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@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 Quality of transmitted data Networking Infrastructure 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 Connectivity 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 Blood pressure (Sys<120, Dia<80) Multiple messages per minute 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 Patient’s Medical History Unusual Conditions Recent Lab-results

28. Obtain Vital_signs and thresholds If Vital_sign<Thres2(low) Emergency Level = High Transmit Emergency Signal No Yes If Vital_sign<Thres1(low) Yes No EM-Points = EM-Points + Thres1(low) - Vital_sign) If Vital_sign<Thres1(high) Yes No No If Vital_sign<Thres2(high) Yes EM-Points = EM-Points + Thres2(high) - Vital_sign If RT_CHNGE>RT_THRSLD No Yes EM-Points = EM-Points + POINTS_RT_CHNGE No If CURR_ACTIVITY = RESTING Yes EM-Points = EM-Points + POINTS_RESTING If Curr_TM>= RPRT_TM If EM-Points >= EM_Thresh-H Yes No Yes No If EM-Points >= 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 patient’s 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

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 expectancy=78 • 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

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)