Is 'Pervasive Healthcare' old wine on a new bottle – or is it a real, but emerging, research discipline? Jakob E. Bardram

The Age Tsunami US Demand/Supply of Nurses

Source : Eric Dishman. Inventing wellness systems for aging in place, IEEE Computer 37:5 (May 2004), 34–41..

Changing the Centralized Model of Healthcare Acute -> Continuous Hospitalization -> Home & out-patient Reactive -> Pro-active & Preventive IT -> Assistive Technology Centralized -> Pervasive Sampling -> Monitoring Doctor-centric -> Patient-centric

Acute -> Continuous

Hospitalization -> Home & out-patient

Reactive -> Pro-active & Preventive

IT -> Assistive Technology

Centralized -> Pervasive

Sampling -> Monitoring

Doctor-centric -> Patient-centric

Pervasive Healthcare Application of pervasive computing, ubiquitous computing, proactive computing, ambient intelligence technologies for healthcare, health, and wellness management. Second, it is about making healthcare pervasively available everywhere, anytime, and to anyone. In essence, pervasive healthcare addresses a set of related technologies and concepts that help integrate healthcare more seamlessly to our everyday lives, regardless of space and time. Source: Korhonen, Ilkka, and Bardram, Jakob B. Guest editorial introduction to the special section on pervasive healthcare, IEEE Transactions on Information Technology in Biomedicine 8:3, 2004, 229–234.

Application of pervasive computing, ubiquitous computing, proactive computing, ambient intelligence technologies for healthcare, health, and wellness management.

Second, it is about making healthcare pervasively available everywhere, anytime, and to anyone.

In essence, pervasive healthcare addresses a set of related technologies and concepts that help integrate healthcare more seamlessly to our everyday lives, regardless of space and time.

Agenda Historical Roots Biomedical Engineering, Medical Informatics, UbiComp Characteristics of Pervasive Healthcare Research Themes Examples Home based monitoring of vital signs Pervasive Computing in Hospitals Methods Evidence-Based Medicine Clinical Proof-of-Concept Is the wine new?

Historical Roots

Biomedical Engineering, Medical Informatics, UbiComp

Characteristics of Pervasive Healthcare

Research Themes

Examples

Home based monitoring of vital signs

Pervasive Computing in Hospitals

Methods

Evidence-Based Medicine

Clinical Proof-of-Concept

Is the wine new?

Historical Roots

Biomedical Engineering – BME Biomedical engineering (BME) is the application of engineering principles and techniques to the medical field. BME combines the design and problem solving skills of engineering with the medical and biological science to help improve patient health care and the quality of life of healthy individuals. Research Areas Bioelectrical and neural engineering Biomedical imaging and biomedical optics Biomaterials Biomechanics and biotransport Biomedical devices and instrumentation Molecular, cellular and tissue engineering Systems and integrative engineering

Biomedical engineering (BME) is the application of engineering principles and techniques to the medical field.

BME combines the design and problem solving skills of engineering with the medical and biological science to help improve patient health care and the quality of life of healthy individuals.

Research Areas

Bioelectrical and neural engineering

Biomedical imaging and biomedical optics

Biomaterials

Biomechanics and biotransport

Biomedical devices and instrumentation

Molecular, cellular and tissue engineering

Systems and integrative engineering

Biomedical Engineering

Medical Informatics – MI Medical informatics (MI) is the intersection of information science, computer science and health care. MI deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication technology(ICT)

Medical informatics (MI) is the intersection of information science, computer science and health care.

MI deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine.

Health informatics tools include not only computers but also

clinical guidelines,

formal medical terminologies, and

information and communication technology(ICT)

Medical Informatics Hospital Information Systems Electronic Patient Record Medicine Charts Nursing Records Clinical Decision Support Systems Integration Standards DICOM, HL7, Medical vocabularies SNOMED, …

Hospital Information Systems

Electronic Patient Record

Medicine Charts

Nursing Records

Clinical Decision Support Systems

Integration

Standards

DICOM, HL7,

Medical vocabularies

SNOMED, …

Ubiquitous Computing PC Mini Mobile Internet Mainframe Ubiquitous

Ubiquitous Computing Embedded / invisible / ambient computing From 1:1 to N:N computing Mobility and Wireless connectivity Collaboration Sensor networks Context-aware Computing Capture and Access From “computer” to “tool”

Embedded / invisible / ambient computing

From 1:1 to N:N computing

Mobility and Wireless connectivity

Collaboration

Sensor networks

Context-aware Computing

Capture and Access

From “computer” to “tool”

Pervasive Healthcare – Characteristics Technology Sensor technology and networks Embedded and mobile devices Context-aware adaptation Capture & Access Clinical approach Pro-active and preventive Patient-focused Monitoring rather that sampling Assistive Technology rather than Information Technology Research Multi-disciplinary – from field studies to hardware design Proof-of-Concept – rather than evidence-based medicine

Technology

Sensor technology and networks

Embedded and mobile devices

Context-aware adaptation

Capture & Access

Clinical approach

Pro-active and preventive

Patient-focused

Monitoring rather that sampling

Assistive Technology rather than Information Technology

Research

Multi-disciplinary – from field studies to hardware design

Proof-of-Concept – rather than evidence-based medicine

Pervasive Healthcare – Research Themes Monitoring Assistive Technologies Preventive and pro-active health systems Self-care & Self-treatment Medication support and compliance Capture and Access, Training Clinical Support Systems Software Architecture Sensor and Network Design Field Studies Persuasive technologies for better health …

Monitoring

Assistive Technologies

Preventive and pro-active health systems

Self-care & Self-treatment

Medication support and compliance

Capture and Access, Training

Clinical Support Systems

Software Architecture

Sensor and Network Design

Field Studies

Persuasive technologies for better health

…

Medication I

Medication II

Telemedicine?

Pervasive Monitoring Wireless Monitors Bodyworn Monitors Mobile Monitoring Body Sensor Network MyHeart Project

Challenges in Monitoring Robust measurement and processing methods requires access to large and representative real data sets Real cases in real environment with real problems and artifacts Reference data - real well-being - collected in parallel Similar problem when collecting evidence for correct functioning and usefulness of the method - required for evidence based medicine (EBM) How to reach this - especially for long term (months - years)? Motivation of (many enough real) subjects to wear/use often bulky and error-prone prototypes Ethics? Practical and economical issues: prototype costs (many copies needed), maintenance costs (battery replacements, data transfer, calibration, etc.) Result: few success stories so far… Source : Ilkka Korhonen

Robust measurement and processing methods requires access to large and representative real data sets

Real cases in real environment with real problems and artifacts

Reference data - real well-being - collected in parallel

Similar problem when collecting evidence for correct functioning and usefulness of the method - required for evidence based medicine (EBM)

How to reach this - especially for long term (months - years)?

Motivation of (many enough real) subjects to wear/use often bulky and error-prone prototypes

Ethics?

Practical and economical issues: prototype costs (many copies needed), maintenance costs (battery replacements, data transfer, calibration, etc.)

Result: few success stories so far…

Example I ElderTech – Technologies for Elders

Purpose Self-care and independent living Easy communication with clinical staff, relatives and peers Continuous updated view on health status Basis for pro-active clinical contingency management Shared care – cooperation across clinical boundaries Features Monitoring – Blood Pressure and Weight (wireless) Medication – administration and management Communication & Coordination – “The Collaboration Book” Deployment 7 Homes, elders 70+ Nursing staff, nurses and assistants ~3 months Qualitative data collection

Purpose

Self-care and independent living

Easy communication with clinical staff, relatives and peers

Continuous updated view on health status

Basis for pro-active clinical contingency management

Shared care – cooperation across clinical boundaries

Features

Monitoring – Blood Pressure and Weight (wireless)

Medication – administration and management

Communication & Coordination – “The Collaboration Book”

Deployment

7 Homes, elders 70+

Nursing staff, nurses and assistants

~3 months

Qualitative data collection

Technical Setup

Findings – Elders Usability Scale & BP monitor used frequently The PC – 5 out of 7 did not use it Communication No changes experienced But was not looking into the ‘collaboration book’ Clinically, Self-care, Monitoring Liked the monitoring Increased their feeling of security/safety Was trusting the staff to monitor their health data and react if necessary Documentation of medicine intake was not considered relevant

Usability

Scale & BP monitor used frequently

The PC – 5 out of 7 did not use it

Communication

No changes experienced

But was not looking into the ‘collaboration book’

Clinically, Self-care, Monitoring

Liked the monitoring

Increased their feeling of security/safety

Was trusting the staff to monitor their health data and react if necessary

Documentation of medicine intake was not considered relevant

Findings – Healthcare Workers Administration Collaboration book Integration with care system Communication Might improve communication with GP Clinically Felt uncomfortable – Responsibility of the GP Extra work – felt not necessary Remote monitoring and prevention Indications Specific groups of elders – diabetics, hypertension, … Concerned about remote monitoring – “not the right picture”

Administration

Collaboration book

Integration with care system

Communication

Might improve communication with GP

Clinically

Felt uncomfortable – Responsibility of the GP

Extra work – felt not necessary

Remote monitoring and prevention

Indications

Specific groups of elders – diabetics, hypertension, …

Concerned about remote monitoring – “not the right picture”

Lessons learned about designing AT Vital sign monitoring is ‘interesting’ but introduces a huge responsibility for actually reading them Communication and sharing seems to be just as interesting between nurses/GP/hospital between clinicians and citizens between citizens If “Information Technology” is part of the solution then IT has to look considerable different that it does now! Experimentation is essential in the design process we actually do not know what we do … what will work … how to design it … and how users will use it hence, close-loop experimentation is essential

Vital sign monitoring is ‘interesting’

but introduces a huge responsibility for actually reading them

Communication and sharing seems to be just as interesting

between nurses/GP/hospital

between clinicians and citizens

between citizens

If “Information Technology” is part of the solution

then IT has to look considerable different that it does now!

Experimentation is essential in the design process

we actually do not know what we do

… what will work

… how to design it

… and how users will use it

hence, close-loop experimentation is essential

Example II The Interactive Hospital – Supporting Awareness in a Operating Ward

Whiteboards in Hospitals Source : J.E. Bardram, Temporal Coordination - On Time and Coordination of Collaborative Activities at a Surgical Department. Computer Supported Cooperative Work , 9(2):157-187, 2000.

Affordances of Whiteboards Core Roles of Whiteboards in Hospitals Visibility Overview Status Coordination Communication Handling contingencies Research Temporal Coordination [Bardram, JCSCW 2000] Cog. Props of Whiteboards [Xiao et al, ECSCW 2001] Inf. & Repres. [Reddy et al., ECSCW 2001] Web of Artifacts [Bardram & Bossen, GROUP 2005]

Core Roles of Whiteboards in Hospitals

Visibility

Overview

Status

Coordination

Communication

Handling contingencies

Research

Temporal Coordination [Bardram, JCSCW 2000]

Cog. Props of Whiteboards [Xiao et al, ECSCW 2001]

Inf. & Repres. [Reddy et al., ECSCW 2001]

Web of Artifacts [Bardram & Bossen, GROUP 2005]

Design of AwareMedia ” Putting the schedule back on the wall” Public and shared social awareness Temporal awareness Spatial awareness Communication Source : J.E. Bardram, T.R. Hansen and M. Soegaard. AwareMedia: a shared interactive display supporting social, temporal, and spatial awareness in surgery. In Proceedings of ACM CSCW '06 , p. 109-118, ACM Press, 2006.

” Putting the schedule back on the wall”

Public and shared social awareness

Temporal awareness

Spatial awareness

Communication

AwareMedia User Interface

AwareMedia Technology & Architecture Technologies Media Spaces Scheduling/Booking Context-awareness Instant Messaging Builds upon AWARE architecture [CSCW 2004] JCAF framework [Pervasive 2005]

Technologies

Media Spaces

Scheduling/Booking

Context-awareness

Instant Messaging

Builds upon

AWARE architecture

[CSCW 2004]

JCAF framework

[Pervasive 2005]

1. Spatial Awareness OR Space Video Status People in the OR Patient Type of surgery & expected end time

OR Space

Video

Status

People in the OR

Patient

Type of surgery & expected end time

2. Temporal Awareness OR Schedule Operations OR Teams Timing Delays Cancellations

OR Schedule

Operations

OR Teams

Timing

Delays

Cancellations

3. Social Awareness Context Picture, Name & Initials Location Activity (e.g. surgery) Tracking device Role (e.g. replacement, coodinator, surgeon)

Context

Picture, Name & Initials

Location

Activity (e.g. surgery)

Tracking device

Role (e.g. replacement, coodinator, surgeon)

Deployment Site OR Ward, Bed Ward, Recovery Supports 3 ORs, 30-50 people pr. day Technology Coordination central -> 2 large interactive displays 3 OR / Wards -> 20’’ touch screens Web cams Location tracking based on Bluetooth Tag Mobile phones ~20 AwarePhones Deployed during 12 months

Site

OR Ward, Bed Ward, Recovery

Supports 3 ORs, 30-50 people pr. day

Technology

Coordination central -> 2 large interactive displays

3 OR / Wards -> 20’’ touch screens

Web cams

Location tracking based on Bluetooth

Tag

Mobile phones

~20 AwarePhones

Deployed during 12 months

Hospital

Operating Ward

AwareMedia in Use Data collection Observations, Interviews, Data Logging Lessons learned Increase Awareness and Communication More efficiency in OR coordination Fewer interruptions Redundant information Location, status, operations, … Simple, stable, and predictable displays Easy to learn, use, and navigate in a critical environment

Data collection

Observations, Interviews, Data Logging

Lessons learned

Increase Awareness and Communication

More efficiency in OR coordination

Fewer interruptions

Redundant information

Location, status, operations, …

Simple, stable, and predictable displays

Easy to learn, use, and navigate in a critical environment

Example III Context-aware Patient Safety in the Operating Room

Patient Safety Institute of Medicine: “To err is Human” 9% adverse events, 40% related to ‘errors’, 60% to complications Danish studies confirm this Utah and Colorado Operative adverse events comprised 44.9% of all adverse events Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery Danish Recommendation Improve communication and coordination Improve patient identification … Source : Institute of Medicine E J Thomas et al (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care., vol. 38, no. 3.

Institute of Medicine: “To err is Human”

9% adverse events, 40% related to ‘errors’, 60% to complications

Danish studies confirm this

Utah and Colorado

Operative adverse events comprised 44.9% of all adverse events

Joint Commission

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

Danish Recommendation

Improve communication and coordination

Improve patient identification

…

Source :

Institute of Medicine

E J Thomas et al (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Med. Care., vol. 38, no. 3.

A Context-aware Patient Safety System Context-awareness RFID sensor input + other input Based on the Java Context-Awareness Framework (JCAF) Extended with reasoning engine (JESS) Features Presenting relevant information during operation PACS, EPR, Operation data Monitors progress and fire warnings Patient, Team, Blood, Patient Status, Equipment, … Clinical Proof-of-Concept Full functioning prototype Deployed inside one OR with a full OR team Used during one day (no real patients, however) Qualitative evaluation

Context-awareness

RFID sensor input + other input

Based on the Java Context-Awareness Framework (JCAF)

Extended with reasoning engine (JESS)

Features

Presenting relevant information during operation

PACS, EPR, Operation data

Monitors progress and fire warnings

Patient, Team, Blood, Patient Status, Equipment, …

Clinical Proof-of-Concept

Full functioning prototype

Deployed inside one OR with a full OR team

Used during one day (no real patients, however)

Qualitative evaluation

So what’s different? ElderTech Continuous Monitoring coupled with patient-clinician reliability and trust Focus on Patient communication – not telemedicine Methods are not clinically oriented The Interactive Hospital Social and Context Awareness Focus on clinical collaboration and usability – not health informatics Patient Safety in the OR Context awareness and reasoning Focus on ‘contextual’ and ‘procedural’ safety – not biological safety

ElderTech

Continuous Monitoring coupled with patient-clinician reliability and trust

Focus on Patient communication – not telemedicine

Methods are not clinically oriented

The Interactive Hospital

Social and Context Awareness

Focus on clinical collaboration and usability – not health informatics

Patient Safety in the OR

Context awareness and reasoning

Focus on ‘contextual’ and ‘procedural’ safety – not biological safety

Methodology

Evidence-Based Medicine – EBM U.S. Preventive Services Task Force & UK National Health Service Level I: Evidence obtained from at least one properly designed randomized controlled trial . Level II-1: Evidence obtained from well-designed controlled trials without randomization . Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies , preferably from more than one center or research group. Level II-3: Evidence obtained from multiple time series with or without the intervention . Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Source : Wikipedia U.S. Preventive Services Task Force & UK National Health Service

U.S. Preventive Services Task Force & UK National Health Service

Level I: Evidence obtained from at least one properly designed randomized controlled trial .

Level II-1: Evidence obtained from well-designed controlled trials without randomization .

Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies , preferably from more than one center or research group.

Level II-3: Evidence obtained from multiple time series with or without the intervention . Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Proof-of-Concept “ The construction of working prototypes of the necessary infrastructure in sufficient quality to debug the viability of the system in daily use; ourselves and a few colleagues serving as guinea pigs” Source : Marc Weiser. “Some Computer Science Issues in Ubiquitous Computing”, in Communications of the ACM , 36(7), 1993, ACM.

“ The construction of working prototypes of the necessary infrastructure in sufficient quality to debug the viability of the system in daily use; ourselves and a few colleagues serving as guinea pigs”

Clinical Proof-of-Concept

Clinical Proof of Concept – CPoC Technology Working prototype Usable (but not necessarily user-friendly) Stand alone Focused on specific research questions Deployment Deployment in a real clinical environment Used by real users (researchers are hands-off) For a short , but sufficient time of period (1 day – 3 months) Collecting ‘Evidence’ Observations Questionnaires Perceived Usefulness and Usability Measure – if possible Qualitative data Quantitative data

Technology

Working prototype

Usable (but not necessarily user-friendly)

Stand alone

Focused on specific research questions

Deployment

Deployment in a real clinical environment

Used by real users (researchers are hands-off)

For a short , but sufficient time of period (1 day – 3 months)

Collecting ‘Evidence’

Observations

Questionnaires

Perceived Usefulness and Usability

Measure – if possible

Examples of Clinical PoC AwareMedia Clinical PoC in a surgical ward for 4-5 months Patient Safety Clinical PoC in an OR during 1 day Home based monitoring Clinical PoC during ~3 months in 7 homes

AwareMedia

Clinical PoC in a surgical ward for 4-5 months

Patient Safety

Clinical PoC in an OR during 1 day

Home based monitoring

Clinical PoC during ~3 months in 7 homes

Summing up

So – is Pervasive Healthcare new Wine?

Call for Action Maintain focus on “pervasive” approach to healthcare Supporting the move from a Mainframe to a Pervasive model of healthcare Define and describe Pervasive Healthcare Post it to Wikipedia International Association of Pervasive Healthcare – IAPHC? Define the research methods for Pervasive Healthcare “ Moving out of the lab” Clinical Proof-of-Concept Ensure research quality Do not be an isolated group of researchers Make profound research which can be published in well-established venues and journals Ensure affiliation with IEEE and ACM

Maintain focus on “pervasive” approach to healthcare

Supporting the move from a Mainframe to a Pervasive model of healthcare

Define and describe Pervasive Healthcare

Post it to Wikipedia

International Association of Pervasive Healthcare – IAPHC?

Define the research methods for Pervasive Healthcare

“ Moving out of the lab”

Clinical Proof-of-Concept

Ensure research quality

Do not be an isolated group of researchers

Make profound research which can be published in well-established venues and journals

Ensure affiliation with IEEE and ACM

Contact details Jakob E. Bardram [email_address] www.itu.dk/~bardram

Jakob E. Bardram

[email_address]

www.itu.dk/~bardram