1. 1(#total) CS5038 The Electronic Society Lecture : eHealth Lecture Outline The Future of Healthcare - The banking metaphor Existing Health on the Web eHealth - terminology Transmural Care Electronic Medical Records (EMR) Medical Records - Access Clinical Decision Support Systems Telemedicine - Case Studies eHealth Standards eHealth / eScience : Cancer Diagnosis Benefits of eHealth Medical Errors Why is eHealth Adopted Slowly? New sources of "health"

2. 2(#total) eHealth - The Future of Healthcare The banking metaphor Most transactions carried out by the customer Centralisation of specialist services Decentralisation of non- specialist services

3. 3(#total) Existing Health on the Web Estimated to be ~20,000 health websites 1 Used by 98 million adults 2 75% of people who have web access average of 3.3 times per month More than consult doctors each day 3 7M e-patients/day on the net; 2-3M patients see a doctor

4. 4(#total) Existing Health on the Web Access to accurate information can lead to more knowledgable, empowered, less anxious patients more participatory health decisions better care as patient and doctor become partners Mis-information can lead to confused and angry patients bad decisions, mis-placed hope, worse care, harm Privacy violations can cause emotional and economic damage

5. 5(#total) eHealth Healthcare which is supported by electronic processes Other terms: Healthcare informatics or Health Information Technology (HIT) Medical Information Systems (MIS) Biomedical informatics (also includes Bioinformatics: gene sequencing etc.)

6. 6(#total) eHealth Healthcare which is supported by electronic processes eHealth includes: Electronic Medical Records: easy communication of patient data between different healthcare professionals (GPs, specialists, care team, pharmacy) Telemedicine: do not require a patient and specialist in same physical location. Decision support systems in healthcare Data can be analysed to provide alerts, reminders and real-time decision aids Evidence Based Medicine: The application of the scientific method to medical practice Check if diagnosis is in line with scientific research. Data can be kept up-to-date. Citizen-oriented Information Provision: for both healthy individuals and patients Specialist-oriented Information Provision: best practice guidelines from latest medical journals. Virtual healthcare teams: collaborate and share information on patients through digital equipment (for transmural care).

7. 7(#total) Transmural Care Transmural: Care should not stop at the walls of the hospital Both intra- and extra-mural, thus transmural care. Care before, during and after the hospital stay. Cooperation and coordination among local practitioner, hospital, home care and rehabilitation centres Patient part of an agreed programme - protocols and standards.

8. 8(#total) Electronic Medical Records (EMR) (also called Electronic Health Record (EHR)) Access of patient data by clinical staff at any given location Accurate and complete claims processing by insurance companies Building automated checks for drug and allergy interactions Clinical notes Prescriptions Scheduling Sending and viewing labs

9. 9(#total) Electronic Medical Records (EMR) (also called Electronic Health Record (EHR)) Two types of record: Born digital" record : information originally entered in electronic format Digital format record : originally produced in a hardcopy form (x-ray film, photographs, etc.), scanned or imaged and converted to a digital form. Also: Personal Health Record (PHR) - stored and maintained by the patient. Issue: Home computer vulnerable to attack

10. 10(#total) Electronic Medical Records (EMR) Maintaining Records May be required many years after a patients death Insurance claims or murder investigation Investigate illnesses within a community industrial or environmental disease doctors committing murders need for periodic conversion and migration to ensure the formats they were captured in remain accessible Media degrades Media becomes obsolete protection of privacy is a major concern - need privacy and security policies

11. 11(#total) Electronic Medical Records (EMR) Abuses Outsourcing of transcription and storage: Could violate patient-physician confidentiality Governments may refuse to disclose records of military personnel used as experimental subjects. http://www.guardian.co.uk/military/story/0,11816,1331784, 00.html

12. 12(#total) Electronic Medical Records (EMR) NHS project in UK: One of the largest projects in the world for a countrywide EMR Goal: 60,000,000 patients with centralised EMR by 2010. Guardian, August 2011 : The Department of Health will not deliver the £11bn programme.... and has been "unable to demonstrate" any benefits for the taxpayer MPs said the intention of creating electronic records was a "worthwhile aim" but one "that has proved beyond the capacity of the department to deliver".... the scale of the project has caused companies to walk away Officials were "unable to show what has been achieved for the £2.7bn spent to date on care records systems

13. 13(#total) Medical Records - Access Laws governing access to medical records: In the UK: Data Protection Acts & Freedom of Information Act 2000 Patients or their representatives have the right to a copy of their record. Except: where information breaches confidentiality (e.g. information from another family member or where a patient has asked for information not to be disclosed to third parties) where information would be harmful to patient's well-being (e.g. some psychiatric assessments). Patients have the right to check for any errors in their record and insist that amendments be made if required.

14. 14(#total) Medical Records - Access Laws governing access to medical records: In the US: Only patient and health care providers directly involved in delivering care have the right to view the record. Patient may grant consent for any person to evaluate the record. Special Situations. Capacity When a patient does not have capacity, a legal guardian is designated Medical emergency involving a non-communicative patient Consent is assumed unless written documentation has been drafted previously Research, auditing, and evaluation Individuals involved in research have access. They are not allowed access to identifying information. Risk of death or harm Information can be shared without permission if failure to do so would result in death or harm.

15. 15(#total) Clinical Decision Support Systems Software to aid clinical decision-making; characteristics of patient are matched to knowledge base, recommendations are presented to the clinician/patient (Sim et al, JAMIA, 2001) Objectives: Diagnostic support Drug dosing Preventive care reminders Disease management (diabetes, hypertension, AIDS, asthma) Test ordering, drug prescription

16. 16(#total) Clinical Decision Support Systems Methods: rule-based, bayesian network, neural network, fuzzy logic, genetic algorithms, case-based reasoning, etc. Forward reasoning (data-driven) use if sparse data start with data, execute applicable rules, see if new conclusions trigger other rules: if high WBC AND cough AND fever AND etc. => pneumonia if pneumonia => give antibiotics, etc. Backward reasoning (goal-driven) use if lots of data start with goal rule, determine whether goal rule is true by evaluating the truth of each necessary premise patient with lots of findings and symptoms is this lupus? => are 4 or more relevant criteria satisfied?

17. 17(#total) Telemedicine The delivery of medicine at a distance. Two basic forms: Live telemedicine - videoconference link Store-and-forward telemedicine - transmit for assessment offline Typical Telemedicine interaction: store and forward followed by live interaction. Data types text (e.g. patient's notes) image (e.g. x-ray) Telemedicine often relies on images (still or moving) Equipment general purpose (e.g. PCs) specialist (e.g. electronic stethoscope)

18. 18(#total) Telemedicine (contd.) The delivery of medicine at a distance. Telemedicine most useful when Specialist services are in very high demand or Patients are extremely isolated (Antarctica or remote communities in Australia, Africa and Alaska) Home care is often delivered by telemedicine Automatic monitoring and pill dispensing etc. Telesurgery may also be considered as a subset of telemedicine. Patient operated on by remotely controlled robotic arms etc.

19. 19(#total) Telemedicine - Case Study 8 Cornwall hospitals - Minor Injury Units: replacing "unviable" accident & emergency departments nurse led Before: No access to specialist consultants Long wait for GP to be called in After: Linked to specialist consultant in Royal Cornwall Hospital Recorded sessions useful for training nurses and for audit Cornwall Healthcare Trust expects to save £100,000 a year http://www.bthealth.com/casestdy/cstudy/case11.htm

20. 20(#total) Telemedicine - Case Study NHS Direct http://www.nhsdirect.nhs.uk/ Biggest telemedicine project in the world Mainly telephone service Expanding to: Web Online diagnosis for common conditions Health encyclopaedia My NHS healthspace (personal info portal): news, reminders, knowledge Digital TV More information on Telemedicine: www.teis.nhs.uk

21. 21(#total) eHealth Standards Not-for-profit organisations involved in the standardization process American Society for Testing and Materials (ASTM), Health Level 7 (HL7) Healthcare Information and Management Systems Society (HIMSS) CEN (European Committee for Standardisation) ISO TC215 Controlled medical vocabularies: Standardized Nomenclature of Medicine, Clinical Terms (SNOMED-CT) Logical Observation Identifiers Names and Codes (LOINC) OpenGALEN Common Reference Model

22. 22(#total) eHealth / eScience : Cancer Diagnosis Telemedicine on the Grid Multi-site videoconferencing Real-time delivery of microscope imagery Communication and archiving of radiological images Supports multi-disciplinary meetings for the review of cancer diagnoses and treatment. Remote access to computational medical simulations of tumours and other cancer-related problems Data-mining of patient record databases Improved clinical decision making. Currently clinicians travel large distances Grid technology can provide access to appropriate clinical information and images across the network. More Information: http://www.escience.cam.ac.uk/projects/telemed/ http://www.rcuk.ac.uk/escience/examplesh.asp

23. 23(#total) Benefits of eHealth Reduced record keeping expenses More accurate data No poor handwriting problems Automated sharing among patients and provider Empower the patient to manage their own health - via Internet information and decision support tools Reduced office visits to get results Avoidance of duplicating tests Automatic summarisation/graphical displays of context-relevant information to the physician

24. 24(#total) Benefits of eHealth (contd.) Decision Support Tools -> Improved decisions Remote access to data - e.g. ill while travelling Improved workflows Decreased risk of malpractice suits Ability to mine large record databases Research causes of disease Assess effectiveness of treatment programmes/drugs Monitor outbreaks of diseases Easier to conduct clinical trials and rapidly incorporate research results in decision support tools

25. 25(#total) Medical Errors Human Errors: IOM Report, 1999 44,000 to 98,000 die in US annually from medical errors at 44,000, would rank as 8th leading cause of death car accidents: 43,458 breast cancer: 42,297 AIDS: 16,516 7000 deaths from medication errors alone

26. 26(#total) Medical Errors Does Software Help? Therac-25 Radiation therapy machine At least six known accidents between 1985 and 1987 Patients were given massive overdoses of radiation At least five patients died of the overdoses Causes: both organisational and technical 100 medical software recalls annually, 40 for software errors

27. 27(#total) Integration of IT IT as a gadget Trojan horse: networks, … Full Integration of IT into Business (Organisational, Legal) Re-engineering of the system 198019902000 Jean-Claude Healy May 2000 Manufacturing Business Services (Banks) Public Services (Health…) Why is eHealth Adopted Slowly? 2010 - WRONG!

28. 28(#total) Why is eHealth Adopted Slowly? Lags behind other industries by 10-15-20? years Complex regulations - e.g. Patient records Privacy laws Lack of interoperability/standards Doctors reject IT systems Scale – hospitals have lots of staff, lots of systems Risks Potential for errors due to software bugs Highly coupled systems - greater risk of catastrophe Decision support systems could lead to mass produced mistakes Privacy - data vulnerable to attack

29. 29(#total) Why is eHealth Adopted Slowly? Many projects have been abandoned after massive investment Report by Standish Group (95): $250 billion each year on 175,000 IT projects 31% projects cancelled before completion = $81 billion for canceled projects 53% of projects cost 190% of estimated costs

30. 30(#total) New sources of "health" 1

31. 31(#total) New sources of "health" 2

32. 32(#total) New sources of "health" 3

33. 33(#total) eHealth - Busan, S Korea Medical Tourism 2 hours by air for 2 billion people 1% with disposable income = 20 million Cardiac - Cancer - Mental Health Costs can be competitive Popular tourist resort for families

34. 34(#total) Summary The Future of Healthcare - The banking metaphor Existing Health on the Web eHealth - terminology Transmural Care Electronic Medical Records (EMR) Medical Records - Access Clinical Decision Support Systems Telemedicine - Case Studies eHealth Standards eHealth / eScience : Cancer Diagnosis Benefits of eHealth Medical Errors Why is eHealth Adopted Slowly? New sources of "health"