Carlos Parra

Implementation of a telehealth programme for patients with severe chronic obstructive pulmonary disease treated with long-term oxygen therapy

We conducted a pilot study of the effectiveness of home telehealth for patients with advanced chronic obstructive pulmonary disease treated with long-term oxygen therapy. Patients were randomized into a telehealth group (n = 24) and a control group (n = 21) who received usual care. Patients in the telehealth group measured their vital signs on weekdays and performed spirometry on two days per week. The data were transmitted automatically to a clinical call centre. After four months of monitoring the mean number of accident and emergency department visits in the telehealth group was slightly lower than in the control group (0.29 versus 0.43, P = 0.25). The mean number of hospital admissions was 0.38 in the telehealth group and 0.14 in the control group (P = 0.47). During the study a total of 40 alerts were detected. The clinical triage process detected eight clinical exacerbations which were escalated by the case manager for a specialist consultation. There were clinically important differences in health-related quality of life in both groups. The mean score on the SGRQ was 10.9 versus 4.5 in the control group (P = 0.53). The EuroQol-5D score improved by 0.036 in the telehealth group and by 0.003 in the control group (P = 0.68). Both patients and healthcare professionals showed a high level of satisfaction with the telehealth programme.

USING SET OF EXPERIENCE KNOWLEDGE STRUCTURE TO EXTEND A RULE SET OF CLINICAL DECISION SUPPORT SYSTEM FOR ALZHEIMER'S DISEASE DIAGNOSIS

In this article we present an experience-based clinical decision support system (CDSS) for the diagnosis of Alzheimers disease, which enables the discovery of new knowledge in the system and the generation of new rules that drive reasoning. In order to evolve an initial set of production rules given by medical experts we make use of the Set of Experience Knowledge Structure (SOEKS). An illustrative case of our system is also presented.

Use of a three-dimensional virtual reality model for preoperative imaging in DIEP flap breast reconstruction.

BACKGROUND The significant variation in the vascular anatomy of the abdominal wall makes preoperative imaging essential when raising a deep inferior epigastric artery perforator (DIEP) flap due to the potential for maximizing operative success, reducing intraoperative error and minimizing operative complications. Computerized models and virtual reality applications are being used to facilitate teaching and preoperative evaluation in a number of other complex anatomical regions. The variability in perforator anatomy makes DIEP flap surgery a suitable candidate for application of such technology. In this context, a study was undertaken to determine the feasibility of computed tomography angiography (CTA)-guided VirSSPA three-dimensional (3D) software for virtual reality navigation in DIEP flap surgery and to compare findings with operative measurements. MATERIALS AND METHODS We recruited 12 consecutive patients planned for an elective DIEP flap for breast reconstruction. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and VirSSPA 3D reconstruction. Imaging findings were compared with operative findings. RESULTS In all cases, the major perforators were accurately localized using both methods. 3D reconstruction of the abdominal wall with VirSSPA demonstrated a significant good correlation with perforator location compared with operative findings, showing an average error rate of 0.23cm (95% CI, 0.17-0.30). CONCLUSION In short, the main advantage of VirSSPA, when used in conjunction with an image assessment such as CTA, is to provide additional and potentially more accurate data over conventional CTA with regard to the site of the best perforators and its course through the muscle.

Sharing clinical decisions for multimorbidity case management using social network and open-source tools

INTRODUCTION Social networks applied through Web 2.0 tools have gained importance in health domain, because they produce improvements on the communication and coordination capabilities among health professionals. This is highly relevant for multimorbidity patients care because there is a large number of health professionals in charge of patient care, and this requires to obtain clinical consensus in their decisions. Our objective is to develop a tool for collaborative work among health professionals for multimorbidity patient care. We describe the architecture to incorporate decision support functionalities in a social network tool to enable the adoption of shared decisions among health professionals from different care levels. As part of the first stage of the project, this paper describes the results obtained in a pilot study about acceptance and use of the social network component in our healthcare setting. METHODS At Virgen del Rocío University Hospital we have designed and developed the Shared Care Platform (SCP) to provide support in the continuity of care for multimorbidity patients. The SCP has two consecutively developed components: social network component, called Clinical Wall, and Clinical Decision Support (CDS) system. The Clinical Wall contains a record where health professionals are able to debate and define shared decisions. We conducted a pilot study to assess the use and acceptance of the SCP by healthcare professionals through questionnaire based on the theory of the Technology Acceptance Model. RESULTS In March 2012 we released and deployed the SCP, but only with the social network component. The pilot project lasted 6 months in the hospital and 2 primary care centers. From March to September 2012 we created 16 records in the Clinical Wall, all with a high priority. A total of 10 professionals took part in the exchange of messages: 3 internists and 7 general practitioners generated 33 messages. 12 of the 16 record (75%) were answered by the destination health professionals. The professionals valued positively all the items in the questionnaire. As part of the SCP, opensource tools for CDS will be incorporated to provide recommendations for medication and problem interactions, as well as to calculate indexes or scales from validated questionnaires. They will receive the patient summary information provided by the regional Electronic Health Record system through a web service with the information defined according to the virtual Medical Record specification. CONCLUSIONS Clinical Wall has been developed to allow communication and coordination between the healthcare professionals involved in multimorbidity patient care. Agreed decisions were about coordination for appointment changing, patient conditions, diagnosis tests, and prescription changes and renewal. The application of interoperability standards and open source software can bridge the gap between knowledge and clinical practice, while enabling interoperability and scalability. Open source with the social network encourages adoption and facilitates collaboration. Although the results obtained for use indicators are still not as high as it was expected, based on the promising results obtained in the acceptance questionnaire of SMP, we expect that the new CDS tools will increase the use by the health professionals.

VirSSPA- A virtual reality tool for surgical planning workflow

ObjectiveA virtual reality tool, called VirSSPA, was developed to optimize the planning of surgical processes.MethodsSegmentation algorithms for Computed Tomography (CT) images: a region growing procedure was used for soft tissues and a thresholding algorithm was implemented to segment bones. The algorithms operate semiautomati- cally since they only need seed selection with the mouse on each tissue segmented by the user. The novelty of the paper is the adaptation of an enhancement method based on histogram thresholding applied to CT images for surgical planning, which simplifies subsequent segmentation. A substantial improvement of the virtual reality tool VirSSPA was obtained with these algorithms.ResultsVirSSPA was used to optimize surgical planning, to decrease the time spent on surgical planning and to improve operative results. The success rate increases due to surgeons being able to see the exact extent of the patient’s ailment. This tool can decrease operating room time, thus resulting in reduced costs.ConclusionVirtual simulation was effective for optimizing surgical planning, which could, consequently, result in improved outcomes with reduced costs.

A three-dimensional virtual reality model for limb reconstruction in burned patients.

Electrical burns are a common cause of injuries. Despite many developments in the treatment of high-tension electrical burns, this type of injury still shows high-morbidity rates. Recently, the use of free flaps for reconstruction in burned patients has increased due to advances in the field of microvascular free tissue transplantation [1]. Free flaps have reached a high level of sophistication. For instance, reexpanded flaps, composite tissue flaps, fascial flaps, multiple autologous flap transplantations and combined flaps (‘‘chimeric flaps’’) based on a single vascular pedicle have been performed in patients with severe burns and large defects in extremities [2]. Traditional methods of learning have helped generations of surgeons to familiarize themselves with flaps anatomy. Nevertheless, even texts with the highest level of accuracy and image quality are limited by the two-dimensional nature of printed material, which cannot impart three-dimensional (3D) views. Video material is similarly limited as to deliver a 3D experience. Another restriction of most traditional methods for the study of anatomy relates to the lack of interactivity and feedback. As a supplement to the knowledge gained from books and observation, cadaver dissections can play an

A Knowledge-based Clinical Decision Support System for the diagnosis of Alzheimer Disease

Alzheimer Disease (AD) has become a major issue in developed countries due to medical advances that have extended the population longevity. Recent advances in early detection date the initial stages of AD several years before the first recognizable symptoms appear visible.

Cost-utility analysis of a telehealth programme for patients with severe chronic obstructive pulmonary disease treated with long-term oxygen therapy

We conducted a cost-utility analysis of a telehealth programme for patients with severe chronic obstructive pulmonary disease (COPD) compared with usual care. A randomized controlled trial was carried out over four months with 45 patients treated with long-term oxygen therapy, 24 in the telehealth group (TG) and 21 in the control group (CG). The analysis took into account whether the severity of comorbidity (defined as the presence of additional chronic diseases co-occurring with COPD) was associated with differences in costs and/or quality-adjusted life years (QALYs). Results of cost-utility analysis were expressed in terms of the incremental cost-effectiveness ratio (ICER). The average total cost was €2300 for the TG and €1103 for the CG, and the average QALY gain was 0.0059 for the TG and 0.0006 for the CG (resulting an ICER of 223,726 €/QALY). For patients without comorbidity, the average total cost was €855 for the TG and €1354 for the CG, and the average QALY gain was 0.0288 for the TG and 0.0082 for the CG (resulting in the telehealth programme being the dominant strategy). For patients with comorbidity, the average total cost was €2782 for the TG and €949 for the CG, and the average QALY gain was −0.0017 for the TG and −0.0041 for the CG (resulting an ICER of 754,592 €/QALY). The telehealth programme may not have been cost-effective compared to usual care, although it could be considered cost-effective for patients without comorbidity.

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke.

Background Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. Objective Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. Methods The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals’ acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. Results A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean “onset-to-hospital” time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean “door-to-needle” time was 82 minutes, and the mean “onset-to-needle” time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. Conclusions The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals.

An architecture for the semantic enhancement of clinical decision support systems

Clinical Decision Support Systems (CDSS) are useful tools that aid physicians during different tasks such as diagnosis, treatment and patient monitoring. Multidisciplinary, heterogeneous and disperse clinical information and decision criteria have to be handled by CDSSs. For such tasks, Knowledge Engineering (KE) techniques and semantic technologies are very suitable, as they support (i) the integration of heterogeneous knowledge, (ii) the expression of rich and well-defined models for knowledge aggregation, and (iii) the application of logic reasoning for the generation of new knowledge. In this paper we propose a generic architecture of a CDSS based on semantic technologies, which also considers the reutilization and enhancement of former CDSS in an organization. Particularly, an implementation of the proposed architecture is also presented, aiming to support the early diagnosis of AD.