VPH in Future Healthcare. Where Will We Be in 10 Years from Now?. Frangi A. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. VPH in future healthcare
where will we be in 10 years from now?
World of Health IT
Barcelona, March 15-18th 2010
www.vph-noe.eu
www.aneurist.org
Alejandro F. Frangi, PhD
Center for Computational Imaging & Simulation Technologies in Biomedicine
Universitat Pompeu Fabra, Barcelona, Spain
Networking Center on Biomedical Research – Bioengineering, Biomaterials and Nanomedicine
Institució Catalana de Recerca i Estudis Avançats
alejandro.frangi@upf.edu
www.cilab.upf.edu

2. Outline
 Context & Current Trends
 Glimpses at a Plausible Routine Future
 Discussion & Conclusions
2

3. CONTEXT &
CURRENT TRENDS
3

4. Current healthcare: Why a change?
The need for change defies
simple solutions, as illustrated by
citizens’ dissatisfaction levels!
• Invest more money?
• Public vs. private systems?
Redefining value – From “sick
care” to healthcare
• from reactive to proactive
• patient as an object or an actor?
4

5. Medical Product Development: why a change?
 R&D expenditure by pharmaceutical industries
has dramatically increased
 The number of successful drugs reaching the
commercialization phase has however stagnated
 Critical Path is mostly focused in the clinical
phases increasingly involving expensive large-scale
multi-centric studies
http://www.fda.gov/oc/initiatives/criticalpath/whitepaper.html 5

6. Healthcare trends for the future?
> A patient-centric and care-cycle perspective
 The hospital/healthcare of tomorrow will have as key
characteristics
 Patient-centric design: for personalized services and
ambient experience
 Individualized risk assessment: based on all relevant
information (incl. demographic, genotype, phenotype,
lifestyle)
 Clinical work-flows: focused on Care Cycles (and care
pathways), not on organizational Departments
 Treatment strategies: minimally invasive and image-guided
procedures
 Converging medical technologies: impacting prevention,
diagnosis & treatment
 Federation of information systems: fully digital and
connected to the clinician, the hospital, the health insurers,
the government and the home
6

7. The patient’s journey through a disease
> care cycles
Verbeek XAAM and Lord WP (2007), The care cycle: an overview, Medica Mundi, 2007;51(2):40-47.
7

8. Converging medical technologies
> are transforming healthcare
8

9. Information & communication systems
> Patient-centric ICT
 Convergence of sensors, digital communications and interfaces
HeartCycle Concept descriptions and Overview on technical specifications and used technologies, Deliverable 4B. www.heartcycle.eu 9

10. Connecting for Health: regional data integration
 Digital archiving and connectivity, and seamless access to population data
derived from regional clinical records
http://www.connectingforhealth.nhs.uk
10

11. Secondary use of EHRs or digital graves?
 From information acquisition & structuring to Information access and enrichment
 Substantial ethical and privacy issues involved on this model of data use!
Normalisation Knowledge
De-identification Discovery
Application Suites:
Patient Record Information
Information access @neuLink
- Genetic Data Clinical
acquisition @neuFuse
- Imaging Data
Information and enrichment @neuRisk
- Clinical Data & structuring
System @neuEndo
Query
Clinical Reference Patient
Denormalisation Record
Re-identification Information Model
(CRIM)
11

12. Virtual Physiological Human (VPH)
or the Digital Me
 A European Network of Excellence operated by 12 core EU institutions
“help support and progress
13 Core Partners
European research in
4 UK (UCL, UOXF, UNOTT, USFD)
biomedical modeling and 3 France (CNRS, INRIA, ERCIM)
simulation of the human 2 Spain (UPF, IMIM)
body.This will improve our 1 Germany (EMBL [EBI])
1 Sweden (KI)
ability to predict, 1 Belgium (ULB)
diagnose and treat 1 New Zealand (UOA)
disease, and have a
dramatic impact on the
future of healthcare, the
pharmaceutical and
medical device Associate / General Members
industries.” 19 Candidate General Members
3 Candidate Associate Members
(organisations)
5 Candidate Associate Members (industry)
9 Associate Projects
www.vph-noe.eu … and growing
12

13. VPH- I FP7 projects
Industry Parallel VPH projects
Grid access CA
CV/ Atheroschlerosis Liver surgery
IP STREP
Breast cancer/
Heart/ LVD surgery diagnosis STREP
STREP
Osteoporosis
Oral cancer/ BM IP
D&T STREP
Cancer
Networking STREP
Heart /CV NoE
disease STREP
Vascular/ AVF & Liver cancer/RFA
haemodialysis STREP therapy STREP
Heart /CV
disease STREP
Alzheimer's/ BM &
diagnosis STREP
Other Security and
Privacy in VPH CA Clinics

14. GLIMPSES AT A PLAUSIBLE ROUTINE FUTURE
14

15. Looking ahead 10 years from now?
> Glimpses of a plausible routine future?
 We are seeing already
the future in some of
the current R&D
projects
 Still substantial
acceptance, penetration,
consolidation to be
achieved
 The challenge:
demonstrating the
anticipated clinical value
 Some glimpses follow
based on @neurIST…
www.aneurist.org 15

16. Cerebral aneurysm management
> The @neurIST “template project”
 Unruptured intracranial aneurysms are increasingly diagnosed due to modern
imaging techniques
 It is more and more important to develop holistic and sound approaches to patient
management.
  Two clinical questions
Management of unruptured aneurysms is controversial
 decision making is currently based mainly on aneurysm size and location mainly
 At-risk individuals/patient selection?
(ISUIA).
D.O. Optimal treatment planning?
Wiebers Unruptured intracranial aneurysms: natural history and clinical management. Update on the
international study of unruptured intracranial aneurysms. Neuroimaging Clin N Am. 2006
Aug;16(3):383-90
 There is evidence that genetic predisposition may be involved in the natural
 VPH as a new perspective for
history of aneurysms.
More principled disease understanding and phenotyping,
Krischek Inoue I. The genetics of intracranial aneurysms. J Hum Genet. 2006;51(7):587-94.
B,
 Development of novel diagnostic and prognostic
 Currently endovascular treatment is favored over surgical treatment for many
biomarkers, and
aneurysms (ISAT)
 both treatments are risky, costly and dotreatment planning and guidance
 Computational tools for not always prevent recurrence.
van Rooij WJ, Sluzewski M. Procedural morbidity and mortality of elective coil treatment of unruptured intracranial
aneurysms. AJNR Am J Neuroradiol. 2006 Sep;27(8):1678-80
Molyneux A. Ruptured intracranial aneurysms - clinical aspects of subarachnoid hemorrhage management and the
International Subarachnoid Aneurysm Trial. Neuroimaging Clin N Am. 2006 Aug;16(3):391-6
 There is a need to support a new generation of endovascular devices treating
the cause rather than symptoms of the disease 16

17. Cerebral aneurysm management
> Natural history of complex diseases
Ruptured
Prevalence 0.2-1.0%/yr
Initiation
1-5%
F>M Mortality 
Growth 33%
vasospasm clotting
ISAT (Oxford)
Etiology Treat! Prevention,
Diagnosis Coil vs clip
follow-up
Treat?
? Morbidity 
Unruptured
[99% silent] 33%
Degenerative
ISUIA (Mayo) Normal
size/location
Prevention Treatment
33% 17

18. Cerebral aneurysm management
> Gathering evidence across Europe
PACS
Descriptive Data
PACS
@neuQuest ERGO
IPCI
Representative Data
PACS
Bonn NHR
ISAT
PACS eRadiology Archives
Conservation of samples
PACS PACS
Bio Bank
PACS
@neurIST BioIS
PACS
I.H. Rajasekaran, L. Iacono, P. Summers, S. Benkner, G. Engelbrecht, T. Arbona, A. Chiarini, C.M. Friedrich, B. Moore, P Bijlenga, J.
Iavindrasana, R.D. Hose, A.F. Frangi (2008), @neurIST: Towards a System Architecture for Advanced Disease Management
through Integration of Heterogeneous Data, Computing, and Complex Processing Services, IEEE International Symposium on
Computer-Based Medical Systems, Finland, pp. 361-66.

19. Cerebral aneurysm management
> integrative applications suites & platforms
Improve decision making processes in
the management of unruptured
aneurysms by providing a score that
@neuRisk integrates all the available information
IT Support Suites
for identifying at-risk patients and
reducing current over treatment
Support computational design
processes towards a next generation
@neuEndo of smart flow-correcting implants to
treat ruptured aneurysms and reduce
current treatment costs, side effects
and recurrence.
@neurIST @neuLink Support the knowledge discovery for
Systems linking genetics to disease, vasospasm
and blood clotting after cerebral
hemorrhage
WSS
Model
& WSS
Support the integration of modeling,
@neuFuse
Enabling IT
CFD vs US
simulation and visualization of
3DRA
Peak velocity
PC-MR vs US
Flow rates
multimodal data
magnitude phase
CFD
Support integration of data and
@neuCompute/Info
computing resources.
www.aneurist.org 19

20. Cerebral aneurysm management
> “Virtual imaging” through simulations
CFD Simulation:
• ICA Terminal aneurysm
• Inflow 230ml/min (yellow)
• 3 Outflows:
•2 Pressure
•1 Flow of 10ml/min
• High wss at neck
• Inflow jet has no clear impaction zone.
• Vortex in aneurysm (with main axis along
feeding vessel) and in bleb.
Courtesy: Philips Healthcare
20

21. Cerebral aneurysm management
> Building disease knowledge in silico
Radiological
Imaging
Vascular Model
Morphology
Streamlines
WSS
OSI
Blood
Genetics
Clinical History Cebral JR, Castro MA, Appanaboyina S, Putman CM, Millan D, Frangi AF.
Efficient pipeline for image-based patient-specific analysis of cerebral
aneurysm hemodynamics: technique and sensitivity. IEEE Trans Med
Imaging. 2005 Apr;24(4):457-67. 21

22. Cerebral aneurysm management
> Treatment planning: virtual stenting
Larrabide I, Radaelli AG, Frangi AF. Fast virtual stenting with deformable meshes: application to inrtracranial aneurysm. Int Conf Med
Image Comput Assist Interv, 5242 (MICCAI’08), 790-7, 2008
Cebral JR, Lohner R. Efficient simulation of blood flow past complex endovascular devices using an adaptive embedding technique. IEEE
Trans Med Imaging. 2005 Apr;24(4):468-76. 22

23. Clot formation: A subtle interplay of genetics,
haemodynamics and arterial wall mechanics
 Coil-induced clot formation is the basis of endovascular treatment for cerebral
aneurysms; on the other hand spontaneous formation in untreated aneurysms is
potentially loose and embolic.
 Computational modelling allows for the evaluation of haemodynamic, rheological
and genetic factors in thrombus formation. Models accounting for activation,
biochemistry and thrombus-blood coupling will help us track the various stages of
the thrombogenic process, and evaluate their significance in disease and treatment.
Evolution of the distribution of thrombin
concentration
A. S. Bedekar, K. Pant, Y. Ventikos, S. Sundaram, A
computational model combining vascular biology
and haemodynamics for thrombosis prediction in
anatomically accurate cerebral aneurysms, Food
Bioprod Proc 83 (C2), 118-126, 2005
23

24. Cerebral aneurysm management
> Individualized risk management
Courtesy InferMed & COSSAC University of Oxford (Prof. J Fox, Y. Chronakis) 24

25. DISCUSSION & CONCLUSIONS
25

26. EHRs, VPH and the Virtual Patient Metaphor
 In practice is very unlikely to have all needed measurements before simulations can take
place
 VPM: A virtual patient is a logical entity that can be queried for any and all
information about a human being
 E.g. on-the-fly access to population average parameters where personalized data is not
available
Input requirements
E Y Z +
Age, sex, clinical
history,
A B C D genotype, etc…
X
@neurIST Database Average & deviations
input conditions
(Flow waveforms,
pressure,
Virtual Patient Mr Jones
haematocrit, etc… )
26
Derived data Literature

27. VPH applications & ubiquitous sensing
 Personalization needs to consider in which homeostatic conditions the
individuals is while being sensed
 Consider environment and allostasis
 “Is this patient at risk of IA rupture?” considering his/her
 Exercise-rest conditions,
 Stress levels,
 Daily biorhythms,
 Seasonal changes, etc.
 Even more: “which will be his/her typical conditions under which this
patient will be at risk”
 Ubiquitous physiological monitoring technologies will ultimate have to
connect to VPH technologies for true personalization and be integrated therein
27

28. Conclusions
 EHR, PHS, VPH: tackle complementary issues to realize patient-centric/personalized care cycles
 VPH will stimulate further developments of EHR and PHS and provided added value services for
healthcare and medical product development
 Low-hanging fruits of VPH-PHS-EHR are available which act as levers for most sophisticated
adoption
28

29. Thanks for your attention
Announcement
@neurIST Open Session
Level 1, Room 114
www.aneurist.org
Thursday 18/3, 14-16hs
Futher contact: alejandro.frangi@upf.edu

30. Final reflection
Validation is key for VPH
technology but still…
Will we/clinicians ever trust
computational models and VPH
technology?
30