VPH in future healthcarewhere will we be in 10 years from now?

World of Health IT

Barcelona, March 15-18th 2010

Alejandro F. Frangi, PhDCenter for Computational Imaging & Simulation Technologies in Biomedicine

Universitat Pompeu Fabra, Barcelona, Spain

Networking Center on Biomedical Research – Bioengineering, Biomaterials and Nanomedicine

Institució Catalana de Recerca i Estudis Avançats

alejandro.frangi@upf.edu

www.cilab.upf.edu

www.vph-noe.eu

www.aneurist.org

Outline

Context & Current Trends

Glimpses at a Plausible Routine Future

Discussion & Conclusions

2

CONTEXT &

CURRENT TRENDS

3

Current healthcare: Why a change?

4

The need for change defies

simple solutions, as illustrated by

citizens’ dissatisfaction levels!

• Invest more money?

• Public vs. private systems?

Redefining value – From “sick

care” to healthcare

• from reactive to proactive

• patient as an object or an actor?

5

Medical Product Development: why a change?

R&D expenditure by pharmaceutical industries has dramatically increased

The number of successful drugs reaching the commercialization phase has however stagnated

Critical Path is mostly focused in the clinical phases increasingly involving expensive large-scale multi-centric studies

http://www.fda.gov/oc/initiatives/criticalpath/whitepaper.html

Healthcare trends for the future?> A patient-centric and care-cycle perspective

The hospital/healthcare of tomorrow will have as key characteristics

Patient-centric design: for personalized services and ambient experience

Individualized risk assessment: based on all relevant information (incl. demographic, genotype, phenotype, lifestyle)

Clinical work-flows: focused on Care Cycles (and care pathways), not on organizational Departments

Treatment strategies: minimally invasive and image-guided procedures

Converging medical technologies: impacting prevention, diagnosis & treatment

Federation of information systems: fully digital and connected to the clinician, the hospital, the health insurers, the government and the home

6

The patient’s journey through a disease

> care cycles

Verbeek XAAM and Lord WP (2007), The care cycle: an overview, Medica Mundi, 2007;51(2):40-47.7

Converging medical technologies

> are transforming healthcare

8

Information & communication systems

> Patient-centric ICT

Convergence of sensors, digital communications and interfaces

HeartCycle Concept descriptions and Overview on technical specifications and used technologies, Deliverable 4B. www.heartcycle.eu 9

Connecting for Health: regional data integration

Digital archiving and connectivity, and seamless access to population data derived from regional clinical records

http://www.connectingforhealth.nhs.uk10

Secondary use of EHRs or digital graves?

From information acquisition & structuring to Information access and enrichment

Substantial ethical and privacy issues involved on this model of data use!

Clinical

Information

System

Query

Patient

Record

Application Suites:

@neuLink

@neuFuse

@neuRisk

@neuEndo

Knowledge

Discovery

Information access

and enrichment

Information

acquisition

& structuring

Patient Record

- Genetic Data

- Imaging Data

- Clinical Data

Normalisation

De-identification

Denormalisation

Re-identification

Clinical Reference

Information Model

(CRIM) 11

A European Network of Excellence operated by 12 core EU institutions

12

Virtual Physiological Human (VPH)or the Digital Me

www.vph-noe.eu

13 Core Partners

4 UK (UCL, UOXF, UNOTT, USFD)

3 France (CNRS, INRIA, ERCIM)

2 Spain (UPF, IMIM)

1 Germany (EMBL [EBI])

1 Sweden (KI)

1 Belgium (ULB)

1 New Zealand (UOA)

Associate / General Members

19 Candidate General Members

3 Candidate Associate Members

(organisations)

5 Candidate Associate Members (industry)

9 Associate Projects

… and growing

“help support and progress

European research in

biomedical modeling and

simulation of the human

body. This will improve our

ability to predict,

diagnose and treat

disease, and have a

dramatic impact on the

future of healthcare, the

pharmaceutical and

medical device

industries.”

VPH- I FP7 projects

Networking

NoE

Osteoporosis

IP

Alzheimer's/ BM &

diagnosis STREP

Heart /CV

disease STREP

Cancer

STREP

Liver surgery

STREP

Heart/ LVD surgery

STREP

Oral cancer/ BM

D&T STREP

CV/ Atheroschlerosis

IP

Breast cancer/

diagnosis STREP

Vascular/ AVF &

haemodialysis STREP

Liver cancer/RFA

therapy STREP

Security and

Privacy in VPH CA

Grid access CA

Heart /CV

disease STREP

Industry

ClinicsOther

Parallel VPH projects

GLIMPSES AT A PLAUSIBLE ROUTINE FUTURE

14

Looking ahead 10 years from now?

> Glimpses of a plausible routine future?

We are seeing already the future in some of the current R&D projects

Still substantial acceptance, penetration, consolidation to be achieved

The challenge: demonstrating the anticipated clinical value

Some glimpses follow based on @neurIST…

www.aneurist.org 15

Cerebral aneurysm management

> The @neurIST “template project” Unruptured intracranial aneurysms are increasingly diagnosed due to modern

imaging techniques It is more and more important to develop holistic and sound approaches to patient

management.

Management of unruptured aneurysms is controversial decision making is currently based mainly on aneurysm size and location mainly

(ISUIA).

Wiebers D.O. Unruptured intracranial aneurysms: natural history and clinical management. Update on the international study of unruptured intracranial aneurysms. Neuroimaging Clin N Am. 2006 Aug;16(3):383-90

There is evidence that genetic predisposition may be involved in the natural history of aneurysms.

Krischek B, Inoue I. The genetics of intracranial aneurysms. J Hum Genet. 2006;51(7):587-94.

Currently endovascular treatment is favored over surgical treatment for many aneurysms (ISAT) both treatments are risky, costly and do not always prevent recurrence.

van Rooij WJ, Sluzewski M. Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol. 2006 Sep;27(8):1678-80

Molyneux A. Ruptured intracranial aneurysms - clinical aspects of subarachnoid hemorrhage management and the International Subarachnoid Aneurysm Trial. Neuroimaging Clin N Am. 2006 Aug;16(3):391-6

There is a need to support a new generation of endovascular devices treating the cause rather than symptoms of the disease

Two clinical questions

At-risk individuals/patient selection?

Optimal treatment planning?

VPH as a new perspective for More principled disease understanding and phenotyping,

Development of novel diagnostic and prognostic biomarkers, and

Computational tools for treatment planning and guidance

16

Cerebral aneurysm management

> Natural history of complex diseases

Etiology

Unruptured

[99% silent]

Growth

Ruptured

Mortality

Morbidity

Normal

33%

33%

33%

Treat?

0.2-1.0%/yrPrevalence

1-5%

F>M

Treat!

?

Degenerative

Initiation

vasospasm clotting

ISAT (Oxford)

Coil vs clip

ISUIA (Mayo)

size/locationPrevention

Diagnosis

Treatment

Prevention,

follow-up

17

PACS eRadiology Archives

Bio Bank

PACS

PACS

PACS

PACS

PACS

PACS

PACS

ISAT

ERGO

IPCI

NHRBonn

@neuQuest

@neurIST BioIS

Descriptive Data

Representative Data

Conservation of samples

I.H. Rajasekaran, L. Iacono, P. Summers, S. Benkner, G. Engelbrecht, T. Arbona, A. Chiarini, C.M. Friedrich, B. Moore, P Bijlenga, J.

Iavindrasana, R.D. Hose, A.F. Frangi (2008), @neurIST: Towards a System Architecture for Advanced Disease Management

through Integration of Heterogeneous Data, Computing, and Complex Processing Services, IEEE International Symposium on

Computer-Based Medical Systems, Finland, pp. 361-66.

Cerebral aneurysm management> Gathering evidence across Europe

@neuEndo

@neuRisk

Improve decision making processes in

the management of unruptured

aneurysms by providing a score that

integrates all the available information

for identifying at-risk patients and

reducing current over treatment

Support computational design

processes towards a next generation

of smart flow-correcting implants to

treat ruptured aneurysms and reduce

current treatment costs, side effects

and recurrence.

Support the knowledge discovery for

linking genetics to disease, vasospasm

and blood clotting after cerebral

hemorrhage

@neurISTSystems

WSS

3DRA

CFDCFD

PC-MR vs US

Flow rates

CFD vs US

Peak velocity

Model

& WSS

magnitude phasemagnitude phase

Support the integration of modeling,

simulation and visualization of

multimodal data

@neuCompute/Info Support integration of data and

computing resources.

@neuFuse

IT S

up

po

rt

Su

ites

En

ab

lin

g I

T

@neuLink

Cerebral aneurysm management

> integrative applications suites & platforms

www.aneurist.org 19

Cerebral aneurysm management> “Virtual imaging” through simulations

CFD Simulation:

• ICA Terminal aneurysm

• Inflow 230ml/min (yellow)

• 3 Outflows:

•2 Pressure

•1 Flow of 10ml/min

• High wss at neck

• Inflow jet has no clear impaction zone.

• Vortex in aneurysm (with main axis along

feeding vessel) and in bleb.

Courtesy: Philips Healthcare

20

Cerebral aneurysm management

> Building disease knowledge in silico

Cebral JR, Castro MA, Appanaboyina S, Putman CM, Millan D, Frangi AF.

Efficient pipeline for image-based patient-specific analysis of cerebral

aneurysm hemodynamics: technique and sensitivity. IEEE Trans Med

Imaging. 2005 Apr;24(4):457-67. 21

Radiological

Imaging

Vascular Model

Morphology

Streamlines

WSS

OSI

Blood

Genetics

Clinical History

Cerebral aneurysm management

> Treatment planning: virtual stenting

Larrabide I, Radaelli AG, Frangi AF. Fast virtual stenting with deformable meshes: application to inrtracranial aneurysm. Int Conf Med

Image Comput Assist Interv, 5242 (MICCAI’08), 790-7, 2008

Cebral JR, Lohner R. Efficient simulation of blood flow past complex endovascular devices using an adaptive embedding technique. IEEE

Trans Med Imaging. 2005 Apr;24(4):468-76. 22

Clot formation: A subtle interplay of genetics,

haemodynamics and arterial wall mechanics

Coil-induced clot formation is the basis of endovascular treatment for cerebral aneurysms; on the other hand spontaneous formation in untreated aneurysms is potentially loose and embolic.

Computational modelling allows for the evaluation of haemodynamic, rheological and genetic factors in thrombus formation. Models accounting for activation, biochemistry and thrombus-blood coupling will help us track the various stages of the thrombogenic process, and evaluate their significance in disease and treatment.

23

A. S. Bedekar, K. Pant, Y. Ventikos, S. Sundaram, A

computational model combining vascular biology

and haemodynamics for thrombosis prediction in

anatomically accurate cerebral aneurysms, Food

Bioprod Proc 83 (C2), 118-126, 2005

Evolution of the distribution of thrombin

concentration

Cerebral aneurysm management

> Individualized risk management

Courtesy InferMed & COSSAC University of Oxford (Prof. J Fox, Y. Chronakis) 24

DISCUSSION & CONCLUSIONS

25

EHRs, VPH and the Virtual Patient Metaphor

In practice is very unlikely to have all needed measurements before simulations can take place

VPM: A virtual patient is a logical entity that can be queried for any and all information about a human being

E.g. on-the-fly access to population average parameters where personalized data is not available

E

A

Y

B

Z

C D

@neurIST Database

Virtual Patient

Literature

Mr Jones

X

Average & deviations

input conditions

(Flow waveforms,

pressure,

haematocrit, etc… )

Derived data

Input requirements

+

Age, sex, clinical

history,

genotype, etc…

26

VPH applications & ubiquitous sensing

Personalization needs to consider in which homeostatic conditions the individuals is while being sensed

Consider environment and allostasis

“Is this patient at risk of IA rupture?” considering his/her

Exercise-rest conditions,

Stress levels,

Daily biorhythms,

Seasonal changes, etc.

Even more: “which will be his/her typical conditions under which this patient will be at risk”

Ubiquitous physiological monitoring technologies will ultimate have to connect to VPH technologies for true personalization and be integrated therein

27

Conclusions EHR, PHS, VPH: tackle complementary issues to realize patient-centric/personalized care cycles

VPH will stimulate further developments of EHR and PHS and provided added value services for healthcare and medical product development

Low-hanging fruits of VPH-PHS-EHR are available which act as levers for most sophisticated adoption

28

Announcement

@neurIST Open Session

Level 1, Room 114

Thursday 18/3, 14-16hs

Thanks for your attention

Futher contact: alejandro.frangi@upf.edu

www.aneurist.org

Final reflection

30

Validation is key for VPH

technology but still…

Will we/clinicians ever trust

computational models and VPH

technology?