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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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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

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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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 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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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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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

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