1. H EALTH I NFORMATICS Week 1

2. M ODULE I NTRODUCTION COM510 - Health Informatics aims to provide you with a basic understanding of the fundamental aspects of ICT within healthcare. We will aim to focus on the main driving forces for the adoption of ICT. We will examine the different areas in which ICT has been applied. And we focus on specific technologies, such as the internet and mobile computing, and demonstrate how these are improving patient care and patient – clinician interaction. In semester 2, you will have the opportunity to learn even more about recent, state-of-the-art developments in Health Informatics – Emerging Healthcare Technologies.

3. O VERVIEW Section 1 Introduction to health informatics Need for health informatics COM510 Overview Section 2 History of Technology in Healthcare Where / How / Who can Healthcare technologies help? Categories of Healthcare Technologies.

4. S ECTION 1 - W HAT IS H EALTH I NFORMATICS ? (1) Health informatics is located at the intersection of information technology (IT) and the different disciplines of medicine and healthcare. Health Informatics attempts to bridge the gap between information technology (IT) and the various disciplines of medicine and healthcare. In this module, we shall also (mostly) use the term ‘Medical Informatics’ without entering into the possible fundamental difference between Health Informatics and Medical Informatics. Has also been referred to as: Medical Computer Science Medical Information Science Computers in Medicine

5. W HAT IS H EALTH I NFORMATICS ? (2) The term has been defined as: the scientific field that deals with resources, devices and formalised methods for optimising the storage, retrieval and management of biomedical information for problem solving and decision making’ (Shortliffe, 1995). ‘comprising the theoretical and practical aspects of information processing and communication, based on knowledge and experience derived from processes in medicine and healthcare’ (Van Bemmel, 1984).

6. P RACTICAL M EANING (1) In Health Informatics, we aim to Develop and Assess methods, systems and devices for acquisition processing, and interpretation of patient data using knowledge gained from scientific research.

7. P RACTICAL M EANING (2) Computers are the ‘vehicles’ used to realise these goals. In Medical Informatics, we deal with the entire domain of medicine and healthcare Such as: Computer based patient records Image processing Primary care practices Hospital healthcare

8. T HE N EED FOR H EALTH I NFORMATICS (1) Health Informatics emerged due to multiple problems facing the practice of medicine. Desire to: reduce Costs improve Patient Care be more efficient with clinicians time migrate away from traditional paper based records reduce medication errors have instant access to patient related data have instant access to educational information

9. R EDUCING C OSTS ! SOURCE: http://www.cambridgeconsultants.com/downloads/Library_presentations/Innovation_ Day_2008/healthcare_market.pdf

10. I MPROVING P ATIENT C ARE (1)

11. L EADING CAUSES OF D EATH / Y EAR

12. N UMBER OF P OTENTIALLY P REVENTABLE D EATHS

13. C HANGING D EMOGRAPHICS (1) Within the UK, over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 per cent in 2008, an increase of 1.5 million people in this age group. Over the same period, the percentage of the population aged 16 and under decreased from 21 per cent to 19 per cent. This trend is projected to continue. By 2033, 23 per cent of the population will be aged 65 and over compared to 18 per cent aged 16 or younger. The fastest population increase has been in the number of those aged 85 and over, the ’oldest old‘. In 1983, there were just over 600,000 people in the UK aged 85 and over. Since then the numbers have more than doubled reaching 1.3 million in 2008. By 2033 the number of people aged 85 and over is projected to more than double again to reach 3.2 million, and to account for 5 per cent of the total population.

14. C HANGING D EMOGRAPHICS (2) Projected population pyramid for the UK 2025 Population pyramid for the UK 2000 Source: http://www.bbc.co.uk

15. C HANGING D EMOGRAPHICS (3) As a result of these increases in the number of older people, the median age of the UK population is increasing. Over the past 25 years the median age increased from 35 years in 1983 to 39 in 2008. It is projected to continue to increase over the next 25 years rising to 40 by 2033. In 2008 in the UK the median age for women (40 years) was higher than for men (38 years). This is because, on average, women live longer than men.

16. C HANGING D EMOGRAPHICS (4) However, the gender gap has narrowed; in 1983 women and men had median ages of 36 and 33 years respectively, a difference of three years. The difference in median ages for women and men decreased to two years in 2008. It is projected to remain at this level to 2033. The ratio of women to men of those aged 65 and over is also falling. In 1983 there were 155 women aged 65 and over for every 100 men of the same age, compared to the current sex ratio of 130 women for every 100 men for this age group. By 2033 it is projected that the 65 and over sex ratio will have fallen still further to 117 women for every 100 men.

17. T HE UK A GING P OPULATION http://www.statistics.gov.uk/cci/nugget.asp?id=949

18. I NTRODUCTION S UMMARY Changing demographics are causing a shift from reactive to preventative healthcare. IT can play a large role in providing home based support to patients to promote healthy ageing. IT can be interfaced directly with clinicians Internet communications High speed processing power Voice recognition Wireless and Mobile technology Medical Informatics is about providing medical information to healthcare workers, anytime, anywhere to assist in education, productivity, patient safety, quality of care and research.

19. M ODULE S TRUCTURE Lectures – 24 hrs Monday 9.15 – 11.05am (04F04) Seminars / Tutorials – 12 hrs ICT – Monday 11.15 – 12.05pm (17E26) CS / SE - Tuesday 1.15 – 2.05pm (16D05) Practical Labs – 22 hrs ICT – Tuesday 3.15 – 5.05pm (16C26/27) CS / SE - Friday 2.15 – 4.05pm (16C26/27) Independent study – > 100 hrs Including assessment

20. T UTORS

21. R ATIONALE (1) This module is designed to introduce and provide a fundamental understanding of the use of technology in healthcare. Emphasis is placed upon the use of technology to develop basic solutions for healthcare delivery and management.

22. R ATIONALE (2) This shall be realised through understanding how technology is used in domains commonly referred to as: Health Informatics / Medical Informatics Telecare Telehealth Telemedicine eHealth The module shall provide a framework to facilitate the design and development of robust solutions to meet current healthcare needs.

23. A IMS 1. Provide the opportunity to understand how technology can be applied in healthcare applications. 2. To understand the need for such technology in healthcare applications. 3. To investigate how robust solutions can be developed using existing technologies. 4. To demonstrate examples of how healthcare delivery has been streamlined using technology. 5. To provide the opportunity to understand common medical devices. 6. To further develop your ability to work independently and collaboratively with your peers.

24. L EARNING O UTCOMES Demonstrate sound understanding of the fundamental concepts, principles, theories and practices underlying the use of technology for healthcare applications. Critically evaluate, from a user needs (user-centered) perspective, current approaches to healthcare delivery. Understand the limitations of technology in healthcare applications. Demonstrate an understanding of the professional, legal, moral and ethical issues associated with healthcare delivery relevant to the computing industry.

25. M ODULE T OPICS Background and need for the application of technology in healthcare. Evolution of Healthcare Technologies. Changing Demographics The Clinical and Patient Needs Trends in Patient – Doctor interaction Ethical Considerations Medical Data Introduction to Medical Data Storing Patient Data (Integrity, Security) Data Processing Electronic Patient Records

26. M ODULE T OPICS Infrastructure to Support Care Delivery Internet and the Web Mobile Communications Thin Client and Thick Client models Standards Healthcare Technology Solutions and Devices Patient Monitoring Systems and Mobile Devices Decision Support E-services Systems for Medical Education

27. A SSESSMENT (1) Three pieces of course are involved. Contributes 50% of the total marks for the module. Coursework 1: Learning Log (20%) Throughout the module (starting Wk1), maintain a weekly learning log of your activities associated with the module. The material should be published online ( word press or webCT ) and will be assessed on a bi-weekly period. Logs should contain reports of activities discussed in lecture / tutorial and also practical’s. Any readings / articles should also be reported in the log. Logs should also contain reports of assignment progress. Logs should be a maximum of 400 words, but can be supported with images / figures.

28. A SSESSMENT (2) Coursework 2: Investigative Study of Existing Healthcare Technologies (40%) Due 5 th November In Week 7 Students will each be expected to deliver a report which will present the results of their findings following an investigative study. review current ICT technologies used in the existing online healthcare systems; Refer to appropriate journal articles; analyse the advantages of online healthcare systems; identify the problems or issues of online healthcare systems; explore one scenario (or disease condition) for an online support system that you are going to implement; and summarise the trend of online healthcare support systems. Coursework 3: Design and Development of Matlab based program to study health related data (40%) Due 3 th December In Week 11, Students will be asked to submit their work. Details to be confirmed later in the semester.

29. E XAMINATION 50% of total grade for the module 3 hour paper containing 6 questions in which there will be an element of choice. Question 1 is compulsory – worth 40% Answer 3 of the remaining 5 questions (20% / question) Therefore, you are required to answer 4 questions!

30. R EADING L ISTS Books Handbook of Medical Informatics, Jan H. van Bemmel et al. Medical Informatics, Edward H. Shortliffe et al. Medical Informatics: Practical Guide for the Healthcare Professional 2007, Robert Hoyt MD et al. Journals International Journal of Medical Informatics The Open Medical Informatics Journal Journal of Medical Internet Research Journal of the American Medical Informatics Association Journal of Telemedicine and Telecare Medical Decision Making IEEE Engineering in Medicine and Biology Magazine Websites Open Clinical – Health Informatics Terms http://www.openclinical.org/healthinformatics.html Healthcare Technology (Selection of White Papers) http://www.hctproject.com/welcome.asp World Health Organisation www.who.int/ International Medical Informatics Association http://www.imia.org/ HSC in NI http://www.hscni.net/ NHS connecting for health http://www.connectingforhealth.nhs.uk/

31. S ECTION 2 - T ECHNOLOGY IN H EALTHCARE (1) In this module, we will focus on how Technology has been applied within the Healthcare domain with the aims of providing improved healthcare delivery. Healthcare technologies can be thought of as those technologies providing improved procedures for: Preventing and Rehabilitating disease Medical and Surgical procedures Managing and Protecting information about patients. Also, about developing new medical devices and equipment to assist with Diagnosis and Treatment.

32. T ECHNOLOGY IN H EALTHCARE (2) What exactly do we mean by the term healthcare? Healthcare is about clinical trained staff providing information to prevent illness, and offering treatment and management of illnesses with the aims of ensuring both mental and physical wellbeing. Healthcare provision plays a major role within society and as a result much effort has been focused on developing and improving techniques over the last 100 years. As such, it is a widely studied topic, not only by those within the medical domain, but by computer scientists and engineers.

33. H ISTORY OF T ECHNOLOGY IN H EALTHCARE : S NAPSHOT (1) 1895 – X-Rays discovered 1903 – Electrocardiograph invented (ECG) 1924 – The Electroencephalogram invented (EEG) 1946 - First general computer (ENIAC) emerges 1000 sq ft of floor space. Source: http://web.archive.org/web/20011118115154/www.medhelpnet.com/medhist10.html

34. H ISTORY OF T ECHNOLOGY IN H EALTHCARE : S NAPSHOT (2) 1950’s – Computers thought to be potentially useful for healthcare. In terms of processing information faster than humans. 1953 – Heart-Lung machine invented Cardiopulmonary bypass 1957 – Ultrasound scanning for pregnancy 1960’s –MEDLARS (Medical Literature Analysis and Retrieval System) created to organise the world’s medical literature, Previously had to reference medical topics using a multi- volume text index called Medicus.

35. H ISTORY OF T ECHNOLOGY IN H EALTHCARE : S NAPSHOT (3) 1967 – CT Scan invented 1969 – Internet Emerges with the US government project, ARPNET. 1974 – First MRI scan attempted 1977 – First MRI examination 1982 – First artifical heart transplant (JARVIK)

36. H ISTORY OF T ECHNOLOGY IN H EALTHCARE : S NAPSHOT (4) 1982 - IBM developed the first PC 16 K of memory 1990 – World Wide Web conceived by Tim Berners-Lee. The ‘Internet’ quickly became the backbone for digital libraries used by both clinicians and patients. 1991 – Electronic Patient Records backed by Institute of Medicine. 1993 – Mosiac, the first web browser launched 1996 – Palm Pilot appeared on the market First proper handheld computer.

37. H ISTORY OF T ECHNOLOGY IN H EALTHCARE : S NAPSHOT (5) 2000’s – Human Genome Project completed following 13 years of international collaborative research. Mapping all of the human genes is regarded as one of the greatest scientific accomplishments in history. Will still take many years to analyse all of the collected information! Many feel will lead to a much greater understanding of the human body and how we practice medicine. 2000’s – Nationwide Infrastructures Supported for managing healthcare through the integration of IT. Specific Case study examined in this module (NPfIT) Goal of collecting all distributed patient information and hosting this so as to provide a shared resource for clinicians. Advantage of removing / eliminating data duplication and providing up to date patient information as multiple sites Disadvantages of the system being attacked, vulnerable etc.

38. E VOLUTION OF T ECHNOLOGY (1) Technology is rapidly evolving, with many new devices appearing on the market. Faster processors, increased data storage, high speed (mobile) broadband, high resolution data capture and digital imaging etc… Typically, devices are becoming smaller, faster and offer more memory for processing and storage. Tablet PCs, Laptops, Netbooks and Smart Phones / PDA Nevertheless, these advances are often asynchronous. i.e. such devices may offer the potential for improved workflow, however, battery life on many of these devices is still unacceptable! Consider a Tablet PC used for home care visits over an 8 hour shift.

39. E VOLUTION OF T ECHNOLOGY (2) This poses a challenge to IT professionals working in the area of healthcare. Not only with regards to improving the usability of devices but in sustaining clinical acceptance and adoption of new technologies. In semester 2, the ‘Emerging Healthcare Technologies’ module will examine recent developments in this area.

40. W HERE CAN I NFORMATION T ECHNOLOGY H ELP ? Information Technology Pharmacy Medical Records Quality Management Patient Safety Medical Education Disease Management Evidence Based Care

41. H OW C AN H EALTHCARE T ECHNOLOGIES H ELP ? Diagnosis RespiratoryCardiovascularOrthopedicNeurological Prognosis Projection models Treatment plans Disease Management Rehabilitation support Implantable devices Medication Patient Management Electronic Health Records Electronic Prescribing Patient Safety / Protection

42. W HO C AN H EALTHCARE T ECHNOLOGIES H ELP ? (1) Patients Online Health Info Web portals Online Booking Online Surveys Access Health Records Telemedicine Telecare Clinicians Digital Libraries Clinical decision support Electronic health records Mobile Devices Telemedicine Telesurgery E-prescibing Disease management Picture archiving and communication systems (PACS) Support Staff Patient Enrollment E-Appointments Billing Inputting Vital Signs Secure patient-office email communications

43. W HO C AN H EALTHCARE T ECHNOLOGIES H ELP ? (2) Hospitals Interoperable EPR Information systems / trend systems to monitor outcomes, length of stay, disease management etc. Bar coding and radio frequency identification (RFID) to track patients, medication, medical equipment etc. Wireless technology Patient and Clinician portals PACS Telemedicine Research Database creation to study populations, genetics and disease states. Online collaborative web sites. Analysis / Data mining software Matlab / Weka / SPSS Literature Searches Improve subject recruitment / data sets through EHRs and e-mails. Technology vendors Applying new technology innovations in the field of medicine. Data Mining Interoperability considerations – Standards - Continua Alliance

44. W HO C AN H EALTHCARE T ECHNOLOGIES H ELP ? (3) Public Health Incident reports Public health warnings Public Information Medical Education Online medical resources for clinicians, patients and staff Medline / Pubmed Searches Video teleconferencing, web conferencing Government Promote interoperable health records Reduce mortality rates with better clinical practice guidelines Promote e- precribing Provide a central resource for patient data - NPfIT

45. I NTRODUCTION TO H EALTHCARE T ECHNOLOGIES Week 2

46. C ATEGORIES OF T ECHNOLOGY IN H EALTHCARE Widely used terms: Medical / Health Informatics Telemedicine Telehealth eHealth Telecare By the end of this section we should see that although some of these terms refer to similar approaches and services, there are subtle differences. Indeed in some cases the definition of the various terms may seem contradictory and confusing.

47. W HAT IS T ELEMEDICINE ? (1) The term telemedicine refers to the execution of medical practice remotely or the remote use of medical expertise at the point of need. ‘tele’ derives from the Greek ‘at a distance’ Although the term has really only been recognised in the past few decades and usually relies on the use of telecommunications its definition would indicate that any exchange of information e.g. a letter between two doctors back in the 1800’s which discussed a case.

48. W HAT IS T ELEMEDICINE ? (2) Telemedicine has largely been dominated by video conferencing. This can be used, for example: by two medical professionals at opposite sides of the world to discuss some rare case of a disease. or can be where a doctor assesses a patient remotely who has no means of transport to the specialist clinic. Although video conferencing has played a large part in this domain, new techniques are being introduced. One such new example of telemedicine is the use of robots to conduct surgery remotely.

49. T ELEMEDICINE MODES (1) Real-time telemedicine could be as simple as a telephone call or as complex as robotic surgery / unmanned surgery. Requires that both parties are present and that a communications link exists between them. Telenursing Telerehabititaion Teleradiology Video conferencing, webcam, telephone, internet rich applications

50. T ELEMEDICINE MODES (2) Store-and-forward telemedicine involves acquiring medical data (medical images, biosignals) and them transmitting this data to a doctor or medical expert at a convenient time for offline assessment. It does not require the presence of both parties at the same time.

51. W HAT IS T ELEHEALTH ? Teleheath is a term which is often used interchangeably with telemedicine but it in fact refers to a much broader collection of services and activities. i.e. Telemedicine generally refers only to the provision of clinical services whereas Telehealth can refer to both clinical and non clinical aspects. Services which may be considered within this definition of telehealth but are not considered examples of telemedicine include, administration (record keeping) and education (training of medical experts). This comparison with telemedicine is analogous to comparing medicine with healthcare.

52. C LINICAL AND N ON -C LINICAL U SES FOR T ELEHEALTH ? Teleheath encompasses preventive, promotive and curative aspects. Clinical Uses Transmission of medical data / images for diagnosis and management Health advice over telephone Video conferencing – exchanging health service and education. Nonclinical Uses Remote admission Overall internet based healthcare system management Healthcare system integration Online information and health data management Administrative uses – email, remote meetings, presentations.

53. T ELEHEALTH M ODES Telehealth encompasses both real-time and store-and- forward modes. But also: Remote monitoring Sensors utilised to monitoring and transmit biometric data. blood pressure, glucose, asthma monitoring. tele-ECG device to monitor arrhythmia.

54. T ELEHEALTH SOLUTIONS

55. W HAT IS E H EALTH ? (1) eHealth is another term where there is some debate about the exact meaning. For the purposes of this module we recognise the use of the internet in healthcare applications as eHealth. This definition therefore excludes applications which use telecommunications technologies which do not rely on internet technologies. For example, older video conferencing systems which do not rely on internet protocols for operation.

56. W HAT IS E H EALTH ? (2) Although we distinguish eHealth systems as being those which rely on internet protocols there is an increasing convergence of this approach. I.e. more and more systems now rely on some form of internet protocol for transmission of data (e.g. even ordinary telephones). Examples include: Electronic Healthcare Records Telemedicine (when used with the internet) mHealth Healthcare Information Systems Appointment scheduling Patient data management

57. W HAT IS T ELECARE ? (1)  The term Telecare also describes a service distinct from those mentioned previously. Telecare, whilst referring to the technology used, also encompasses the data transferred and the response to the transmission of this data. Systems that are used to promote elderly support and independent living (living at home without needing continual care).

58. W HAT IS T ELECARE ? (2)  Telecare is the continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living.  Devices range from those where a user presses a button to raise an alarm.  to monitoring lifestyle changes and issuing warnings if a persons’ well-being deteriorates or they have an accident.

59. W HAT IS T ELECARE ? (3)  Some systems provide real time feedback.  In particular, this can be used to assist with memory problems. The equipment can sense risks such as smoke, floods and gas, can remind you to take pills and even call for help if you fall. A help centre can be contacted automatically if any of these problems occur in your home. If needed the help centre can arrange for someone to come to your home or can contact your family, doctor or emergency services.

60. W HAT IS T ELECARE ? (4) The system can also warn you of problems by sounding an alarm, flashing lights or vibrating a box which can be kept in your pocket or under your pillow. Equipment can be categorised into: 1.telecare control boxes, which plug into your telephone socket 2.buttons and sensors (if you press one of these buttons, or the sensor detects a potential danger, then they trigger an alert) 3.alerting devices, such as pagers and flashing lights

61. T ELECARE SOLUTIONS (1) Movement sensors Fire / smoke alarms Window / door sensors Bed / Chair occupancy sensors Gas shut off devices Fall sensors Pressure sensors Lighting sensors Door sensors Temperature sensors Medication reminder systems

62. T ELECARE SOLUTIONS (2)

63. W HAT ’ S RIGHT ? If you search the internet you will find many people’s interpretations of these terms. The following articles provide further descriptions of some of the terms. In some cases they contradict what we say here!! http://www.hhdev.psu.edu/nurs/ojni/dm/52/article3.htm http://www.aafp.org/online/en/home/aboutus/specialty/rural /telemed/telehealth.html http://www.ic.gc.ca/epic/site/ict-tic.nsf/en/it07554e.html http://www.telehealth.ihs.gov/Links%20and%20Informatio n/glossaryOfTerms.htm http://www.telecareaware.com/what-is-telecare/ The only certain thing is that there is no concrete description for each. Perhaps this is due, in part, to the fact that all these terms rely on ever changing and advancing technologies.