These are some of the Chinese Lanterns exhibited at the SM North Edsa 2016. Artworks by Dr. Alvina Pauline Santiago.
These are some of the Chinese Lanterns exhibited at the SM North Edsa 2016. Artworks by Dr. Alvina Pauline Santiago.
This week’s task for #MI227, Clinical and Laboratory Information Systems for #MSHI required us to find an article describing the adoption or use of an EMR system, a CPOE system, a medication administration system, a telemedicine system, a telehealth system, a PHR, or other clinical or laboratory information system or application, discuss its key points, lessons learned and how this can relate to the Philippines. I chose
Automated retinal image analysis for diabetic retinopathy in telemedicine by Sim et al, published online in Curr Diab Rep (2015) 15:14. https://www.researchgate.net/publication/272518326_Automated_Retinal_Image_Analysis_for_Diabetic_Retinopathy_in_Telemedicine
The article by Sim et al discusses how an automation process analysis can negate the heavy reliance of current telemedicine practices on specially trained retinal image graders, thereby improving the delivery of diabetes eye care, expediting diagnosis and facilitating referral to a treatment facility. In addition, the potential of such a system integrating with the electronic medical record permits a more accurate analysis and prognostication of the disease.
The need for early diagnosis (and necessary intervention) is diabetic retinopathy is recognized as a major factor in reducing blindness due to this pathology. In England and Wales where systematic population based screening is in place, diabetic retinopathy is no longer the leading cause of blindness. Yet, even in the developed countries, such as the US for example, access to eye care is only 60-90%, and is presumably much lower elsewhere. The ARIA potentially can distribute quality eye care or screening to virtually anywhere, with the software providing automated image analysis algorithms.
It is the need for “trained personnel for image reading and grading a large volume of retinal images” that the ARIA addresses, making the reading process less dependent on humans. Human readers, however, will continually be required for quality control, arbitration, and interpretation of atypical retinal images. The ARIA is envisioned to be linked to a patient’s electronic medical record.
ARIA was developed to perform computer algorithms capable of computer-aided detection (CADe) and computer-aided diagnosis (CADx). ARIA addressed two issues: image quality assessment and image analysis. Image quality assessment required that pre-processing improve on factors affecting image quality such as brightness, contrast, signal/noise ratio, and/or determining image clarity by assessing vessels around the macula. Image analysis begins with initial segmentation or the identification and localization of normal anatomy so that the “normal” is excluded from image analysis of what is pathologic (microaneurysms, exudates, hemorrhage, beading, neovascularization). The challenge encountered with such a system was how ARIA could deal with distractors such as retinal capillaries, choroidal vessels, and reflection artifacts.
ARIA systems currently deployed in telemedicine and screening programs include the iGradingM, The Triad Network, Iowa Detection Program (IDx-DR), RetmarkerDR, and Retinalyze System.
Future development of ARIA algorithms require a set of images used for calibration and “training” where human labeled sample images are used to teach the computer to remember such an image and its reading. Two public datasets are available for such use, the Methods for Evaluating Segmentation and Indexing techniques Dedicated to Retinal Ophthalmology (MESSIDOR) and Retinopathy Online Challege (ROC). More could be made available if only regulatory and proprietary barriers could be breached.
Telemedicine programs done right, can fill a void by exponentially increasing the capabilities of performing early screening and detection (with computer-aided detection and diagnosis in the case of ARIA), virtually eliminating boundaries. To quote the article by Sim et al “telemedicine programs for diabetic retinopathy should include:
Telemedicine diagnosis is still continually evolving and changing and requires research, validation, revalidation, improvement in software, image capture, and image sharing. Human intervention still cannot be fully removed as human readers will continually be required for quality control, arbitration, and interpretation of atypical retinal images.
Finally, collaboration is required at different levels:
What this means for the Philippines
In the Philippines, there remains a heavy reliance of screening on trained specialists in Retina, a human resource that is concentrated in the urban areas such as the National Capital Region and wanting in the provinces and outskirts of the metropolis and most especially in the remote areas. Using telemedicine partially solves the problem as reading centers are staffed by these trained Retina specialists. Specialists staff reading centers and commit to evaluating photographs within a predetermined time. This minimizes the cost of unneccessary travel to urban centers, and includes the primary care physician in diabetes care. We are at this stage.
Automating the process of reading can exponentially increase the number that can be screened, in real time. Readings can be provided to the health care team, almost immediately after a patient performs the test. This frees up the the retina specialist to deal more with patients for counseling, education, performings lasers, or surgeries.
We have problems to deal with, the infamous slow internet connection precludes real time image transfer. Patient privacy issues remain a concern. Multilevel collaboration, interhospital collaboration, data sharing are still wanting. Diabetic Retinopathy ranks among the leading cause of vision impairment in the Pacific. (ref 2) The World Health Organization estimates that 15% of blindness is due to diabetic retinopathy or glaucoma in the Western Pacific region. If telemedicine can take off, if screening can exponentially increase, and intervention introduced early, this number can drastically reduce a significant cause of blindness.
Telemedicine and the Facebook platform seem to be tempting bed fellows, but there are many reasons why physicians, who swore to protect our patient’s privacy, need to step back and rethink, if not condemn this as an option for telemedicine.
Driving question?: What features are considered critical or most useful by users of personal health records (PHR)? This assignment was coupled with a requirement to sign up for a free trial on an online PHR service or a mobile PHR application, create a scoring system to evaluate usefulness of PHRs and publish on your blog.
To understand what a PHR is, how it works, and how I can evaluate one (for this assignment), I signed my mother up at WEBMD. Not that I didn’t want to expose myself to risks with my own health data, I felt with my mom’s long list of life-threatening and chronic illnesses, I may as well use to opportunity to create a health record for her. I had my ulterior motives. Perhaps now I need not write down all that I can remember that was important… her diabetes, ventricular arrhythmia, hypothyroidism, cirrhosis, bicytopenia, portal hypertension, splenomegaly, etc. and of course the history of a near fatal anaphylactic reaction to penicillin.
For a scoring system, I borrowed emoticons from clipartbest.com, to represent my 5-point grading scale. Tongue out for 1, a pout for 2, a sleepy smiley for 3, a thumbs up for 4, and a two thumbs up for 5.
ACCESS and SECURITY.
WebMD did not permit me to create a PHR for my mom through my account. I couldn’t make one for my entire family using my one and only account. I guess it’s one email = one account. Realizing this, I created an email in her behalf, with my email as her rescue email. After signing in for webMD, I proceeded to explore what I can do with the site. Security features were password protection, and the fact that the system logged you out after 20 min of inactivity. I hesitate only because I wasn’t sure how secure data handling was. But so far I liked what I saw.
This section was the best, and the most user friendly of all its features. A primary and secondary emergency contact persons were permitted allowing access inc axe of an emergency. Even insurance information and legal initiatives and lawyers had their own spaces. There was an unlimited number of physician contacts allowed, as it should be when there were more than one physician addressing my mom’s numerous medical problems.
There was no room for story telling, a clinical history so to speak, as we would ordinarily in clinical practice. How long have you had symptoms? What were the triggers? Associated with trauma? Family History?. The system went straight to diagnosis. The PROCEDURES section however, provided good usable fields in required data input.
To DIAGNOSIS I go then. I quickly realised there were occasions when different terminologies were used from what I was accustomed to. I would have preferred the facility of an ICD-10 code to come with the diagnosis, and perhaps a free text for additional remarks. If one were to foresee that PHR will later be integrated into the health care provider’s electronic medical records, a common language should be utilised. It was good too, that I was able to enter both current and old diagnosis.
It was worse when I tried to input LABORATORY TESTS and PROCEDURES. I started with the routine complete blood count (CBC). For the life of me, it contained one box for one figure. Isn’t the CBC a test for haemoglobin, white blood cells and platelets? Did they mean blood to be haemoglobin only? The same happened for urinalysis. What saved WEBMD was the fact that one could still record entries as individual tests for CBC, as there were separate listings for red blood cell, white blood cell, platelets, among others. I wasn’t sure how to go about entries for urinalysis. For total cholesterol, low density lipoprotein and high density lipoproteins, all the entries were in one “test.” I couldn’t change the units of measure that was used in the laboratory that provided the result. The same was true for thyroid function tests that included thyroid stimulating hormone, free T3, and free T4, that had only one numerical blank to fill in, when there were three tests. The results tabulation was also cryptic, making it difficult to detect problems at first glance. What I liked about it is that the system allowed a tracker graph to represent data that was entered showing trends. In addition, useful health information was also readily accessible at this site.
MEDICATIONS and IMMUNIZATIONS
Listing of medications was impressive, as even the prescribing physician, prescription number, dispensing pharmacy, dates dispensed, quantity and number of days of supply were all tracked. WebMD also issued medical alerts and informs the user almost as soon as an entry is suspicious for drug interactions, wrong dosage, and side reactions. Alerts were classified as potentially inappropriate, potential drug-condition interaction, each classified further as mild, moderate, or severe. Guiding literature about drugs and their interaction were made available. Drug allergies were also clearly defined. The immunisation section, however, can still be improved as it caries no alerts for when the next booster dose is due.
Personal Health Records (PHR) can be very useful even just for the patient to have a clear picture of her past and current illness that affect his current sense of well-being. At the very least, WEBMD provided a more consistent, and more reliable clinical history that permitted health care providers to exchange clinical health data.
So, do we need a PHR? My answer is YES. Even in its present condition, i.e., with inability to connect with physician provider, or be integrated into a physician’s patient chart, WEBMD, provided a consistent PHR format that will gain more widespread clinical utility as the Health Information Exchange infrastructure improves.