Health Informatics: Applications, Requirements, and Emerging Research

1
Health Informatics Applications,
Requirements, and Emerging Research

• Upkar Varshney
• Department of CIS
• Georgia State University
• E-mail uvarshney_at_gsu.edu

2
Format of the Tutorial

• Health Informatics (HI)
• Information and Communications Technologies in
  Healthcare
• Specific Examples of Health Informatics
• Conclusions and Future

3
Health Informatics (HI)

• The intersection of several fields including
  computer science, healthcare, and business
• To provide the needed information anywhere
  anytime to anyone authorized in prompt, correct
  and secure ways
• Resources, devices and methods to provide
  healthcare services
• Consumer health informatics, nursing health
  informatics, organizational health informatics,
  public health informatics, and medical health
  informatics

4
E-health and Health Informatics
5
Major Goals of HI

• Reducing Various Errors in Healthcare
• Extending the Coverage and Delivery of Healthcare
• Improving Medication Adherence/Adverse Drug
  Events
• Support Independent Living for the Elderly
• Improved Decision Making
• Wellness and Managing Chronic Conditions
• Improving Efficiencies and Reducing Overall Cost
• Supporting Patient Empowerment
• Addressing Limited Human Resources

6
Chronic Diseases

• A disease for which there is no cure
• Managing it well to reduce other complications
• CDC Chronic diseases such as heart disease,
  stroke, cancer, diabetes, and arthritis are
  among the most common, costly, and preventable of
  all health problems in the U.S.
• Heart disease, cancer and stroke 50 of all
  deaths
• The four most common reasons lack of physical
  activity, poor nutrition, tobacco use, and
  excessive alcohol consumption

7
Wellness and Proactive Health

• People with good health need to maintain it
• Exercise, stress, food, sleep, weight
• People with chronic conditions need to manage it
• Medications, sleep, weight
• Elderly want to live independently
• Activities of daily living, medications, sleep,
  weight, behaviour
• Use of ICT to enable monitoring and management of
  health

8
IT-based Wellness Management

• Various IT/communications technologies for
• sensors in shoes
• Internet-aware exercise machines
• cell-phone based applications for managing
  wellness
• Wellness diary
• Social networking/group communications/twitter
• Suitability/evaluation of technologies
• Theoretical Support (or lack of suitable theories)

9
Information and Communications Technologies in
Healthcare

• Smart computing
• Wearable computing
• Sensors
• RFID
• Wireless LANs
• 3G/4G networks
• Personal area networks

10
The Big Picture
Quality of integrated data
Health Databases
Data from multiple sources (patients, doctors,
labs, pharmacies)
Quality of Processed data
Quality of retrieved data
Quality of stored data
Quality of data from sensors
Quality of service
Healthcare Decision Systems
Networking Infrastructure
Quality of transmitted data
Quality of received data
Devices
Compressed and Processed data
Quality of network control data
Quality of healthcare decisions
Quality of life for the patient
Quality of healthcare services
11
Improvements with Wireless Technologies

• How wireless technologies can help improve
  healthcare systems worldwide
• Wireless technologies can lead to the desired
  evolution of healthcare system
• In general, these technologies
• can allow information to be available anywhere
  any time to anyone who is authorized to access it
• make the delivery of healthcare services more
  efficient
• reduce the number of tasks that need to be done
  by healthcare professionals
• encourage patients to take better control of
  their healthcare needs and life style

12
Healthcare Quality of Service (H-QoS) and
Wireless Requirements

• Real-time delivery
• Cellular/3G/4G
• Reliability
• Challenges for most wireless networks
• Wide Coverage
• Cellular/3G/4G, wireless LANs, satellites, ad hoc
  networks
• Bandwidth
• Wireless LANs and 4G networks
• Location Management
• Cellular/3G/4G and wireless LANs
• Pricing
• Wireless LANs

13
Suitable Technologies for Healthcare

• Suitable technologies for healthcare implanted
  (inside body), wearable, portable, and
  environmental technologies
• Implanted technologies RFID to store information
  and sensors to measure medical parameters
• The wearable technologies Smart Shirts with
  sensors designed to wear for extended monitoring
  of health conditions. Could be washed, ironed and
  charged for use, and in future, networked with
  devices and people
• The portable devices, such as handheld devices
  and phones, used in monitoring and recording
  health conditions
• Environmental technologies computing and
  communications close to the patients (Smart
  Home)

14
Wireless Technologies in Healthcare

• Cellular Networks
• Wireless LANs
• Sensors
• Radio Frequency Identification
• Bluetooth and ZigBee
• Satellites
• Characteristics Indoor vs outdoor, real time vs
  no real-time services, coverage (PANs to WANs),
  reliability, varying bit rates and levels of
  location-awareness

15
Sensors Applications

• Small devices with sensing, computation and
  wireless communications capabilities (not
  mobile!!)
• Sensors measure ambient conditions in their
  surrounding environment and then transform these
  into signals (which can be processed to determine
  the conditions of the sensed environment)
• Applications
• Use in wearable, portable and environmental
  implementations (Smart Shirt, Smart House,
  Appliances)
• Monitoring of vital signs
• Many more applications with sensor networks (fall
  detection with embedded smart carpet)

16
Mobile monitoring devices

• Implanted, portable, wearable or in the
  surrounding environment
• Devices with sensors to measure a range of vital
  signs and other parameters for its patient
• The devices with intelligence would detect
  certain conditions by the touch of a user
• Many of the smaller medical devices can be
  integrated in the hand-held/wearable wireless
  device
• Pulse-rate, blood pressure, level of alcohol
• Specific requirements of vital signs
• how to measure and process vital signs such as
  blood pressure (BP), ElectroCardioGram (ECG),
  temperature, oxygen saturation
• Each of these requires different type of
  sensor(s) at a certain part of human body

17
Sensors in Healthcare
Sensors on Neck, Bed, Kitchen, Appliances, and
Bathroom
Sensor locations and user movement Reliability of
sensors Unintentional removal of sensors Wear and
tear of sensors Sensor-body contact/noise Connecti
vity for body area networks False positive/false
negative
18
Sampling rate Quantization
Vital Signs
Minimum bit rate
Breathing (12-18/min)
1 sample/sec 4 bits/sample
4 bps
ECG Signal (60-80/min)
1 beat
240 samples/sec 12-36 bits/sample
2.9-8.7 Kbps
Multiple messages per minute
Blood pressure (Syslt120, Dialt80)
1 sample/minute 64 bits/sample
1 bps
Oxygen Saturation (95-99)
1 sample/sec 16 bits/sample
16 bps
Body core temperature (97.1-99.1F)
1 sample/min 16 bits/sample
0.3 bps
19
Radio Frequency Identification (RFID)

• Location tracking of
• Patients and healthcare professionals
• Supplies, equipments, and blood
• Authentication of expensive medications
• Storage of (compact) information (such as EMR)
• (Ingestible) RFID on smart capsules to monitor
  the condition of internal organs (GI tract
  diseases)
• Further Research
• Requirements of new applications/bio
  compatibility/side effects/long-term use
• Cost-benefit of RFID deployment

20
Smart House

• Assistive environments (for older and/or disabled
  people) for sensing themselves and their
  residents
• Gator Tech Smart House at University of Florida
• smart blinds to control ambient light (and
  privacy)
• smart bed to monitor sleep patterns
• smart closet to make clothing suggestions
• smart mirrors for messages reminders for
  medications
• smart bathroom with sensors for measurement of
  weight, height and temperature, and ECG
• SmartWave to refuse to heating up the items that
  you are not suppose to eat
• social-distant dining using immersive video
• smart floor for fall detection

21
Smart House
22
Cellular/3G/4G Networks

• Offers from about 100 Kbps to 2 Mbps
• Designed to support multimedia, data, and video
• Short Messaging Service
• stored delivered in few seconds (not real-time)
• reminders, or compressed information on patient
• General Packet Radio Service (GPRS) 160 Kbps
• Enhanced Data rate for GSM Evolution (EDGE)384
  Kbps
• 4G (not available in places where patients may
  live) but useful for video-oriented healthcare
  applications
• Telemedicine, tele-radiology, tele-surgery
• Video-clips of patients, healthcare professionals

23
Wireless LANs IEEE 802.11a, 802.11g, 802.11n

• 802.11a
• Supports 54 Mbps in 5 GHz band (smallest range)
• 802.11g
• Supports 54 Mbps in 2.4 GHz band
• 802.11n
• As high as 600 Mbps and up to 70 meters (indoors)
  and 250 meters (outdoors)
• 5 GHz and 2.4 GHz both possible
• Useful for independent homes, assisted living and
  nursing homes

24
Bluetooth and ZigBee In Healthcare

• Bluetooth Unlikely to be a standalone technology
  due to short range (10m), limited bit rate (few
  hundred Kbps) and not more than eight devices in
  a piconet
• The range could be increased by adding Bluetooth
  adapters in hand-held devices and phones
• ZigBee ad hoc and mesh networking format
• One of the intended environments is Hospital Care
• More likely to be a front-end technology and will
  require another network to carry monitoring
  messages to one or more healthcare professionals
• Sensors Bluetooth or ZigBee for communications
  to other devices or among themselves (sensor
  networks)

25
Comparison of Wireless Technologies
26
Wearable Computing Variations
27
Context-awareness
Thresholds Rate of Change Previous Values
Vital Signs
Type of Health Monitoring
Medicine1, ..N Recent doses Missed doses
Prescribed Medicines
Context Generation and Processing
Filtering Information Integration
Physical Cognitive Sensory
Patient Handicaps
Patient Info And Context
Sweat Palpitations Breathing
Sensory Information
Sitting Walking Running Sleeping
Current Activities
Temperature Humidity Air quality
Environmental Variables
Patients Medical History
Unusual Conditions
Recent Lab-results
28
Obtain Vital_signs and thresholds
If Vital_signltThres2(low)
Emergency Level High Transmit Emergency Signal
No
Yes

If Vital_signltThres1(low)
Yes
No
EM-Points EM-Points Thres1(low) - Vital_sign)

If Vital_signltThres1(high)
Yes
No
No
If Vital_signltThres2(high)
Yes
EM-Points EM-Points Thres2(high) - Vital_sign
If RT_CHNGEgtRT_THRSLD
Yes
No
EM-Points EM-Points POINTS_RT_CHNGE
No
If CURR_ACTIVITY RESTING
Yes
EM-Points EM-Points POINTS_RESTING
If EM-Points gt EM_Thresh-H
If Curr_TMgt RPRT_TM
Yes
No
Yes
No
If EM-Points gt EM_Thresh-M
Emergency Level Medium Transmit Abnormal Signal
Transmit Normal Signal
Yes
29
The Monitoring of Monitoring System
Monitoring System
Monitoring of Alert Generation
Monitoring of Alert Transmission
Monitoring of Alert Processing
Monitoring of Decisions/updates
Patient Information
Wireless Networks
Monitoring device
Healthcare Professional
30
Specific Components

•  
• EMR/EHR
• Telemedicine and Health monitoring
• Medication monitoring and management
• Independent Living and Activity of Daily Life
• Medical and clinical decision making

31
EMR/EHR
32
More Research in EMR/EHR

• Patient information from multiple sources
• Verification by patients/healthcare professionals
• Tagging (source, time)
• Use of handheld devices to access EMR
• Displaying important information first/Cognitive
  load
• Viewing part of EMR on small screen vs all on big
  screen
• Reliability of Mobile Infrastructure
• Coverage, access and delay
• Access to EMR in Emergency
• Use of stored information on patients body
  (RFID/shirt)

33
Health Monitoring Vital Signs and Processing
34
Transmitting video can add considerable traffic
depending on the duration, frequency,
resolution, frame rate, and compression
35
Types of Monitoring
36
Threshold-based (multiple vital signs)
37
Cellular/3G/4G for Monitoring

• Advantages
• Real-time Delivery
• Wide Coverage
• Bandwidth for WHM
• Ability to Work with other Wireless Technologies
• Widely Used Technology
• Secure
• Location Management
• Limitations
• Availability and presence of dead-spots
• Reliability Challenges
• Lack of Broadcast/Multicast
• Pricing and the impact of commercial traffic

38
Experience in using Cellular/3G/4G

• The cost was a major factor for many users and
  even some hospitals
• The quality was variable (packet loss, delays,
  disconnections)
• Sometimes healthcare professionals were not
  reachable (coverage, network overload problems)
• Patients were not always able to access the
  network (access and coverage problems)
• Sometimes the device battery was a limitation
• Video quality was variable (bandwidth issues)

39
Wireless LANs for Monitoring

• Advantages
• Bit Rates
• Transmission from Patients to AP (access point)
• Support for Mobile Patients
• Location Management
• Limitations
• Limited Coverage
• Security
• Monitoring Delays
• Co-located Networks
• Reliability
• Multicast

40
Experience in Wireless LANs

• The coverage was unpredictable
• The data speed was variable (monitoring delays
  were highly variable)
• Shared bandwidth
• Interference in shared unlicensed ISM band
• The device could not access the network
• Reaching to HP was difficult
• Sometimes video quality was not good (variable
  delays)

41
Lack of Medication Adherence

• With prescriptions (2010) at 3.5 billion/year,
  prescription medications a major component of
  healthcare expenses
• From no-use (about one third), infrequent use
  (about one third), to overuse to abuse (about one
  third)
• The non-adherence leads to 125,000 deaths and 90
  billion in additional hospitalization and
  procedures
• People who miss their doses are three times more
  likely to see doctors again, resulting in further
  increase in healthcare expenses
• About 20 people in US have used prescription
  drugs for non-medical reasons (prescription drug
  abuse)

42
Smart Medication Management System

• Medication is only dispensed certain doses at
  certain number of times a day to certain people
• SMMS to keep track of the time and the number of
  times/day a certain medication was taken (also
  how many times the medication system was
  attempted to be opened unsuccessfully)
• Physicians can check/communicate with SMMS on
  medication adherence and/or abuse before renewing
  the prescriptions
• SMMS can prepare and transmit short video clips
  of various actions of the patient

43
(No Transcript)
44
Context-aware Reminders
45
Using SMMS in Multiple Interventions
46
The (Seniors or) Elderly

• Eligibility for Medicare 65 senior
  citizen/geriatric
• old (65-85) vs very old (85)
• 700 million seniors Worldwide (1.3 billion in
  2040)
• US life expectancy78
• People at 65, expected to live another 18.7 years
  
• Women outnumber the man in the elderly population

47
Age, Abilities and Deficits in Percentages
Age Sensorimotor and cognitive abilities (average) Deficit (average) Technology support needed for daily activities
60-70 100-90 0-10 Minimal
70-80 70 30 Moderate
80-90 50 50 High
90 0-10 90-100 Very high
48
Activities of Daily Living and Falls

• ADL includes hygiene, food, social needs,
  medications, sleep, managing chronic conditions,
  safety and financial needs (video clips of ADL)
• Elderly with increased susceptibility to falls
  (hours or days before someone finds out)
• Health complications due to falls and the delayed
  response increases the severity of such
  conditions
• Detection of falls an important requirement
• Automatic detection of falls based on
  detection/estimation of posture and pressure on
  sensor-equipped floors
• Visual fall detection along with context
  information

49
Grand Challenge

• A 70 year old widow at home all by herself
• Mild cognitive impairment, but does most of the
  household work on her own
• Wants to remain as much independent as possible
  (grown up children in another state, but call to
  check if she is fine)
• Wants to help her friends with similar problems
• Multiple chronic illnesses requiring multiple
  medications
• If not taking medications, her condition may
  become acute
• Partial compliance one or more side effects
• A visit from home health nurse once a week
• Goal to manage chronic conditions and delay her
  transition to assisted living/nursing home for 10
  years (independence and 500,000 savings in her
  nursing home expenses)

50
Suitable ICT for the Elderly

• Appropriate for sensori-motor and cognitive
  problems
• wearable, portable, implanted, and environmental
• Another classification can be
• simple computers, Internet, websites, cell
  phones and alarm
• Intermediate RFID, emergency alarms, medication
  and task reminder systems, fall detection systems
• Elaborate Smart Home and all smart devices
• Reliable, smart and context-aware, personalized,
  robust, self-configuring, and no harm to the
  patients
• Cognition, including executive function, decision
  making and dual-task performance, decline with
  age (dual-task could lead to increased task
  complexity, may lead to falls, especially if the
  home is not well kept)

51
Some Examples of Current Research

• Monitoring and stray prevention system (RFID,
  GPS, GSM and Geographical Information Systems)
• Markov decision processes (MDPs) to provide
  prompts to a user for guidance through the
  activity of hand-washing
• Wrist-worn integrated health monitoring device
  (WIHMD) for fall detection, ECG, blood pressure,
  pulse oximetry, respiration rate, and body
  temperature
• Selective video-clips for automated/human
  analysis (even remote help based on the context)

52
Medical Decision Making

• Complex in terms of number of parameters and
  variables, outcome possibilities, and information
  that must be processed
• Healthcare professionals need to make these
  complex decisions with no margins for errors
• 15 of medical decisions lead to misdiagnosis
• Cognitive load (Sweller, 1988) Excessive
  cognitive load could affect the quality of
  decision making (medical errors and lower quality
  of healthcare services) and mobile devices could
  make it worse

53
Cognitive Load and Decision Making
Cognitive Capacity (Working Memory)
Intrinsic Cognitive Load
Visual Component
Total Cognitive Load
Quality of Decision Making
Extraneous Cognitive Load

Audio Component
Germane Cognitive Load
Prior Experiences
Residual Load
54
Mobile Alert to Healthcare Professional
SPO2 99
BP 140/90
PATIENT-ID U93
Temp98
Pulse 120
Medications
Screen 1
Screen 2
Screen N
55
Simple Decision Making(context-aware system)
Do Nothing
Get More Information
Hospitalize
PATIENT-ID U93
Likely condition 1
Get More Information
Likely condition 2
Call a Physician
Hospitalize
56
Conclusions and Future

• Health Informatics is one of the most exciting
  advances in healthcare and computing
• With the increasing cost of healthcare and
  limited healthcare professionals, health
  informatics can play a very important role in the
  future of healthcare
• How information can be used most effectively in
  various healthcare processes (EMR/EHR, health
  monitoring, medication adherence, and medical
  decision making)

57
Conclusions and Future

• HI can further lead to many important advances in
  healthcare and technologies
• Proactive health and wellness management
• Design and use of medications that are most
  suited to individual patients
• Healthcare systems that are context aware to
  provide necessary interventions for health and
  medications
• Smart technologies that can sense and support the
  needs of elderly in independent living
• Personalized and intelligent monitoring of
  patients can lead to better health outcomes at
  lower healthcare cost

58
Questions?
For more information Pervasive Healthcare
Computing EMR/EHR, Wireless and Health
MonitoringVarshney, Upkar 2009
(Hardcover)ISBN 978-1-4419-0214-6 Springer.com