Resolving the health care crisis; health informatics for holistic medicine.

1. Resolving the health care crisis; health informatics for holistic medicine. Andrew Stranieri Centre for Informatics and Applied Optimisation, University of Ballarat, Victoria Tony Sahama Queensland University of Technology, Queensland

2. Health informatics research

3. Health informatics research • Holistic Medicine informatics (with Uni Colombo, QUT, ICHM 2012) • Data mining Cardiovascular disease, TCM (with CSU) • Online Dispute Resolution in Health (with Deakin) • Decision Support for cancer patients, multi-disciplinary groups • Smart Information Portal (with Monash)

4. University of Ballarat and QUT for ICHM 2012 Health informatics: transforming health care • Technologies • Telemedicine • Decision support systems • Data mining • Standards for interoperability • Information systems • Simulation • Electronic Health Record

5. University of Ballarat and QUT for ICHM 2012 Backdrop: Health care is in crisis • Australia spends 9% of GDP on health • More chronic illnesses, diabetes, CVD. No cure ; • Increasing costs of medical advances; • Problems with health workforce supply and distribution – HCP flock to major cities of developed countries ; • Persistent concerns about the quality and safety of health services; • Achieving equity in health • 1 billion people never see a doctor • Information Communication Technologies are transforming Health

6. University of Ballarat QUT ICHM 2012 Backdrop: Diverse medical systems are prevalent • Body-person. • Physical (WM, TCM, N, H, AM) • Psychological (WM, H, TCM, AM, N), • Spiritual (AM, H) • Energetic (TCM, AM) • Illness. • Caused by external agent (WM, AM, TCM) • Caused by internal imbalance (TCM, AM) • Practitioner-patient relationship • Passive.............................Active

7. University of Ballarat 2011 Diverse medical systems are popular • CAM are prevalant in the West (Dawn and Upchurch 2005, Hastings and Torada 2009, Lim et al 2005) • Western Medicine growing in prevalence outside West (Hesketh and Zhu 1997; Chua and Furnham 2008)

8. Backdrop: Co-existence of diverse medical systems All systems co-exist as diverse but equally regarded practices • TCM and Ayervedic prevalence enhanced by emerging economies of China and India • Homeopathy already quite popular in many Western countries • CAM (in West) arguably provides good models of patient empowerment • Allopathic is very expensive. Few countries can afford 10%GDP on health • Chronic (lifestyle) conditions resistant to Allopathic • Many colleges of CAM around the world

9. University of Ballarat, QUT ICHM 2012 How/When will patients select a medical system ? • Which practitioner • Treatment effectiveness • Empathy (Dose of doctor) • Empowerment (Patient centred care) • Practicalities (Availability, Cost) Open research question: How to support patients to make a decision about which system?

10. University of Ballarat and QUT for ICHM 2012 Health informatics: transforming health care • Technologies • Telemedicine • Decision support systems • Data mining • Standards for interoperability • Information systems • Simulation • Electronic Health Record

11. University of Ballarat and QUT for ICHM 2012 Health informatics: transforming health care • Trends • Toward more preventative health care • Toward more participatory health care • Toward co-existence of medical systems

12. University of Ballarat and QUT for ICHM 2012 Empowering patients Telemedicine • Access HCP remotely by video conference • https://gp2u.com.au/

13. University of Ballarat and QUT for ICHM 2012 Tele-dentistry • UB Consortium Pilot. Nursing home to Dentist for Cost effective treatment plans

14. University of Ballarat and QUT for ICHM 2012 HD3D Pilot project • Tele-oncology • Oncologist and patient with nurse. Record consultation onto DVD • Tele-psychiatry • HD3D Specialist psychiatrist for fine motor movements • Tele-wound management • Nurse in home uploads a 3D image of a wound for a wound specialist to assess

15. University of Ballarat 2011 HD3D Pilot project • Tele-wound. Automated depth assessment Open Research question: Identify image processing applications within holistic medicines

16. University of Ballarat 2011 Remote surgery • Japan/Korea Arata et al 2007 World Congress on Medical Physics and Biomedical Engineering 2006 IFMBE ProceedingsVolume 14, 2007, pp 3065-3068. A remote surgery experiment between Japan-Korea using the minimally invasive surgical system

17. University of Ballarat and QUT for ICHM 2012 Telemedicine for holistic medicine Acupuncture at sea. Information Technology in Alternative Medicine. 2010. Bernard Fong, A. C. M. Fong, C. K. Li Mindfulness by telehealth. Measuring mindfulness: which aspects of mindfulness change following a brief telehealth intervention for PTSD? B Niles1*, A Seligowski1 and A Silberbogen2 BMC Complementary and Alternative Medicine 2012, 12(Suppl 1):P191 doi:10.1186/1472-6882-12-S1-P191 Open Research question: Identify which practices within holistic medicines can appropriately be performed by Tele-health

18. University of Ballarat and QUT for ICHM 2012 Decision support systems • Systems that encode knowledge, use an inference and reach a conclusion. Examples: • Intensive Care Unit Ballarat Hospital. Knowledge from experienced nurses in a DSS for training • DSS for inferring supportive care (relationship, spiritual, financial, transport, etc) needs of cancer patients • DSS for inferring pathology lab test diagnosis

19. University of Ballarat and QUT for ICHM 2012 Supportive care needs DSS • Typically with Quality of Life instruments but; • Difficult to fit QOL instruments into busy HCP workflows • Difficult to engage patients. Non interactive, always the same questions. • Not customised for local settings. Questions validated over large populations cannot be modified • Our approach: DSS; • DSS infers needs, and infers appropriate referrals. Report adds value to HCP • Interactive. Patients/carers online, at home, dynamic questions. • Can be customised for local settings. Eg no referrals to psychologists if none around. Question content and nuances evolves locally

20. University of Ballarat 2011 Decision support systems in holistic medicine • CAMEO (2012) helps cancer patients identify useful CAM evidenced based • Zhou et al (2012) TCM DSS for Syndrome differentiation and diagnosis • Wang et al (2008) Self learning system for TCM diagnosis • Vithoulkas Compass DSS for helping homeopathy practitioners select remedies http://www.vithoulkas.com/en/books-study/vithoulkas-compass.html

21. University of Ballarat 2011 Decision support systems in holistic medicine: open questions • How best to represent knowledge for DSS given high level of tacit knowledge in many holistic medicine systems? • How to support patients to choose between medical systems • Ripple down rules? :

22. University of Ballarat and QUT for ICHM 2012 Data mining Data mining = Statistics + Computer Science + Maths • Discovering patterns from data • Adverse drug reaction • Cystic Fibrosis Predictors. Quinn, Stranieri, Yearwood, Gauditz 2010 • Cardiovascular autonomic neuropathy - replacement tests

23. University of Ballarat and QUT for ICHM 2012 Data mining to discover interactions Quinn Weighted sum discovery Clinical Data warehouse – de Silva

24. University of Ballarat and QUT for ICHM 2012 Data mining open questions How to identify tasks in holistic medicine suitable for data mining? How to collect and pre-process data in standard ways to facilitate data mining? How to integrate clinical knowledge into data mining exercise?

25. University of Ballarat and QUT for ICHM 2012 Simulation systems • Quality of Care • Virtual hospital SecondLife Imperial College London • Games for health • WII, UQ Distraction for burns victims • Simulation for education • Knee surgery http://www.edheads.org/activities/knee/ • Virtual patient UB Miller et al SecondLife Nursing (2009-10) • Simulation for empowerment • Interactive DVD for people who stutter Meredith (2010)

26. University of Ballarat and QUT for ICHM 2012 Ubiquitous health information • Patients Like Me • http://www.patientslikeme.com/ • Cochrane Collaboration • http://www.cochrane.org/ • Breast Cancer Online • Health InSite Portal • http://www.healthinsite.gov.au/

27. University of Ballarat and QUT for ICHM 2012 Standards

28. University of Ballarat 2011 Terminology standards SNOMED

29. University of Ballarat 2011 Terminology standards SNOMED

30. University of Ballarat 2011 OpenEHR arhetypes

31. University of Ballarat 2011 Open questions SNOMED • New work proposal for TCM in SNOMED • Open question about SNOMED and • Ayurveda • Homeopathy • Other holistic medicines • OpenEHR archetypes for holistic medicine

32. University of Ballarat 2011 Health informatics is based on allopathic medicine • Telemedicine, Decision support, Data mining, Electronic health record, Simulation • Co-existance of complementary medicine with allopathic medicine can also help alleviate the crisis • However, requires a concerted effort by health informaticians to ensure developments are applicable to Holistic medicine

33. University of Ballarat 2011 HL7 for CAM? 1777.1801 : HL7 Event : A01 : Admit Patient 1777.1802 : HL7 Event : A02 : Transfer Patient 1777.1803 : HL7 Event : A03 : Discharge Patient 1777.1804 : HL7 Event : A04 : Register Patient 1777.1805 : HL7 Event : A05 : Preadmit Patient 1777.1806 : HL7 Event : A06 : Transfer ?Outpatient to Inpatient 1777.1807 : HL7 Event : A07 : Transfer ?Inpatient to Outpatient 1777.1808 : HL7 Event : A08 : Update Patient 1777.1811 : HL7 Event : A11 : Cancel Admit 1777.1812 : HL7 Event : A12 : Cancel Transfer 1777.1813 : HL7 Event : A13 : Cancel Discharge 1777.1817 : HL7 Event : A17 : Bed Swap 1777.1818 : HL7 Event : A18 : Merge Patient 1777.1220 : HL7 Segment : DG1 : Diagnosis Information 1777.1225 : HL7 Segment : EVN : Event Information 1777.1250 : HL7 Segment : MSH : Message Header 1777.1255 : HL7 Segment : NK1 : Next of Kin Information 1777.1260 : HL7 Segment : NTE : Notes and Comments 1777.1265 : HL7 Segment : OBR : Order Information 1777.1270 : HL7 Segment : OBX : Observation Information 1777.1275 : HL7 Segment : ORC : Order Common Information 1777.1280 : HL7 Segment : PD1 : Patient Demographic Information 1777.1295 : HL7 Segment : PID : Patient Information 1777.1300 : HL7 Segment : PR1 : Procedure Information 1777.1305 : HL7 Segment : PV1 : Patient Visit Information 1777.1800 : HL7 Event Summary

34. Electronic health record • In Australian NEHTA. PCEHR • Microsoft Health Vault • http://www.healthvault.com/ • Denmark • Bernstein 1995 • US • Obama E H R by 2014

35. University of Ballarat 2011 Electronic health record A virtual electronic record of every health event from before birth to after death Integrated so that every authorised health care professional can add to or access the record

36. University of Ballarat 2011 Electronic health record: More complaints Patient empowerment means more queries, complaints, disputes Online Dispute Resolution – argument structure based organisation of the dispute to help its resolution

37. University of Ballarat 2011 Electronic Health Record Open question: Should CAM events be entered in an electronic health record? If so, how?

38. University of Ballarat 2011 Electronic Health Record Open question: Should CAM events be entered in an electronic health record? If so, how?

39. University of Ballarat and QUT for ICHM 2012 Conclusion • Technologies • Telemedicine • Decision support systems • Data mining • Standards for interoperability • Information systems • Simulation • Electronic Health Record