ehealth technologies for lithuanian health care prof. arūnas lukoševičius biomedical engineering...
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eHealth Technologiesfor Lithuanian Health Care
Prof. Arūnas Lukoševičius
Biomedical Engineering InstituteKaunas University of Technology,
,
eBaltic Forum Riga 2006 04 06
Biomedical Engineering InstituteKaunas University of Technology
Studentų street. 50, Kaunas, LT-51368, tel. 407118, ISDN: 407114-407119http://www.bmii.ktu.lt
Activities:
•Telemedicine support centre
•eHealth architecture and implementation
•Clinical decision support systems
•Signal and processing methods and software
•Ultrasonic medical diagnostics
•Prototyping of hardware, sensors and transducers
•Wireless technologies
Topics
• Why eHealth? Lithuanian statistics and arguments• Principles of proposed architecture: patient centered• Principles of implementation: standard based• Electronic Health Record• Data mining and clinical decision support• Building bricks: international projects • Efficiency of eHealth: user benefits and functionalities • Cross - boarder cooperation and networking
Why eHealth? Lithuanian statistics and arguments
District Citizens GPs SpecialistsTotal
Physicians
Total Physicians
(other source) Nurses
Hospital Beds
Klaipeda 486,685 385 1,092 1,477 1,477 3,866 4,714Kaunas 880,967 696 2,710 3,406 3,406 6,649 8,536Siauliai 544,260 430 757 1,187 1,187 3,651 3,920Panevezys 478,474 378 811 1,189 1,189 3,500 3,475Vilnius 1,033,757 817 3,339 4,156 4,156 7,567 9,910Extrapol. Total 3,424,143 2,707 8,708 11,415 11,415 25,233 30,555Total 3,430,600 2,707 8,708 11,415 13,682 25,233 31,031
District HospitalsGP
OfficesMedical
points Ambulatory
Primary HC centers,
polyclinics, Family
medicine, Diagnostic
centersPrivate HC providers Pharmacies Pharmacists
Klaipeda 27 105 31 37 156 529Kaunas 29 176 52 96 290 958Siauliai 21 102 37 43 175 592Panevezys 21 91 45 24 132 521Vilnius 54 306 39 60 31 347 1,125Extrapol. Total 152 780 0 204 260 31 1100 3725Total 181 750 906 190 225 504 1,100 3,725
Citizens, specialists and facilities: figures
Statistics of health transactions
Events Registered Per Annum Per Month Per DayBirths 29,765 2,480 113PHC encounters 22,910,700 1,909,225 86,783Emergency 780,700 65,058 2,957GP, PC, Ambu. 14,695,500 1,224,625 55,665Referred to SHC (Specialist) 7,434,500 619,542 28,161Epicrisis from SHC SP 7,434,500 619,542 28,161Hospitalised 811,300 67,608 3,073Epicrisis from Hospitalisation 811,300 67,608 3,073Lab test at PHC level 15,896,417 1,324,701 60,214Results from PHC lab 15,896,417 1,324,701 60,214Radiology at PHC level 2,180,201 181,683 8,258Results from PHC Radiology 2,180,201 181,683 8,258Lab test at SHC level 12,007,240 1,000,603 45,482Results from SHC lab 12,007,240 1,000,603 45,482Radiology at SHC level 892,430 74,369 3,380Results from SHC radiology 892,430 74,369 3,380Prescriptions 25,000,000 2,083,333 94,697Sickness leave certification 1,787,686 148,974 6,772Total Transactions 120,737,827 10,061,486 457,340
Network of GP offices in Lithuania
101713
14
1713
164
014613
16 0
178
10
5
3
11
131
7
26
3
1203
123
4
9 19
1021 0
62
17
3
114437 4
17
7
4
9
13
210
4
710 8
444 20
121
Summary of data volumes generated at
healthcare institutions
Volume*/doc Per Annum Per Month Per DayVolume from EncountersVolume from Referrals F028a-1a (1600 characters) 1,6 11.895.200 991.267 45.058Volume from Epicrisis F027a (2700 characters) 2,7 20.073.150 1.672.763 76.035Volume from Ambulatory reports F025a-LK (1900 characters) 1,9 27.921.450 2.326.788 105.763Volume from In-patient reports F066a-LK (1500 characters) 1,5 1.216.950 101.413 4.610Volume from Prescriptions (460 characters) 0,5 14.928.200 1.244.017 56.546Volume from lab 0,5 6.011.568 500.964 22.771
Sub-total Volume of data generated in documents, (kB) 82.046.518 6.837.210 310.782Volume from radiology, (GB) 0,075 67.096 5.591 254
Total Volume, (GB) 67.178 5.598 254
”Balls” rise steadily!!
Cost = demand x unit price + mcUnits = operative care,diagnostics, medication..Value of a unit staysroughly equal
Unit price raises
Demand stays equal or grows due to relative aging !
Year 2015 USA = 100 %
mc = management cost
ICT assistance is necessary
Proposed eHealth system
• Development of the Lithuanian Electronic Health Services Infostructure (EHSI): Implementation of an official health and healthcare information sharing and exchange system, to support lifelong continuity-of-care for healthcare professionals and citizens. (expert team lead by Dr. Dimitris Kalogeropoulos)
First part - WB financed pilot national eHealth project 2005-6
• The project submitted in 2004 by MoH of Lithuania
Principles of proposed architecture: patient centered
Components of eHealth system with patient and his EHR in the centre
Citizen
Patient
GP
Pharmacy
Polyclinics
Hospitals II level
Hospitals III level
Stakeholders
Contributions Services
Person/ Machine user interface
SPF
Sec
uri
ty L
aye
r
MoH
State Public Health Ins. Service
Lithuanian Health Inform. Centre
State Patient Fund
Social Ins. Fund
Co
nti
nu
ity
of
Ca
re
E H
R b
as
ed
bil
lin
gGovernment registries – Pop Reg.
Legacy IS
Ca
re P
oli
cy
Pla
nn
ing
Mid
dle
war
e L
ayer
Co
re E
.H.R
. (E
pis
od
es o
f C
are,
Dia
gn
os
is,
Ser
vice
s)
Bil
lin
g
An
alyt
ical
E.H
.R.
(Dia
gn
ost
ic S
ervi
ce D
epa
rtm
ents
)
Cli
nic
al,
Ma
nag
emen
t &
Co
mm
un
icat
ion
Lo
gic
Dat
a P
roce
ssin
g
Sta
tist
ica
l In
form
atio
n
Kn
ow
led
ge
ba
se
EHR Phase IPassive EHR
Dec
isio
n S
up
po
rt
Lo
gic
EHR Phase IIActive EHR
State Drug Control Service/State Pharmacy Department
Electronic Health Record
-9 months death
Episode of Care (PHC)
1 2 3 4 5 6
1 2
3
4
Primary care
Emergency
Secondary Care
Tertiary Care
3 6
5
recovery plan
Continuous episode oriented health record
Principles of implementation: standard based
Middleware of common services
APPLICATIONS
Responsible for supporting the useractivities in the various areas of
the organisation
Medical care
Nursing .............
Diagnostics
Administration
GENERIC
Responsible forsupporting genericrequirements, not
specific to thehealthcare domain
HEALTHCARE-RELATEDResponsible for supporting functionalities and information
relevant for the whole healthcare organisation
Authoris-ations
Subjectsof
care
Healthdata
Activities ResourcesConcepts
andterminology
.......
Middleware of common services
BITWAYS Providing facilities for the integration andinterworking of the technological environments
Low Level Record Components (Standard Controlled Medical Vocabularies, classification systems and registries – ICPC-2, ICD-10, ATC, GP registry,
Citizens registry, Institutions registry, etc.)
Primary Care Secondary Care Tertiary Care
Continuity of Care Concepts (CEN/TC251 ENV 13940) (Standard Controlled Medical Vocabularies, classification systems and registries)
Information Modelling (EN WI 133/DOM & ENV 12967: 2003 parts 1-3)
Clinical Process Modelling Swimlane(perceived patient condition, health issues)
Healthcare (Business) Process/
Logic Modelling
(ENV 12967, SAMBA)
Management Process Modelling Swimlane(healthcare mandate, decisions)
Communication Process Modelling Swimlane
Semantic Relationship Modelling (EN WI 133/DOM & ENV 12967: 2003 parts 1-3)
Messaging Engine (CEN/TC251, ENV 13606-3 & 4,
13607, 12612, EN WI 130(SSR-MES))
Healthcare Delivery &
Decision Making Task
DomainDevelopment
(metadata, rules, control)
Info
rmat
ion
m
od
el
H M
Ds
Co
ntr
ol
– ru
les
etc.
Contributors Consumers
Citizens GPs/ FMPs SpecialistsMedical
TechnologyADT, Logistics, Scheduling
other Hospital systems
Car
e M
and
ate
(dir
ect
man
dat
e, r
efer
ral)
Car
e s
erv
ice
s
EHRInstanceRegistry
Patient Data Collection, Ordering & Review
DecisionSupport
Data mining and clinical decision support
• Rationale
• Technologies
Philadelphia Inquirer Sunday, September 12, 1999
Helping AVOID costly clinical errors
World population
Re-calculated statistics of deaths caused by medical errors
(rough estimate, no direct evidence)
Country Population Deaths/year Deaths/day
World 6446131400 2593234 7105
US 298290000 120000 329
Germany 82468000 33176 91
UK 60441457 24315 67
Sweden 9001774 3621 10
Denmark 5432335 2185 6
Finland 5223442 2101 6
Estonia 1332893 536 1
Latvia 2290237 921 3
Lithuania 3596617 1447 4
System of Clinical Decision SupportSystem of Clinical Decision Support
select patient record observation enter order
Alert/Reminder
Clinical Workstation
Trigger
beeperfaxemaildatabase
Common Data Repository
Rules Engine
Gather data
Event MonitorAdd data
Generation of decision tree (example)
New cases with diagnostic
parameters
New data with known diagnosis
Diagnosis
Decision tree Data Mining
Data with known diagnosis
Other medical testing
(histology)
By D.Jegelevicius, Biomedical Engineering Institute, KTU.
Example of decision tree automatically generated to support decision about differential diagnostics of intraocular tumours
PatientPatient
Intervention,
Health service
Generalization
Data
Information
Rules
Knowledge, rule bank
Knowledge
Personalization
Decision support
Personal
information
Generalinformation
Decision support:
from the patient to knowledge bank and back
Expert foresights
Gartner Group:
Predicts through 2002, >75% of healthcare organizations will implement rule-based technologies
Beginning in 2000, computer-based patient record systems and data repositories that do not support an Arden Syntax-based, user-definable rules-processing system will lose market share.
Vendors using Arden: SiemensMcKessonHBOCEclipsysIBM
Building bricks: international projects
Kaunas eHealth cluster
• Medical Component - Kaunas Medical University, Biomedical Research Institute, University hospital (largest in Lithuania, 2000 beds) other Kaunas hospitals and polyclinics, Society of GP of Lithuania
• Technological Component – Kaunas University of Technology, (KTU), ( the greatest technical university in Baltic countries, with 11 faculties, it’s Biomedical Engineering Institute having Telemedicine Support Center, (TSC), Biomedical Engineering Master Program, other Kaunas universities (5 in total);
• Industry component – SMS companies Kardiosignalas[7], Elinta[8], Elintos prietaisai[9], Elsis[10] and other.
EU FP 5 PROJECT TELEMEDICARE
• "The TelemediCare system permits advanced home care with maintained medical safety. The result is increased quality of life without increased costs."
• - Bo Lundell, Acting Division Manager,Astrid Lindgren Children's Hospital.• • New Market Possibilities• Advances on modern information and communication technology have together with
miniaturization of health diagnostic equipment given birth to a new revolution within health care.
• Body sensor technology facilitating mobile, multi-modal and wireless functionality will be key components to future intelligent and user friendly medical monitors.
• The integration of such sensors with new wireless network technology has given life to new possibilities for cost-efficient patient treatment.
•
Efficiency of eHealth: user benefits and functionalities
Users (beneficiaries) of eHealth srevices
• Patients• Citizens • General Practitioners (GP)• Primary Care Centers • Specialists• Polyclinics• Hospitals • Health Information Centre (HIS) under the State Public
Health Service (SPHS) • State Patient Fund (SPF)• Dept. of Pharmacy, State Drug Control Office (SDCO)• Software industry
Benefits and rationale categories
• Benefits and rationale are already discussed evident enough to be structurised and even numbered !!!
• HL7 EHR System functional Model and Standard Release 1.0., August, 2003, Why rationale categories, v.1.2
1 To serve: ( HL7 EHR System functional Model and Standard Release 1.0., August, 2003,
Why rationale categories, v.1.2)
1.1 Patient-centered/oriented care
1.2 Longitudinal, interdisciplinary healthcare delivery (per episode, disease, problem)
1.3 Point of service, point of care: immediate, real-time
1.4 Multiple care settings: acute inpatient, emergent (including trauma and mobile care, ambulance), ambulatory, long term, home, school, occupational, military
1.5 Personal health record: per patient
1.6 Provider business record: per organization, per business unit
1.7 Practitioner service record: per caregiver
1.8 Primary and secondary record uses
2 To promote2.1 Patient safety
2.2 Best practice - effective, efficient and timely care
2.3 Patient empowerment: participation in care, self care
2.4 Improved outcomes, patient satisfaction
2.5 Confidentiality
2.6 Personal health, wellness and preventative care
2.7 Population health, wellness and prevention
2.8 Personal security (military personnel, special agents, government officials)
2.9 Population security (homeland security, bioterrorism, chemical terrorism, terrorist activity)
3 To ensure and ascribe3.1 Accountability: of organizations, of business
units, of persons
3.2 Continuous record availability and access
3.3 Integrity of clinical decision making/Effectiveness of clinical decisions
3.4 Integrity of the health record
3.5 Integrity of the health(care) delivery process
3.6 Health record privacy, PHI protection
4 To facilitate and enable4.1 Health(care) delivery: immediate, real-time point of service, point of care
4.2 Efficient work flow and operations performance - streamline the way people work
4.3 Communication: inter-practitioner
4.4 Clinical decision making
4.5 Trusted record management
4.6 Trusted record/information flow
4.7 Correlated business, clinical and caregiver record
4.8/.9
Continuous quality improvement and monitoring, measures of quality, performance and outcomes
4.10 Payment and eligibility determination
4.11 Effective communication between patient, family, caregiver and care team
5 Based on
5.1 Patient safety and best practice guidance
5.2 Legal and regulatory requirements - national and regional mandates
5.3 Accreditation and professional practice standards
ID Function E/D[1] Benefits
CC1. Clinical communication E 1.1; 1.2; 1.3; 1.8; 2.2; 2.6; 2.7; 3.2; 3.3; 3.4; 3.5; 4.1; 4.3; 4.4; 4.6; 4.7; 4.8; 4.11; 5.1; 5.2; 5.3.
CC6. Support for clinical guidance E 1.1; 1.3; 2.2; 2.4; 2.7; 3.3; 5.1.
CC10. Sharing of laboratory test results E 1.1; 1.2; 1.3; 1.8; 2.2; 3.4; 3.5; 4.2; 4.3;
CC14. Support for chronic disease protocols D 1.2; 2.6; 2.3; 3.3; 4.2.
AM3. Clinical workflow tasking, scheduling D 1.2; 2.2; 3.3; 4.2; 4.3.
AM4. Referrals and registration for care E 1.2; 1.3; 2.2; 2.3; 2.4; 4.1; 4.2; 4.3.
AM8. Claims and encounter reports for reimbursement E 1.6; 1.7; 3.1; 4.7; 4.10.
AM11. Report generation (EHR data extraction in accordance with analysis and reporting requirements)
E 1.6; 3.1; 4.2; 4.8; 5.2; 5.3.
CS7. Controlled vocabulary [2] E 1.2; 3.2; 3.4; 3.5; 4.3; 4.4; 4.6; 5.1; 5.2; 4.11;
CS12. Axessibility from point of care E 1.1; 1.3; 2.4; 3.3; 3.5; 4.4; 5.1.
[1] E - Essential function, to be implemented within present stage of project; D - Desirable function, to be implemented if possible or in the next stage of the project.[2] Codification and terminology vocabularies(e.g. SNOMED), Classification of diseases ICD -10, International Classification of Primary Care (ICPC – 2 ) should be applied
Functionalities for nurses ( an example of function – benefit relation)
Levels of services
• Basic services
• Integrated common services
• High level professional medical services
Registries Integration
• Population Registry (MoI)• State Registry of Managers of Personal Data• Drug Registry: State Drug Control Office (+ve
lists), State Pharmacy Department (prices)• Doctor & Nurse License Identification Codes
(MoH)• Services Codes (SPF) in ICD-10 context?• Classification systems (SCMV) – ICPC-2 ?
Functions ensured for patient 1
• Information support of Continuity of Health Care in time and across institutions
• Clinical communication• Practitioner – patient relationship• Support for preventive care and wellness• Capture and manage patient – reported or externally available patient
clinical history• Create and maintain patient-specific problem, procedure and medication list• Medication and medication management
Functions ensured for patient 2• Pharmacy communication • Sharing of laboratory test results• Support for chronic disease protocols• Identification of citizen/patient and his status• Provider/practitioner registry• Report generation (EHR data extraction in accordance
with analysis and reporting requirements)• Secure access to the system, secure data routing,
privacy[1], authentication, role-based authorisation• Axessibility from point of care• Capture of insurance information from state register
reportable and traceable over time
Functions ensured for GP 1• Clinical communication• Practitioner – patient relationship• Support for preventive care and wellness• Capture and manage patient – reported or externally available patient clinical
history• Create and maintain patient-specific problem, procedure and medication list• Support for clinical guidance• Medication and medication management• Support medication prescriptions• Pharmacy communication • Sharing of laboratory test results• ECG cardiology• Imaging • Support for chronic disease protocols• Integrate device monitoring and remote health services such as telehealth data • Present clinical guidelines• Identification of citizen/patient and his status• Provider/practitioner registry
Functions ensured for GP 2
• Clinical workflow tasking, scheduling• Referrals and registration for care• Registration of care encounters• Health service reports at the end of episode of care• Integration of clinical data with administrative and financial
data• Claims and encounter reports for reimbursement• Integrate cost management information • Data availability• Report generation (EHR data extraction in accordance with
analysis and reporting requirements)• Disease registries • Data analysis and research
Functions ensured for GP 3• Audit trial• Standard based interoperablity, messaging and integration[1]• Maintain and identify a single patient record for each patient. • Secure access to the system, secure data routing, privacy[2],
authentication, role-based authorisation• Authorisation of the access to the EHR• Authentication of record authorship • EHR data extraction in accordance with analysis and reporting
requirements • Controlled vocabulary [3]• Capture and creation of clinical documents and notes• Responsiveness, user response time• Axessibility from point of care• Capture demographical information from state register, reportable and
traceable over time • Capture of insurance information from state register reportable and
traceable over time
Cross - boarder cooperation and networking
Online international teleconsultations
Video camera: • SONY DXC-950P• 3CCD• 750 TV lines• 58dB S/N ratio
Framegrabber miroVIDEO PCTV from Pinnacle Systems GmbH• S-Video PAL signal from SONY DXC-950P camera• Capture with 750X580 resolution• Colors calibrated using test table
Databases and portals
Telemedicine network TechNetBaltic 2001
8
TechNet Baltic 2001Technical setup
Telia satellit SUNET
Telia Streaming Media
SUNET
VisbyUniversity
Multipoint bridgeGate H.323 / H.320
Streaming encoderReal ShureStream
(modem, dual ISDN & ADSL)
Oslo
Stockholm
Helsingfors
St:Petersburg
Kaunas
2 Mbps
2 MbpsIS
DN384 kbps
384 kbps
384 kbps
384 kbps
384 kbps
Router Router
KontrollrumScen / studio
Codec CodecCamera, mic, TV-monitor
Camera, mic, video- & audiomixer, VCR, TV-monitor
Telia ISDN
Codec
2 Mbps
2 M
bps
2 M
bps
2 M
bps
Streaming back-up Luleå
2 Mbps >10 Mbps
Internet
Web-enable PC´s
>2 Mbps
Telemedicine network Litnet life connections, March 15 2002
Conclusions
• eHealth comes inevitably• It’s important to start from right architecture• Lithuania is taking pilot steps• Data mining and clinical decision support are
important goals• User benefits and funcionalities are highly
evident• R&D projects and collaboration are vital
