Beyond Telemedicine: Infrastructures for Intelligent Home Care Technology

The Pre-ICADI Workshop on Technology for Aging, Disability, and Independence

The Royal Academy of Engineering, London, England

Steve Warren, Ph.D.Kansas State University

June 26-27, 2003This material is based upon work supported by the National Science Foundation under grants BES–0093916, CCR/ITR–0205487, and EPS–9874732 (with matching support from the State of Kansas). Opinions, findings, conclusions, or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the NSF.

Beyond Telemedicine

2Presentation Objectives

Assess telemedicine system design Describe where home care is headed

– Characteristics– Getting there

• Research areas• Infrastructure development

Early work– Component architectures– Standards-based devices

Beyond Telemedicine

3Where Home Health Care is Headed

In-person visits telemedicine smart sensors

Internet Telemedicine

Home Nets Novel Devices

Patient-Centric

Health Care

“Virtual” medical systems: distributed, networked devices

EPRse-Appliances

MonitorAssess /Predict

Treat

Courtesy Dr. Richard Re,

Ochsner Clinic

PhysicianStation

PatientStation

Telemedicine Technology Assessment

Beyond Telemedicine

5What is Telemedicine?

Telemedicine is a technology-rich alternative to a traditional, face-to-face, patient/physician consultation.

Audio/video interaction Data exchange: real-time / store-and-forward Multimedia electronic patient records (EPRs) Medical devices: blood pressure cuff, pulse oximeter,

stethoscope, glucose meter, weight scale, temperature probe, electrocardiogram, ...

HomMed (http://www.hommed.com)American Telecare

(http://www.americantelecare.com)

ProviderStation

Patient Station

Beyond Telemedicine

6Typical Telemedicine Systems

Point-to-point design Stovepipe systems

(one vendor creates all) expensive and inflexible

Lack of standards for information exchange & plug-and-play operation

Minimal surety mechanisms

Limited read/write access to electronic patient records

Beyond Telemedicine

7Response

Desirable point-of-care systems– Plug-and-play interoperability

• vendor competition• flexible design

– Surety (security++)– Commodity, commercial-off-the-

shelf (COTS) components

Reduce Cost

Misconception: “Telemedicine” real-time communication with a care provider

Future Home Care Systems

Beyond Telemedicine

9Future Home Layout

Beyond Telemedicine

10Characteristics of Future Home Care Delivery

New Care Delivery Model– High risk patients: continuous monitoring, trend analysis– Health prediction– Patients: greater care roles

Closed-Loop System– Non-traditional consultations– Care providers in exceptional circumstances– Systems seek & assimilate knowledge to make care

decisions Pervasive Monitoring

– Sensor webs within patient environments– Surrogate health indicators– Medical/environmental/behavioral/lifestyle data EPRs

MonitorAssess /Predict

Treat

Beyond Telemedicine

11Characteristics of Future Home Care Systems

Capable Intelligent

CollectivelyIntelligent

Decision-Capable

Self-, Location-,Owner-, Role-Aware

Interoperable

Plug-and-play

Self-Identifying

Diagnostic

Therapeutic InformationReducing

SensorLaden: Novel,Wearable,Surrogate

EPR-Enabled

Beyond Telemedicine

12Characteristics of Future Home Care Systems (cont.)

High-Surety

RedundantReliableSecure

Ergonomic

Distributed

Dynamic Fractal

Confederated Hardwired

WirelessFuzzy Bounds

Sensible

Cost Effective

StandardsBased

Commodity

PatientSpecific

SafeRobust

Easy to Use

Beyond Telemedicine

13Secure, Reliable Exchange of Medical Information

Distributed Medical Information Database

Clinic

Emergency Scene

Hospital

PrisonSchool

Research Facility

BattlefieldCompany

Home

LSTAT , in this artist rendering, is under development by Northrop Grumman

Getting There: Infrastructure Development Approaches

Beyond Telemedicine

15

Home Networking Standards & Initiatives

HomeRF: Shared Wireless Access Protocol (disbanded January 2003)

HomePNA (Home Phoneline Networking Association)

Microsoft/3Com (and similar network adapters)

Connected.Home (Intel)

Home API (active thru 1999; status unknown)

802.11b Bluetooth X10 IEEE 1394 (FireWire)

http://www.homerf.org3Com

HomeConnect Home Network

Phoneline Adapter

Linksys HomePNA Adapter

Beyond Telemedicine

16Interoperability Technology

Architecture– CORBA [OMG]– Java (Java Beans, Jini,

Enterprise Java) [Sun]– .NET [Microsoft]– Generic Web Services– uPnP [Microsoft]– Salutation

Telemedicine Interoperability Architecture http://telemedicine.sandia.gov (2/2003, Chapter 3)Connecting for Health, Markle Foundation http://www.connectingforhealth.org/resources/DSWG_Report.pdf (6/5/2003)

System/Device Bus– IP-based home

LAN– IEEE 1394

(FireWire)– HAVi– 802.11b– Bluetooth*– IrDA– USB– PCMCIA– IEEE 1451 (Smart

Sensors)

Context– .NET My Services– Liberty Alliance– CCOW

Patient Record Access– Good European

Health Record– HL7 CDA– OMG COAS, CIAS– CEN ENV

Medical Interoperability– DICOM– IEEE 1073 (MIB)*– Point of Care Test– TWAIN– PTP

Beyond Telemedicine

17Component Confederacies

Devices: smart, aware

Collective Intelligence

Distributed Dynamic Secure

Beyond Telemedicine

18Basic Component Interaction

Beauty– Public interfaces; Private

implementations– Standards: interaction– Object: client or server– Component-level security

Attributes

Methods

A

Attributes

Methods

B

MediatorComponent Object

What it knows

What it can do

– Distributed (C++/Java CORBA/Jini/DCOM)

– Fractal: component = device, collection, etc.

Beyond Telemedicine

19Requirements for Smart Home Care Systems

Component Self-Awareness Component Interoperability Component-Level Security

Beyond Telemedicine

20Requirement: Component Self-Awareness

Each component should know… about itself …

• What it can do• Its limitations• How to interpret its data• How to assess its condition

… about its context …• Who may use it and how it may be used• Roles/scenarios for valid data

Beyond Telemedicine

21Requirement: Component Interoperability

Procedures

Device Specificatio

ns

Device

The Rest of the Medical System

“I am here!”

“Identify yourself.”

“I am a pulse oximeter that ...”

“Start waveform.”

“235, 233, 230, ...”

Standard, vendor-independent interfaces Lego-like construction of diverse systems “on the

fly”

Beyond Telemedicine

22Requirement: Component-Level Security

Components will negotiate secure transactions

Point-to-point systems: straightforward to secure – Small user population– Static network topologies– Limited range of technologies

Distributed systems: security is more important/ problematic – Mass-market communications– Less emphasis on private networks– Legacy and leading-edge technologies

Early Work

Beyond Telemedicine

24Telemedicine Interoperability Architecture

Backplane

UserInterface

Comms

Processing

ProtocolsMedicalDevices

PatientRecords

“Lego-like” Component Interactions

Goal: Create application-specific, distributed medical systems “on-the-fly”

Benefits:• Flexible• Cost-effective• Secure

Telemedicine Interoperability Architecture: http://telemedicine.sandia.govThe Role of Technology in Reducing Health Care Costs: http://www.sandia.gov/CIS/6200/Telemedicine/

Beyond Telemedicine

25Smaller-Scale Systems

Backplane

UserInterface

Comms

MedicalDevices

Ophthalmoscope/Otoscope

Thermometer

Backplane

UserInterface

MedicalDevices

Personal Status Monitor

Beyond Telemedicine

26Typical Point-to-Point Telemedicine System

MedicalDevices

UserInterface

Backplane

Comms

Protocols

Patient Station

UserInterface

PatientRecords

Backplane

Comms

Protocols

Processing

Caregiver Station

Communication Link

Beyond Telemedicine

27Distributed Telemedicine System

PatientStation

CaregiverStation

Patient

Record

Server

Diagnostic

ServicesSystem

ProtocolServer

PatientRecords

Backplane

Comms

Backplane

Comms

ProcessingMedicalDevices

UserInterface

Backplane

Comms

Backplane

Comms

Protocols

UserInterface

Backplane

CommsLink

Beyond Telemedicine

28Build 1 Patient Station

USB Hub:WeightHeart RateBlood O2 SatTemperatureBlood PressureECGStethoscope

Telemedicine Interoperability Architecture: http://telemedicine.sandia.govThe Role of Technology in Reducing Health Care Costs: http://www.sandia.gov/CIS/6200/Telemedicine/;http://www.sandia.gov/CIS/6200/Telemedicine/index_tra.htm

Beyond Telemedicine

29Build 1 Architecture

Temp

SpO2

Physical

Devices

CORBACORBA Services

(Security, Naming,Transactions, Trader, Event)

USB

Backplane

BP

DeviceX

VITALSPulse

BPSpO2

BP12080

Desktop

Virtual Device

System I/F Logic Display

MODEL VIEWCONTROL

Component Pattern:

ala Java Beans

Beyond Telemedicine

30

Medical Component Design Laboratory

Research Goals– Point-of-care system design– Plug-and-play component

infrastructure– Medical devices EPR’s– Wearable light-based sensors– State of health

assessment/prediction Education Goals

– Project design space– New curriculum and web resources– Community outreach

Support– National Science Foundation– Kansas EPSCoR Program– Sandia National Laboratories

2.17

2.171

2.172

2.173

2.174

2.175

2 2.5 3 3.5 4 4.5 5Time (sec)

Sig

nal

(Vol

ts)

http://www.ieee1073.org/

http://www.bluetooth.com/

Beyond Telemedicine

31Technology Layout

Set-Top Box

T/R

Wearable Sensor Platforms

Local Electronic Patient Record

Security Server

Local Terminal

Protocol Server

Internet

Telemetric Link

Hospitals & Other External Entities

Other Devices Patient Identity

Verification

Heart Rate

Blood Oxygen Saturation

Respiration

Vessel Compliance

Activity

Vital Parameter Processing Modules

Blood Flow

Blood Pressure Indicators

Trend Analysis

Continuous Monitoring Modules

Information Reduction

Arrhythmias

State-of-Health Assessment

Internet Gateway

Home

Local Area Network

Motion Artifact Removal

Processing Repository

Security Server

Internet Gateway

Beyond Telemedicine

32Wearable Monitoring System

Base Station

(PC)

Data Logger

Sensor

Sensor

Sensor

Internet

Data Logger Sensor

Sensor

Telemetry

Telemetry

Ambulatory ECG & Pulse Oximeter; Data Logger in a ‘Fanny Pack’

Nested Master/Slave ConfigurationsBluetooth – Telemetry; Device discoveryMIB – Device Association; Nomenclature; Data exchange

ECG

Data Logger

Beyond Telemedicine

33Monitoring System Hardware

Bluetooth Telemetry – Brightcom Callisto II

Pulse Oximeter

Electrocardiogram

Data Logger

Beyond Telemedicine

34Light-Based Sensors

Heart rate Oxygen saturation Respiration Motion (activity) Vessel hemodynamics Relative blood

pressure Wearer identity Hemoglobin

derivatives Hematocrit 2.17

2.171

2.172

2.173

2.174

2.175

2 2.5 3 3.5 4 4.5 5Time (sec)

Sig

nal

(Vol

ts)

-0.01

-0.005

0

0.005

0.01

3 4 5 6 7 8Time (sec)

Sig

nal (

volt

s)

Red Plethysmograph - Fingertip, Hamamatsu S5106 Large Area Detector, TM, SW - 8/19/96

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 2 4 6 8 10Time (sec)

Sig

nal

(vol

ts)

0.93

0.94

0.95

4 5 6

ACpp: 10 mVDC: 0.94 VAcpp/DC: 1.1%

Beyond Telemedicine

35Components in Education

Laboratory

Lecture

Beyond Telemedicine

36Community Outreach

Girls Researching Our World

Light-Based Sensors to Indicate Hypertension

Beyond Telemedicine

37Application: Animal Monitoring

Cow with sensor

Fast analysis

Bluetoothreceiver

Offline analysis

rapidtreatment

Medical centers

Goal: Continuously assess and predict cattle state of health

Impact: Improve the ability of the livestock industry to react to and predict disease onset and spread Mechanisms: Wearable/remote biomedical sensors,

environmental sensors, and global positioning devices

Bluetooth-enabled monitoring stations Regional information infrastructure

Beyond Telemedicine

38Prototype System

Handheld

computer

Bluetooth

telemetry link

GPS HR Core Temp

SpO2

Microcontroller-based sensor module with serial

communication to a Bluetooth telemetry moduleActivit

yAmbient

TempHumidity

Mobile Monitoring Components

Ear Tags Light-Based Sensors

Concluding Remarks

Beyond Telemedicine

40Key Messages

Home health care– Reactive/episodic preventative/predictive – Closed-loop systems: beyond “telemedicine”– Novel sensing technology & pervasive

infrastructures Medical systems: Component confederacies

– Ability: Smart, decision-enabled, and capable– Layout: Distributed and dynamic– Practicality: Cost-effective & high-surety

Interoperable & Secure

Vendor Competition &

Economy of Scale

Cost

Beyond Telemedicine

41Challenges

Standards– Require consensus from entities with competing

goals– Difficult to define given quickly changing

technology

High-Surety

RedundantReliableSecure

ErgonomicSafe

Robust

Easy to Use

– Rules of engagement for role-based devices– Control of systems with nebulous boundaries– Unintended component interactions (“model checking”)– Systems that incorporate non-medical devices– Inexperienced users

Surety & Regulation– Closed loop, high reliability

systems constructed on-the-fly

– Read/write access to secure information

Beyond Telemedicine

42Contact Information

Steve Warren, Ph.D.Associate ProfessorDepartment of Electrical & Computer EngineeringKansas State University2061 Rathbone HallManhattan, KS 66506 USAPhone: (785) 532-4644Fax: (785) 532-1188Email: swarren@ksu.eduhttp://www.eece.ksu.edu