Outline ehealth & telemedicine László Daragó Ph.D. associate professor Semmelweis University Health Informatics Institute Introduction Definitions Expert systems and telemedicine Protocol vs. eprotocol Telemedicine architecture Communication model Financial model The phases of creating eprotocol Legal and ethical questions Our participation in the developing ehealth & telemedicine L. Daragó Ph.D. 2/39 Challenges of the future Ageing population Rising costs of healthcare Growing expectations of citizens Improving Patient safety Addressing mobility of patients Support to healthier lifestyle (health promotion) ehealth & telemedicine L. Daragó Ph.D. 3/39 ehealth & telemedicine L. Daragó Ph.D. 4/39 Problems 1) The rising cost of Health Care High Transaction Cost (Manual processes, duplication, etc) Inefficient economic/market forces (Visibility, incentives, mind set) Inefficient Information Flow (Clinical and Administrative) 2) Timeliness and Accuracy of Health Care Information Specialist needs patient EHR from primary care physician Doctor needs to know drug information (quality, price & interactions) before prescribing Patients needs to share their EHR/Rx with multiple providers Doctor needs timely and accurate lab information to make diagnosis 3) Access to Care Patient needs to physically go see doctor to get EHR and advice Problem Statistics-Timeliness & Accuracy A Study from the Health Care Industry Organization shows: 57 % of patients had to tell the same story to multiple health professionals 26% received conflicting information from different health care professionals 22% had duplicative tests ordered by different health professionals 25% of test results didn t reach the office in time for the patients appointment Source: Designing HealthCare Solutions with Microsoft BizTalk Server 2004, Jim Casey and Elizabeth Redding ehealth & telemedicine L. Daragó Ph.D. 5/39 ehealth & telemedicine L. Daragó Ph.D. 6/39 1
Traditional medicine all the way? growing claims to health services in amount and quality more effective use of resources decision making during the cure, collecting, processing and forwarding the data on the status of the patient, performing therapy does NOT need direct, physical doctor-patient contact in every cases patient surveillance, executing of some procedures does NOT claim the whole ward infrastructure there upraise new technologies for continuous data collecting in non-hospital environment the investment in telemedicine and ehealth may return on patient or nation level. ehealth vs. telemedicine telemedicine is the use of electronic communication and information technologies to provide or support clinical care at a distance. tele-health is defined as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health related education, public health and health administration. e-health is combined utilization of electronic communication and information technology to generate, capture, transmit, store and retrieve digital data for clinical, educational and administrative purposes. The purpose of e-health is to contribute to the improvement the health status of the people through optimal use of ICT. e-health care delivery (e-hcd) is the Integration of e-health into every day life of a health worker is becoming a reality. It strengthens systems to reduce medical errors through Provision of vital information It encompasses applications that directly support Prevention of illness and disease. Patient care and management ehealth & telemedicine L. Daragó Ph.D. 7/39 ehealth & telemedicine L. Daragó Ph.D. 8/39 Knowledge based system / expert system An expert system is software that attempts to provide an answer to a problem, or clarify uncertainties where normally one or more human experts would need to be consulted. Expert systems are most common in a specific problem domain, and is a traditional application and/or subfield of artificial intelligence. A wide variety of methods can be used to simulate the performance of the expert however common to most or all are 1. the creation of a knowledge base which uses some knowledge representation formalism to capture the Subject Matter Expert (SME) knowledge and 2. a process of gathering that knowledge from the SME and codifying it according to the formalism, which is called knowledge engineering. Expert systems may or may not have learning components but a third common element is that once the system is developed it is proven by being placed in the same real world problem solving situation as the human SME, typically as an aid to human workers or a supplement to some information system. ehealth & telemedicine L. Daragó Ph.D. 9/39 Architecture of ES 1. The sequence of steps taken to reach a conclusion is dynamically synthesized with each new case. It is not explicitly programmed when the system has built. 2. Expert systems can process multiple values for any problem parameter. By this fact, it is permitted more than one line of reasoning to be pursued and the results of incomplete (not fully determined) reasoning to be presented. 3. Problem solving is accomplished by applying specific knowledge rather than specific technique. This is a key idea in expert systems technology. It reflects the belief that human experts do not process their knowledge differently from others, but they do possess different knowledge. knowledge database data data request decision rule system action request conclusion ehealth & telemedicine L. Daragó Ph.D. 10/39 Explanation system The end-user usually sees an expert system through an interactive dialog, an example of which follows: Q. Do you know which restaurant you want to go to? A. No Q. Is there any kind of food you would particularly like? A. No Q. Do you like spicy food? A. No Q. Do you usually drink wine with meals? A. Yes Q. When you drink wine, is it French wine? A. Yes A major distinction between expert systems and traditional systems is illustrated by the following answer given by the system when the user answers a question with another question, "Why", as occurred in the above example. The answer is: A. I am trying to determine the type of restaurant to suggest. So far Chinese is not a likely choice. It is possible that French is a likely choice. I know that if the diner is a wine drinker, and the preferred wine is French, then there is strong evidence that the restaurant choice should include French. ehealth & telemedicine L. Daragó Ph.D. 11/39 Problem-solving system The principal distinction between expert systems and traditional problem solving programs is the way in which the problem related expertise is coded. In traditional applications, problem expertise is encoded in both program and data structures. In the expert system approach all of the problem related expertise is encoded in data structure only; no problemspecific information is encoded in the program structure. Problem solving systems are made for specific, well structured (or well determined) problems, while expert systems can give result in wrong structured (wrong determined) problems, when some or the problem parameters lack. In these case the result may be incomplete. ehealth & telemedicine L. Daragó Ph.D. 12/39 2
Advantages and disadvantages: advantages Provides consistent answers for repetitive decisions, processes and tasks Holds and maintains significant levels of information Encourages organizations to clarify the logic of their decision-making Always asks a question, that a human might forget to ask Can work continuously (no human needs) Can be used by the user more frequently A multi-user expert system can serve more users at a time Advantages and disadvantages: disadvantages Lacks common sense needed in some decision making Cannot respond creatively like a human expert would in unusual circumstances Domain experts not always able to explain their logic and reasoning Errors may occur in the knowledge base, and lead to wrong decisions Cannot adapt to changing environments, unless knowledge base is changed ehealth & telemedicine L. Daragó Ph.D. 13/39 ehealth & telemedicine L. Daragó Ph.D. 14/39 Expert systems and telemedicine Definitions Data analysis database Care management Decision support Patient unit doctor/health provider (immediate filtering by personal attributes, syndromes, test results) expert system (algorithm) telemedicine interface (sensors for data collection, remote controlling of tools) Patient guidance Indicators Telemedicine knowledge base ehealth & telemedicine L. Daragó Ph.D. 15/39 Staff-oriented Patient-oriented Communication scheme ehealth & telemedicine L. Daragó Ph.D. 16/39 Medical protocol Ordered list of events and procedures to perform a medical care, procedure or the patient management, allowing for the National Guideline and professional studies. Order of doings to apply, for solving a medical problem. Algorithm, containing the practical sort of procedures with decision (selection) points divergences junctions In a small compassed intuitive, mainly well learned and/or experienced sort of paces. (see: Evidence Based Medicine) It exists on medical, nursing and other (such as Quality Assurance) level. Levels of protocol 1. Medical College (ministry level) National Guideline for Professional supervision Health Insurance Company Legal affairs Some people misapply as protocol (i.e. practical guideline). 2. Institutional, local descriptions of procedures: protocol. An institute may rise the National Guideline on protocol level It is allowed to diverge, but in that case it must be explained and documented. ehealth & telemedicine L. Daragó Ph.D. 17/39 ehealth & telemedicine L. Daragó Ph.D. 18/39 3
Protocol vs. National Guideline National Guideline (syllabus): Guideline, accepted by medical college, made by professional (medical) organisations Countrywide valid. Protocol (practical guideline): Statements, accepted and made by professional (medical) organisations, particularly describes the diagnostic and therapeutic procedures by the aspects of Conditions Standard for curing Reliability Sensitivity Field of indications Valid inside an institute. eprotocol: (beyond the above) Works by rigorous communication and financial model. It regulates forms and content of communication (metadata) how to fit, test and apply sensors financial model medical and technical support ehealth & telemedicine L. Daragó Ph.D. 19/39 eprotocol Principles Applicability/validity fields of protocols Where and when the telemedicine applicable for healing, that is, when diagnostic or therapeutic activity may be substituted by telemedicinal tools. That means, that the substituting or surrogate method for the traditional medicine supposes keeping or raising the level of the healing. It also increases the economical and social efficacy for the individual patient or the population. Stipulations to introduce the protocols Keeping on level the efficiency and efficacy of the healing. Continuous medical and technical supervision. Must be determined Data, created by the telemedicine, to execute and analyse the cure and to support the medical decision. Metadata, defining the data-communication. Input and output interfaces. Algorithms of diagnostics and therapy To identify those algorithm, which can be substituted whole or particularly by the methods and tools of telemedicine. To build in and fit the telemedicine processes into the algorithm and data flow. Complete the algorithm with the potentials and possibilities (analysis, aggregations, patient-oriented reports, alarming). ehealth & telemedicine L. Daragó Ph.D. 20/39 Protocol vs. eprotocol III. Treatment III/1. Without drug (applied evidences, their level) Identification of algorithms, which can be substituted in whole or particularly by the technology of telemedicine. Build in and fit the surrogate processes into the algorithm and data flow. 5. Therapy algorithms Identification of algorithms, which can be substituted in whole or particularly by the technology of telemedicine. Build in and fit the surrogate processes into the algorithm and data flow. Indicators or efficiency Medical and economical evaluation of the cure. Automatic data processing, observ the data security rules. V. Nursing 1. Systematic supervision Identification of algorithms, which can be substituted in whole or particularly by the technology of telemedicine. Build in and fit the surrogate processes into the algorithm and data flow. 2. Prevention Alarming. Alarming at extreme measured datum or other tendency, which may refer some danger. 4. Expectable duration of the cure / Forecast Planning and evaluating the case by the measured and input data. ehealth & telemedicine L. Daragó Ph.D. 21/39 Main parts of the protocol Clinical diagnosis/procedure it s significance in the public health Critical circumstances for introducing this protocol Definitions in the protocol Current technical background in the care of the given disease managed by telemedicine General aim of the care supported by telemedicine Diagnostic and therapeutic criteria of telemedicine care the rules of the care! Emergency care rules Rehabilitation through telemedicine applications Indicators for evaluation, quality control and controlling Patient guidance Hot line (help desk) ehealth & telemedicine L. Daragó Ph.D. 22/39 The ehealth architecture Based on two components: Medical workstation Registration (patient, health personnel) Electronic Patient Record Graphical data visualization and statistics Visit management module Feedback from patient self-management! Data analysis and decision making Patient unit Data entry, collection, transfer Electronic mail, consultation ehealth & telemedicine L. Daragó Ph.D. 23/39 ehealth & telemedicine L. Daragó Ph.D. 24/39 4
Telemedicine, actors and rules Definitions and descriptions Patient (customer) Ordering the attendance of the Health provider. Keeping in contact the other actors of the attendance (Health provider, Agent). Health provider Curing the patient applying the tools of telemedicine, got from the Agent and supervised by the Protocol provider. Ordering the tools and services of the Agent. Keeping in touch in medical aspects and emergency to the Patient and the Agent. Concurrent providers are allowed, they are supervised by the Protocol provider. Protocol provider Maintenance and operation the protocol base and the active database. Supervisor of the applying of the eprotocol. Only one actor, no concurrency allowed. Telemedicine service agent Data transfer by the eprotocol between Patient and the Health providers instruments and interfaces. Temporary data storing by the eprotocol and communication schemes. Technology support and supervision for the for the actors. Concurrent agents are allowed, they are supervised by the Protocol provider Architecture of telemedicine Knowledge / Protocol base(1) Guideline eprotocol Health knowledge base Technology knowledge base Protocol provider(1) Telemedicina service agent (n) Health provider (n) Active database (1) Patient (n) Actors and rules Patient Order the telemedicine curing of the Health provider. Participate in the cure via the tools (sensors, data transmit and output devices) of the Agent. Health provider Cure the Patient with the tools of the agent, by the protocol of the Protocol provider. Order the Agent s service, patient communication. Protocol provider Serve protocol interface to the Health provider, the Agent and the Patient, via the Agent. Database managing for active data. Telemedicine service agent Control the tools and data transfer in the Patient-Health provider communication by the protocol, got from the Protocol provider. Temporary data storing (for store-and-forward technique or troubleshooting). Transfer to the Protocol provider. Technological hot-line and help desk service both for the Patient and the Health provider. ehealth & telemedicine L. Daragó Ph.D. 25/39 ehealth & telemedicine L. Daragó Ph.D. 26/39 Communication model Financial model Protocol provider (1) eprotocol request, order of telemedicine service Acknowledgment of eprotocol order eprotocol Order of service Telemedicine service agent (n) Telemedicina I/O Acknowledgement of order Telemedicine I/O Telemedicine I/O Patient (n) Health provider (n) ehealth & telemedicine L. Daragó Ph.D. 27/39 eprotocoll service receipt Protocol provider (1) Telemedicine service receipt Telemedicine service agent (n) Health provider (n) Health service receipt Angel (financial supporter) of telemedicine service (insurance company, fund, patient, etc.) ehealth & telemedicine L. Daragó Ph.D. 28/39 Phases of making eprotocol 1. Select the medical activity (curing). Study and analyse the healing process and its national guideline. Indentify, describe and analyse the subprocesses. 2. Describe the data flow the of the process, to be transformed, and create its data flow diagram. 3. Iteration, back to step 2, until the medical and technical teams both are satisfied with the process description. 4. Indentify the subfunctions, to be substituted, and analyse by the aspects of I/O, supervision of the procedures. Create the data flow diagram and the flow chart of those subprocesses. 5. Iteration, back to step 4, until the medical and technical teams both are satisfied with the subprocess description. 6. Describe the communication protocol of the eprotocol. 7. Develop, embed, test and validate the sensors. 8. Create eprotocol (that is modify and supplement the original guideline/protocol). 9. Compare the traditional guideline/protocol and the eprotocol by the point of view of patient, doctor, health insurance company and by the aspects of efficacy, duration, complications, critical times. 10. Explain and answer the questions of implementation. 11. Explain and answer the questions of operation and maintenance ehealth & telemedicine L. Daragó Ph.D. 29/39 ehealth & telemedicine L. Daragó Ph.D. 30/39 5
Ethics Candor - Disclose information that if known by consumers would likely affect consumers understanding or use of the site or purchase or use of a product or service. Honesty - Be truthful and not deceptive. Quality - Provide health information that is accurate, easy to understand, and up to date. And provide the information users need to make their own judgments about the health information, products, or services provided by the site. Informed Consent - Respect users right to determine whether or how their personal data may be collected, used, or shared. Privacy - Respect the obligation to protect users privacy. Professionalism in Online Health Care - Respect fundamental ethical obligations to patients and clients. And inform and educate patients and clients about the limitations of online health care. Responsible Partnering - Ensure that organisations and sites with which they affiliate are trustworthy. Accountability - Provide meaningful opportunity for users to give feedback to the site. And monitor their compliance with the ehealth Code of Ethics Raising new legal and ethical questions Surveillance dataveillance. Who may suspend the data collection (remote control)? Overwriting the system s decisions: in the case of diverging from the protocol, how to handle the medical and financial consequences. The data, collected by several reason are connectable privacy rights. Internet Health Coalition - Code of Ethics http://www.ihealthcoalition.org/ ehealth & telemedicine L. Daragó Ph.D. 31/39 ehealth & telemedicine L. Daragó Ph.D. 32/39 Dataveillance Dataveillance: it is a raising problem, worldwide: Our personal data are stored and analysed in huge amount thanks technology ICT, and it s owning becomes dangerous. The amount of these scares about the ICT and IT developing grows, since the ICT became mobile, getting intelligent and pervasive (totally covers a person) Surveillance is not located physically. Technology able to adapt itself to the environment and human society. Dataveillance* The systematic surveillance of all the electronic records of a person's activities, especially the usage of credit cards, mobile phones, email and the Internet *Source: http://en.wiktionary.org/wiki/dataveillance ehealth & telemedicine L. Daragó Ph.D. 33/39 ehealth & telemedicine L. Daragó Ph.D. 34/39 Barriers of the Telemedicine Applications Reimbursement of the telemedicine-oriented care from public fund is not supportive at this time Legal and ethical aspects are confuse Patient-oriented decision-making is not accepted Concerns regarding automatic decisions making Rigid care structure changes slowly Educational tools are poor New form of the health care Radical changes in the health care delivery by using telemedicine New protocols, guidelines are needed for utilizing the benefit of the telemedicine The protocols containing rules for Clinical Pathways, Education, Financing, Legal environment, Patient rights, Ethical issues of the patient care. ehealth & telemedicine L. Daragó Ph.D. 35/39 ehealth & telemedicine L. Daragó Ph.D. 36/39 6
ehealth8: Goals of our research ehealth8 (2008-2011) funded by a Hungarian governmental agency Consortium including five members Semmelweis University, Budapest Health Informatics Institute Answare Ltd. Bay Zoltán Public Foundation Thormed Ltd. Humansoft Ltd. Main issues of the project: Developing standards for protocols in the telemedicine Developing telemedicine-oriented clinical protocols Implementing telemedicine applications in clinical settings, as model Evaluating the pilot and modeling the changes in the health care delivery with financial, educational consequences Elaborating recommendations for the government for financing and legal changes in the health care system General aim of the project: More effectiveness and efficiency by using telemedicine application ehealth & telemedicine L. Daragó Ph.D. 37/39 Remember: Paradigm Shifts Food is power Slave is power Land is power Money is power Information is power Information sharing is power ehealth & telemedicine L. Daragó Ph.D. 38/39 Slide idea from presentation of András Jávor M.D, ehealth Never & telemedicine L. Daragó too Ph.D. late! 39/39 7