Trends in e-Health and Telemedicine FRANCESCO SICURELLO
President of IITM-International Institute of Medical Informatics &TeleMedicine; Professor
of Medical Informatics, University of Milano Bicocca
Today Medicine challenges • Increase of elderly people Cronical diseases Cardiovascular diseases Cancer Neuropathologies
• Infectious diseases • Genetic causes of diseases • Diseases prevention (epidemiology) • Rehabilitation • Home care assistance • Citizens/patients ask for more information
Needs of health assistance and biomedical research
• Circulation of knowledge, information and data with the aim of achieving productivity management control and of maintaining high standards of healthcare;
• Population ageing with leads to demand for continuous treatment and care improving quality;
• Globalization of health, seems as market and demands of ever more qualified health services.
Economic aspects in healthcare:
Industrialized Countries Health care expenditures: ~ 10% GDP • USA 12% • Japan 7% • Australia 8,5% • European Union 8% • Italy 6% Strong GAP with Developing Countries
Change of Paradigm
• Cost containment • Changing demographies • Peripheralization of Health care delivery • Changing disease patterns • Impact of ICT in supporting clinical decisions • More informed and expectant patients • Well-being factor (wellness paradigm ) • Moving information and knowledge • Creation of health network
3°
2°
1°
University
Hospitals
Healthcare
Healthcare
Healthcare
Regional
Hospitals
District clinics and general hospitals
GP
Challenges of healthcare providers (public and/or private)
• To improve quality and treatment and care of patient and of life of the citizens.
• To reduce costs (expenditure control). • To use advanced diagnostic and therapeutical
technologies (CT,MRI, etc.) for a large number of patients/citizens.
ICT and Telemedicine can contribute to win this challenges:
• Improving level of health maintainance. • Reducing costs.
ICT Market in Health Sector
• Rapidly increasing Percentage of ICT growth (y. 2009) of health
budget: • USA 10% • Japan 12% • Canada 14% • Australia 15% • European Union 7% • Italy 5,5% Digital Divide betwen developed and developing countries
ICT in health care delivery
• Globalisation • Health care economics • Patient process • Medical profession • New technologies
(mobile videophone, mobile networks)
Growing
2000 2010
Medical informatics
Health telematics (telemedicine)
e-Health
e-health includes: • medical information systems, • public health surveillance, • e-learning for health professionals, • telehomecare
• telemedicine
e-Health
Access to care Quality of care
•Telemedicine
•Teleconsultation
•Home care
•Monitoring
economy of care
•Image assistant by computers
•Continuos education
•E-prescription
•Electronic health record
•Digitalized health system
•Hospital information systems
•Regional networks
•E-reimbursement/procurement
•Smart cards
e-Health 3rd industrial pillar for health
• Pharmaceutical (7% of HC expenditures) XIXth century • Medical imaging (3%) XXth century • e-Health (5%) XXIth century
Focus • Medical record
– Electronic patient record – Patient data card – ……. • Record linkage - Integration of health database - Epidemiology - Evaluation of care and structures quality - Clinical research • Networking - Telemedicine (teleconsulting/telediagnosis) - Teleassistance/telemonitoring - Internet in health care - Medical www
Internet in medicine • Diffusion of Internet services in healthcare; • Building of web sites and portals in medicine
fields; • To share and to access to clinical information
(protocols of care, guidelines, etc.); • Teleconsulting and telediagnosis in
peripherical health structures and also at home (Telemedicine)..
TELEMEDICINE
sub-field of e-health Telemedicine means, literally, 'medicine at a
distance'. Telemedicine is the interactive transmission
of clinical data, signals and biomedical images, in order to enable patients, living in remote locations, to receive the best possible care delivery and services.
ICT CONVERGENCE
DEFINITION OF TELEMEDICINE / 1
The IOM (Institute Of Medicine) of American National Academy of Science on 1996, in a Guide to accessing telecommunications for Health Care defined telemedicine as “the use of electronic information and communications technologies to provide and support health care when distance separates the participants”
DEFINITION OF TELEMEDICINE / 2
The definition of telemedicine adopted by an international consultation group convened by the WHO in Geneva in December 1997 says:
“Telemedicine is the delivery of health-care services, where distance is a critical factor, by health-care professionals using information and communication technologies for the exchange of valid information far diagnosis, treatment and prevention of disease and injuries, and for the continuing education of health-care providers as well as research and evaluation, all in the interests of advancing the health of individuals and their communities.”
Telemedicine Activities: Teleconsulting (clinicians clinicians) Telediagnosis (clinicians phisicians) Telemonitoring (clinical centers
patients) Telesurveillance [i.e. home telecare] (health
structure patients) Tele-emergency (first aid centers health
operators ambulances patients)
TELEMEDICINE APPLICATIONS The main application areas of telemedicine systems are: • telecardiology, • teleradiology, • telepathology • teleophthalmology • telehomecare and
(There are other specialties that use telemedicine
services, as teledermatology,telesurgery, telepsychiatry etc., but these are poor of applications at moment).
TeleCardiology
TeleRadiology
Teleradiology
Images visualization 1. PC based systems 2.Workstation
TelePathology
TELEPATHOLOGY • Pathology is the medical study of
disease related changes in cells and tissue
• Pathologists frequently need opinions from those who specialize in particular disease
• Telepathology is the practice of pathology at a distance
• Telepathology can be used for obtaining a second opinion or a primary diagnosis
• Telepathology has been especially useful in the support of isolated and non-specialty pathologists
Teleophthalmology
Retinopathy
Some Sample
Retinograph JPEG IMAGE OF RETINA
TELECARE
• The ageing of the population poses significant economic, social and health-care challenges.
• The elder age is characterized by high incidence of chronic multi-pathologies and disabilities, such as diabetes, hypertension, heart disease, chronic respiratory failure and asthma.
• ICT in the home setting can support the management of chronic disease in a number of ways
TELECARE SYSTEMS • Other telecare systems
regard signal and data transmission from homecare, connection to IP based WAN, detecting automatically arrhythmia for patient at home and sending ECG data to a Service Center.
TELECARE DEVICES
Mobile phone, Personal Digital Assistant (PDA), laptop and palmtop computers are all set to be transformed by these developments which will have far reaching effect in ICT programs in healthcare
• GSM • Emergency botton (dialing with service center) • Electodes for ECG recording • Location function by means GPS
Devices
DIGITAL ECG
ECG with continuous memory
HW/SW for acquiring and transmitting ECG using PDA
Windows CE and Pocket PC 2002 compatible
Unlimited achieving of ECG files
6 and 12 leads cables
displaying of ECG
direct measurement
print from PDA, wireless, by means Bluetooh and infra red
E-mail sending ECG by means modem or mobile network
(GSM, GPRS)
Devices
Some Sample <?xml version="1.0" encoding="ISO-8859-
1"?> <utenti> <utente>
<nome>Luca</nome> <cognome>Ruggero<
/cognome> <indirizzo>Milano</in
dirizzo> </utente> <utente>
<nome>Max</nome> <cognome>Rossi</c
ognome> <indirizzo>Roma</in
dirizzo> </utente> </utenti>
Pocket size SpO2/CO2 monitors SpO2/CO2 Monitors
Device for glucose monitoring
T-shirt with BIO-SENSORS
Device for emergency/2
Portable Radiological Device
Telemedicine and emergency Data transmission from ambulances to ED: • Patient vital signs/ECG (portable monitor cum defibbrillator) • Blood pressure • Heart rate and pulse oximetry • Other information communicated by paramedics in ambulances
(collected in notebook), ex: - respiratory rate, objective evidence, patient mental
state (Glasgow Coma Scale). (SW system can compute trauma score). - transmission of data, before leaving site, to receiving
hospital ED ad initial pre-arrival information. ED staff can prepare therapeutical procedures, useful drugs, etc.
Telecardiology in emergency Server System Manage:
– Manage data patient – Manage ECG signal – Manage data base – Manage transtelephone emitters tools – Manage electro-biomedical signs
Client System: • Multitasking electro-Medical devices (ECG, tolls for blood pressure,
SpO2, CO2, temperature , glucose, etc. • Communication tools
– Telephone (also mobile) – satellites
• Cellular (GSM, GPRS and UMTS) • PDA, etc.
Radio exchange between e-ambulance and operative station of: • Audio • Video • Intervention card • Patient biological data (ECG, blood pressure, etc)
Communication tools
Mobile phones or Smart Phones / PDA connected with the simple biomedical devices for “at home” data acquiring and data transmission;
WIRELESS TECHNOLOGY IN HEALTH TELEMONITORING
Transmission of multimedial data can be
realized by;
telecommunication lines
wireless system
mobile telephony
palm devices MOBILE AND WIRELESS TELECOMMUNICATION DEVICES
used for receiving medical parameters related to pathologies (e.g. : cardiological diseases)
WIRELESS TECHNOLOGY IN HEALTH TELEMONITORING
Mobile phone, Personal Digital Assistant (PDA) can be used for monitoring, checking and diagnosing.
PDAs, in particular, can be used:
to collect information from a variety of sources
to integrate data from a variety of users
to create a comprehensive records, such as Multimedial Medical
Record (MMR)
Some communication standard
• General Packet Radio Service (GPRS) – is a Mobile Data Service available to users of GSM
and IS-136 mobile phones. GPRS data transfer is typically charged per megabyte of transferred data, while data communication via traditional circuit switching is billed per minute of connection time, independent of whether the user has actually transferred data or has been in an idle state. GPRS can be utilized for services such as WAP access, SMS and MMS, but also for Internet communication services such as email and web access.
Some communication Standard/2
• Wi-Fi – Wi-Fi is a brand originally licensed by the Wi-Fi
Alliance to describe the embedded technology of wireless local area networks (WLAN) based on the IEEE 802.11 specifications. Wi-Fi, standing for "wireless fidelity", was developed to be used for mobile computing devices, such as laptops, in LANs, but is now increasingly used for more services, including Internet and VoIP phone access, gaming, and basic connectivity of consumer electronics such as televisions and DVD players, or digital cameras.
Cooperation in e-Health and Telemedicine
• Developing of health network; • Interconnecting services and actors of
healthcare system between Italy and developing countries.
• Spreading information to several structures,
local care units, hospitals, GPs etc.
Aims of cooperation: • Multi-country training in public health; • Creation of specialized regional databases; • Organization of epidemiological surveillance
groups; • Implementation of computerized solutions
for telediagnosis; • Coordination of policies in the treatment of
major diseases.
Actors of cooperation:
• Research Institutes and hospitals; • Health care administration;
• Individual doctors/researchers in biomedicine.
Projects In the frame of Scientific/Technological Cooperation
• Europenan projects: NeuroWeb; e/T-Care; Diabcare Teleyecare.
• Mediterranean Network in Medicine (Egypt, Lebanon, Tunisia, Morocco, Italy France, … ) Intr@med
• InterHospital and Health cooperating Network for Telemedicine between some Eastern Europe Countries.
• TelePathologyNet for cancer diseases •
56
Neuroweb - Integrated computer based system to
support over internet diagnostic/therapeutical medical process in neurology (cerebrovascular diseases)
- E-Health & BioMedical informatics project
57
Information and knowledge
– clinical databases: patient’s files with lists of signs and symptoms, results of laboratory tests, referrals, therapies and outcomes
– genomic databases, in particular containing collections of SNP’s related to specific pathologies;
– epidemiological databases at state/region and level, containing information about the final outcome of the considered pathology and its incidence wrt the whole population of the region/state;
– shared taxonomy, ontological relations and dictionary of symptoms and signs;
– medical literature databases such as MEDLINE;
– standard guidelines issued by medical associations to approach selected pathologies
– diagnostic and therapeutical protocols.
58
Integration
• Within Bio-Medical patient records related to neurological disease
Integration of: – Anamnestic Data (textual) – Objective Data – Lab Data (signals, images, etc.) – Genomic data – Therapeutical data – Epidemiological data
ESSENTIAL DATA SET OF CLINICAL
DATA BASE
59
NEUROWEB: Integration • Between Clinical databases of four
Neurological Centers (Italy, Hungary, Greece, The Nederland)
• Harmonization of information systems • Interoperability of clinical protocols derived from
similar guide line used
60
System Architecture - LOGICAL
Web Service Interface
•Databanks •Literature •Genomics Data •Guidelines •...
•Clinical DB •Images DB •PDT •Ontologies •Epidemiological Registers
•SQL - ENSEMBLE •Statistical Package •Neural Network SW •Data mining •Text explorer •Search explorer •...
New PDT Relations between
tests/diagnosis/outcome
HL7/CDA DICOM
XML ....
NW
Internet Connection VPN Connection
DATA
Knoledg Base Genomic
DB CLINICAL
DB CLINICAL
DB CLINICAL
DB
Genomic DB
Genomic DB
MEDIATOR
CLINICAL DB
Genomic DB
MAPPING TOOL
API
Intelligent Visualization explorer (Query on KBi, DBJ,
COMPk) Protocol & GL appliccation
GL SEARCH ENGINE
DeGeL LIBRARY
GENOMIC ENGINE
GENOMIC DATA BANK
Knoledg Base
Acq.ti Acq.ti
Computational Services
T-CARE: Telecare based on Digital TV
• “The aim of this system is to extend the time during which elderly people can live independently in their preferred environment with the support of ICTs.”
• T-Care is an innovative integrated system, (TV + Biomedical devices) favouring the independent living of the disable and elderly people, especially those suffering with chronic diseases, ensuring them timely health assistance, alert and education for life styles.
T-Care permits to receive in interactive way on specific channel general or specific information, knowledge, alert or instructions, (educational exercises, etc.) relating to the targeted patients diseases (diabetics, cardiopaties, neurological diseases) production Application
Users
Broadcast
Return Channel
Application Services Delivery
Video Server
TV-News and Personalized information
TeleyeCare: Telemonitorig of ocular diseases
Integrated ICT system for tele-monitoring medical parameters related to patients affected by chronic diseases (like diabetes) and in particular ocular disease (Diabetic Retinopathy, Age Related Macular Disease and Glaucoma).
DIAB-EYE-CARE Telemedicine in Ophthalmology
InterHospital Teleconsulting System between Italy and Romania
Hospitals involved: County Hospital of Timisoara General Hospital of Firenze Hospital of Brescia/Desio
• TELE – Cardiology • TELE – Radiology • TELE – Pathology
SPECIALITIES
Common data set and DB and liver DISEASES (hepatopathies) and HIV Diseases
INTERHOSPITAL BETWEEN ITALY AND ROMANIA
•Telecardiology
•Telepatology
•Teleradiology
Timisoara Hospital
Brescia Hospital
Florence Hospital
Hospital/Health Network Model to extend to Balkan Area by
The Balkan Area
Split
• Integration among services already available to the local communities or extended to a wider geographical area.
• accessing to clinical information and processing in the health services for clinical activity to users (doctor, radiologists, etc.) and the clinical activity of teleconsulting and telediagnosis.
• offering the opportunity to integrate and coordinate methods of care and diagnostic/therapeutical protocols.
INTR@MED Mediterranean Medical Intranet based
on Web Portal to access clinical database and for
teleconsulting/telediagnosis.
INTR@MED PORTAL
INTR@MED PORTAL
TeleCardiology Section:
patient’s clinical data
INTR@MED and Mediterranean Basin
Euro-Mediterranean Basin
• Countries ~30. • Area: more then 2,000,000 km². • Inhabitants ~ 500.000.000.
Towards EMU (Euro Mediterranean Union):
•free exchange of people and goods
•Cooperation between Governments
•Cooperation between Health Structures and Operators (hospitals, out patients clinics, Physicians, researcher, Professionals ecc. )
TELEMEDICINE PROJECT BETWEEN ITALY AND EGYPT
Intramed Portal can provide integration among services aready available to the local communities or extended to a wider geographical area.
It can favorite the access to clinical information and processing in the health services for clinical activity to users (doctors, radiologists, etc.) and the clinical activity of teleconsulting and telediagnosis.
It can also offer the opportunity to integrate and co-ordinate methods of care and diagnostic/therapeutical protocols).
2nd opinion.
Telemedicine Project: Italy (Palermo) – Egypt (Cairo)
INTR@MED PORTAL
TelePathology Section:
patient’s clinical data and pictures slides
Telepathology
▀ Telepathology platform is constituted by: microscope,telecamera, PC, communication network, architecture client/server, relational DBMS, SW Firewall, SW of compression of the images (i.e. Jpeg).
Telepathology Net for Cancer Registry: Epidemiology, Research and Treatment
Telepathology Net for Cancer Registry: Epidemiology, Research and Treatment
Experience in Telephatology between Italy and some
African countries
THE ORGANIZATION OF REGULAR DIAGNOSTIC ACTIVITY WITH VOLOUNTEERS EUROPEAN PATHOLOGISTS
Use Satellite Technology and GIS in Health Care
• A GIS is a system designed to capture, store, manipulate, analyze, manage, and present all types of geographical data.
• GIS is the merging of cartography, statistical analysis, and database technology.
• Satellite images can be used to do a Spatial Analysis (tool to describe analytic processes applied to georeferenced data.) – ESRI's ArcGIS Desktop (ArcYiew 9)
GIS and Telemedicine Sample: • Using GIS Technology to Track Virus Prevalence (Mapping
Helps Ability to Assess Cancer Risk) California - National Cancer Institute
Satellite Internet services • Satellite Internet services are used in locations
where terrestrial Internet access is not available and in locations which move frequently. Internet access via satellite is available worldwide, including vessels at sea and mobile land vehicles. There are three types of satellite Internet service:
• one-way multicast, • one-way with terrestrial return, and • very small aperture terminal (VSAT) (two-way)
satellite access.
Towards GRID Cumputing The term GRID started in the mid 1990s to describe a distributed
computing structure for scientific research (in particular on the field of particle physics). The concept underlying the GRID technology is coordinated resource-sharing and problem-solving in dynamic, virtual organisations. (Today GRID technology is encroaching on a spectrum of new application fields such as meteorology, biology and also medicine).
GRID technologies could improve the management of Medical Information Systems, in order to enable a coordinate, flexible and secure sharing of diverse resources, including computers, applications, data, storage, networks and scientific tools across dynamic and geographically (at regional, national and international level) dispersed health structures and clinical communities (Virtual Organizations).
Healthgrid uses GRID technologies applied to health care information (at molecular level as genomic data, at individual level as medical record and imaging and at population level as epidemiological registers and database), in order to establish a distributed environment providing basic common services (web portals, computing resources) to the health professionals and biomedical researches located in various Hospitals, clinical and research centers.
The most important fields in which Grid technology is exploited for health purposes are Proteomics, Genomics, Bio-images analysis and transmission, simulations of biological events and clinical knowledge sharing, Neuroscience, Epidemiology.
GRID IN HEALTH CARE
CLOUD COMPUTING • HAS POWER AT EDGE OF NETWORK (EVEN
BY MEANS OF SMART PHONE) WITH ABILITY TO CONNECT DEVICES ACROSS INTERNET TO VAST COMPUTING POWER THAT COMES FROM VIRTUALISING THOUSANDS AND THOUSANDS OF SERVERS TO APPEAR AS ONE (grid Technology)
• NEEDS of COMPUTING POWER & STORAGE ARE PROVIDED AS SERVICES (AS ELECTRICITY Grid)
• IT ENABLES NEW OPPORTUNITY FOR INNOVATION FOR SOCIETY SEEN AS WHOLE
CLOUD COMPUTING • USING COMPUTING CAPABILITY DELIVERED
ACROSS INTERNET IN UTILITY OR ON-DEMAND FASHION
• COMPUTING BASED ON VIRTUAL DATA CENTRES WITH INFINITE SCALE PROVIDING VAST PROCESSING CAPABILITY TO ANY USER (Consumer, small or larg Enterprise, etc.)
• CLOUD TAKES ADVANTAGES OF CENTRALIZED COMPUTING RESOURCES in LARGE DATA CENTRES with COMPUTING SHARED in MANY and VARIOUS COMPUTERS
Cloud Computing • Cloud computing is the
delivery of computing as a service rather than a product, whereby shared resources, software, and information are provided to computers and other devices as a utility (like the electricity grid) over a network (typically the Internet).
• Cloud computing provides computation, software applications, data access,data management and storage resources without requiring cloud users to know the location and other details of the
ti i f t t
Service Model • Cloud computing
providers offer their services according to three fundamental models: – Infrastructure as a
service (IaaS), – platform as a service
(PaaS), – and software as a
service (SaaS)
Cloud Examples • Cloud storage • Internet TV • Online banking • Social media and networking • Synced data • Online retailing • Blogging • Peer-to-peer file sharing • Collaborative distributed computing
Cloud Examples • Cloud storage • Internet TV • Online banking • Social media and networking • Synced data • Online retailing • Blogging • Peer-to-peer file sharing • Collaborative distributed computing
Cloud computing: Future prospect for e-health
• Mobile healthcare information management utilizing Cloud Computing and Android OS
• Wireless Communications and Mobile Computing
• Challenges of Cloud Computing to Improve Health Care
Cloud Computing in Health Care
• Technology Aspect • Security Aspect • Legal Aspect
THANK YOU
