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Leonard Fass.GEHealthcare

A Vision of the Wireless Hospital

International Workshop onWearable and Implantable SensorsImperial College London

April 7. 2004

Integration of Medical Technology,IT and Nanotechnology will be

the basis of future medicine

Biotechnology Bio-informatics

Nanotechnology

Transfunctionalteams

Systems Integration is Key to Success

• In Vitro Analysis• Protein targeting fluorescent

nanoparticles, Lab on a Chip

• Medical Imaging- MEMS, Nano Systems

• Communication Satellites- 3D, Thin, Low Power

Packaging

• Mobile Communications- Miniature, High Performance

Systems

Point of Decision Application

Technology drivers for remote sensing

• MEMS devices• Sensors and electronic circuitry on same chip• Low power wireless transmitting devices(100 µWatt)• Millimetre scale batteries• Micro-sensor networks using 2.5mm3 motes• Transmitter range 20m between motes• Wireless portable display devices• Hardware encryption • Local decision support software

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Application of BIS Sensor• Based on 1-channel EEG• Either left or right hemisphere

BIS(Bi-Spectral Index) Monitoring of depth of anaesthesia

BIS-XP Technology, with 4. electrodes• Improved artefact detection via internal 2 EEG channels• Improved EMG• Improved near-suppression handling• Filter to stop electrocautery interaction (Bovie resistance)

EEGs are typically symmetrical

Artifacts are typically asymmetrical

Awake Eye Blinks Unconscious

BIS Monitoring

Wireless solutiontechnically feasible for home based sleep studies

Falling asleep

For details see: Acta Anaesthesiol Scand 2004, 48(2): 154-161

Depth of anaesthesia by ENTROPY of EEG

• Measuring method: Eight-Electrode Technology:• Small, stable current (2,5 mAeff & 70 kHz) is transmitted via the outer

electrodes through the thorax, travelling mainly along the blood-filled aorta• Voltage drop is sensed by independent inner electrodes (no current)

Impedance Cardiography - ICG

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• All ICG hemodynamic parameters plus Mean Arterial Pressure MAP

• Choice of Normal Rangesor Units of Measurement to be displayed

• Lower or Higher parameter values are labelled by – or +

“Fast Look” of ICG Parameters

–– COCO

++

Low High

12 Oct 22:11

ICGHR 107MAP 108CO 4.5CI 3.1SV 42SI 29SVR 1829SVRI 2634TFC 43ACI 65VI 53LVSWI 50LCWI 4.4STR 0.32PEP 82LVET 256eDO2I 500

60 10070 1054.0 8.02.5 4.560 13035 65900 14001900 240021 37 90 17035 6540I 603.0 5.50.30 0.50

++++

----++++++--

(Normal Ranges,(Normal Ranges,

no Alarm Limits)no Alarm Limits)

Impedance Cardiography

Thermodilution by PAC ICG via Skin Electrodes

Impedance Cardiography - ICG

Trend to non invasive sensing

Transcutaneous Measuring Technology

Miniaturized chemo-electricalcombined O2/CO2 sensor:

Solid state central CO2 electrode

Measuring membranes covering the electrodesand enclosing a very small amount of electrolyte

O2 micro electrode out of center,slightly protruding

TC Monitoring

• Sensor is placed directly on the skin, locking it to an adhesive ring

• Sensor is heated to 42°C - 45°C in order to arterialize the capillaries (Need to monitor arterial blood gases)

Transcutaneous Measuring Technology

TC Monitoring

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• LNOP sensors with recessed photodiode• Reducing motion interference• Conventional two-wavelength photometry

SpO2 Monitoring• Efficient signal extraction from noise

• Adaptive (dynamic) filtering - not just fixed band-pass to reduce „in-band noise“

• Estimating actual noise characteristics and subtracting estimate from signal

• Rule for estimate: Red and infrared arterial signals are highly correlated, noise is not correlated

SpO2 Monitoring

Nanotechnology and Biosensors

Nanotechnology will contribute to a wide range of diagnosic applications through the development of:

• Implantable Diagnostic Devices• Internal Diagnostics• Intracellular Diagnostics• Pathogen Detection

In-vivo Sensor• Organic sensor, with telemetry• 100 microns• Biocompatible, Biodegradable

New Applications:• Stent Monitor - restenosis, pressure gradients, plaque

build-up, artery thickening• Smart Catheter, Fibrillation Detection• Post-operative Patient Monitoring, Drug Delivery• Radiation Therapy

•Dynamic Dose Control, Micro-Targeting, Reconstruction Aid (angular uncertainty)

Bio-Sensors & Actuators

Micromachines (MEMS sensors) are expected to have an enormous impact in the healthcare and pharmaceutical industries - Physics World April 2000

Innovative, Biocompatible, Biodegradable

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Benefits• Portable applications• Flexible sheet-like “probe”• Low-cost manufacturing

Enabling TechnologiesIntegration

• MEMS transducer and electronics in the same miniature circuit

Miniaturization• Highest density, performance

interconnect & packaging

cMUT MEMS Array

MEMS Enabled Portable, Integrated, Imaging & Information Devices

Solid state ultrasoundReal Time Remote Imaging and Compression

Auto-detection of Femoral Vein

Remote Treatment Delivery

Early Detection and Treatment Using Intelligent Systems

Auto-detection of Femoral Vein, Remote Acquisition of Images. Test Compressibility, Prescribe Treatment

Guided Ultrasound Therapy

Encapsulated Drugs Released by Ultrasound at Disease Site

Ultrasound Hyperthermia

Destroy or Treat Disease TissueGlucose

Gluconic Acid

Glucose-oxidizing enzymes attached with gold nanoparticles to electrodes

Potential for use as biosensors to measure blood glucose

Courtesy I.Willner Jerusalem

Nanoparticle Plug

• Enzyme oxidizes glucose • Electrons flow through nanoparticle into the electrode • Amount of current indicates level of glucose present

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PSA Activated Cantilevers

Three cantilevers are coated with antibodies to prostate-specific antigen (PSA).

The left cantilever bends as the protein PSA binds to the antibody.

The other cantilevers, exposed to human plasminogen and human serum albumin, do not bend because the anti-PSA antibodies do not recognize these molecules.

Courtesy of Flavio Robles/Protein Data Bank

Nano-cantilevers for detection of molecules

Surface stress change on cantilever due to adsorption of molecules in static mode

Ds=Et2/{4R(1-n)} (Stoney,1909)E=Young`s modulusn=Poisson`s ratiot= thickness

Change in resonance frequency due to mass adsorbed in dynamic mode

Dm=(k/4p)x(f1-2-f0-2)k equals the spring constant of the cantileverk=Et3w/4l3

w =width t=thickness l=length

Nano-cantilevers for detection of molecules

Can be used in heat mode to detect thermal changes by using more than one metal coating

Experiments are conducted with reference cantilevers that do not react with target molecules to eliminate errors due to thermal drift and unknown reactions

Electrochemical

pH

Thermometric

Optical

Piezoelectric

Pathogen Biosensor

Signal

Physicochemical Transducer

Change

•Binding (affinity)•Chemical reaction•Release of a detectable species

Biomolecularrecognition event

Enzyme

Antibody

Micro-organism

Cell

Aptamer

Nucleic Acid

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Multiple binding sites

Raman Tag

YY

Y

Y

Y

Y

YY

50 nm Au

SiO2 Shell

Antibodies

SERS-Surface Enhanced Raman Spectroscopy• Nanoparticles engineered to provide Raman signal• Antibody-coated for specificity for pathogens• Multiple tags and multiplexed assays• Microfluidics provide simple new methods

1 particle gives Raman signal ~ 5 billion moleculesRaman signal of 1 mM Analyte from 2 µg Au/L particles

PathogenYY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

YYY

Y

Y

YY

Y

Y

YY

Y

Y

YY

Y

Y

Pathogen detection with Raman spectroscopy Portable Raman Spectrometer

Sensing targets• Biological Warfare Agents

(BWA)• Chemical Warfare Agents

(CWA)• Narcotics identification• Explosives identification

Enabling Technologies• Nanotubes & nanowires• Quantum dots• Hybrid

organics/inorganics

Nano BioSensors in the ER

Benefits• Real time, in situ reading of

biochemical activity

• Cellular level optical imaging

• Sensor guided precision surgical tools

NanowiresGE Global Research (2002)

1st SiC Analog-Digital Op-amp (GE Global Research, 2002)

Nano BioSensors for physiological measurements

Benefits• Total blood analysis in minutes

• Rapid, accurate disease diagnosis

• Patient specific disease treatment

Self Assembled Block Copolymer Thin Films (GE Global Research, 2002)

100 nm100 nm

Enabling Technologies• Molecular recognition

• High density nano-arrays

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Enabling Technologies• Wireless communications

• Self powered devices

• High resolution displays

Nano BioSensors for remote patient diagnostics

Organic Light Emitting Diode (GE Global Research, 2002)

Benefits• Simple patient administered

diagnostic tests

• Automatic transmission of outpatient data

Integrated Hall Effect Sensor (GE Global Research, 1998)

Micro Electronic Systems

Healthcare of Tomorrow …• In-Vivo, In-Vitro Sensors

• Hand-held, Wireless Diagnostics

• Wearable, Wireless Monitors

Enabling Technologies…• Micro-Nano Electronic

Packaging

• High Density Interconnect

• Organic Electronics & Systems

• High Performance MaterialsBodyMedia Inc.

Micro-System Technology “Building Blocks”

Denser Packaging

High Density Flexible InterconnectUp to 5X Greater Density

“Zero” Interconnect Length For 10X Greater Speed

5cm

1 cm1 cm

Miniaturized Functionality

“Postage Stamp” Memory100X Volume Reduction

Communications Module10X Area Reduction

1cm

0

50

100

150

200

250

2001 2003 2005 2007 2009 2011

Interconnect

Density

Required

Greatest Function, Performance in Smallest Volume

Speed of Light• Data transmission• Computation

Miniaturization• Smaller, lighter, mobile• More function in same

space

High Performance• Max computational power• System integration

Electro-Optical• Computer Aided Detection• Real time processors

1.5 cm6 cm6 cm

Enabling Technologies• MEMS• Miniature Packaging• High Density Interconnect• Specialty Materials

Benefits• Smaller volumes … Up to 500X• Faster processing … Up to 100X• Greater functionality … Up to 10X• Mobile, portable• System integration

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Wireless Networks in Healthcare

• Wireless networks are used to access patient records from central databases, add observations to the databases and to check on medications, among a growing number of other functions.

• The growing use of wireless networks by health care professionals presents tremendous challenges to health care IT managers.

• There is a trade-off between access and security: easier access translates to greater security risks.

• Decisions made today about the deployment of wireless local area networks (WLANs) must take into account the impact of the administrative simplifications of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the USA.

Vision of the Wireless Hospital• Everything will be connected and giving off a signal• People, Process & Technology will all be interconnected in one hospital network that’s sharing and analyzing data

PACS Network

HIS/RIS

Connectivity to HIS/RIS

Real time radiologist interaction with patient imaging

Battery Powered Portable Flat Panel Digital X Ray Detector With Wireless Transmission of Data to Hospital Networks

Mobile Digital Radiography

LAN(Optional)

TeleMammography

Senographe 2000DWorkstation

Senographe 2000D

Easy consultation for underserved populations with regional coverage for centers of excellence

Mobile Full Field Digital Mammography Systems

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Technology Growth Enables Diagnosis• Wifi Tags Capture Patient Flow Data

• 100% Wireless Infrastructure

• Business & Clinical Decision Real-time

• Infinite Scalability via Grid Computing

Information Integration Enables Therapy• Collision of Telecommunications & IT

• Real Time Data Collection & Simulation

• Broadband & Web Services Everywhere

• Smart Systems Talk to Central, Learning Engines

Wireless technologies everywhere……Tracking people, assets & patient flow

Telemetry systems will capture, analyze and transfer critical patient data• Ability to monitor hundreds or thousands of patients at a time on an advanced telemetry system

• Ensures that patient data is transmitted clearly and completely to a central patient monitoring station

• Network Patient Data Servers will collect and store monitoring data continuously as patients are admitted from one monitor to another

Life-Critical Data Network

• Clinicians will have access to vital signs and alarm history events as the patient is transferred between hospital departments, enabling them to make confident decisions at any stage

• The telemetry system will be connected to a life-critical data network dedicated solely to patient monitoring

• Clinicians will be able to use a secure web connection to view the information anytime, anywhere

Multiple healthcare information technologies will be integrated

.Critical CarePerioperative Wireless TelemetryCardiologyRadiologyImage Management Services

EmergencyPhysician`s Office CPOE(Computerized Physician Order Entry) Laboratory PharmacyPerinatal

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IHE (Integrating the Healthcare Enterprise)

• The IHE initiative has successfully started to validate the compatibility between devices using different IT and communications standards.

• IHE is a concerted action from users and vendors resulting from the initiative of the RSNA (Radiological Society of North America) and HIMSS (Healthcare Information and Management Systems Society)

Industry Standards in Healthcare

HL7 CCOW CDA V2 Messages

Radiology CardiologyICU/CCU/Med/Surg OR/Periop Emergency

Pharmacy Registration/ Scheduling

Clinical Informatics

Women’s Health

BillingAmbulatory

IEEE

NC

CLS DICOM

X12 EDI

DICOM

SNOMED

Arden

CPT

IT / Support

LDAP Kerberos Syslog NTP

ICD

DHCP DNS SNMP

NDC NCPDP ICD

EthernetWireless

WADO

AAMI AAMI AAMI AAMI

ebXML

Lab

NCCLS

LOINC

LongitudinalHealth Record

CCR

Bridging the gap ?How to guide

effectivestandards

Implementations• Policies (purchase, operational,

legal) are required to deploy and use properly the integrated systems and shared information

Providers, Payers & Policy Makers define constraints for health-system, regional structures,

business objectives, legal reqmts.

PoliciesPoliciese.g. HIPAA, RFP, Product Acquisition Contracts, Patient EHR Portability

Policies

Putting standards together….for effectiveinformation exchange

Providers and Vendors think “solutions” to address specific

workflows in clinical or infrastructure domains

Workflow IntegrationWorkflow Integration

• Set of specific information exchange standards to be specified for product plug & play for each specific workflow

Specific and Common

Options RemovedIHE

IntegrationProfile

e.g. IHE:1. Integration Profiles Spec.2. Testing Process3. Education4. Compliance Stmts

• Standards designed to span a broad range of use cases for the present and the future

Healthcare domains require highly structured and specialized application level standards well

beyond generic IT standards

Base HC StandardsBase HC Standards

HL7 CCOW CDA V2 Messages

Radiology CardiologyICU/CCU/Med/Surg OR/Periop Emergency

Pharmacy Registration/ Scheduling

Clinical Informatics

Women’s Health

BillingAmbulatory

Hilltop(GE)

Unity (GE)

IEEE

NC

CLS

IEEE

DICOM

X12 EDI

DICOM

SNOMED

Arden

CPT

IT / Support

LDAP Kerberos Syslog NTP

IEEE

ICD

DHCP DNS SNMP

NDC NCPDP ICD

Ethernet

Wireless

WADO

AAMI AAMI AAMIAAMI

ebXML

Lab

NCCLS

LOINC

LongitudinalHealth Record

CCR

e.g. HL7,

DICOM

Solid & long-lasting

Flexibility & many options

New technology & data availability.Higher demand for information for real time decisions

ConsumerismConsumerism

More Process DataMore Process Datafrom IT Systemsfrom IT SystemsNew Services / LinesNew Services / Lines

New TechnologyNew Technology

Increased Increased LabourLabour Demand / MixDemand / Mix

More Ambulatory, More Ambulatory, Specialized Care Specialized Care

CentersCenters

New RegulationsNew Regulations

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Information will help solve problems… …before they occur

Management in the Future Hospital Environment will Require:

Wireless Data Collection & Analytics - People, Process & Technology

Data Fusion - Decisions From Interdependencies

Proactive Decisions & Prediction

EnterpriseDepartmentDevice

High Speed Wireless Integration … Real-time Access to Critical Information

Seamless Data & Location Integration

Enterprise-wide Data Capture

Instant Access to Information

Information Portability

Complete Operations Visibility

Targeted Messages and Alarms

Know where things are, what they’re doing and how best to do it

Expanding Device Informatics

Increasing Reliability• Real-time Diagnostics & Calibrations• Digital Check-ups and Upgrades• Embedded Agents - Predictive Services

Enhancing Performance• Adaptive Learning System Optimization• Increased Throughput … Optimal Care

Improving Utilization• Exam History & Trends• Facility / Case Mix Benchmarking Clinical and Diagnostic Imaging

Systems

Products built to take advantage of wireless networkDevices talk to each other, learn from each other operate in an optimal manner.

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Exponential performance growth enables real-time diagnosis anywhere in the enterprise

1

10

100

1000

10000

100000

1000000

1990

1994

1998

2002

2006

2010

Processor Speed

Memory Size

Disk Storage

NetworkBandwidthImages/Study

Proliferation of Broadband & Wireless To Analyze and

Benchmark SystemsAnywhere in the World

Data Management … Integrating the Elements of the Enterprise

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Computational Hardware Development

CPUCPU

MemoryMemoryThousands ofImages /Acquisition

Postage Stamp Sized Memory Module

Large Volumes

3D & 4D Images

MassMassStorageStorage

Processing power, Miniaturization, Scalabilty

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Data Management … Integrating the Elements of the EnterpriseBenchmarking, Pre-emptive problem solving

Decision Support & Algorithms

Soft Computing

Artificial Intelligence

StatisticsStatistical Models

Physics-based ModelsData Mining

Neural NetworksBayesian Belief Networks

Fuzzy Logic

Case-based ReasoningRule-based Reasoning

Induction TreesFusion

Outcome OptimizedDecision Making

Business Processes

Product Intelligence

Workflow ModelingCapital & Resource PlanningSystem Optimization

Pattern RecognitionEmbedded Remote DiagnosticsProbability of Failure

Problem/Solution CorrelationRemote Anomaly Detection Failure Prediction

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Data Integration and Certainty … Giving up to the minute Business Operations Status

Self correcting system, automatic resource redeploymentto resolve problem before it occurs such as queueing

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Data Integration and Certainty … Giving up to the minute business operations status at the department or enterprise level

HelpOptimize ForecastMonitor

Rad

ED

ICU

OR

Lab

Card

CTMRXR

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SICUNICUPICUCICU

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HemoNecr

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1815NM

1210RAD4

1610RAD3

138RAD2

105RAD1

1415MR2

1515MR1

1810CT2

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BacklogWait TimeRoom

1815NM

1210RAD4

1610RAD3

138RAD2

105RAD1

1415MR2

1515MR1

1810CT2

2410CT1

BacklogWait TimeRoom

PatientsVisitors

EquipmentCritical Staff

Key:Enterprise LevelFinancials, Performance, Trends

Departmental LevelPerformance, Quality, Exceptions

Combining informatics/process modellingProactively provide business centric solutions

CapacityPlanning

BusinessModeling

Workflow

DepartmentOptimization

FacilityUtilization

BusinessBusinessData WarehouseData Warehouse

Analysis EngineAnalysis Engine Simulation EngineSimulation Engine

Natural LanguageNatural LanguageProcess SystemsProcess Systems

DeviceData

PatientVolume

HospitalResource

Transforming Data Into Decisions

Advanced modelling, simulation tools, statistical optimizer to makechanges so that business is adapting to changes in environment

Transforming Data Into Decisions

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Transforming Data Into DecisionsDeciding what’s important and how to act upon it

5075503015

4575503090

4530503090

7045405060

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4575503090

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ED

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More

StaffingBlocks

Hours

Prep TimeLess

Volume

Margin

Clinical Quality

Patient Sat

Physician Sat

More

StaffingBlocks

Hours

Prep TimeLess

Volume

More

StaffingBlocks

Hours

Prep TimeLess

Volume

More

StaffingBlocks

Hours

Prep TimeLess

Volume

Margin

Clinical Quality

Patient Sat

Physician Sat

Margin

Clinical Quality

Patient Sat

Physician Sat

Margin

Clinical Quality

Patient Sat

Physician Sat

Innovative Decision Support Tools

Quantitative Analysis

Detection TherapyDiagnosis

Lung

DiseaseManagement

EarlyEarlyDetectionDetection

Individual RiskIndividual RiskAssessmentAssessment

InterventionIntervention& Therapy& Therapy

DifferentialDifferentialDiagnosisDiagnosis

ComputationalComputationalDisease Management ToolsDisease Management Tools

QuantitativeQuantitativeMeasurementsMeasurements

PersonalizedPersonalizedPatient ManagementPatient Management

ToolsTools

Computer Aided Computer Aided Detection &Detection &DiagnosisDiagnosis

TherapyTherapyMonitoring &Monitoring &InterventionIntervention

ToolsToolsAdvanced

ComputationalSolutions

Next generation applications will advise with increased knowledge of scanner physics & disease management

Optimized Disease Management

Massive, HighMassive, HighQuality MolecularQuality Molecular

& Traditional& TraditionalImage DataImage Data

Workflow StreamlinedWorkflow StreamlinedDecision MakingDecision Making

Tools & ReportingTools & Reporting

RealReal--Time,Time,Comprehensive,Comprehensive,

& Automated Data& Automated DataInterpretationInterpretation

Globally DistributedGlobally DistributedElectronic DiseaseElectronic Disease

ManagementManagementProtocolsProtocols

PatientPatient--specificspecificDecision MakingDecision MakingBased on RiskBased on Risk

Patient Gene/Patient Gene/EnvEnvRisk AssessmentRisk Assessment

ToolsTools

Outcome OptimizedOutcome OptimizedDecision MakingDecision Making

Advanced Advanced Intervention PlanningIntervention Planning

& Real& Real--TimeTimeGuidanceGuidance

Algorithms

Computational power will revolutionize medicine

Hardware Connectivity

Prognostic Model

Assessments &Evaluations

RadiologyResults

Therapy Choices& Similar Cases

Personal &FamilyHistory

Medication

IVD / Lab TestResults

PredictDrug Response

Therapy Planning & Monitoring

SurvivalProbability

Rate of Diseaseprogression

Risk Assessment Clinical Outcome

Prediction

Computer-Aided Prognostics Vision

PatientMedical History

Towards Predictive Medicine

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SummaryCapturing the Right Data

AvailabilityUtilizationPerformance

From Across the EnterprisePeopleProcessTechnology

To Enable DecisionsWorkflow OptimizationCapacity Planning & ForecastingBusiness Modelling

Diagnosing & Treating the Business Like a Patient