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Paradigm Shifts in Health Paradigm Shifts in Health Paradigm Shifts in Health Paradigm Shifts in Health InformaticsInformatics

Luca Dan Serbanati and Serban RaduPolitehnica University, Bucharest, Romania

HEALTHINF 2013 - 6th International Conference on Health Informatics

11-14 February 2013

AgendaAgenda1 What is a paradigm?1. What is a paradigm?◦ “Canon of proportions” => “Vitruvian Man”

2. How can we use a paradigm?p g3. New paradigms in healthcare◦ “Pay for performance“, “Personalized medicine”, etc.◦ “Patient-Centered Care”

4. Shift of paradigms from business to healthcare◦ “Business Meta-Model”◦ Business Meta-Model◦ “HL7 RIM Meta-Model”

5. Paradigm shifts of from information engineering to ehealthg g g◦ “Interconnecting Health”◦ “Integrating health”

6 New paradigms in health informatics6. New paradigms in health informatics◦ Multi-agent system◦ “R2V2R - Real-to-Virtual-to-Real”◦ “Ecosystem”

7. Conclusions

Example of Example of Paradigm ShiftParadigm ShiftVitruvius described the human figure as being the principal source of proportion

Homo Vitruvianus

among the classical orders of architecture.

P di

Architecture

Paradigm:

Canon of Proportions:Human body proportions Paradigm Human body proportions are the golden proportions of architectural styles

shift

y

Cosmography of the i A S i

Leonardo daVinci believed the ki f th h b d t b

microcosm, Art, Science

workings of the human body to be an analogy for the workings of the universe.

What is a paradigm?What is a paradigm?p gp gDefinition: A f d l f f d t l l id l A reference model of fundamental value widely accepted in a particular field because it is an expression of a comprehensive belief system or world view in that field.f◦ Usually a paradigm emphasizes relationships

between some fundamental concepts that between some fundamental concepts that shape the thinking.◦ A paradigm is derived from a specific way of

thinking, communicating and viewing the g, g gworld.

AgendaAgendaAgendaAgenda1 What is a paradigm?1. What is a paradigm?2. How can we use a paradigm?3. Paradigms in healthcare4. Shift of paradigms from business to p g

healthcare5 Shift of paradigms from information 5. Shift of paradigms from information

engineering to ehealth6 New paradigms in health informatics6. New paradigms in health informatics7. Conclusions

How How to use to use a paradigm?a paradigm?How How to use to use a paradigm?a paradigm?A paradigm influences how an individual

i f h l ld perceives an area of the real world or reacts to this perception. A di id h d ti i th A paradigm guides research and practice in the field of interest.It can be used as:It can be used as:◦ a structuring schema in both teaching and

model-driven design processes;model-driven design processes;◦ a benchmark to assess methods or conceptual

tools that are related to the paradigm goal or tools that are related to the paradigm goal or idea, and◦ as this research claims, we can use paradigms , p g

for transferring knowledge across domains.

ModelModel--based design processbased design processModelModel based design processbased design process

1. Choose a simple schema to be the first model of the future

system

2. Validate the model against 2. Validate the model against the design target

[Th d l i 4 Describe the model in [The model issatisfactory]

[The model is notsatisfactory]

4. Describe the model in a design specification

language

3. Refine the model

y]

5. Use the model to implement the system

AgendaAgendaAgendaAgenda1 What is a paradigm?1. What is a paradigm?2. How can we use a paradigm?3. Paradigms in healthcare4. Shift of paradigms from business to p g



New paradigms in healthcareNew paradigms in healthcareNew paradigms in healthcareNew paradigms in healthcare

New paradigms are arising in healthcare to New paradigms are arising in healthcare to mark epochal changes in the domain:◦ "pay for performance“ focuses on cost control ◦ "personalized medicine" and "evidence-based p

medicine“ focus on the quality of services ◦ "patient-centered care” and "patient patient centered care and patient

empowerment" focus on the citizens’ perception concerning the quality and efficiency of concerning the quality and efficiency of healthcare.

“Patient“Patient--Centered Care” ParadigmCentered Care” Paradigmgg

Or:

"Nothing about me without me“ Or:

The right care in the right way at the right time.Method

Four new communication behaviors:Four new communication behaviors:◦ Understanding and validating the patients’ perspective◦ Extension of understanding the patient to his / her ◦ Extension of understanding the patient to his / her

global psychosocial context◦ Shared understanding with the patient of his / her ◦ Shared understanding with the patient of his / her

health problem and its treatment◦ Partnership with “empowered” patients in decision ◦ Partnership with empowered patients in decision

making, power and responsibility.

AgendaAgendaAgendaAgenda1 What is a paradigm?1. What is a paradigm?2. How can a paradigm be used?3. Paradigms in healthcare4. Shift of paradigms from business to p g

health5 Shift of paradigms from information 5. Shift of paradigms from information


A business metaA business meta modelmodel**))A business metaA business meta--modelmodel ))

<<situation>> Objective

achievesintends/ is concerned to

<<act>> Activity

<<role>>Agent

decides/controls/performs

BusinessRules(constraints)

<<role>><<role>>

aids to carry out

extends

(co st a ts)

plays

uses as a means

creates/ uses/modifies

<<role>> Object

role Tool

is applied to

<< tit >>

plays

<<entity>>Entity

plays

*) L. D. Serbanati, Integrating Tools for Software Development, Yourdon Computing Series, Prentice Hall, 1992.

A Business A Business Model of Clinical TrialsModel of Clinical Trials **))

Organisation:Coordinator Center (CC)Agents:CT CoordinatorStatistical unitData Safety Board

Managementof clinical trial

Organisation: Investigator centre Managment of

t ti ti l it

starts

Data Safety Board

Environment:Clinical wardA t

Agents:Chief investigatorCRF data collector

statistical units

creates

Medical treatment ofenrolled patients StartupMasterAgents:

Health care providersenrolled patients Startup

experimentationMaster

File

PatientEnrollment

management

Directives

Investigator CT Protocol

ResourcePatient

Information

Patient monitoring

Compiled CRF

Directives

Investigator

PatientInformation

Directives

Experimentation closureDirectives

InvestigatorCompiled

CRF

*) L. Collada Ali, P. Fazi, D. Luzi, F.L. Ricci, L.D. Serbanati, M. Vignetti, Toward a Model of Clinical Trials, ISBMDA 2004, 5th International Symposium of Biological and Medical Data Analysis, Barcelona, 2004.

The RIM HL7 V3 MetaThe RIM HL7 V3 Meta model model **))The RIM HL7 V3 MetaThe RIM HL7 V3 Meta--model model ))

R l Li k ActRelationship0, *

RoleLink

0, *

1

0, *

1

0, *Playes

10, *

Scopes

Entity Role0, *

0..1

Participation 0, * 11 11 1

0, *0..1 Act

*) Health Level Seven International, HL7 version 3, http://www.hl7.org

HL7 Domain HL7 Domain AnalysisAnalysis ModelModel (DAM) (DAM) forforth th L MiRL MiR H lthH lth D i D i the the LuMiRLuMiR HealthcareHealthcare Domain Domain

Domain Message Information Model Domain Message Information Model ((DD--MIM) of the Contact conceptMIM) of the Contact concept

HL7 HL7 generatedgeneratedmessagemessage


healthcare5. Shift of paradigms from information 5. Shift of paradigms from information


The “Interconnecting health” The “Interconnecting health” didiparadigmparadigm

Progress in IT has made possible the Progress in IT has made possible the development of some new paradigms in health informaticsinformatics.Interconnecting health focuses on the ability to connect health organizations and systems and connect health organizations and systems, and the role of IT as an enabler in achieving this connectivity connectivity. ◦ The growth in importance of electronic health records

in the last two decades marked a technological but in the last two decades marked a technological but also "cultural" shift. ◦ The evolution of “Interconnecting health” was a g

continuous broadening of the horizon of interoperability in health.

Electronic Health Electronic Health R f

Virtual Health Record (RHIO)

Electronic Health Electronic Health RecordsRecords

Reference content

Patient Schedule

History & Allergies

Drugs & Immunization

Patient Lab Data

Diagnostic Image

Reference content

Patient Schedule

History & Allergies

EMR PHR

History & Allergies


Patient Lab Data

Diagnostic Image

Reference content

Patient Schedule

History & Allergies


Patient Lab Data

EMR

EMR

PHRPHR

Diagnostic ImageEMR

KBPHR

Community

Hospitalization

Outpatient specialist care EHR

Reference content

Patient Schedule

History & Allergies


Patient Lab Data

Diagnostic Image

Reference content

Patient Schedule

History & Allergies

EMR Personal Health Record

Reference content

Patient Schedule

History & Allergies

D & I i i

Drug prescriptions

Residential care

Emergency


Patient Lab Data

Diagnostic Image

Reference content

Patient Schedule

History & Allergies


Patient Lab Data

Reference content

Patient Schedule

EMR

EMR


Patient Lab Data

Diagnostic ImageEMR

g yservices

Home care

Diagnostic Image History & Allergies


Patient Lab Data

Diagnostic Image

EMR

EMR

Electronic Health Record

Electronic Medical Record

Clinical documents

Virtual Health RecordVirtual Health Record**))

RH

IO)

Drug and lab test prescriptions

Patient

Notification /Alarm

atio

n (R

Emergency Summary

Clinical Event

ContactsHome RecoveryEmergency

CAT analysis

Past medical history

Current health status

Health conditions

Org

aniz

a

Patient summaries

Lab test results NotificationHome Recovery

HospitalizationEmergency

Observations Therapy Medication

GP Encounter Clinical Event

Notification

Clinical Trial Evaluation Reportat

ion

O

Medical image and report

Trends in Episodes of Care

Knowledge Base• Ontology• Clinical guidelines• Process Templates

• Service & Metadata Registry• Clinical Document Repository

Security & Privacy Clinical E t In

form

a

Clinical Pathways

*Sickness Prevalence

Demographics

Clinical Event

Notification

y yRepositories

• Care consumers• Care providers• Care organizations• Role profiles

Event Notification

Hea

lth

I

*

Workflow Engine

Discharge Summary

Demographics

Process

Instance

Ongoing treatments

gion

al H

Care Plan

Vital Sign Progress Report

*) L.D.Serbanati, F.Ricci, G.Mercurio, A.Vasilateanu, Steps towards a digital health ecosystem, J Biomed Inform, Elsevier, 2011

Reg

MultiMulti--AgentAgent System (MAS)System (MAS)gg y ( )y ( )The MAS paradigm could be used to model, design and implement software platforms that integrate software applications in healthcare systems.MASs are a more natural way to represent many situations that often occur in medical settings such as: situations that often occur in medical settings, such as: ◦ absence of a comprehensive control system, ◦ limited or insufficient resources for a care provider to solve a

i bl d given problem, and ◦ geographical distribution of the needed information and

knowledge. On the other hand, in health systems we can identify many recurrent features common to MASs: ◦ delegation of responsibility ◦ delegation of responsibility, ◦ re-allocation of tasks, ◦ need to consider a large variety of user concerns and problems, ◦ planning the collaborative work , ◦ think and work in open spaces, etc.

R2V2RR2V2RIn the case of “agentification” of a regional health information organization

Due to sensors and actuators, information flows from Real toDigital and from Digital to Real information organization

(RHIO), all stakeholders (care providers, professionals,

i d h i l i )

Digital and from Digital to Real(R2V2R):

patients and their relatives) from the real should be represented as avatars: highly

Caregiver

Caregiver’s avatar

Sensors

p g yproactive agents acting with own initiatives on behalf of an individual.

Actuators

Caregiver

an individual. Other virtual entities in the system may represent real

i i b l i l

SensorsPatient’s avatar

organizations but also virtual, temporary, ad-hoc created organizations as teams of ActuatorsReal world Virtual world

Patient

gprofessionals involved in the patient’s care process.

People, ad-hoc-createdteams, organisations, material and information resources, activities

Avatars, virtual entities, digital resources, applications

EcosystemEcosystemEcosystemEcosystemA natural ecosystem is a biological community of interacting organisms plus their physical environment. g g p p yCorrespondingly, a health ecosystem can be defined as a network consisting of a multitude of health service suppliers and consumers and healthcare organizations suppliers and consumers, and healthcare organizations, all of them supported by IT. Digital business ecosystem is a self-organising digital g y g g ginfrastructure aimed at creating a digital environment for networked organisations that supports the cooperation, the knowledge sharing, the development of cooperation, the knowledge sharing, the development of open and adaptive technologies and evolutionary business models. Di ital health ecos stem (DHE) is an IT infrastr ct re Digital health ecosystem (DHE) is an IT infrastructure designed to work in synergy with the health ecosystem by mainly supporting health activities in the real world.

The health ecosystem and its digital The health ecosystem and its digital ecosystemecosystem**))

Healthcare Ecosystem

ecosystemecosystem ))

EHR Infrastructure

Digital Healthcare Ecosystem

Patient

Shared Resources

Clinical GuidelinesMandate-based

Organization

Regional Health Organization

Home

Medical Ontology

PHR

Organization

Measurement device

VHR's Virtual Entity

Supervisor

H it lPatient's

Record

VirtualHealthRecord

Organization Business’s Rules Organizational Structure

Government

eE

Reports

Hospital Avatar

HIS

GP Office Research Laboratory Virtual Team Care

O i iOrganizational

Organization’s Roles

Gov. Agency's Virtual EntityHospital EMR Hospital's

Virtual Entity

Governmental Agency

eE

An ad-hoc GP's Virtual

Avatar

OrganizationgMediator

POS eE

Researcher's Avatar

GPResearcher

GP’s EMR Organization e-CRFs

*) L.D.Serbanati, F.Ricci, G.Mercurio, A.Vasilateanu, Steps towards a digital health ecosystem, J Biomed Inform, Elsevier, 2011

ConclusionsConclusionsConclusionsConclusionsThis paper aims to open a discussion on the This paper aims to open a discussion on the role of paradigms in our reasoning and proposes the use of innovative paradigmproposes the use of innovative paradigm-based solutions in one or another field of activityactivity.A paradigm better captures the nature of the diff b diff h differences between different approaches to solve a problem. Paradigm shifts in health informatics are good go-betweens in transferring knowledge to g g gand from healthcare.

THANK YOU!THANK YOU!THANK YOU!THANK YOU!

[email protected]@serbanati.com

This work was supported by the project ERRIC No. 264207, pp y p j ,FP7-REGPOT-2010-1.

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