Is 'Pervasive Healthcare' old wine on a new bottle – or is...

Is 'Pervasive Healthcare' old wine on a new bottle – or is it a real, but

emerging, research discipline?Jakob E. Bardram

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The Age Tsunami

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US Demand/Supply of Nurses

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5Source: Eric Dishman. Inventing wellness systems for aging in place, IEEE Computer 37:5 (May 2004), 34–41..

Changing the Centralized Model of Healthcare

Acute → ContinuousHospitalization → Home & out-patientReactive → Pro-active & PreventiveIT →  Assistive TechnologyCentralized →  PervasiveSampling →  MonitoringDoctor-centric →  Patient-centric

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Pervasive Healthcare

• Application of pervasive computing, ubiquitous computing, proactive computing, ambient intelligence technologies for healthcare, health, and wellness management.

• Second, it is about making healthcare pervasively available everywhere, anytime, and to anyone.

• In essence, pervasive healthcare addresses a set of related technologies and concepts that help integrate healthcare more seamlessly to our everyday lives, regardless of space and time.

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Source: Korhonen, Ilkka, and Bardram, Jakob B. Guest editorial introduction to the special section on pervasive healthcare, IEEE Transactions on Information Technologyin Biomedicine 8:3, 2004, 229–234.

Agenda

• Historical Roots– Biomedical Engineering, Medical Informatics, UbiComp

• Characteristics of Pervasive Healthcare• Research Themes• Examples

– Home based monitoring of vital signs– Pervasive Computing in Hospitals

• Methods– Evidence-Based Medicine– Clinical Proof-of-Concept

• Is the wine new?

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Historical Roots

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Biomedical Engineering – BME

• Biomedical engineering (BME) is the application of engineering principles and techniques to the medical field.

• BME combines the design and problem solving skills of engineering with the medical and biological science to help improve patient health care and the quality of life of healthy individuals.

• Research Areas– Bioelectrical and neural engineering– Biomedical imaging and biomedical optics– Biomaterials– Biomechanics and biotransport– Biomedical devices and instrumentation– Molecular, cellular and tissue engineering– Systems and integrative engineering

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Biomedical Engineering

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Medical Informatics – MI

• Medical informatics (MI) is the intersection of information science, computer science and health care.

• MI deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine.

• Health informatics tools include not only computers but also – clinical guidelines, – formal medical terminologies, and – information and communication technology(ICT)

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Medical Informatics

• Hospital Information Systems• Electronic Patient Record

– Medicine Charts– Nursing Records

• Clinical Decision Support Systems

• Integration• Standards

– DICOM, HL7,

• Medical vocabularies – SNOMED, …

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Ubiquitous Computing

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PC

Mini

Mobile

Internet

Mainframe

Ubiquitous

Ubiquitous Computing

• Embedded / invisible / ambient computing• From 1:1 to N:N computing• Mobility and Wireless connectivity• Collaboration• Sensor networks• Context-aware Computing• Capture and Access• From “computer” to “tool”

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Pervasive Healthcare – Characteristics

• Technology– Sensor technology and networks– Embedded and mobile devices– Context-aware adaptation– Capture & Access

• Clinical approach– Pro-active and preventive– Patient-focused– Monitoring rather that sampling– Assistive Technology rather than Information Technology

• Research– Multi-disciplinary – from field studies to hardware design– Proof-of-Concept – rather than evidence-based medicine

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Pervasive Healthcare – Research Themes

• Monitoring• Assistive Technologies• Preventive and pro-active health systems• Self-care & Self-treatment• Medication support and compliance • Capture and Access, Training• Clinical Support Systems• Software Architecture• Sensor and Network Design• Field Studies• Persuasive technologies for better health• …

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Medication I

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Medication II

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Telemedicine?

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Pervasive Monitoring

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BodywornMonitors

Wireless Monitors

Mobile Monitoring

Body Sensor Network

MyHeart Project

Challenges in Monitoring

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• Robust measurement and processing methods requires access to large and representative real data sets– Real cases in real environment with real problems and artifacts– Reference data - real well-being - collected in parallel– Similar problem when collecting evidence for correct functioning

and usefulness of the method - required for evidence based medicine (EBM)

• How to reach this - especially for long term (months - years)?– Motivation of (many enough real) subjects to wear/use often

bulky and error-prone prototypes– Ethics?– Practical and economical issues: prototype costs (many copies

needed), maintenance costs (battery replacements, data transfer, calibration, etc.)

• Result: few success stories so far…Source: Ilkka Korhonen

Example I

ElderTech – Technologies for Elders

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• Purpose– Self-care and independent living– Easy communication with clinical staff, relatives and peers– Continuous updated view on health status– Basis for pro-active clinical contingency management– Shared care – cooperation across clinical boundaries

• Features– Monitoring – Blood Pressure and Weight (wireless)– Medication – administration and management– Communication & Coordination – “The Collaboration Book”

• Deployment– 7 Homes, elders 70+– Nursing staff, nurses and assistants– ~3 months– Qualitative data collection

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Technical Setup

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Findings – Elders

• Usability– Scale & BP monitor used frequently– The PC – 5 out of 7 did not use it

• Communication– No changes experienced– But was not looking into the ‘collaboration book’

• Clinically, Self-care, Monitoring– Liked the monitoring– Increased their feeling of security/safety– Was trusting the staff to monitor their health data and

react if necessary– Documentation of medicine intake was not considered

relevant

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Findings – Healthcare Workers

• Administration– Collaboration book– Integration with care system

• Communication– Might improve communication with GP

• Clinically– Felt uncomfortable – Responsibility of the GP– Extra work – felt not necessary

• Remote monitoring and prevention– Indications– Specific groups of elders – diabetics, hypertension, …– Concerned about remote monitoring – “not the right

picture”

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Lessons learned about designing AT

• Vital sign monitoring is ‘interesting’– but introduces a huge responsibility for actually reading them

• Communication and sharing seems to be just as interesting– between nurses/GP/hospital– between clinicians and citizens– between citizens

• If “Information Technology” is part of the solution– then IT has to look considerable different that it does now!

• Experimentation is essential in the design process– we actually do not know what we do– … what will work– … how to design it– … and how users will use it– hence, close-loop experimentation is essential

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Example II

The Interactive Hospital – Supporting Awareness in a Operating Ward

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Whiteboards in Hospitals

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Source: J.E. Bardram, Temporal Coordination - On Time and Coordination of Collaborative Activities at a Surgical Department. Computer Supported Cooperative Work, 9(2):157-187, 2000.

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Affordances of Whiteboards

• Core Roles of Whiteboards in Hospitals– Visibility– Overview– Status– Coordination– Communication– Handling contingencies

• Research– Temporal Coordination [Bardram, JCSCW 2000]– Cog. Props of Whiteboards [Xiao et al, ECSCW 2001]– Inf. & Repres. [Reddy et al., ECSCW 2001]– Web of Artifacts [Bardram & Bossen, GROUP 2005]

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Design of AwareMedia

• ”Putting the schedule back on the wall”– Public and shared social awareness– Temporal awareness– Spatial awareness– Communication

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Source: J.E. Bardram, T.R. Hansen and M. Soegaard. AwareMedia: a shared interactive display supporting social, temporal, and spatial awareness in surgery. In Proceedings of ACM CSCW '06, p. 109-118, ACM Press, 2006.

AwareMedia User Interface

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AwareMedia Technology & Architecture

• Technologies– Media Spaces– Scheduling/Booking– Context-awareness– Instant Messaging

• Builds upon– AWARE architecture

• [CSCW 2004]– JCAF framework

• [Pervasive 2005]

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1. Spatial Awareness

• OR Space– Video– Status– People in the OR– Patient– Type of surgery & expected end time

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2. Temporal Awareness

• OR Schedule– Operations– OR Teams– Timing– Delays– Cancellations

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3. Social Awareness

• Context– Picture, Name & Initials– Location– Activity (e.g. surgery)– Tracking device– Role (e.g. replacement, coodinator, surgeon)

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Deployment

• Site– OR Ward, Bed Ward, Recovery– Supports 3 ORs, 30-50 people pr. day

• Technology– Coordination central → 2 large interactive displays– 3 OR / Wards → 20’’ touch screens– Web cams– Location tracking based on Bluetooth

• Tag• Mobile phones

– ~20 AwarePhones

• Deployed during 12 months

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Hospital

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Operating Ward

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AwareMedia in Use

• Data collection– Observations, Interviews, Data

Logging

• Lessons learned– Increase Awareness and

Communication• More efficiency in OR coordination• Fewer interruptions

– Redundant information• Location, status, operations, …

– Simple, stable, and predictable displays

• Easy to learn, use, and navigate in a critical environment

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Example III

Context-aware Patient Safety in the Operating Room

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Patient Safety

• Institute of Medicine: “To err is Human”– 9% adverse events, 40% related to ‘errors’, 60% to

complications– Danish studies confirm this

• Utah and Colorado– Operative adverse events comprised 44.9% of all adverse

events

• Joint Commission– Universal Protocol for Preventing Wrong Site, Wrong

Procedure, Wrong Person Surgery

• Danish Recommendation– Improve communication and coordination– Improve patient identification– …

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Source: • Institute of Medicine• E J Thomas et al (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care., vol. 38, no. 3.

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A Context-aware Patient Safety System

• Context-awareness– RFID sensor input + other input– Based on the Java Context-Awareness Framework (JCAF)– Extended with reasoning engine (JESS)

• Features– Presenting relevant information during operation

• PACS, EPR, Operation data– Monitors progress and fire warnings

• Patient, Team, Blood, Patient Status, Equipment, …

• Clinical Proof-of-Concept– Full functioning prototype– Deployed inside one OR with a full OR team– Used during one day (no real patients, however)– Qualitative evaluation

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So what’s different?

• ElderTech– Continuous Monitoring coupled with patient-clinician

reliability and trust– Focus on Patient communication – not telemedicine– Methods are not clinically oriented

• The Interactive Hospital– Social and Context Awareness– Focus on clinical collaboration and usability – not health

informatics

• Patient Safety in the OR– Context awareness and reasoning– Focus on ‘contextual’ and ‘procedural’ safety – not

biological safety69

Methodology

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Evidence-Based Medicine – EBM

• U.S. Preventive Services Task Force & UK National Health Service– Level I: Evidence obtained from at least one properly designed

randomized controlled trial.– Level II-1: Evidence obtained from well-designed controlled trials

without randomization.– Level II-2: Evidence obtained from well-designed cohort or case-

control analytic studies, preferably from more than one center or research group.

– Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

– Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

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Source: WikipediaU.S. Preventive Services Task Force & UK National Health Service

Proof-of-Concept

• “The construction of working prototypes of the necessary infrastructure in sufficient quality to debug the viability of the system in daily use; ourselves and a few colleagues serving as guinea pigs”

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Source: Marc Weiser. “Some Computer Science Issues in Ubiquitous Computing”, in Communications of the ACM, 36(7), 1993, ACM.

Clinical Proof-of-Concept

Lab PoC

• Controlled Experiment• Inside a lab or test facility ~ less valid• Short term

Clinical PoC

• Controlled Experiment• In a real clinical setting ~ more valid• Short term

Clinical Trial

• Randomized controlled trial• In a real clinical setting ~ valid ~ EBM• Long term

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Clinical Proof of Concept – CPoC

• Technology– Working prototype– Usable (but not necessarily user-friendly)– Stand alone– Focused on specific research questions

• Deployment– Deployment in a real clinical environment– Used by real users (researchers are hands-off)– For a short, but sufficient time of period (1 day – 3 months)

• Collecting ‘Evidence’– Observations– Questionnaires– Perceived Usefulness and Usability– Measure – if possible

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Qualitative data

Quantitative data

Examples of Clinical PoC

• AwareMedia– Clinical PoC in a surgical ward

for 4-5 months

• Patient Safety– Clinical PoC in an OR during 1 day

• Home based monitoring– Clinical PoC during ~3 months in 7

homes

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Summing up

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So – is Pervasive Healthcare new Wine?

Pervasive Healthcare

Biomedical Engineering

Medical Informatics

Ubiquitous Computing

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Call for Action

• Maintain focus on “pervasive” approach to healthcare– Supporting the move from a Mainframe to a Pervasive model of

healthcare• Define and describe Pervasive Healthcare

– Post it to Wikipedia– International Association of Pervasive Healthcare – IAPHC?

• Define the research methods for Pervasive Healthcare– “Moving out of the lab”– Clinical Proof-of-Concept

• Ensure research quality– Do not be an isolated group of researchers– Make profound research which can be published in well-

established venues and journals– Ensure affiliation with IEEE and ACM

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Contact details

• Jakob E. Bardram– bardram@itu.dk– www.itu.dk/~bardram

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