patients in England. • Choose and Book - electronic appointment booking system for GPs/hospitals and patients • ETP - Electronic Transmission of Prescriptions: a system designed to support the electronic transmission of prescriptions between GPs (General Practitioners), pharmacies and the Prescription Pricing Authority (PPA) • HealthSpace: a web service allowing patients to access their own NHS care records • Picture Archiving and Communications Systems (PACS) • Quality Management and Analysis System (QMAS) (for primary care)

  5. NHS – Connecting for Health • N3: a new national network to provide broadband network capacity and support interoperability between above applications and activities such as telemedicine and telecare. • the Spine: the "core data storage and messaging system" underlying and integrating the CRS and associated functionality. Standard terminologies will include SNOMED CT. Health Language Inc.'s language engine technology will support interoperability, including integrating and sharing patient data. • Decision support: the electronic prescribing programme (support for prescribing in different care settings); online knowledge and library systems: integrated care pathways; NICE clinical recommendations; National Service Frameworks (NSFs); e-referral support; support for ordering clinical investigations; "accredited protocols of care, procedures and clinical guidance".

  6. Healthcare • Pervasive – involves everyone • I’ve never used eBay but … • Large • NHS employs about 1 M people • Diverse • different rates of change • Political

  7. Healthcare - Costs • Expensive EU - 2002 • expenditure on total health care as % of GDP: • from: 10.7% (Germany) to 6.7% (Ireland) – say 8% overall • European GDP ~ €10,000 B (1000 M) • so EU health care expenditure ~ €800 B (£570 B) UK 2002/3 2003/4 2004/5 2005/6 £56 B £64 B£69 B£76 B (estimated)

  8. Healthcare - People • Patient • Doctor • Nurse • Other health care professional • Pharmacist, Radiographer, Pathologist, … • Administrator • Finance, Human resources, Appointments, … • Researchers • Students

  9. Healthcare - Professionals • Professionals • Long Training (6+ years for doctors) • Large body of knowledge – constantly changing • Medicine is not an absolute science – uncertainty • Time pressures • Dealing with patients (not insurance quotes)

  10. Healthcare - Locations • Home • Primary care and local clinic • District general hospital many departments • Tertiary hospital + more specialised departments • Research laboratory • Classroom • Everywhere! …

  11. Healthcare - Sensitivity • Need for • Privacy • Security • Access • Right people • Right time

  12. Healthcare - Change • Not all organisations at the same stage. • Distinguish • What is all pervasive • What has been adopted by some but not by others • What is ready to be deployed • What is still ‘blue skies’ research

  13. Informatics • Input • Transmit • Store • Process • Retrieve • Transmit • Output Home

  14. Agent … Nurse Doctor Patient Home Surgery Location Hospital … Healthcare Informatics • Input • Transmit • Store • Process • Retrieve • Transmit • Output Home

  15. Computers vs Humans Human • Research and development • Treatment • Reasoning (diagnosis and treatment planning) • Processing • Data Acquisition, Storage and Retrieval • Data Transmission Computer

  16. Data Transmission • Use ‘standard’ technologies • fax • phone • email • intra-net • web • etc. • Encryption

  17. Telemedicine Patient (home) Local Hospital Remote Hospital GP National service • Remote monitoring for chronic illnesses • Diabetes • Renal failure • Cardiac problems • …

  18. Telemedicine Patient (home) Local Hospital Remote Hospital GP National service • 24 hour call centres • NHS Direct (England & Wales) • NHS 24 (Scotland)

  19. Telemedicine Patient (home) Local Hospital Remote Hospital GP National service • Sharing expertise • Video conferencing • Data sharing

  20. Data Acquisition • Human input • Unstructured - e.g. word documents • Semi-structured - e.g. free text in an input box • Structured (coded) – selection from a fixed list, check boxes, etc • Machine input (often with analogue/digital conversion) • Single point in time • Laboratory results • Images • Continuous • Physiological data

  21. X-Rays

  22. CT Scans

  23. ECG

  24. ICU

  25. Data Storage and Retrieval • ‘Standard’ database technologies • Can be very large • especially if picture achieving is involved (terabytes – 1012 bytes) • Coding is a real problem • signs (what the doctor can see and feel) • symptoms (what the patient says) • diagnoses • treatments

  26. Formal medical languages • Name objects and events in the external world • Need for sharing • Computerisation increases the need for precision • communication • audit • research • resource management • decision support

  27. Formal medical languages • Need for structuring • retrieval • abstraction • Hierarchies – dimensions/attributes/axes kind-of infection hepatitis viral hepatitis hepatitis-A part-whole body arm hand finger causal plaque thrombosis infarction arrhythmia

  28. Formal medical languages • Enumerative • List all the possibilities in advance (and structure them) • International Classification of Diseases (ICD) 9/10 • Compositional • Agree on a set of primitives which are combined • acute bacterial septicemia • Knowledge which controls the way in which terms can be combined • can’t say: a fractured lung • can say: a fracture of the second bone in the third toe of the left foot • Common • SNOMED, UMLS (USA) • Read (UK)

  29. Processing • Repetitious and formalised computations • construction of CT scans • 3-D reconstruction • image analysis • ECG analysis • radiation dose calculation • finance and accounting • administration

  30. ReasoningDiagnostic/Therapeutic Cycle Patient Observe Treat TherapyPlan Observation Reason Reason Diagnosis(Interpretation)

  31. Clinical Guidelines and Protocols • Clear statements of the optimal management for a specific group of patients which, when properly applied, will improve the quality of the care they receive. • Guideline • often formulated nationally or internationally • often evidence-based • widely disseminated • Protocol • more detailed • local (one clinician or group of clinicians) • often mandatory

  32. Computerised Protocols • Represent the protocol in a formal language • Apply the protocol automatically to the electronic patient record (EPR) • Present the advice from the protocol to the doctor or nurse

  33. Aberdeen Research • Neonatal Intensive Care • BabyTalk • Computerised Guidelines • TSNet

  34. A Neonatal ICU

  35. Data in intensive care • Continuous: • Monitor (one second resolution) : heart rate, blood pressures, O2, CO2, temperatures ... (i.e. 86,400 samples/channel/patient/day) • Sporadic: • Ventilator : Mode, pressures, FiO2, respiration rate … • Incubator : O2, temperature, humidity • On-ward blood gases : pH, pO2, pCO2 ... • Laboratory : Haemoglobin, Na, K, Urea … • Manual: Notes, medication, ...

  36. Complex high volume data

  37. BabyTalk • Textual summarisation of Neonatal ICU data

  38. Experiment: Graphs vs. Text • To compare the effects of • different presentations – graphical and textual • of the physiological history of a neonate • on decision-making • in terms of • 'accuracy‘ • response time • Hypothesis • clinical staff will make more accurate decisions when informed by graphical displays than by textual summaries.

  39. Graphs

  40. Text

  41. Appropriate Actions

  42. BabyTalk • EPSRC funded project • 4 years • 2 research fellows and 2 research students • BT- 45: Replicate the original experiment with automatically generated text • BT- Doc: Summarise several hours for clinical decision support • BT- Nurse: Generate 12 hour nurse shift summary • BT- Family: Reports for family members

  43. BabyTalk Architecture Numerical and Interval Data Abstraction Interval Pattern Recognition Interval ++ Content Determination Interval -- Text Generation Text

  44. Protocols in the ICU • Automatic Medical staff have no time to answer questions • Clinical autonomy • advice must always be advisory, not mandatory • must cater for differences in practice • between units • within units

  45. Protocols in the ICU • Timing • many medical decisions made at a daily or weekly ‘encounter’ with the patient • ICU: continuous • WHAT to do • WHEN to do it • advice provision • system often has access to actions taken by staff

  46. Protocols in the ICU • Access to data • humans and computers have different ‘windows’ on to the patient • computers have: • monitor data, lab results, etc. • humans have this plus: • sight, touch, sound, (smell, (taste)) • actions taken

  47. Protocols in the ICU • Data abstraction • protocols expressed in higher level clinical terms than the raw patient data • try to ‘reconstruct’ sensory input • deal with artefacts