Telecare

Intelligent healthcare monitoring for hospital and home care

The Saphire Consortium

The Saphire Project has developed an intelligent healthcare monitoring and decision-support system based on a 'semantic interoperability' platform that integrates wireless medical sensor data with hospital information systems.

The EU-funded project (IST- 27074) is run by a consortium of eight organisations from Turkey, France, Germany, Romania and Greece, and co-ordinated by the Middle Eastern Technical University Software Research and Development Centre in Ankara, Turkey.

The project is designed to address the problem of the increasing workload of healthcare services due to the increasing numbers of elderly people. This system is designed to continuously monitor patients and deliver alarms to medical personnel whenever needed.

Clinical decision support systems (DSSs) broadly refer to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and processed to enhance patient care. Recently, there has been an explosion in basic and clinical research on disease pathophysiology and treatment. Coupled with increased demands on healthcare delivery systems, this rapid growth has made the practice of medicine increasingly complex.

The healthcare community response to this growing complexity has been to develop clinical practice guidelines to simplify and improve healthcare delivery. As an example, the US National Guideline Clearinghouse (1) provides a comprehensive database of evidence-based clinical practice guidelines and related documents.

Despite the widespread publication of clinical standards and practice guidelines, however, healthcare professionals have difficulties in understanding and applying these guidelines in the clinical care setting.

Therefore, computerised decision-support systems automating clinical guidelines to support the health professionals are needed. When used at the point of clinical care, automated, computer-based DSSs can improve healthcare professional compliance with specific treatment guidelines. However, the challenge is in providing timely and complete access to the many disparate data sources to retrieve patient-specific information.

In the SAPHIRE system, patient vital signs are received from the sensor devices through web services from the Gateway computer, and patient history stored in medical information systems is accessed through IHE XDS (2) profiles to tackle the interoperability problem.

In this way, not only are the observations received from biosensors, but also the patient medical history is used in the reasoning process in the clinical decision support system. This is an essential component, because in clinical guidelines, the physiological signs received from wireless medical sensors, the patient care plan and medical history (such as previous diagnosis, medication list, allergy/adverse drug reactions) all affect the clinical path to be followed.

Creating such an information infrastructure requires safeguards to maintain security and privacy of patient data. Patient identification and medical records cannot be disclosed indiscriminately and different healthcare providers have different access rights. The Saphire Project proposes comprehensive security and privacy mechanisms to complement the infrastructure proposed.

Furthermore, while the guideline definition is executed, alarms are delivered to the medical personnel in a secure way through a dedicated Saphire Alarm Distribution Component.

Demonstrator projects

The implementation of Saphire is almost complete and the system will be validated with the help of two practical demonstrations: the Hospital Pilot Application and a Homecare Pilot Application.
For each of the pilot applications, each patient taking part has to sign an informed consent form.

Hospital Pilot Application

The scope of the Hospital Pilot Application (HPA) is to test the intelligent bedside monitoring of the patients through wireless sensors and to integrate the data from the sensors with the data from the electronic medical records in the hospital information system. Based on this continuous execution of specific clinical guideline models, the intelligent decision support system generates alerts and recommendations to assist the healthcare personnel in the hospital.

The ultimate goal of this pilot application is to provide guideline-based, patient-specific recommendations to the hospital doctors, in order to optimise in-hospital care in terms not only of timing of reaction and medical action, but also in terms of European standards.

This system is expected to be useful for the patients (optimised care), useful for the doctors (guidelines implementation, medical education, reducing workload, avoiding human error) and also useful for the hospital care system in terms of cost-effectiveness.

The Hospital Pilot Application (HPA) will be developed in the Department of Cardiology of the Emergency Hospital of Bucharest. Two regular wards, each of 2 beds, will be dedicated to the application (4 patients will be monitored at a time). One of the wards will have oxygen availability for oxygen mask ventilation. Depending on patients' diagnosis and severity, 24 to 48 hours of monitoring will be performed for each patient during the application.

The monitoring/development area will be located very near the wards, being isolated by walls from the main corridor. All the area will be secured and the equipment will be installed in the office in this area. The distance from the wards will be no more than 10 meters.

Personnel in charge of the development of the application will access the area every two hours to check for emails/ messages/ malfunctioning. Rapid response to red alerts will be provided from the intensive care unit (25m distance) upon receiving of the message on a dedicated phone to be carried by the person on-call in charge for the HPA.

As this is an emergency facility, 24-hour supervision will be available. The recruited patients will be patients with acute coronary syndromes in a sub-acute phase (3-4 days from admission), when they are stable enough to be moved from the CCU to a regular ward. This timing has been chosen to avoid endangering patients in any way and to allow the application to run on the dedicated premises.

The guidelines that have been implemented in the clinical guideline model for the pilot are a set of four guidelines of the European Society of Cardiology (ESC) regarding acute coronary syndromes. Each patient will be assigned a specific guideline, correlated with the diagnosis from the electronic healthcare record (EHR). Interchange of the guidelines will be made possible during monitoring if a new diagnosis emerges and new recommendations will be generated according to the new status.

The guidelines have been modelled firstly into medical flowcharts, and then they have been computerised by project member METU and IPA using an extension of the Guideline Interchange Format (GLIF 3).

During its development, the application will test the safety and the accuracy of the sensor data, the Alerts System, the accuracy of the history data from the electronic medical records and the recommendations generated by the system by correct interpretation and implementation of the guidelines.

Continuous active validation by the physician of the medical decisions will be mandatory and no action will be performed on the patient without the doctor’s involvement, in order not to endanger patient’s safety.

Finally, validation and evaluation of the HPA will be performed into a specific task based on pre-designed questionnaires and evaluation metrics, to assess efficiency on endpoints, feasibility, security and accuracy of the system. Also dissemination and exploitation activities will be addressed to possible extension of the hospital pilot to other categories of hospital patients and clinical guidelines.

Homecare pilot application

The same patients that benefit from Saphire's Hospital application can later benefit from its homecare pilot application, which was conceived in co-operation with, and is being tested by, the Schüchtermann-Schillersche Kliniken (SSK) which is is an integrated heart centre in Bad Rothenfelde, Germany.

Inpatient rehabilitation following cardiosurgical intervention is a proven and effective method. However, this form of rehabilitation is cost-intensive and often lacks the means to establish a sound basis for sustained long-term success of the intervention. If a patient doesn't happen to live in the vicinity of a rehabilitation clinic, conventional outpatient rehabilitation is often deemed too impractical. This is often the case for patients living in less developed regions of Germany, for whom travelling to the clinic and back would be stressful and cost-intensive.

Tele-rehabilitation, as it is being realised in the homecare scenario, taking place at a patient’s home offers several advantages: it allows for a shorter inpatient-phase of the rehabilitation, reducing the costs without diminishing the quality of care. An earlier discharge from inpatient rehabilitation means an earlier return of the patient to their home, which is generally considered to add to the quality of life.

The active involvement of the patient and thorough supervision both aid the process of secondary prevention. Feasibility and cost-effectiveness have been demonstrated for patients with cardiovascular diseases.

For rehabilitation clinics, tele-rehabilitation is a new service they can offer to their patient, allowing them to guide the patient through the process of rehabilitation while maintaining a close relationship their patients. Since patients do not have to make use of heart sports groups in order to enjoy a medically supervised training, the clinic can serve more patients with only minimal investment.

The homecare pilot application offers a platform for tele-rehabilitation of cardiac patients by providing a modified ergometer bike and a set of wireless sensors that facilitate a safe and supervised training, using the sensor platform that has been developed for the hospital scenario as a basis. Based on thresholds customized for each patient, the system implements a control loop for patient stabilization in order to guarantee the patient’s safety.

Before and after the actual training session, the patient answers a set of questions that help the clinician interpret the sensor data that is gathered during the training session. These answers, as well as the sensor data, are compiled in a report that is sent to the rehabilitation clinic so the clinician can validate it and update the training recommendation. The platform deployed at the patient's home can be seen as a gateway for services that go beyond rehabilitation.

Secondary prevention is just as important a goal as rehabilitation, and the Saphire homecare platform can be used for this purpose. On the one hand, the patient can continue the supervised exercise and go beyond rehabilitation. The platform can not only be used to monitor the patient's vital signs, it can also serve as communication platform between a patient and the treating physician. Using the platform to disseminate health-related information is another possible use that allows the clinic to help the patient achieve the change of lifestyle that is necessary for most patients after a cardiac infarction.

References

1. US National Guideline Clearing House: www.guideline.gov/

2. Integrating the Healthcare Enterprise profile for cross-enterprise electronic health record document sharing. For more information see www.ihe.net

Project website

www.srdc.metu.edu.tr/webpage/projects/saphire/index.php

Project participants

• Middle Eastern Technical University METU-SRDC, Turkey, (Co-ordinator).
• Cyberfab, France
• Kuratorium OFFIS e. V. Germany;
• ALTEC S. A. Information and Communication Systems, Greece;
• Institute for Automation Bucharest, Rumania;
• The Internal Medicine and Cardiology Department of the Emergency Hospital of Bucharest, Rumania;
• Schüchtermann-Klinik, Germany; and
• Tepe Technology, Turkey.