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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 delivery—patient education, information about services
offered by clinics and medical centers
Appointment scheduling
E-mail with provider
Emerging applications—delivery 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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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
Telemedicine and Home Health Care
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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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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
Home Healthcare Network Application Service Provider
Patients’ Homes Patients
Hospitals, Clinics, and Doctors’ Homes
Internet
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E-Medicine Architecture
WebServer(IIS)
Database(SQL Server)
.NET Common Language Runtime
Applications
ASP.NET EMedicineLib
HTTPS
HTTPS
Mail ServerSMTP
Other ClientsSOAP
HTTPS
Pipes
Pipes
TCP/IP
Web Browser
DataCollection
Plug-in
DHTMLUser
Interface
EMedicineClientLib
AS
P.N
ET
Pu
bC
oo
kie
Cookies
Application Server(Microsoft .NET)
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Personal Health Knowledge Management
Personal health knowledge management systems (KMS) Web-based patient-owned repository for all of an individual’s
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
PHIMS
Medical records, X-rays,glucometer readings,
vaccinations, allergies,medications, genome
Home & MobilePhysiological
Sensors
Hospitals, Clinics,and ER
Specialists and Other Clinicians
Primary Care Provider
EMRs
Imaging Systems
Patients
Laboratory Systems
Multimedia DigitalLibrary
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FARMS
Referral—request to see a specialist for a problem beyond the experience of patient’s 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
Provider evaluatesreferral request
Patient providesmedical history and problem information
Suggest alternativetreatment and/or
redirect to another provider
Scheduleconsultation?
Appointment
Yes
No
FARMS checks forrecords required to
make referral request
FARMS directsreferral to
appropriate provider
Patient establishesPHIMS account
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System Architecture
WebServer(IIS)
Database(SQL Server)
Mail ServerSMTP
Pipes
Pipes
TCP/IPA
SP
.NE
TP
ub
Co
oki
e
Cookies
.NET Common Language Runtime
PHIMS/FARMS User Interface
ASP.NET
EMedicineLib
FARMSLib
Application Server(Microsoft .NET)
Client
Client
Client
HTTPS
HTTPS
HTTPS
…
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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 (PCC—patient care coordinator)
Patients asked to completerest of PHIMS before theappointment
Specialist reviews patients’information in PHIMS beforeand/or during appointment
Patients asked to fill out survey2 weeks after initial contact
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Subject Demographics Study period: December 2002-July 2003
61 patients, 5 specialists 10 times more visitors to
study recruiting web page
3 patients outside of the US
1
1
1
1
3
11
2
2
12
1
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Clinic Study p-value
Age (Mean (SD)) 51.79 (16.79) 45.70 (12.93) 0.00461
Location (No. (%)) West 2691 (97.54) 54 (88.52) Other 68 (2.46) 7 (11.48)
0.0000365
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Usage
17-Dec 6-Jan 10-Mar 30-Mar 19-Apr 9-May 29-May 18-Jun 8-Jul 28-Jul
Date
Referrals
PCC messages
Patient messages
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Survey Response
0
2
4
6
8
10
12
14
16
18
20
1. L
oggin
g in
was e
asy
2. A
ccou
nt s
et u
p ea
sy
3. F
illing
in he
alth
reco
rd e
asy
4. F
illing
in re
ferra
l req
uest
eas
y
5. V
iew o
f hea
lth re
cord
help
ful
6. L
earn
ed m
ore
abou
t hea
lth
7. C
omfo
rtable
com
mun
icatin
g
8. R
espo
nse
time
acce
ptab
le
9. S
atisf
ied w
ith re
ferra
l pro
cess
Question
Nu
mb
er
of
Re
sp
on
se
s
Strongly Agree = 1 Agree = 2 Somew hat Agree = 3 Somew hat Disagree = 4 Disagree = 5 Strongly Disagree = 6
1.44 2.44 1.81 2.09 3.74 2.19 2.00 2.062.56Avg. Response:
32 respondents, 85% satisfied with usability, 94% with online referral experience
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Patient Comments
Topic # of CommentsEnhanced quality of service 10Online forms preferred vs. paper forms 5Convenience of messaging 3Technical suggestions 6System-related service complaint 3Other service complaint 3
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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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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 >30% 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
MyUW
Pubcookie
MIND WebPinePatient
EducationDiabetes
MonitoringE-Medicine
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Diabetes Foot Care Application
WebServer(IIS)
Database(SQL Server)
.NET Common Language Runtime
Diabetic Foot Care
ASP.NET EMedicineLib
HTTPS
HTTPS
Mail ServerSMTP
MyUWHTTPS
HTTPS
Pipes
Pipes
TCP/IP
Web Browser
Digital PhotoPlug-in
DHTMLUser
Interface
EMedicineClientLib
AS
P.N
ET
Pu
bC
oo
kie
Cookies
Application Server(Microsoft .NET)
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Results
Photographs examined by endocrinologist specializing in diabetes care Calluses, fissures, corns, warts, ulcers, and fungus
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Summary
E-Medicine
Time
Patient requests referral
Clinic and patient
correspond Appointment(s)
Intervention follow-up
Monitoring and intervention follow-up
Orthopaedic surgery
Chronic disease management
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Unified E-Medicine Architecture
WebServer(IIS)
Database(SQL Server)
.NET Common Language Runtime
ASP.NET EMedicineLib
HTTPS
HTTPS
Mail ServerSMTP
Other ClientsSOAP
HTTPS
Pipes
Pipes
TCP/IP
Web Browser
DataCollection
Plug-in
DHTMLUser
Interface
EMedicineClientLib
AS
P.N
ET
Pu
bC
oo
kie
Cookies
Application Server(Microsoft .NET)
PHIMS&
FARMSDiabetes Shoulder
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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 particularSayan Pathak, Jim Cabral, Niko Pagoulatos, Ravi
Managuli, Chris Chung, Eung-Hun Kim
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