Systems and Methods for Patient-Centered e-Health Services

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Systems and Methods forPatient-Centered e-Health
Services

• Chris Lau
• Ph.D. Final Examination
• August 14, 2003

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Patient-Centered e-Health

• Purpose
• Improve productivity and efficiency in health
  care
• Improve quality of care and patient outcomes
• Current status
• Content deliverypatient education, information
  about services offered by clinics and medical
  centers
• Appointment scheduling
• E-mail with provider
• Emerging applicationsdelivery of care
• Personal health knowledge management systems
  (PHKMS)
• Referrals
• Home monitoring

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Presentation Outline

• Home monitoring with asynchronous video a
  feasibility study
• A platform for building e-health applications
• Personal health knowledge management system
  applied to referral management
• Diabetic foot care monitoring
• Conclusion

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Telemedicine and Home Health Care

• Home health care (nursing, rehabilitation, social
  services)
• of patients increased 54 from 1992-1994, 7.2
  million in 1996
• Costs increased 400 from 1992-1997
• Telemedicine for home health
• Goal improve clinical outcomes and reduce costs
  (visits)
• Home nursing for congestive heart failure,
  chronic obstructive pulmonary disease, diabetes,
  cancer, wound care
• Reduced cost in home nursing (Johnston, 2000 and
  Dansky, 2001)
• Synchronous videoconferencing with custom
  equipment

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E-Medicine

• Asynchronous web-based telemedicine
• Combination of patient-provider messaging,
  web-accessible medical records, and patient
  monitoring at home
• Characteristics
• Just-in-time access
• Geographic neutrality and economy
• Medical recording and service documentation

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Feasibility Study

• Total shoulder replacement arthroplasty
• Helps restore comfort and function to shoulders
  damaged by degenerative joint disease,
  osteoarthritis, or rheumatoid arthritis
• Patients learn to do their own physical therapy
  and are discharged about three days after surgery

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E-Medicine for Post-Operative Monitoring

• Patients can use the E-Medicine website to
• Review treatment plans
• Send status reports to doctors with video
• Send questions to doctors, optionally with video
• File health status surveys to track how surgery
  is affecting everyday activities

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Patients Video Recording Interface
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Physicians Status Report Review Page
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Feasibility Study Conclusions

• 6 patients with a wide range of prior computing
  experience successfully used the system
• System useful for patients with questions (e.g.,
  Would it be okay if I? or Is it normal
  that?)
• Interoperability with other systems desirable
  (e.g., EMRs)
• Permanent storage area for patient-generated data
  needed
• Next steps
• Refine feasibility study system into a platform
  that can support e-health applications
• Implement new applications and evaluate their
  effectiveness

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E-Medicine Platform Features

• Secure messaging between patients and providers
• Interface for implementing data collection
  instruments
• Rapid development of new applications
• Interoperability
• HIPAA security requirements

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E-Medicine Architecture
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Personal Health Knowledge Management

• Personal health knowledge management systems
  (KMS)
• Web-based patient-owned repository for all of an
  individuals medical information
• Problems addressed
• Patients medical records scattered across points
  of care
• No place in traditional EMR to store
  patient-generated information
• Prior work
• Implementations focused on use in emergency and
  travel
• Evaluations compared personal health KMS features
  against EMR features (Schneider, 2001 and Kim,
  2002)

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PHIMS

• Personal Health Information Management System

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FARMS

• Referralrequest to see a specialist for a
  problem beyond the experience of patients
  current provider
• Prior electronic referral systems
• Enable providers to request referrals with
  patient information in EMR (Sittig, 1999 and
  Murphy, 1998)
• Facilitated Accurate Referral Management System
  (FARMS) linked with PHIMS
• Contains information not just from a single
  provider
• Allows patients to request referrals
  electronically
• Patients can maintain a permanent record of their
  consultations

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Referral Procedure with FARMS
Patient providesmedical history and problem
information
Patient establishesPHIMS account
FARMS checks forrecords required tomake
referral request
FARMS directsreferral toappropriate provider
Provider evaluates referral request
Scheduleconsultation?
No
Yes
Suggest alternativetreatment and/orredirect to
another provider
Appointment
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System Architecture
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Study Overview

• Deployed into an orthopaedics surgical clinic to
  evaluate usability and clinical utility of PHIMS
  and FARMS for managing self-referrals
• Procedure
• Patients recruited through UW Dept. of
  Orthopaedics web site
• Patients fill out essential parts of PHIMS for
  referral request and share with clinic staff
  (PCCpatient care coordinator)
• Patients asked to completerest of PHIMS before
  theappointment
• Specialist reviews patientsinformation in PHIMS
  beforeand/or during appointment
• Patients asked to fill out survey2 weeks after
  initial contact

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Dept. of Orthopaedics Arthritis Source
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PHIMS Health Problem Entry
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Referral Review
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Referral Management
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PHIMS Message
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PHIMS Allergies
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Subject Demographics

• Study period December 2002-July 2003
• 61 patients, 5 specialists
• 10 times more visitors tostudy recruiting web
  page

3 patients outside of the US
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Usage
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Survey Response
32 respondents, 85 satisfied with usability, 94
with online referral experience
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Patient Comments
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Provider Comments

• Physician acceptance
• Physicians satisfied with completeness of PHIMS
  and found it to improve the usage of time during
  visits
• Usefulness of patient-entered information
• PHIMS data gives physicians a unique baseline
  assessment of patients in their own words
• Nowhere else is this type of information captured
  for later comparison on effectiveness of
  treatment
• PCC acceptance
• PCCs felt messaging system resolved the problem
  of telephone tag
• Workflow-oriented design of interface allows them
  to prioritize patients and efficiently respond to
  each request
• Physician request image and video uploads

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Image and Video Uploads
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Conclusion

• Patient health knowledge management system built
  on top of the E-Medicine platform
• Applied to referral management in a surgical
  clinic
• Improved efficiency for patients, PCCs, and
  physicians
• System found to be user friendly, convenient, and
  able to facilitate patient-provider
  communications
• Extensible to include surveys, photos, videos,
  and other data types
• Limitation
• Work on standards and universal identifiers for
  all parties needed to enable more automatic
  consolidation of patients medical records

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Diabetes Foot Care Monitoring

• Background peripheral neuropathy
• Loss of pressure and pain sensations
• Affects gt30 of diabetics
• Most common complication foot ulcers in 5-10 of
  diabetics, up to 3 will require lower limb
  amputation
• Diagnosis requires physical exam, but general
  foot care can be monitored using digital
  photographs
• Monitoring with E-Medicine
• Digital camera photo upload to E-Medicine using
  web browser plug-in
• Image quality evaluated at a diabetes clinic
• Home test conducted with patient from diabetes
  self-management project

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Integration with Diabetes Self Management

• Patients issued a UW NetID and SecurID hardware
  token
• Pubcookie single sign-on authentication allows
  users to access any application inside the box

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Diabetes Foot Care Application
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Foot Examination User Interface (1/3)
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Foot Examination User Interface (2/3)
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Foot Examination User Interface (3/3)
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Results

• Photographs examined by endocrinologist
  specializing in diabetes care
• Calluses, fissures, corns, warts, ulcers, and
  fungus

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Fungus
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Summary
Clinic and patient correspond
Patient requests referral
Appointment(s)
Intervention follow-up
Orthopaedic surgery
E-Medicine
Chronic disease management
Monitoring and intervention follow-up
Time
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Unified E-Medicine Architecture
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Conclusion

• Low cost asynchronous telemedicine system
  implemented using commercial off-the-shelf
  components
• Utility shown in post-operative monitoring
• Both patients and surgeons appreciated the
  ability to communicate between clinic visits in a
  mode richer and more convenient than telephone
• Post-operative monitoring application transformed
  into a modular platform for building e-health
  applications
• Personal health knowledge management system
• Applied to referral management
• Patients and providers reported enhanced quality
  of communications
• Unique storage area where patients can record
  health status in their own words
• Home monitoring of diabetic foot care

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Future Directions

• Clinical
• Outcome measurements for diabetic foot care
• Long-term effects of PHIMS on quality of care
• Technical
• Use of PHIMS in a public key infrastructure
• Patient-targeted decision support tools built on
  PHIMS

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Acknowledgements

• Committee Yongmin Kim, Rick Matsen, Bill Lober,
  Ceci Giachelli, Buddy Ratner, Scott Eberhardt
• E-Medicine Hugh Chang, Maisie Wang, Justine Liu,
  Janice Kim, Mark Wilson, Judy Gattinella
• Clinical Sean Churchill, Irl Hirsch, Harold
  Goldberg, Seth Leopold, Paulette Gayton, Suzi
  Hughes
• PETTT Scott Macklin, Aaron Louie, Kristen
  Shuyler
• ICSL All current and former members and in
  particular Sayan Pathak, Jim Cabral, Niko
  Pagoulatos, Ravi Managuli, Chris Chung,
  Eung-Hun Kim

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EMedicineLib Examples
HealthRecord
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MediaDisplayControl
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MessageAttachment
MessageAttachmentFactory
NamePath Render()
creates
CreateAttachment()
HAQAttachment
FileAttachment
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GetPath()
PhotoAttachment
VideoAttachment
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