Design of Health TechnologiesDesign of Health Technologieslecture 1lecture 1

John CannyJohn Canny8/29/058/29/05

OutlineOutline

Background on Health and Health CareBackground on Health and Health Care

Goals of the courseGoals of the course

Course formatCourse format

BackgroundBackground

Current estimates of the cost of health care in the US Current estimates of the cost of health care in the US put it at put it at 1.8 billion1.8 billion (about 4x the defense budget). (about 4x the defense budget).

Health spending is about Health spending is about 15% of US GDP15% of US GDP, much , much higher than European countries or Canada.higher than European countries or Canada.

Health costs in the US are accelerating again, after a Health costs in the US are accelerating again, after a steady period in the 1990s.steady period in the 1990s.

The health care system is under stress – CHCF report. The health care system is under stress – CHCF report.

Negative Effects of Cost Negative Effects of Cost Escalation.Escalation.

What can technology do? What can technology do?

Acute care (i.e. hospital & outpatient treatment) is Acute care (i.e. hospital & outpatient treatment) is dependent on technology more and more:dependent on technology more and more:

– New wonder drugsNew wonder drugs– New imaging techniques – MRI, sonar etc.New imaging techniques – MRI, sonar etc.– New diagnostic methods, DNA chips, biosensorsNew diagnostic methods, DNA chips, biosensors– Minimally-invasive surgical methodsMinimally-invasive surgical methods– Radiation treatmentsRadiation treatments

These approaches are very powerful, and very These approaches are very powerful, and very specialized. We specialized. We wontwont be covering them in this course be covering them in this course (but see Ruzena Bajcsy’s course from last Spring).(but see Ruzena Bajcsy’s course from last Spring).

What can technology do? - What can technology do? - EMR EMR But actually, medical “treatment” is only a part of the But actually, medical “treatment” is only a part of the health care challenge…health care challenge…

A surprising challenge is A surprising challenge is medical record-keepingmedical record-keeping. Care-. Care-givers today spend a significant fraction of their workday givers today spend a significant fraction of their workday documentingdocumenting their work (Newhouse talk, forthcoming, and their work (Newhouse talk, forthcoming, and note the “administration” category in the CHCF report).note the “administration” category in the CHCF report).

Electronic Medical Records (EMR)Electronic Medical Records (EMR) promise to promise to streamline and improve care. It is near the top of every streamline and improve care. It is near the top of every HMO’s priorities, and most have an EMR strategy HMO’s priorities, and most have an EMR strategy unfolding. unfolding.

EMR challengesEMR challenges

EMR challenges many areas of IT:EMR challenges many areas of IT:Record security and privacyRecord security and privacyPOE transcription (Physician Order Entry)POE transcription (Physician Order Entry)Human-Machine interaction – efficiency, low error rateHuman-Machine interaction – efficiency, low error rateData mining – better care, better economicsData mining – better care, better economicsMultimedia storage and retrievalMultimedia storage and retrievalHigh availability and persistenceHigh availability and persistenceInteroperabilityInteroperability

New technologies for EMR could enable much more New technologies for EMR could enable much more effective field studies of medical interventions (drugs effective field studies of medical interventions (drugs as well as lifestyle changes). See Newman as well as lifestyle changes). See Newman presentation…presentation…

EMR challenges: AdoptionEMR challenges: Adoption

EMR faces major adoption challenges in the short EMR faces major adoption challenges in the short term. term.

Many care-givers have developed their own record-Many care-givers have developed their own record-keeping practices, and are reluctant to adopt wholly keeping practices, and are reluctant to adopt wholly new ones. Nurses bear the brunt of record-keeping new ones. Nurses bear the brunt of record-keeping today, but often have minimal say in the adoption of today, but often have minimal say in the adoption of new systems. new systems.

Several early record-keeping systems failed because Several early record-keeping systems failed because they were built for they were built for idealized practicesidealized practices, not the , not the actual practicesactual practices of working care-givers. of working care-givers.

Health in the largeHealth in the large

Almost all the health budget today is spent on acute Almost all the health budget today is spent on acute care, but most experts argue for a general approach to care, but most experts argue for a general approach to health.health.

This should include the home, facilities for palliative and This should include the home, facilities for palliative and elder care, and other supports. The reasons are:elder care, and other supports. The reasons are:

Lifestyle can dramatically influence health –Lifestyle can dramatically influence health –Obesity, Psychological health, MobilityObesity, Psychological health, Mobility

Health care costs increase sharply with age (4x >60)Health care costs increase sharply with age (4x >60)The boomer generation is aging (2010-30 The boomer generation is aging (2010-30

retirement)retirement)Expected lifetime for a child born today is probably Expected lifetime for a child born today is probably

> 90 years > 90 years

Diagnostic toolsDiagnostic tools

Personal Health monitoring in the home:Personal Health monitoring in the home:

Blood pressure, pulse, temperature, glucose…Blood pressure, pulse, temperature, glucose…

Home diagnostic challengesHome diagnostic challenges

Clearly, these systems need to be reliable, accurate, Clearly, these systems need to be reliable, accurate, and secure (beware wireless links).and secure (beware wireless links).

The inference done on this data needs to be robust as The inference done on this data needs to be robust as well, minimizing false positives and negatives. well, minimizing false positives and negatives.

Many simple tests today (e.g. blood pressure) require Many simple tests today (e.g. blood pressure) require non-trivial skill – the accuracy reports by customers non-trivial skill – the accuracy reports by customers are wildly different – suggesting there is a big range are wildly different – suggesting there is a big range in skill. in skill.

UsabilityUsability of home medical tests is going to be a big of home medical tests is going to be a big issue for the foreseeable future.issue for the foreseeable future.

In-vivo diagnosticsIn-vivo diagnostics

Some types of monitoring, e.g. glucose monitoring for Some types of monitoring, e.g. glucose monitoring for diabetes, must be invasive.diabetes, must be invasive.

But tiny implanted sensors are a new option. But tiny implanted sensors are a new option.

E.g. the Grimes group at Penn State buildsE.g. the Grimes group at Penn State buildsmagneto-elastic sensors that measure glucosemagneto-elastic sensors that measure glucoselevels under the skin.levels under the skin.

Other groups, e.g. Intel Seattle, are working on Other groups, e.g. Intel Seattle, are working on modified RFID tags that produce a few bits of sensing modified RFID tags that produce a few bits of sensing (WISPs). (WISPs).

Diagnostic toolsDiagnostic toolsActivity – accelerometers, pedometers, heart rate Activity – accelerometers, pedometers, heart rate and GPSand GPS

e.g. Suunto’s T6, Footpod and X9ie.g. Suunto’s T6, Footpod and X9i

Fitsense pacer and “bodylan”Fitsense pacer and “bodylan”

DietDiet

A few university projects have looked at estimating A few university projects have looked at estimating caloric input using sensed data:caloric input using sensed data:

Jen Mankoff at UCB: used PDAs to scan receiptsJen Mankoff at UCB: used PDAs to scan receipts

Kay Connelly at Indiana: used Kay Connelly at Indiana: used product barcodesproduct barcodes

The goal is to guide users The goal is to guide users toward better dietary choices. toward better dietary choices.

TelemedicineTelemedicine

Telemedicine is an attractive alternative to visits to Telemedicine is an attractive alternative to visits to the hospital or doctor’s surgery. the hospital or doctor’s surgery.

Telemedicine typically involves teleconferencing in Telemedicine typically involves teleconferencing in conjunction with some remote diagnosis sensors. conjunction with some remote diagnosis sensors.

It can also support continuous patient monitoring. It can also support continuous patient monitoring.

e.g. the Health Buddy:e.g. the Health Buddy:

Telemedicine – Health BuddyTelemedicine – Health Buddy

http://www.healthhero.com/products_services/health_buddy_demo.html

Clinical Decision-MakingClinical Decision-Making

Medical diagnosis and treatment are decision Medical diagnosis and treatment are decision problems with incomplete information, and can be problems with incomplete information, and can be automated. automated.

Probabilistic methodsProbabilistic methods are well-established today. are well-established today. They work well in constrained decision problems with They work well in constrained decision problems with few variables – symptoms, patient demographics and few variables – symptoms, patient demographics and health.health.

Decision-making is often Decision-making is often case-basedcase-based – a system’s – a system’s decision is supported by the retrieval of a set of decision is supported by the retrieval of a set of relevant cases. relevant cases.

Clinical Decision-MakingClinical Decision-Making

But there is still a desire for “naturalistic” or human-But there is still a desire for “naturalistic” or human-like decision-making. Machines have a difficult time like decision-making. Machines have a difficult time narrowing down an unconstrained decision-problem. narrowing down an unconstrained decision-problem.

When the datasets are broad and sparse (like a When the datasets are broad and sparse (like a doctor’s clinical experience), automated inference doctor’s clinical experience), automated inference stalls. stalls.

Alternatives include “situated cognition” or “activity Alternatives include “situated cognition” or “activity based” inference. based” inference.

Health in the Developing WorldHealth in the Developing World

Health measures – esp. infant mortality and life Health measures – esp. infant mortality and life expectancy – are often used as expectancy – are often used as the the measures of measures of development. development.

Those countries which have made dramatic Those countries which have made dramatic economic progress in the last few decades (e.g. economic progress in the last few decades (e.g. India and China), have made similar strides in India and China), have made similar strides in health.health.

Life Expectancy in IndiaLife Expectancy in India

Infant Mortality in IndiaInfant Mortality in India

Per 1000 live birthsPer 1000 live births

Economic GrowthEconomic Growth

China and India since 1980 have been among the China and India since 1980 have been among the fastest-growing economies in the world. fastest-growing economies in the world.

China’s GDP growth, around 7% per year, is the China’s GDP growth, around 7% per year, is the highest in the world. highest in the world.

India is not far behind with a 6% annual growth. India is not far behind with a 6% annual growth.

Health in the Developing WorldHealth in the Developing World

The gains with economic development are not The gains with economic development are not automatic however. Both India and China built automatic however. Both India and China built strong public health systems. strong public health systems.

They instituted vaccination programs, regional They instituted vaccination programs, regional hospitals, and high-yield agriculture (green hospitals, and high-yield agriculture (green revolution) to provide adequate nutrition to revolution) to provide adequate nutrition to everyone. everyone.

In the rush to economic liberalization, some of these In the rush to economic liberalization, some of these gains appear to be eroding. gains appear to be eroding.

Health in the Developing WorldHealth in the Developing World

Poor health drains economic growth in many ways – Poor health drains economic growth in many ways – Absenteeism and low productivity at workAbsenteeism and low productivity at work

Costs of medicines and treatmentsCosts of medicines and treatments

Excessive birth rates, infant and child mortalityExcessive birth rates, infant and child mortality

Jeffrey Sachs (author of “The End of Poverty”) argues Jeffrey Sachs (author of “The End of Poverty”) argues that health problems have been the biggest obstacle that health problems have been the biggest obstacle to growth in recent years in sub-saharan Africa. to growth in recent years in sub-saharan Africa.

Inadequate health creates a downward spiral back Inadequate health creates a downward spiral back into povertyinto poverty

Health in the Developing WorldHealth in the Developing World

Some health challenges in the developing world:Some health challenges in the developing world:– Clean water/sanitationClean water/sanitation– Inadequate nutritionInadequate nutrition– Lack of access to doctors and medicinesLack of access to doctors and medicines– Respiratory illnessRespiratory illness– Reproductive healthReproductive health– MalariaMalaria– AIDSAIDS– Meningitis, Cholera, other epidemicsMeningitis, Cholera, other epidemics

Health in the Developing WorldHealth in the Developing World

Many of these challenges don’t require exotic Many of these challenges don’t require exotic solutions, but might be improved by simple, locally-solutions, but might be improved by simple, locally-appropriate solutions. appropriate solutions.

e.g. Smoke monitoring (~ $2 sensors) + smoke e.g. Smoke monitoring (~ $2 sensors) + smoke hoodshoods(Kirk Smith)(Kirk Smith)

WaterWater

Satellite data in India is used to map likely targets Satellite data in India is used to map likely targets for wells with very high accuracy (from 30 to 90%). for wells with very high accuracy (from 30 to 90%).

Local sensing (via cell phones) might achieve a Local sensing (via cell phones) might achieve a similar result. similar result.

Some coordination of water use would be extremely Some coordination of water use would be extremely valuable, since there is often competition for valuable, since there is often competition for available wells. available wells.

MedicationMedication

Tracking medicines and dosages is a big challenge Tracking medicines and dosages is a big challenge in many developing countries. in many developing countries.

The same techniques used in developed countries The same techniques used in developed countries seem to work (bar code scanners/terminals), but seem to work (bar code scanners/terminals), but they need to be very inexpensive. they need to be very inexpensive.

Several programs have beenSeveral programs have beendeveloper to support barcodedeveloper to support barcodereading on cellphones:reading on cellphones:Airclic, Motorola, SonyEricssonAirclic, Motorola, SonyEricsson

TelemedicineTelemedicine

Telemedicine is seen as Telemedicine is seen as an important part of the an important part of the health care puzzle in health care puzzle in almost all developing almost all developing countries. countries.

The health center in The health center in Amrita, Kerala, India Amrita, Kerala, India serves 34 local sites.serves 34 local sites.

Uses satellite links…Uses satellite links…

diagnosis, telesurgery. diagnosis, telesurgery.

OutlineOutline

Background on Health and Health CareBackground on Health and Health Care

Goals of the courseGoals of the course

Course formatCourse format

Course GoalsCourse GoalsFamiliarity with emerging health challengesFamiliarity with emerging health challenges

Select a topic for a course projectSelect a topic for a course project

Build a team (2-3 people) for your projectBuild a team (2-3 people) for your project

Develop a prototype throughout the semester, Develop a prototype throughout the semester, using a human-centered design process:using a human-centered design process:

– Needs analysis, interviews, observation*Needs analysis, interviews, observation*– Informal prototypesInformal prototypes– Design iterationDesign iteration

Human-Centered DesignHuman-Centered DesignHealth care (and health maintenance) are complex Health care (and health maintenance) are complex social practices. Technologies that are not adapted social practices. Technologies that are not adapted to those practices are apt to fail. to those practices are apt to fail.

In medical jargon, you In medical jargon, you have to test health systems have to test health systems “in vivo”, not just “in vitro”.“in vivo”, not just “in vitro”.

Iterative design keeps user Iterative design keeps user needs in the loop. needs in the loop.

DesignPrototype

Evaluate

Participatory DesignParticipatory DesignUsers of an IT system may be excellent designers:Users of an IT system may be excellent designers:

Historically, doctors have been responsible for Historically, doctors have been responsible for health innovations of all kinds. They are excellent health innovations of all kinds. They are excellent potential critics and design partners. potential critics and design partners.

Nurses are also health experts, and understand Nurses are also health experts, and understand clinical practice at all levels. clinical practice at all levels.

Participation helps technology adoption. When Participation helps technology adoption. When stakeholders participate actively, there is a much stakeholders participate actively, there is a much better chance their needs are addressed. better chance their needs are addressed.

They also feel ownership of the innovation. They also feel ownership of the innovation.

Participatory DesignParticipatory DesignIn developing regions, contextual factors can be In developing regions, contextual factors can be extremely difficult to anticipate. extremely difficult to anticipate.

Participation by actual users can be very hard, but Participation by actual users can be very hard, but is worth attempting. is worth attempting.

Otherwise, local experts can represent users’ Otherwise, local experts can represent users’ interests on the design team. These are people interests on the design team. These are people with extensive field experience with the target with extensive field experience with the target community.community.

OutlineOutline

Background on Health and Health CareBackground on Health and Health Care

Goals of the courseGoals of the course

Course formatCourse format

Course FormatCourse FormatGuest Presentations Guest Presentations – format will vary but – format will vary but normally a presentation followed by Q&A. There normally a presentation followed by Q&A. There will be a ready assigned by the guest speaker. You will be a ready assigned by the guest speaker. You should come prepared with questions based on it. should come prepared with questions based on it.

Regular ClassesRegular Classes

Each week there will be an assigned reading,Each week there will be an assigned reading,

one student will give a presentation (1/2 hour),one student will give a presentation (1/2 hour),

short post-script by me,short post-script by me,

then small group discussion,then small group discussion,

and some questions to look for in the next and some questions to look for in the next lecture.lecture.

Course FormatCourse Format

Homework:Homework: For each class you should turn in a summary (1/2 page or so) of the reading for that class.

Projects: Projects can be computer programs, electronic or mechanical prototypes, studies or designs that address a health challenge.

Project planning starts after the first section of the course (weeks 1 to 3).

Questions for next time…Questions for next time…Normally, I would give you some questions to think about as you read the next reading…

The next reading is “Medical Data: Their Acquisition, Storage and Use”, which is chapter 2 from Medical Informatics: Computer Applications in Health Care and Biomedicine, by Shortliffe and Perreault, Springer, 2001

That reading comes with its own set of framing questions, and some discussion questions at the end. These are all you need..