Download Introduction of the topic

Demonstration of an Intelligent Platform
for Personalized Remote Monitoring of the
Cardiac Patients with Electronic Implant
Devices
Asuman DOGACa,1, Gokce B. LALECIa, Yıldıray KABAKa, Elif ERYILMAZa,
a
SRDC Ltd., Ankara, Turkey
Abstract. In iCARDEA Project, we have developed an intelligent platform to
automate the remote follow-up of patients with Cardiac Implantable Electronic
Devices (CIEDs) through adaptable computer interpretable clinical guideline
models which access data seamlessly in EHR data resources, CIED data, and
PHRs using standard interfaces. In this demonstration, iCARDEA system will be
presented at the backdrop of the realistic patient case inspired by clinical practice.
Keywords. Patient monitoring, cardiac patients, implant devices
Introduction of the topic
Over the last decade, there has been an exponential growth in the number of cardiac
implantable devices (CIEDs), in their electronic and software complexity widening
their function and application. However, due to their limited processing capabilities
restricted by their size, CIEDs need to be supported with software running on the data
centers. Currently, the data center processing is standalone with their custom software
and proprietary interfaces. The EU co-funded iCARDEA Project [1] exposes CIED
data through standard interfaces for developing an intelligent platform to semiautomate the follow-up of CIED patients with context-aware, adaptable computer
interpretable clinical guideline models. The CIED is exposed through standard
interfaces based on the HL7, ISO/IEEE 11073 standards and the IHE IDCO Profile.
Interoperability with EHR Systems is achieved by exposing legacy EHR systems
through standard HL7 CDA interfaces in conformance to IHE Care Management
Profile so that information about patients’ medical history such as the non-cardiac
conditions denoting contraindications to the proposed therapies can be obtained from
the patient EHR data and used in the clinical follow-up workflow. The patients are
empowered with Personal Health Records (PHR) to enable informed and responsible
participation in the care process. iCARDEA platform provides comprehensive security
and privacy mechanisms and will be validated in a hospital in Austria with CIEDs from
two major vendors, namely St. Jude and Medtronic.
1
Corresponding Author. Asuman Dogac
Way of presentation
In this demonstration, the basic components of the iCARDEA architecture will be
presented at the backdrop of one of the realistic patient cases inspired by clinical
practice and the scenario for the management of Ventricular Tachycardia (V-
tach or VT) the potentially life-threatening arrhythmia will be followed.
Within the scope of scenario description explained briefly in the following section,
the follow-up of one of the CIED patients is coordinated through clinical guideline
model remotely and the control flow is steered dynamically by checking the data
coming from CIED, EHR and PHR of the patient through IHE based standard
interfaces in order to semi-automate the follow-up. Through a graphical monitoring
tool in Care Planner component, the physicians are allowed to follow the execution of
the care plan in detail, and coordinate the flow of actions when consultations to
physicians are required.
The aim of this demonstration is increased awareness of the cost and effort
involved in the implementation of integrated services based on IHE profiles in a real
world setting to improve the efficiency and effectiveness of follow-up for cardiac
patients with implantable electronic device. The intended audience is engineers and
health professionals that are interested in the implementation of integrated services for
the remote follow-up of cardiac patients through this scenario description for clinical
practice.
Scenario Description
Our patient Mrs Mayr is a 38 year old manager in a busy hotel in a ski resort in Austria.
She had her near sudden cardiac death episode and epilepsy since childhood but no
other health problems. In Turkey as she spends her summer there, she was diagnosed
with Sarcoidosis by coronary biopsy as she has history of prolonged QT interval with
Sedacoron. Based on these information, medical history of the patient is retrieved
through Salzburg Clinic (SALK) Hospital Information System (HIS) and also from
Turkey through epSOS Network to EHR Interoperability System which automatically
sends a IHE Patient Care Coordination (PCC) 10 “Care Management Update Messages”
to Care Planner.
On 14.06.2010, in order to help to comfort the patient it was suggested that she can
be followed by telemonitoring. The patient also filled in the online consent form by
using Consent Editor Tool to allow the doctors and nurses in SALK to see the her
medical data. Additionally, Dr. Jones introduced the iCARDEA PHR portal to her as a
tool to support the management of her disease such as recording important symptoms,
weight and medication changes. The patient was also taught how to send her own ICD
interrogation for control. When a sample CIED report is sent, CIED Information
System processes the report to create an IHE IDCO compliant message.
On 21.09.2010, the patient see the medication list received from EHR by using
PHRS system and she updates PHRS stating that she uses the medications regularly but
she is not using Psychopax anymore. On the same day, patient reported that she has had
a decrease in weight of 7 kg over a 3 month period as well as feels sick to her stomach
at times and cannot eat. PHR System prepares PCC 10 messages to report these
changes to Care Planner. Care Planner processes these messages and stores them to the
Care Management Database.
On 29.09.2010, the regular 3 monthly ICD transmission was performed remotely.
The report showed some PVC (Premature Ventricular Contraction) yet nothing
abnormal. CIED Information System prepares and sends the corresponding IHE IDCO
PCD 09 Send Observation message to Care Planner. Care Planner processes this
message and stores the extracted data the Care Management Database. During regular
in clinic follow-up, Dr. Jones Cardiologist in the heart failure clinic checked the
summary of patient’s states through Patient Parameter Monitor (PPM) presenting the
most recent status of patient and he observed that patient has had some problems and
loss of weight reported on 21.09.2010 via PHRS Portal. Then, the patient was called by
nurse Allan to give her an appointment to have a gastroscopy.
On 01.10.2010, the regular heart failure clinic control was conducted. No changes
in the cardiac condition of the patient were observed. Also in this visit, chronic gastritis,
esophagitis, and hiatal hernia were observed from available gastroscopy report. Due to
patient complaints, the prednisone dose was decreased to 5 mg a day as this causes
ulcers. EHR Interoperability System automatically sends PCC 10 “Care Management
Update Messages” to Care Planner for these changes.
On 07.10.2010, using the PHRS tool, the patient presented that she was feeling
better with treatment for stomach. PHR Interoperability system prepares a PCC 10
message to provide this newly added PHR data to Care Planner.
On 05.12.2010, a Vtach alert received by Nurse Allan which stated a shock with 3
bursts of non sustained VT was observed. In the mean time, the generated PDF CIED
report is processed by CIED Information System, a PCD 09 Send Observation message
is sent to Care Planner to be processed in conformance to IEEE 11073 Nomenclature.
Then, Nurse Allan initiated the care planner. Through the graphical interface it was
checked that there were frequent episodes and the shock was effective. Since there
were frequent episodes, the care plan recommended considering decompensating
factors. For this, the medication compliance, medication changes and patient reported
symptoms were checked from the data retrieved from PHR and no problems were
detected. Then based on the care plan definition, it was decided to check the lab values
and a lab appointment was arranged. When the lab results are available, the EHR
Interoperability System automatically sends a PCC 10 “Care Management Update
Message” to Care Planner for the recent lab results retrieved from SALK HIS. When
the lab results are ready, the doctor was informed via SMS in order to continue the care
plan. After the results were collected and showed in the monitoring, it was realized that
there were no abnormal results and the care plan recommended to “consider
antiarrhythmic drug”. As there is LV dysfunction retrieved from the EHR, the care plan
recommended to change to increase concor to 2 1/2 mg for the evening dose as
betablocker. The care plan is paused for one week, and one week later, an SMS
message is sent to the patient to ask for a self monitoring. The patient does a self
monitor one week later and CIED report is sent to the Medtronic Gateway. After the
message is received, the care planner presents the CIED report to Dr. Jones, he
confirms that the medication change is effective.
References
[1]
http://www.srdc.com.tr/icardea (February 20, 2012)