An open platform for the protocolization of home medical supervision
Highlights
► SERVANDO is a distributed platform for the home supervision of multiple diseases. ► Protocolized home follow-up helps patients to autonomously manage their conditions. ► Follow-up protocols are towards an standardization of home medical supervision.
Introduction
The progressive incorporation of Information and Communication Technologies (ICT) at home determines the arise of new opportunities that cannot be ignored by the public health systems, considering the serious problems they have to deal with, such as the progressive population aging, with the consequent increase in chronic diseases prevalence; the organization of its activity based on the episodic treatment of diseases in acute phase; an excessive concentration of this activity in a reduced number of hospitals which accumulate most of the available resources; or the difficulties for an adequate incorporation of new knowledge, derived from research, to routine care. Telemedicine, understood as the use of ICT for providing remote medical services, brings together a set of strategies, techniques and devices that deal with some of the aforementioned problems. Thus, we find an extensive bibliography showing a wide diversity of application proposals (Koch, 2006), like chronic disease telemonitoring (Paré, Jaana, & Sicotte, 2007), fetal telemonitoring (Kosa et al., 2008), therapy management (Zao, Wang, Tsai, & Liu, 2010), or surveillance of convalescent people (Vincent, Reinharz, Deaudelin, Garceau, & Talbot, 2006), among others, leading to a high heterogeneity of technologies and systems that, still and all, hinder the widespread adoption of telemedicine (Koch, 2006).
A progressive standardization of the processes involved in the development and provision of home telehealth is among the recognized issues to address in the telemedicine research agenda for the next years (Hardisty et al., 2011). In this sense, there are proposals trying to provide generic solutions across a wide range of diseases, involving signal acquisition, data transmission, compression and cyphering (Sufi et al., 2006, Zeeb et al., 2010), as well as proposals to develop comprehensive and scalable information infrastructures (Savel et al., 2010), or for the detection and notification of emergency situations (Rialle, Lamy, Noury, & Bajolle, 2003). Two representative examples sharing this standardization objective but with different approaches are the INHOME (Vergados, 2010) and SANA (Anthony & Sarmenta, 2009) projects. The first one deals with the problem of information flow between the different actors and systems that can be part of a telecare architecture, offering a set of models and interfaces which permit its adaption to different supervision scenarios. The SANA platform (Anthony & Sarmenta, 2009), in turn, is oriented to the optimization of the communications and cost savings, providing a solution to the transmission of clinical information of very different nature (X-ray examinations, audio, video, etc.) in developing regions.
Yet further steps are necessary in order to provide a set of configurable telehealth medical services, by means of new open and reusable solutions that can be used in the context of different diseases, and whose practical implementation in diverse scenarios follow the same procedures (Hardisty et al., 2011). On the other hand, there is a compelling need for a strong integration of home telehealth into routine clinical practice, with the aim of extending a real medical care to the home, beyond the simple proof of concept. This should be made by providing the physician with new tools to design and implement follow-up plans at home, based on specific clinical practice guidelines for each disease (De Clercq, Kaiser, & Hasman, 2008). Besides, any follow-up plan must be customized to each patient, and must be flexible and adaptive enough in order to be accepted and, at the same time, be a positive influence from a pedagogical perspective, which has proven to be enormously useful to improve the self-management of diseases by the patients (Hesselink, 2004), and which explains the telemedicine evolution from a perspective exclusively aimed at providing information to the medical staff to a more user-centered perspective (Koch, 2006).
The SERVANDO platform develops a set of configurable medical services at home through the definition and implementation of follow-up protocols, that is, an adaption of the notion of clinical practice guidelines to the scope of home supervision. We propose a mechanism for generating a follow-up agenda from a follow-up protocol, and for a scheduled execution of the medical actions described in that agenda, providing flexibility to the patient to avoid drastic changes in their lifestyles. The agenda and the scheduler that manages it are integrated in a distributed architecture that develops its functionality through an extensible set of services.
This work is an extension of Teijeiro, Félix, Presedo, and Gándara (2011), which presents a preliminary version of the platform focusing on communications, interoperability, and extensibility issues. The paper is organized as follows: Section 2 shows a typical follow-up scenario that allows the identification of some of the problems we attempt to address; Section 3 formally describes the proposed protocolized follow-up model; Section 4 introduces the architecture of SERVANDO and describes some of its most relevant services; Section 5 exposes the validation process performed with a prototype that has been used for the supervision of real patients; finally, we discuss the main contributions and ideas for future work.
Section snippets
Follow-up scenario
One of the most important challenges facing healthcare systems is the increasing number of chronic patients. Among chronic conditions, chronic obstructive pulmonary disease (COPD) is particularly relevant because of its high prevalence worldwide. COPD is characterized by progressive airflow obstruction. As the disease progresses, subjects experience increasing deterioration of their health related quality of life, with greater impairment in their ability to work and declining participation in
Protocolized home follow-up
A home follow-up protocol describes the temporal scheduling of a set of medical actions. For each of these actions, a time interval for its completion is established, which led us to adopt the Simple Temporal Problem (STP) formalism for its representation (Dechter, Meiri, & Pearl, 1991). An STP defines a temporal constraint Lij between two temporal variables Ti and Tj as a closed interval , which restricts the temporal extension between both variables, so
SERVANDO architecture
Fig. 1 shows the architecture designed to support the protocolized home supervision. At hardware level SERVANDO is distributed into two kinds of systems: (1) a central information system, located at the medical center, which coordinates the home supervision of the patients, manages communications, stores the information relative to each patient, and permits the visualization of the generated alarms during the supervision and the corresponding physiological parameters; and (2) a mobile follow-up
Experimental study
To validate the viability and capabilities of the proposed architecture, we have implemented a prototype of the platform, and deployed it in a real supervision scenario of COPD patients enrolled in a home supervision program carried out by the Pneumology Service at the University Hospital Complex of Santiago de Compostela. The protocol describes the following actions: (s1) The automatic processing of 5-min electrocardiogram every morning; (s2) 10-min blood oxygen saturation monitoring every
Discussion
In the bibliography we can find different proposals for the computerization of clinical guidelines (De Clercq et al., 2008). Our proposal enables an easy integration with any of them, because we have no prior commitments to an ontological organization of the medical domain concepts. As an added value, SERVANDO emphasizes on bringing best practices specifications to a home care setting, where the representation and management of temporal uncertainty and the adaption to the patient behavior are
Conclusions
In this article we present the design and implementation of SERVANDO, a distributed architecture for telehealth services providing, establishing a framework for the development of applications for the supervision and assistance in multiple diseases, with an implementation for mobile devices. In short, the main contributions of our work are:
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A language for the representation of flexible and adaptive follow-up protocols is defined, and an interpreter of that language is provided, in order to
Acknowledgements
This work was supported by the Spanish Ministry of Science and Innovation (MICINN) under Grant TIN2009-14372-C03-03. T. Teijeiro is funded by an FPU Grant from the Spanish Ministry of Education (MEC) (Ref. AP2010-1012).
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