1. 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 2

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 3

4. E-health and Health Informatics 4

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 5

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 6

7. 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) 8

9. Information and Communications Technologies in Healthcare Smart computing Wearable computing Sensors RFID Wireless LANs 3G/4G networks Personal area networks 9

10. 10 Quality of data from sensors Health Databases Networking Infrastructure Devices Compressed and Processed data Quality of transmitted data Quality of stored data Quality of received data Healthcare Decision Systems Quality of healthcare decisions Data from multiple sources (patients, doctors, labs, pharmacies) Quality of life for the patient Quality of network control data Quality of Processed data Quality of retrieved data Quality of healthcare services Quality of service Quality of integrated data The Big Picture

11. 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 12

13. 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. 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. 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. 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 17 + 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. 18 ECG Signal (60-80/min) 1 beat 240 samples/sec 12-36 bits/sample 2.9-8.7 Kbps Multiple messages per minute Vital Signs Sampling rate Quantization Minimum bit rate Breathing (12-18/min) 1 sample/sec 4 bits/sample 4 bps Body core temperature (97.1-99.1F) 1 sample/min 16 bits/sample 0.3 bps Oxygen Saturation (95-99%) 1 sample/sec 16 bits/sample 16 bps Blood pressure (Sys<120, Dia<80) 1 sample/minute 64 bits/sample 1 bps

19. 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. 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 21

22. 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. 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. 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 25

26. 26 Wearable Computing: Variations

27. Context-awareness 27 Vital Signs Environmental Variables Current Activities Sensory Information Prescribed Medicines Unusual Conditions Thresholds Rate of Change Previous Values Medicine1,..N Recent doses Missed doses Patient Handicaps Physical Cognitive Sensory Sweat Palpitations Breathing Sitting Walking Running Sleeping Temperature Humidity Air quality Recent Lab-results Filtering & Information Integration Patient’s Medical History Type of Health Monitoring Context Generation and Processing Patient Info And Context

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

29. 29 Wireless Networks Monitoring device Healthcare Professional Patient Information Monitoring of Alert Generation Monitoring of Alert Transmission Monitoring of Alert Processing Monitoring of Decisions/updates Monitoring System The Monitoring of Monitoring System

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 30

31. EMR/EHR 31

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) 32

33. 33 Health Monitoring: Vital Signs and Processing

34. 34 Transmitting video can add considerable traffic depending on the duration, frequency, resolution, frame rate, and compression

35. 35 Types of Monitoring

36. 36 Threshold-based (multiple vital signs)

37. 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. 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. 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. 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. 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. 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

43. 43

44. Context-aware Reminders 44

45. Using SMMS in Multiple Interventions 45

46. 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. 47 Age, Abilities and Deficits in Percentages Age Sensorimotor and cognitive abilities (average) Deficit (average) Technology support needed for daily activities 60-70100-900-10Minimal 70-807030Moderate 80-9050 High 90+0-1090-100Very high

48. 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. 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. 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)

51. Some Examples of Current Research Monitoring and stray prevention system (RFID, GPS, GSM and Geographical Information Systems) Markov decision processes (MDPs) to provide prompts to a user for guidance through the activity of hand- washing Wrist-worn integrated health monitoring device (WIHMD) for fall detection, ECG, blood pressure, pulse oximetry, respiration rate, and body temperature Selective video-clips for automated/human analysis (even remote help based on the context) 51

52. Medical Decision Making Complex in terms of number of parameters and variables, outcome possibilities, and information that must be processed Healthcare professionals need to make these complex decisions with no margins for errors 15% of medical decisions lead to misdiagnosis Cognitive load (Sweller, 1988): Excessive cognitive load could affect the quality of decision making (medical errors and lower quality of healthcare services) and mobile devices could make it worse 52

53. Cognitive Load and Decision Making 53 Intrinsic Cognitive Load Extraneous Cognitive Load Germane Cognitive Load Total Cognitive Load + Visual Component Quality of Decision Making Cognitive Capacity (Working Memory) Residual Load Audio Component Prior Experiences

54. Mobile Alert to Healthcare Professional 54 PATIENT-ID = U93 BP = 140/90 SPO2 = 99 Temp=98 Medications Screen 1Screen 2Screen N Pulse = 120

55. Simple Decision Making (context-aware system) 55 PATIENT-ID = U93 Do Nothing Get More Information Hospitalize Get More Information Call a Physician Hospitalize Likely condition 1 Likely condition 2

56. 56 Conclusions and Future Health Informatics is one of the most exciting advances in healthcare and computing With the increasing cost of healthcare and limited healthcare professionals, health informatics can play a very important role in the future of healthcare How information can be used most effectively in various healthcare processes (EMR/EHR, health monitoring, medication adherence, and medical decision making)

57. 57 Conclusions and Future HI can further lead to many important advances in healthcare and technologies Proactive health and wellness management Design and use of medications that are most suited to individual patients Healthcare systems that are context aware to provide necessary interventions for health and medications Smart technologies that can sense and support the needs of elderly in independent living Personalized and intelligent monitoring of patients can lead to better health outcomes at lower healthcare cost

58. Questions? 58 For more information: Pervasive Healthcare Computing EMR/EHR, Wireless and Health Monitoring Varshney, Upkar 2009 (Hardcover) ISBN: 978-1-4419-0214-6 Springer.com