Reconstructing the whole: present and future of Personal Health Systems

pHealth 2009

Oslo 24‐26 June2009

Cristiano Codagnone

Università degli Studi di Milano

Cristiano.codagnone@unimi.it

Introduction: PHS2020 

Vision and definition

Healthcare pressures and PHS promises

The five roadmaps

Implementation gaps

Roadmaps: Filling in the missing pieces

• Current challenges

• Proposals of how to fill the gaps

http://www.phs2020.com/

From theory to practice…

Introduction: PHS2020 

Vision and definition

Healthcare pressures and PHS promises

The five roadmaps

Implementation gaps

The first roadmap: The New Atlantis (1627)

• Francis Bacon, the first foresight thinker: science and technology to improve the human condition through technology and, for instance, delay ageing, heal incurable diseases, relieve pain, change the temper and psychology of individuals in short maximize human beings intellectual, physical and psychological capacities

• New electronic, micro‐, nano‐ and bio‐ technologies can seriously reshape the human body (intended as both body and mind) and provide new potential to come close to the New Atlantis utopia

• Roadmapping is thinking out of the box, although not always easy…

If everything is connected to everything else…

• 20th century science based on reductionist assumption: to comprehend nature ‘we first must decipher its components…and see the world through its constituents’ …(Barabási 2003 Linked: How Everything is Connected to Everything Else and What It Means for Business, Science, and Everyday Life. New York: Penguin Books, p. 6) 

• … Ended up into ‘ the hard wall of complexity’,  where the mechanistic re‐composition of the parts into the whole is often ineffective (ibid.)

• Reductionism and fragmentation have characterised healthcare  practice and research to the point of drifting often into the dry attitude of dealing with diseases rather than treating human beings.

• Even within the specific domain of PHS one could claim that too much segmentedattention has been placed on distributed sensing and too little on tools to manage, analyse, and understand the data gathered to turn it into knowledge and wisdom

If everything is connected to everything else…

• The vision of PHS is that they will play a key role in supporting a new holistic approach to the human body and well being while at the same time promoting the “Response‐Ability of Individuals”.  

• In a nutshell :

• The future evolution calls for the infusion of clinical evidence and molecular and genetic data into PHS, advancing the development of sensors and lab on chips, developing more sophisticated algorithms and data processing solutions capable of turning inert data and information into knowledge and knowledge into support for action and actuation, and ensuring that  all this rests uponinterfaces and channels of interaction maximising inclusiveness and users friendliness 

Infusion of biomedical Knowledge•Bio‐ & molecular data•CGL incorporating genetics•Integration and link of pharma‐genetic‐historical (prognosis)•Co‐morbid CGL•standards and consensus about knowledge

Data processing Interacting & Interfacing

SensorsLab-on-Chip

PHS: parts of a wholeThe research themes have been divided into four main parts:

Data processing

Sensors

Interacting and interfacing

Point of Care (Lab‐on‐Chip) 

PHSInfusion of biomedical knowledge•Bio- & molecular data•CGL incorporating genetics•Integration and link of pharma-genetic-historical (prognosis)•Co-morbid CGL•standards and consensus about knowledge

PHS definition• Personal Health Systems (PHS) assist in the provision of continuous, 

quality controlled, and personalized health services to empowered individuals regardless of location. They consist of: 

– Ambient and/or body (wearable, portable or implantable) devices, which acquire, monitor and communicate physiological parameters and other health related context of an individual (e.g. , vital body signs, biochemical markers, activity, emotional and social state, environment); 

– Intelligent processing of the acquired information and coupling of it with expert biomedical knowledge to derive important new insights about individual’s health status;

– Active feedback based on such new insights, either from health professionals or directly from the devices to the individuals, assisting in diagnosis, treatment and rehabilitation as well as in disease prevention and lifestyle management.

Introduction: PHS2020 

Vision and definition

Healthcare pressures and PHS promises

The five roadmaps

Implementation gaps

Pressures and PHS potential contribution

Pressures

Demand

Ageing and more

Consumerism & access

Income

Delivery

Capacity to cure

Resource allocation

Fragmentation

Financing

Fat administration

Opportunistic behaviour

Poor monitoring

• Disease MGMT better cure less cost• Prevention and lifestyle• Elderly happy at home and less cost for care

• Foster “Respons-ability “• Better educated consumption • Improve access

• In combination with organisational innovation can realise 80/20 scenarios

• Increase job satisfaction for professionals

• If inter-operable among each other and with PHRs can enable integrated care

• Reduce errors and adverse event

• PHS can be a component of a new system (including PHRs, guidelines and measurement) increasing transparency and reducing opportunistic behaviours

(unnecessary costs )

The health and wealth of nations

Human capital

depreciation slows down

incentives to invest in education increase

If Health Capital

increasesWorkdays

lost decrease

Labour productivity

increases

Cost of healthcare decrease

GDP Increases

Senior workers

retire later

Welfare & Pension

more sustainable

Independent living

Other PHS applications

A huge market opportunity still to be realised

Most PHS applications have less than 1% market penetration

Estimate of remote patient monitoring market globally at about € 800 million

That is a tiny share of Healthcare IT expenditure

Why:– Some technical‐scientific gaps to 

be filled by research

– But also many socio‐economic, cultural, and organisational barriers

…the emergence of a new “e‐Health industry” that has the potential to be 

the third largestindustry in the health sector with a 

turnover of €11 billion. By 2010 it could account for 5%

of the total health budget

eHealth Action  Plan COM(2004) 356 final, Brussels, p. 4

The eHealth market is currently some 2% of total healthcare expenditure in Europe, but has the potential to more than double in size, almost reaching …half the size of the pharmaceuticals 

market

Vivian Redding, Foreword to  the report eHealth is Worth it:, p. 5

Introduction: PHS2020 

Vision and definition

Healthcare pressures and PHS promises

The five roadmaps

Implementation gaps

Key gaps for future research to fill in

Infusing biomedicine knowledge into technology

More intelligent data processing: from personal to personalised

New generation sensors: self‐calibrating, with on board‐processing, multi‐signs/multi‐diseases, non invasive, energy efficient, plug and play into BAN

More inclusive and user friendly inter‐faces and interaction channels

More integrated and faster lab‐on‐chip testing

Domain Identified Gaps

Infusion of biomedical knowledge

• Lack of integration of  updated clinical evidence, biomedical and genetic information to ensure scientific control, risk assessment, and personalisation 

• Data from uncontrolled conditions  in need of validation• Need of holistic clinical guidelines and pathways to align PHS delivered care to best practices and to capture the multi‐facet nature of health status

Data processing

• Lack of capacity to process data coming from different sources and to address the issue of data generated under “uncontrolled conditions”;

• Lack of  capacity to recursively learn from individuals specific characteristics and context and automatically adapt data processing to personalise monitoring and enabling actuation reducing the need of healthcare professionals intervention

• Lack of  personalised aid decision tools for users

Sensors

• Lack of capacity to capture new signs on the environment (both physical and chemical parameters) and on the peculiar situations of individuals (activity, location, emotional status)

• Monitoring techniques  not able to correctly link physiological signs, with motions, gestures, and environmental data;

• Need to go beyond  the “one sensor‐ one signal” and “one sensor‐ one disease”paradigm to optimise energy and bandwidth usage 

• Need to simplify and reduce the amount of data transfers• Need to increase flexibility and better adapt the sensors to individual characteristics  (reduce invasiveness and consider allergies)

• Lack of knowledge on the long term effect of sensors contact with, and presence in, the human body;

• Lack of closed loop systems moving PHS beyond monitoring and into diagnosis and treatment (i e dispensation and reaction):

Domain Identified Gaps

Interfacing and interaction

• Lack of  multi‐channel delivery and inter‐action creating risk of exclusion due to lack of access to, or confidence in, PHS typical interaction channels

• Need of  more understandable and easy to interpret input and guidance to users;

• Need to better inform and educate PHS users

Point of Care (Lab on chip)

• Fragmentation of testing due to limitation in number of encompassed markers

• Complex and manual sample preparation & handling• Time to result too long

2011 2015 2018 2020Bi

o(m

edic

ine)

Infu

sed

PHS

Evidenced based standard of knowledge into holistic clinical guidelines

Advancements in genetic and molecular medicine

Development of shared patient–doctor DSS

Inter-operability and Development and supplement of legal framework

PHS synergies with BMI and VPH

Integration of genome-specific data

holistic guidelines modelled into PHS

Increased interdisciplinary and inter-institutional cooperation across healthcare system

Pilots including patients with co-morbidities

EnablersIssuesforResearch

Implem

entation

20

MI BIClinical 

Practice & Research

FunctionalGeonomicsResearch

User interfacesDecision‐making Support

Probabilistic Expert ReasoningTechnology Assessment and ValidationStandard, Terminologies, Vocabularies

Comparison and Prediction algorithmsDatabase integrationAutomatic annotation

Medical Informatics in support ofFunctional Genomics

Bioinformatics in support ofPersonalised Healthcare

•Computational Grid•Security•Processing of 3D Images•Large Data Acquisition Systems•Noise detection & error handling•Controlled Vocabularies•Knowledge representation & ontologies

•Text mining & information retrieval•Knowledge data mining & discovery•Modeling & Simulation

BMI and PHS

2011 2015 2018 2020ScopingIn

telli

gent

PHS

Data

Pro

cess

ing

PHS Into chaotic environments

PHS for lifestyle management & rehabilitation

Pre-processing of data

Patterns assessment & knowledge extraction

Predictive methods/algorithms and modelling

Interoperability

Privacy preserving algorithms

Development and integration of legal framework

Auto-adaptive and self-calibrating processing

Issues for ResearchIm

plementation

Multimodal Data fusion and integration

Development of shared patient–doctor DSS

Treatment of “uncontrolled conditions” data

2011 2015 2018 2020Th

irdGe

nera

tion

PHS

Sens

ors

MINABIO andrelated

Power generation potentialities

New smart minimally invasive wearable

Multi-signs sensing including context awareness

Contactless sensing

Bio-imaging

Modular network architecture (Plug&Play)

Interoperability & Standardisation

Sensors computation al capacity

Future all encompassing sensors / actuators

Scoping / Enablers

Issues for ResearchIm

plementation

New smart minimally invasive implantable

Current actuators

Studies on sensors materials and their effect on the body

2011 2015 2018 2020Us

ersI

nclu

sive

PHS

Inte

rface

s Guidelines for quality stamps and certifications

Force-feedback applications

Multi-modal interaction

Alternative sensing

Motivational support toolsAffective Computing

Multi-channel interactions

Integration of tailored ergonomics

Involvement of end users for assessment and evaluation

Scoping / Enablers

Issues for ResearchIm

plementation

2011 2015 2018 2020Ad

vanc

ing

Poin

t-of-C

are

EnablersIssues for Research

Implem

entation

Cheap, flexible and bio-degradable materials

Miniaturisation of components

Full integration of processes on LoC devices

Multi-markers on one chip

Personal-enabled LoC for in/on body analysisIntelligibility of results & user-friendly interfaces

Non-invasivaness and portability

Involvement of end users for assessment and evaluation

Acceleration of chain reaction

Introduction: PHS2020 

Vision and definition

Healthcare pressures and PHS promises

The five roadmaps

Implementation gaps

Implementation gaps (1/2)Domain Gap

Financing, business models, evaluation

• PHS have yet little market penetration ;• Institutional reform to introduce new financing models;• Lack of consolidated  evaluation and measurement methodologies to validate  clinical and cost‐effectiveness outcomes;

Higher  barriers  for preventive services

• Lack of consolidated evaluation methods and supporting evidence

• Lack of large enough databases for genetic mass screening of population (and of supporting legal framework);

• Need of incentives  for healthy behaviours backed by sanctions;

The Users Dimension

• Need of education campaign and integration between eHealth and eInclusion policies

• Need of PHS embedded eLearning• Need of quality controlled Web 2.0 tools;• Off and online information on scientific reliability, privacy issue, benefits, etc;

Implementation gaps (1/2)Issue Gap

Standardisation and  interoperability bottlenecks

• Lack of bodies setting binding standards on inter‐operability, protocols, pathways and clinical guidelines and stakeholders fora (including industry) at both national and EU level;

• Lack of shared infrastructures and standards for data exchange;

• Lack PHR inter‐operability even at national level (strongly stressed by experts from ICT industry);

• Need of citizen owned fully inter‐operable Personal Health Records (PHR) integrated with PHS;

Body adventures (ethical and legal issues)

• Lack of clear legal framework;• Lack of tailoring of security and encryption techniques for healthcare sector application;

• Need of data management and mining applications integrated into PHS that embed, support and protect privacy;

Thank you for your attention!

Scenario Key Dimensions

State keeps on trying

The Caring State (Good Big Brother)

Two‐tier healthcare management

Self‐caring Society

Health divided societies 

Governance

Societal Health consumerism

Pluralist andOpen 

Society & Health 

Scenarios full stories

Government Dominated

Socio‐demographic factors• European population may not decrease 

but will surely grow older…– 2004: 1 to 4– 2005: 1 to 2

• Ageing of the population is bound to bring about:

– Increase in chronic disease  in general

– Increase in co‐morbidities in chronic diseases

– Increasing problems of compliance and overconsumption

– Crisis in long term care

• In addition changes in lifestyles, though through different mechanisms, will increase:

– Obesity related diseases– The burden on social and economic 

life of neuro‐psychological disorders

 

Share of population aged 65 and over, 1960 and 2005

Old age dependency ratio, EU-25, 2004-2051

Source :OECD Health Data 2008, June 2008

Source: Eurostat, Statistics in Focus: 3/2006

Rising expenditure• healthcare expenditure as a 

percentage of GDP has grown substantially in all OECD countries between 1980 and 2005

• Currently the costs of healthcare in the EU is around 9% of GDP but they are projected to reach 16% of GDP by 2020

• On average 75% comes from public funds

• Coupled with Europe's ageing population, the situation is clearly unsustainable, with fewer and fewer economic “producers” to support the social and health costs related to an increasing population of retirees

Total expenditure on health, as %of GDP, 1980 to 2005

Source :OECD Health Data 2008, June 2008