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VPH in future healthcarewhere will we be in 10 years from now?
World of Health IT
Barcelona, March 15-18th 2010
Alejandro F. Frangi, PhDCenter for Computational Imaging & Simulation Technologies in Biomedicine
Universitat Pompeu Fabra, Barcelona, Spain
Networking Center on Biomedical Research – Bioengineering, Biomaterials and Nanomedicine
Institució Catalana de Recerca i Estudis Avançats
alejandro.frangi@upf.edu
www.cilab.upf.edu
www.vph-noe.eu
www.aneurist.org
Outline
Context & Current Trends
Glimpses at a Plausible Routine Future
Discussion & Conclusions
2
CONTEXT &
CURRENT TRENDS
3
Current healthcare: Why a change?
4
The need for change defies
simple solutions, as illustrated by
citizens’ dissatisfaction levels!
• Invest more money?
• Public vs. private systems?
Redefining value – From “sick
care” to healthcare
• from reactive to proactive
• patient as an object or an actor?
5
Medical Product Development: why a change?
R&D expenditure by pharmaceutical industries has dramatically increased
The number of successful drugs reaching the commercialization phase has however stagnated
Critical Path is mostly focused in the clinical phases increasingly involving expensive large-scale multi-centric studies
http://www.fda.gov/oc/initiatives/criticalpath/whitepaper.html
Healthcare trends for the future?> A patient-centric and care-cycle perspective
The hospital/healthcare of tomorrow will have as key characteristics
Patient-centric design: for personalized services and ambient experience
Individualized risk assessment: based on all relevant information (incl. demographic, genotype, phenotype, lifestyle)
Clinical work-flows: focused on Care Cycles (and care pathways), not on organizational Departments
Treatment strategies: minimally invasive and image-guided procedures
Converging medical technologies: impacting prevention, diagnosis & treatment
Federation of information systems: fully digital and connected to the clinician, the hospital, the health insurers, the government and the home
6
The patient’s journey through a disease
> care cycles
Verbeek XAAM and Lord WP (2007), The care cycle: an overview, Medica Mundi, 2007;51(2):40-47.7
Converging medical technologies
> are transforming healthcare
8
Information & communication systems
> Patient-centric ICT
Convergence of sensors, digital communications and interfaces
HeartCycle Concept descriptions and Overview on technical specifications and used technologies, Deliverable 4B. www.heartcycle.eu 9
Connecting for Health: regional data integration
Digital archiving and connectivity, and seamless access to population data derived from regional clinical records
http://www.connectingforhealth.nhs.uk10
Secondary use of EHRs or digital graves?
From information acquisition & structuring to Information access and enrichment
Substantial ethical and privacy issues involved on this model of data use!
Clinical
Information
System
Query
Patient
Record
Application Suites:
@neuLink
@neuFuse
@neuRisk
@neuEndo
Knowledge
Discovery
Information access
and enrichment
Information
acquisition
& structuring
Patient Record
- Genetic Data
- Imaging Data
- Clinical Data
Normalisation
De-identification
Denormalisation
Re-identification
Clinical Reference
Information Model
(CRIM) 11
A European Network of Excellence operated by 12 core EU institutions
12
Virtual Physiological Human (VPH)or the Digital Me
www.vph-noe.eu
13 Core Partners
4 UK (UCL, UOXF, UNOTT, USFD)
3 France (CNRS, INRIA, ERCIM)
2 Spain (UPF, IMIM)
1 Germany (EMBL [EBI])
1 Sweden (KI)
1 Belgium (ULB)
1 New Zealand (UOA)
Associate / General Members
19 Candidate General Members
3 Candidate Associate Members
(organisations)
5 Candidate Associate Members (industry)
9 Associate Projects
… and growing
“help support and progress
European research in
biomedical modeling and
simulation of the human
body. This will improve our
ability to predict,
diagnose and treat
disease, and have a
dramatic impact on the
future of healthcare, the
pharmaceutical and
medical device
industries.”
VPH- I FP7 projects
Networking
NoE
Osteoporosis
IP
Alzheimer's/ BM &
diagnosis STREP
Heart /CV
disease STREP
Cancer
STREP
Liver surgery
STREP
Heart/ LVD surgery
STREP
Oral cancer/ BM
D&T STREP
CV/ Atheroschlerosis
IP
Breast cancer/
diagnosis STREP
Vascular/ AVF &
haemodialysis STREP
Liver cancer/RFA
therapy STREP
Security and
Privacy in VPH CA
Grid access CA
Heart /CV
disease STREP
Industry
ClinicsOther
Parallel VPH projects
GLIMPSES AT A PLAUSIBLE ROUTINE FUTURE
14
Looking ahead 10 years from now?
> Glimpses of a plausible routine future?
We are seeing already the future in some of the current R&D projects
Still substantial acceptance, penetration, consolidation to be achieved
The challenge: demonstrating the anticipated clinical value
Some glimpses follow based on @neurIST…
www.aneurist.org 15
Cerebral aneurysm management
> The @neurIST “template project” Unruptured intracranial aneurysms are increasingly diagnosed due to modern
imaging techniques It is more and more important to develop holistic and sound approaches to patient
management.
Management of unruptured aneurysms is controversial decision making is currently based mainly on aneurysm size and location mainly
(ISUIA).
Wiebers D.O. Unruptured intracranial aneurysms: natural history and clinical management. Update on the international study of unruptured intracranial aneurysms. Neuroimaging Clin N Am. 2006 Aug;16(3):383-90
There is evidence that genetic predisposition may be involved in the natural history of aneurysms.
Krischek B, Inoue I. The genetics of intracranial aneurysms. J Hum Genet. 2006;51(7):587-94.
Currently endovascular treatment is favored over surgical treatment for many aneurysms (ISAT) both treatments are risky, costly and do not always prevent recurrence.
van Rooij WJ, Sluzewski M. Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol. 2006 Sep;27(8):1678-80
Molyneux A. Ruptured intracranial aneurysms - clinical aspects of subarachnoid hemorrhage management and the International Subarachnoid Aneurysm Trial. Neuroimaging Clin N Am. 2006 Aug;16(3):391-6
There is a need to support a new generation of endovascular devices treating the cause rather than symptoms of the disease
Two clinical questions
At-risk individuals/patient selection?
Optimal treatment planning?
VPH as a new perspective for More principled disease understanding and phenotyping,
Development of novel diagnostic and prognostic biomarkers, and
Computational tools for treatment planning and guidance
16
Cerebral aneurysm management
> Natural history of complex diseases
Etiology
Unruptured
[99% silent]
Growth
Ruptured
Mortality
Morbidity
Normal
33%
33%
33%
Treat?
0.2-1.0%/yrPrevalence
1-5%
F>M
Treat!
?
Degenerative
Initiation
vasospasm clotting
ISAT (Oxford)
Coil vs clip
ISUIA (Mayo)
size/locationPrevention
Diagnosis
Treatment
Prevention,
follow-up
17
PACS eRadiology Archives
Bio Bank
PACS
PACS
PACS
PACS
PACS
PACS
PACS
ISAT
ERGO
IPCI
NHRBonn
@neuQuest
@neurIST BioIS
Descriptive Data
Representative Data
Conservation of samples
I.H. Rajasekaran, L. Iacono, P. Summers, S. Benkner, G. Engelbrecht, T. Arbona, A. Chiarini, C.M. Friedrich, B. Moore, P Bijlenga, J.
Iavindrasana, R.D. Hose, A.F. Frangi (2008), @neurIST: Towards a System Architecture for Advanced Disease Management
through Integration of Heterogeneous Data, Computing, and Complex Processing Services, IEEE International Symposium on
Computer-Based Medical Systems, Finland, pp. 361-66.
Cerebral aneurysm management> Gathering evidence across Europe
@neuEndo
@neuRisk
Improve decision making processes in
the management of unruptured
aneurysms by providing a score that
integrates all the available information
for identifying at-risk patients and
reducing current over treatment
Support computational design
processes towards a next generation
of smart flow-correcting implants to
treat ruptured aneurysms and reduce
current treatment costs, side effects
and recurrence.
Support the knowledge discovery for
linking genetics to disease, vasospasm
and blood clotting after cerebral
hemorrhage
@neurISTSystems
WSS
3DRA
CFDCFD
PC-MR vs US
Flow rates
CFD vs US
Peak velocity
Model
& WSS
magnitude phasemagnitude phase
Support the integration of modeling,
simulation and visualization of
multimodal data
@neuCompute/Info Support integration of data and
computing resources.
@neuFuse
IT S
up
po
rt
Su
ites
En
ab
lin
g I
T
@neuLink
Cerebral aneurysm management
> integrative applications suites & platforms
www.aneurist.org 19
Cerebral aneurysm management> “Virtual imaging” through simulations
CFD Simulation:
• ICA Terminal aneurysm
• Inflow 230ml/min (yellow)
• 3 Outflows:
•2 Pressure
•1 Flow of 10ml/min
• High wss at neck
• Inflow jet has no clear impaction zone.
• Vortex in aneurysm (with main axis along
feeding vessel) and in bleb.
Courtesy: Philips Healthcare
20
Cerebral aneurysm management
> Building disease knowledge in silico
Cebral JR, Castro MA, Appanaboyina S, Putman CM, Millan D, Frangi AF.
Efficient pipeline for image-based patient-specific analysis of cerebral
aneurysm hemodynamics: technique and sensitivity. IEEE Trans Med
Imaging. 2005 Apr;24(4):457-67. 21
Radiological
Imaging
Vascular Model
Morphology
Streamlines
WSS
OSI
Blood
Genetics
Clinical History
Cerebral aneurysm management
> Treatment planning: virtual stenting
Larrabide I, Radaelli AG, Frangi AF. Fast virtual stenting with deformable meshes: application to inrtracranial aneurysm. Int Conf Med
Image Comput Assist Interv, 5242 (MICCAI’08), 790-7, 2008
Cebral JR, Lohner R. Efficient simulation of blood flow past complex endovascular devices using an adaptive embedding technique. IEEE
Trans Med Imaging. 2005 Apr;24(4):468-76. 22
Clot formation: A subtle interplay of genetics,
haemodynamics and arterial wall mechanics
Coil-induced clot formation is the basis of endovascular treatment for cerebral aneurysms; on the other hand spontaneous formation in untreated aneurysms is potentially loose and embolic.
Computational modelling allows for the evaluation of haemodynamic, rheological and genetic factors in thrombus formation. Models accounting for activation, biochemistry and thrombus-blood coupling will help us track the various stages of the thrombogenic process, and evaluate their significance in disease and treatment.
23
A. S. Bedekar, K. Pant, Y. Ventikos, S. Sundaram, A
computational model combining vascular biology
and haemodynamics for thrombosis prediction in
anatomically accurate cerebral aneurysms, Food
Bioprod Proc 83 (C2), 118-126, 2005
Evolution of the distribution of thrombin
concentration
Cerebral aneurysm management
> Individualized risk management
Courtesy InferMed & COSSAC University of Oxford (Prof. J Fox, Y. Chronakis) 24
DISCUSSION & CONCLUSIONS
25
EHRs, VPH and the Virtual Patient Metaphor
In practice is very unlikely to have all needed measurements before simulations can take place
VPM: A virtual patient is a logical entity that can be queried for any and all information about a human being
E.g. on-the-fly access to population average parameters where personalized data is not available
E
A
Y
B
Z
C D
@neurIST Database
Virtual Patient
Literature
Mr Jones
X
Average & deviations
input conditions
(Flow waveforms,
pressure,
haematocrit, etc… )
Derived data
Input requirements
+
Age, sex, clinical
history,
genotype, etc…
26
VPH applications & ubiquitous sensing
Personalization needs to consider in which homeostatic conditions the individuals is while being sensed
Consider environment and allostasis
“Is this patient at risk of IA rupture?” considering his/her
Exercise-rest conditions,
Stress levels,
Daily biorhythms,
Seasonal changes, etc.
Even more: “which will be his/her typical conditions under which this patient will be at risk”
Ubiquitous physiological monitoring technologies will ultimate have to connect to VPH technologies for true personalization and be integrated therein
27
Conclusions EHR, PHS, VPH: tackle complementary issues to realize patient-centric/personalized care cycles
VPH will stimulate further developments of EHR and PHS and provided added value services for healthcare and medical product development
Low-hanging fruits of VPH-PHS-EHR are available which act as levers for most sophisticated adoption
28
Announcement
@neurIST Open Session
Level 1, Room 114
Thursday 18/3, 14-16hs
Thanks for your attention
Futher contact: alejandro.frangi@upf.edu
www.aneurist.org
Final reflection
30
Validation is key for VPH
technology but still…
Will we/clinicians ever trust
computational models and VPH
technology?