Design of Health Technologies lecture 1

1. Design of Health Technologieslecture 1 John Canny8/29/05

2. Outline Background on Health and Health Care Goals of the course Course format

3. Background Current estimates of the cost of health care in the US put it at 1.8 billion (about 4x the defense budget). Health spending is about 15% of US GDP, much higher than European countries or Canada. Health costs in the US are accelerating again, after a steady period in the 1990s. The health care system is under stress – CHCF report.

4. Negative Effects of Cost Escalation.

5. What can technology do? Acute care (i.e. hospital & outpatient treatment) is dependent on technology more and more: • New wonder drugs • New imaging techniques – MRI, sonar etc. • New diagnostic methods, DNA chips, biosensors • Minimally-invasive surgical methods • Radiation treatments These approaches are very powerful, and very specialized. We wont be covering them in this course (but see Ruzena Bajcsy’s course from last Spring).

6. What can technology do? - EMR But actually, medical “treatment” is only a part of the health care challenge… A surprising challenge is medical record-keeping. Care-givers today spend a significant fraction of their workday documenting their work (Newhouse talk, forthcoming, and note the “administration” category in the CHCF report). Electronic Medical Records (EMR) promise to streamline and improve care. It is near the top of every HMO’s priorities, and most have an EMR strategy unfolding.

7. EMR challenges EMR challenges many areas of IT: Record security and privacy POE transcription (Physician Order Entry) Human-Machine interaction – efficiency, low error rate Data mining – better care, better economics Multimedia storage and retrieval High availability and persistence Interoperability New technologies for EMR could enable much more effective field studies of medical interventions (drugs as well as lifestyle changes). See Newman presentation…

8. EMR challenges: Adoption EMR faces major adoption challenges in the short term. Many care-givers have developed their own record-keeping practices, and are reluctant to adopt wholly new ones. Nurses bear the brunt of record-keeping today, but often have minimal say in the adoption of new systems. Several early record-keeping systems failed because they were built for idealized practices, not the actual practices of working care-givers.

9. Health in the large Almost all the health budget today is spent on acute care, but most experts argue for a general approach to health. This should include the home, facilities for palliative and elder care, and other supports. The reasons are: Lifestyle can dramatically influence health – Obesity, Psychological health, Mobility Health care costs increase sharply with age (4x >60) The boomer generation is aging (2010-30 retirement) Expected lifetime for a child born today is probably > 90 years

10. Diagnostic tools Personal Health monitoring in the home: Blood pressure, pulse, temperature, glucose…

11. Home diagnostic challenges Clearly, these systems need to be reliable, accurate, and secure (beware wireless links). The inference done on this data needs to be robust as well, minimizing false positives and negatives. Many simple tests today (e.g. blood pressure) require non-trivial skill – the accuracy reports by customers are wildly different – suggesting there is a big range in skill. Usability of home medical tests is going to be a big issue for the foreseeable future.

12. In-vivo diagnostics Some types of monitoring, e.g. glucose monitoring for diabetes, must be invasive. But tiny implanted sensors are a new option. E.g. the Grimes group at Penn State buildsmagneto-elastic sensors that measure glucoselevels under the skin. Other groups, e.g. Intel Seattle, are working on modified RFID tags that produce a few bits of sensing (WISPs).

13. Diagnostic tools Activity – accelerometers, pedometers, heart rate and GPS e.g. Suunto’s T6, Footpod and X9i Fitsense pacer and “bodylan”

14. Diet A few university projects have looked at estimating caloric input using sensed data: Jen Mankoff at UCB: used PDAs to scan receipts Kay Connelly at Indiana: used product barcodes The goal is to guide users toward better dietary choices.

15. Telemedicine Telemedicine is an attractive alternative to visits to the hospital or doctor’s surgery. Telemedicine typically involves teleconferencing in conjunction with some remote diagnosis sensors. It can also support continuous patient monitoring. e.g. the Health Buddy:

16. Telemedicine – Health Buddy http://www.healthhero.com/products_services/health_buddy_demo.html

17. Clinical Decision-Making Medical diagnosis and treatment are decision problems with incomplete information, and can be automated. Probabilistic methods are well-established today. They work well in constrained decision problems with few variables – symptoms, patient demographics and health. Decision-making is often case-based – a system’s decision is supported by the retrieval of a set of relevant cases.

18. Clinical Decision-Making But there is still a desire for “naturalistic” or human-like decision-making. Machines have a difficult time narrowing down an unconstrained decision-problem. When the datasets are broad and sparse (like a doctor’s clinical experience), automated inference stalls. Alternatives include “situated cognition” or “activity based” inference.

19. Health in the Developing World Health measures – esp. infant mortality and life expectancy – are often used as the measures of development. Those countries which have made dramatic economic progress in the last few decades (e.g. India and China), have made similar strides in health.

20. Life Expectancy in India

21. Infant Mortality in India Per 1000 live births

22. Economic Growth China and India since 1980 have been among the fastest-growing economies in the world. China’s GDP growth, around 7% per year, is the highest in the world. India is not far behind with a 6% annual growth.

23. Health in the Developing World The gains with economic development are not automatic however. Both India and China built strong public health systems. They instituted vaccination programs, regional hospitals, and high-yield agriculture (green revolution) to provide adequate nutrition to everyone. In the rush to economic liberalization, some of these gains appear to be eroding.

24. Health in the Developing World Poor health drains economic growth in many ways – Absenteeism and low productivity at work Costs of medicines and treatments Excessive birth rates, infant and child mortality Jeffrey Sachs (author of “The End of Poverty”) argues that health problems have been the biggest obstacle to growth in recent years in sub-saharan Africa. Inadequate health creates a downward spiral back into poverty

25. Health in the Developing World Some health challenges in the developing world: • Clean water/sanitation • Inadequate nutrition • Lack of access to doctors and medicines • Respiratory illness • Reproductive health • Malaria • AIDS • Meningitis, Cholera, other epidemics

26. Health in the Developing World Many of these challenges don’t require exotic solutions, but might be improved by simple, locally-appropriate solutions. e.g. Smoke monitoring (~ $2 sensors) + smoke hoods(Kirk Smith)

27. Water Satellite data in India is used to map likely targets for wells with very high accuracy (from 30 to 90%). Local sensing (via cell phones) might achieve a similar result. Some coordination of water use would be extremely valuable, since there is often competition for available wells.

28. Medication Tracking medicines and dosages is a big challenge in many developing countries. The same techniques used in developed countries seem to work (bar code scanners/terminals), but they need to be very inexpensive. Several programs have beendeveloper to support barcodereading on cellphones:Airclic, Motorola, SonyEricsson

29. Telemedicine Telemedicine is seen as an important part of the health care puzzle in almost all developing countries. The health center in Amrita, Kerala, India serves 34 local sites. Uses satellite links… diagnosis, telesurgery.

30. Outline Background on Health and Health Care Goals of the course Course format

31. Course Goals Familiarity with emerging health challenges Select a topic for a course project Build a team (2-3 people) for your project Develop a prototype throughout the semester, using a human-centered design process: • Needs analysis, interviews, observation* • Informal prototypes • Design iteration

32. Human-Centered Design Health care (and health maintenance) are complex social practices. Technologies that are not adapted to those practices are apt to fail. In medical jargon, you have to test health systems “in vivo”, not just “in vitro”. Iterative design keeps user needs in the loop. Prototype Design Evaluate

33. Participatory Design Users of an IT system may be excellent designers: Historically, doctors have been responsible for health innovations of all kinds. They are excellent potential critics and design partners. Nurses are also health experts, and understand clinical practice at all levels. Participation helps technology adoption. When stakeholders participate actively, there is a much better chance their needs are addressed. They also feel ownership of the innovation.

34. Participatory Design In developing regions, contextual factors can be extremely difficult to anticipate. Participation by actual users can be very hard, but is worth attempting. Otherwise, local experts can represent users’ interests on the design team. These are people with extensive field experience with the target community.

35. Outline Background on Health and Health Care Goals of the course Course format

36. Course Format Guest Presentations – format will vary but normally a presentation followed by Q&A. There will be a ready assigned by the guest speaker. You should come prepared with questions based on it. Regular Classes Each week there will be an assigned reading, one student will give a presentation (1/2 hour), short post-script by me, then small group discussion, and some questions to look for in the next lecture.

37. Course Format Homework:For each class you should turn in a summary (1/2 page or so) of the reading for that class. Projects: Projects can be computer programs, electronic or mechanical prototypes, studies or designs that address a health challenge. Project planning starts after the first section of the course (weeks 1 to 3).

38. Questions for next time… Normally, I would give you some questions to think about as you read the next reading… The next reading is “Medical Data: Their Acquisition, Storage and Use”, which is chapter 2 from Medical Informatics: Computer Applications in Health Care and Biomedicine, by Shortliffe and Perreault, Springer, 2001 That reading comes with its own set of framing questions, and some discussion questions at the end. These are all you need..