Remote clinical examination:the key issue of telemedicine

Enrico M. StaderiniHaute Ecole d'Ingénierie et de Gestion du Canton de Vaud – HES-SO

Western Switzerland University of Applied SciencesRoute de Cheseaux, 1

CH-1400 Yverdon les Bains (Vaud) Switzerlandenrico.staderini@heig-vd.ch

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How physicians are made

Information diggersPattern findersProblem solversAlarm triggers

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Direct patient interaction

orMediated patient interaction

Medicine not only lacks precision...

It lacks a formal methodology

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Medical practice is a practice indeed!

Not a formal theory behind it

Epistemology of diagnostics

Patient is suffering from somethingTask of diagnostics is to discover it

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The diagnostic process implies– Interaction & Communication– Physical measurements

A social constructA technological construct

The process of subject-caregiver interaction

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sensations

cognitive process (awareness)

perception of symptoms

cultural process

complaint

subject

discourse

cultural process(discipline)

shareable medical record

formalization of symptoms

cultural process

hypothesized disease from a set of disease models

hypothesis probing process

caregiver

physical interaction

formalization of diagnosis

signs

Interaction in the hypothesis probing

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patientdecisionprocess

stimulation vector

response vector

perception

biometricdevice

biometricdevice

signs & findings

formalization of diagnosis

action

care-giver

The caregiver decision process

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stimulation vectorstimulation vector

generator

perception

perceived finding

expected finding

similarity

min expected similaritydecision

formalization of diagnosissigns & findings

caregiver decision process

+-

Interaction in the hypothesis probing

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patientdecisionprocess

stimulation vector

response vector

perception

biometricdevice

biometricdevice

signs & findings

formalization of diagnosis

action

care-giver

The “device only” interaction

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patientdecisionprocess

stimulation vector

response vector

perception

biometricdevice

biometric device

signs & findings

formalization of diagnosis

action

care-giver

Interaction through a telecom channel

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patient

decisionprocess stimulation

vector

response vectorperception

telebiometric device

signs & findings

formalization of diagnosis

action

telebiometric device

care-giver teleconsultation

telediagnostics

The engineering science of medical practice

Engineering the medical practice

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Formalizing a method of diagnostic reasoning (a science of diagnostics)– Syntax– Semantics– Pragmatics

Formalizing the knowledge base

The social issue of telemedicine

What about if the communication/interaction part of the diagnostic process is technologically mediated ?No formal training of physicians to cope with this situation–Methodology must be strengthened– Security and legal issues in data

transmission are just details

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What we need

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Formalism for data representationFormalism for data transmissionFormalism for data fruitionFormalism for decision makingFormalism for action performing– Standardization and formal theory of

medicine

Modern attempts to theorize medicine from Prof. Sadegh-Zadeh

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• Sadegh-Zadeh K.: “Fundamentals of clinical methodology 1. Differential indication”. Artificial Intelligence Med. 1994, 6, 83-102

• Sadegh-Zadeh K.: “Fundamentals of clinical methodology 2. Etiology”. Artificial Intelligence Med. 1998, 12, 227-270

• Sadegh-Zadeh K.: “Fundamentals of clinical methodology 3. Nosology”. Artificial Intelligence Med. 1999, 17, 87-108

• Sadegh-Zadeh K.: “Fundamentals of clinical methodology 4. Diagnosis”. Artificial Intelligence Med. 2000, 20, 227-241

• Sadegh-Zadeh K.: “Fuzzy Health, Illness and Disease”. J. Med. Phyl. 2000, 25, 605-638

• Sadegh-Zadeh K.: “The Prototype Resemblance Theory of Disease”. J. Med. Phyl. 2008, 33, 106-139

A roadmap to telemedicine

Formalizing medical reasoningIs clinical judgment computable ?Classical knowledge not appropriateFuzzy logic may beDiagnostic and therapeutic knowledge is procedural knowledge (medical practice) on fuzzy statements

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Teaching telemedicine

We have to, at university levelDon't make just examplesTeach methodology insteadCoping with an unreachable patientInsist on the social interplay of the medical taskUse (develop) standards for medical data communication

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An evolution process

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dire

ct in

tera

ction

with

pati

ent

100

% conventional semiotics

invention of the stethoscope(Laennec 1816)

invention of the telephone (Bell 1876)

invention of X-ray imaging (Roentgen 1895)

invention of electrocardiograph (Einthoven 1902)

invention of 2D M-mode echocardiography (Reid 1970)

invention of computed tomography (Hounsfield 1972)

invention of the microprocessor (Hoff 1968)

invention of the World Wide Web (Berners-Lee 1991)

telemetry

teleconsultation

assistive technologies

caregiver alone

time

Warnings

Medicine remains a cultural process– verify that standards and methods will comply

with different social cultures

Consider the business model of the medical practice– Samaritans are not widespread !

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