eHealth Standards
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Transcript eHealth Standards
CS5038 The Electronic Society
Lecture : eHealth
Lecture Outline
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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"
1(#total)
eHealth - The Future of Healthcare
The banking metaphor
Most transactions carried out by
the customer
Centralisation of specialist
services
Decentralisation of nonspecialist services
2(#total)
Existing Health on the Web
Estimated to be ~20,000 health websites
Used by 98 million adults
75% of people who have web access
average of 3.3 times per month
More than consult doctors each day
7M e-patients/day on the net; 2-3M patients see a doctor
1
2
3
3(#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
4(#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.)
5(#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).
6(#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.
7(#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
8(#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
9(#total)
Electronic Medical Records (EMR)
Maintaining Records
May be required many years after a patient’s 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
10(#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
11(#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”
12(#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.
13(#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.
14(#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
15(#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
16(#total)
is this lupus? => are 4 or more relevant criteria satisfied?
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)
17(#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.
18(#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
19(#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
20(#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
21(#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
22(#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
23(#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
24(#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
25(#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
26(#total)
Why is eHealth Adopted Slowly?
Integration of IT
Public Services
(Health…)
2010 - WRONG!
Business Services
(Banks)
Manufacturing
1980
1990
2000
Jean-Claude Healy
May 2000
IT as a gadget
Trojan horse: networks, …
Full Integration of IT into Business (Organisational, Legal) Re-engineering of the system 27(#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
28(#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
29(#total)
New sources of "health" 1
30(#total)
New sources of "health" 2
31(#total)
New sources of "health" 3
32(#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
33(#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"
34(#total)