MOBISAUDE: Mobile Application Scenario for the Hospital de São

Sebastião Patient-Side Unit

Luís Velez Lapão1,2

, Luís Martins3, Rui Gomes

3, Paulo Reis

4 and Reiner Herzog

4

1Grupo de Sistemas de Saúde, Instituto Nacional de Administração, Portugal,

2Instituto Superior Técnico, Universidade Técnica de Lisboa, Portugal,

3Hospital S. Sebastião – Sta. Maria da Feira, Portugal,

4ERICSSON

Abstract

Mobile Healthcare offers a new paradigm for

reducing costs while improving processes and

the quality of care. There are though many

aspects to be proven mainly actual cost

reductions. The introduction of an innovative,

mobile patient monitoring solution in the

inpatient Cardiology Service at the Hospital de

são sebastião was build as an evidence based

project involving many actors to allow proper

assessment. The developed system is in the last

phases of clinical and economic validation.

Keywords:

Mobile Healthcare, Body Area Network,

Communication Systems, Sensors, Inpatient

Cardiology Service.

Introduction

There is a vision for mobile healthcare as a

response to today's demands. The introduction

of an innovative, mobile patient monitoring

solution for the collection and transmission of

body values over the public wireless network,

including value propositions and lessons

learned from pre-commercial validation is an

example of evidence based quality and cost

advantages for the Healthcare System [1].

During the last fours years a consortium of

universities, hospitals and commercial

companies has been working together for

the development of innovative systems

and services for mobile health care [2].

Two major projects were financed by the

European Union allowing the development

of a complete mobile healthcare system

and its validation with extensive medical

trials. MobiHealth and Health-Service24

have developed a generic Body Area

Network (BAN) for healthcare [1].

Biosignals measured by sensors connected

to the BAN are transmitted to a remote

healthcare location over public wireless

networks (GPRS/UMTS), where doctors

can monitor, diagnose and provide advice

to patients in real time. The developed

system is in the last phases of clinical

validation.

The health sector faces serious and increasing

problems in the management of resources for

disease prevention, follow-up and remote

assistance of patients [3]. The cost of in-patient

care is increasingly creating problems for both

patients and social security organizations [4].

The above described needs of patients

combined with the evolution and availability of

wireless communication networks and the ever-

advancing miniaturization of sensor devices and

computers, will give rise to new services and

applications that will have a major effect in

health care. Towards this direction, a validation

project has been running for the development

and deployment of innovative value-added

mobile health services, based on mobile

networks.

The Hospital de São Sebastião is aware of the

importance of mobile health applications for

addressing local challenges in healthcare. The

Ericsson Mobile Health (EMH) platform seems

to overcome insight into an innovative and

mobile end-to-end mobile health application.

Since the cost of in-patient care or regular

appointments for lab result analysis is

increasingly expensive for both patients and

health care institutions and the advanced

miniaturization of sensors devices and

computers, will give rise to new services and

applications that will have a major effect in

home side unit monitoring [1] [5] [6] .

The Hospital de São Sebastião desires to get

clear benefits from the project. To ensure a trial

experience and technical validation of the

sensors and the EMH methodology the hospital

is playing an important role right from the

development and until the final tests, in real

environment, of an intelligent system using

“adaptative” sensors for monitoring of

physiologic parameters of patients discharged at

home. By means of Bluetooth and UMTS or

GPRS communications network (by Vodafone)

for data transfer the system outputs should be

integrated in home-care delivery strategies for

our population in risk [7].

Clinical Environment

The Clinical component was taking very

seriously in order to obtain evidence based

results. The prototype developed considered the

following pathologies:

● Patients with coronary diseases

discharged from cardiology hospital

inpatient service.

● Patients with congestive heart failure

(CHF) after clinical discharge.

● Patients with potential history of

malicious dysrhythmia.

● Patients with certain cardiopathy and

profiling an explicit high vascular risk.

● Dicumarin treated patients.

● Patients with diabetes.

Clinical difficulty to overcome

Under observation, in the Hospital de São

Sebastião inpatient Cardiology Service, are the

patients with the coronary illness condition

detected within severe symptom. If one is able

to long distance monitor some of those patients,

they could benefit from early discharge since

their therapeutics can be wireless network

monitored.

The benefits recurring to long distance

monitoring from these patients and those with

congestive cardiac insufficiency are enormous.

Other and particularly important issues are the

active daily life patients’ reintegration, the

safety of therapeutically proposal schemes, the

kind of programs and exercises to be

implemented and consequently the posterior

diminution of the re-inpatient act.

In case of patients with high-risk profile,

particularly Isquemic Heart Disease risk or

Cardiac arrhythmia, over patients with

suspicious of severe cardiac dysrhythmia, the

importance of a professional care long distance

ECG monitoring is instantly recognizable. The

possibility of recognise premonitory signals of

arrhythmias that overcame daily life risk of the

patient and the surveillance of therapeutic

efficacy will ensure definitively major

repercussions on quality treatment and quality

of life to this kind of patients.

Monitoring procedure: Existing and

Future

The procedures nowadays followed to deal with

those problems are based on the clinical

evolution of the internment, such as the results

of complementary exams, before the hospital

discharge and the clinical evaluation during

followed outpatients’ delivery consultancy.

Patients with heart deceases

Heart deceases such as insufficiency, heart

failure, arrhythmia should have on the

following sensors:

1. Pulse oximeter;

2. ECG 3 lead;

3. Body weight scales;

The inpatient Cardiology Service of hospital

can make available the possibility for

monitoring a group of patients with EMH

sensors. Additionally is possible to measure the

same patients using the local conventional and

certified equipments in a way to grant to the

EMH sensors a clinical scientific validation.

As a result the scientific validation of the

methodology and the sensors the hospital is

able to test the solution under discharged

patients as possible as the challenges related to

security, privacy and integrity of data during

communications transmission to end points are

achieved. The variables to be monitored

depends of patients pathology:

Dicumarin treated patients

Patients with prosthetic heart valves, carriers of

arrhythmias, carriers of thrombophylias and

other diseases, which indicates life-term

anticoagulant therapy were followed. These

careful chosen patients should have the

following equipment at home:

4. Coagulation monitor

Due to the ageing of the population and the

better survival of several illnesses the number

of patients who does anticoagulant therapy has

been increasing in the past recent years. A

higher number of patients survive to do cardiac

surgeries and these ones have better survival

rates. An unexpected number of young patients

are now carriers of arrhythmias and plus the

worse atherosclerotic profile of the population

in younger generations, all contribute to the

increase the number of anticoagulant treated

patients. Furthermore, due to recent tests, a

several of thrombophylia conditions have been

identified and also indicate life-term

anticoagulation therapy.

As a consequence, the numbers of attendants to

Consults of monitorization of anticoagulation

therapy have increased enormously and no one

knows when is going to stop. These are turning

the life of the patients in a heal. Recently,

several enterprises released on the market,

portable anticoagulation monitors that unable

the self-assessment of the test. With this

technology, the patient can perform the test

quietly at home and by several means of

communication be in contact with his doctor.

By these means, the patient no longer has to

travel to the hospital/laboratory or clinic to

perform its test and no longer has to wait for the

consultation by his doctor.

Dicumarin treated patients are 90% (70 patients

3 times a week) of the outpatients at the

Haematology Medicine Department. They

come frequently from local and very long

distant areas just to perform anticoagulation

monitoring tests. After the collection of blood,

by venous puncture (with all difficulties of this

technique), the patients have to wait for the

laboratory result and medical consultation,

performing all this an average of 90-120

minutes.

Selected patients, having a coagulation monitor

connected to the Hospital can make an auto-

control determination of the INR (International

Normalized Ratio that serves to control the

anticoagulant therapy and permits to compare it

from lab to lab) and this results will be checked

at the hospital with a return message for

eventual changes of the medication they are

taking. This will represent a huge achievement

for the workload at this department, by reducing

this, but still keeping all the patients screened.

Another issue is the recent law that introduces

the concept of appointment without the

presence of the patient using different

communication means. The hospital will not

lose this income because the payment is the

same.

For the perspective of the patient, this will be a

great improvement because two steps will be

by-passed. Blood tests at the hospital or on a

private system, and frequent visits to the

hospital with all the inherent negative aspects

(costs of transport, time consumed, work hours

lost). Another important aspect is that the

patient will be treated on an optimized manner

(right dose at the right moment) rather than on a

system that depends of the day of appointment

(right dose at a fixed date). This system will

slowly change the healthcare paradigm shifting

de decisions of better treatment to the patient

making him more proactive on his care and

moving the care outside of the healthcare

centres, but always with a supervision of them.

MOBI-SAUDE: Network and

Technological Platform

The MobiHealth research project (IST-2001-

36006, May 2002 – February 2004), developed

a technically validated and fully functioning

mobile platform for ambulant patient

monitoring with measurements transmitted over

public wireless networks [1]. This was achieved

with the integration of sensors in a wireless

Body Area Network (BAN). The BAN

connected sensors continuously measure and

transmit vital constants to health service

providers. With the completion of the research

project and the very encouraging results, the

first phase of the commercialisation of the

system has been targeted. A new 18 months

project, HealthService24, under the eTen

framework was launched in February 2005,

with the goal of to validating the existing

service in the market in order to have a fully

marketable solution at the end of the project.

Hospital São Sebastião Validation trial

In order to test and verify the system, nine

validation trials have been conducted within the

project in four different countries in Europe:

Netherlands, Spain, Cyprus and Portugal

(Hospital de São Sebastião) [1]. Three different

groups of patients are testing the service: (high-

risk) pregnant women, cardiac patients and

COPD-patients (Chronic Obstructive

Pulmonary Disease) with respiratory problems.

This trial lasted approximately 3 months

followed by 1 month results analysis. As the

market validation is an interactive process, the

results obtained during the first set of trials are

fed into the next phases.

Metrics for evaluating the test results include

general indicators such as quality of life (and

care) for both patient and doctor, economic

benefits for a patient/government of not staying

in hospital (and freeing a hospital bed), overall

costs of the service and adaptation issues to

adjust the service to national requirements as

well as reliability, accuracy and sensitivity of

the equipment and ease of use for patient and

health professional [7]. A number of

questionnaires are prepared, issued and

evaluated in order to analyse all necessary pre-

requisites for commercial deployment [8] [9]

[10] [11].

Conclusions

The results of the project are so far quite

positive. The measurements reveal a

comparable quality with the old measurement

system at the inpatient cardiology service. The

patient behaviour and response was good with

high levels of comfort. Nevertheless there were

some indications that several issues need to be

resolved by both network operators and

hardware manufacturers for a better support to

mobile health services. Some monitoring

equipment is still too cumbersome for

ambulatory use, because of the nature of the

equipment or because of power requirements.

Other challenges relate to security, integrity and

privacy of data during transmission to both

local transmission and long range

communications. Legislation differences

between European countries do create some

problems in the adoption of mobile systems.

Some harmonization is expected in the future

but it will take time to become reality. Business

models for healthcare and accounting and

billing models for network services was also

addressed to properly value the innovation.

Standardization at all levels is essential for open

solutions to prevail. At the same time

specialization, customization and

personalization are widely considered to be

success criteria for innovative services.

Partnership for Evidence based assessment was

a major goal. The partnership between Ericsson,

INA (Portuguese Institute for Public

Administration), the Hospital de S. Sebastião

(Santa Maria da Feira- Portugal) and Vodafone

Foundation represents a important asset that

allowed to build a real prototype with real

patients and obtain all the relevant data to

properly assess the advantages of applying

mobile technology to healthcare fostering

innovation to solve real problems.

Acknowledgements

We thanks the collaboration and support from

Vodafone Foundation.

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Address for correspondence.

Luís Velez Lapão,

Grupo de Sistemas de Saúde

Instituto Nacional de Administração,

2784-540 Oeiras

Portugal

Email: luis.lapao@ina.pt