M.S. Rebelo

Mobile health in emerging countries: A survey of research initiatives in Brazil

OBJECTIVE To conduct a comprehensive survey of mobile health (mHealth) research initiatives in Brazil, discussing current challenges, gaps, opportunities and tendencies. METHODS Systematic review of publicly available electronic documents related to mHealth, including scientific publications, technical reports and descriptions of commercial products. Specifically, 42 projects are analyzed and classified according to their goals. This analysis considers aspects such as security features provided (if any), the health condition that are focus of attention, the main providers involved in the projects development and deployment, types of devices used, target users, where the projects are tested and/or deployed, among others. RESULTS The study shows a large number (86%) of mHealth solutions focused on the following categories: health surveys, surveillance, patient records and monitoring. Meanwhile, treatment compliance, awareness raising and decision support systems are less explored. The main providers of solutions are the universities (56%) and health units (32%), with considerable cooperation between such entities. Most applications have physicians (55%) and Community Health Agents (CHAs) (33%) as targeted users, the latter being important elements in nation-wide governmental health programs. Projects focused on health managers, however, are a minority (5%). The majority of projects do not focus on specific diseases but rather general health (57%), although solutions for hearth conditions are reasonably numerous (21%). Finally, the lack of security mechanisms in the majority of the surveyed solutions (52%) may hinder their deployment in the field due to the lack of compliance with general regulations for medical data handling. CONCLUSION There are currently many mHealth initiatives in Brazil, but some areas have not been much explored, such as solutions for treatment compliance and awareness raising, as well as decision support systems. Another research trend worth exploring refers to creating interoperable security mechanisms, especially for widely explored mHealth categories such as health surveys, patient records and monitoring. Challenges for the expansion of mHealth solutions, both in number and coverage, include the further involvement of health managers in the deployment of such solutions and in coordinating efforts among health and research institutions interested in the mHealth trend, possibly exploring the widespread presence of CHAs around the country as users of such technology.

Managing Medical Images and Clinical Information: InCor's Experience

Patients usually get medical assistance in several clinics and hospitals during their lifetime, archiving vital information in a dispersed way. Clearly, a proper patient care should take into account that information in order to check for incompatibilities, avoid unnecessary exams, and get relevant clinical history. The Heart Institute (InCor) of Satildeo Paulo, Brazil, has been committed to the goal of integrating all exams and clinical information within the institution and other hospitals. Since InCor is one of the six institutes of the University of Satildeo Paulo Medical School and each institute has its own information system, exchanging information among the institutes is also a very important aspect that has been considered. In the last few years, a system for transmission, archiving, retrieval, processing, and visualization of medical images integrated with a hospital information system has been successfully created and constitutes the InCors electronic patient record (EPR). This work describes the experience in the effort to develop a functional and comprehensive EPR, which includes laboratory exams, images (static, dynamic, and three dimensional), clinical reports, documents, and even real-time vital signals. A security policy based on a contextual role-based access control model was implemented to regulate users access to EPR. Currently, more than 10 TB of digital imaging and communications in medicine (DICOM) images have been stored using the proposed architecture and the EPR stores daily more than 11 GB of integrated data. The proposed storage subsystem allows 6 months of visibility for rapid retrieval and more than two years for automatic retrieval using a jukebox. This paper addresses also a prototype for the integration of distributed and heterogeneous EPR

Automatic quantification of three-dimensional kinetic energy in gated myocardial perfusion single-photon-emission computerized tomography improved by a multiresolution technique

The visualization of the left ventricle (LV) motion in gated single-photon-emission computerized tomography (SPECT) studies is complicated by the fact that 3-D density images cannot be directly presented using common display devices. A number of techniques, most of them concerned with visualization, have been developed to aid in the classification of the images. However, it has been shown that interpretation of LV images by strictly visual techniques is sub- ject to errors and inconsistencies. For this reason, assistance in diagnosis can be improved only through the development of auto- matic or semiautomatic methods to analyze and to quantify LV pa- rameters. We propose an automatic method to estimate the myocar- dial kinetic energy directly from gated SPECT sequences based on the optical flow method refined with a multiresolution technique. Specifically, the method quantifies the LV motion by a series of 3-D velocity vector fields computed for each voxel on the sequence of images. The 3-D velocity vector field obtained is used to estimate the kinetic energy, which may be an indication of the cardiac condi- tion. The proposed procedure was applied to a group of volunteers and the cardiac condition of each subject studied by taking the re- lation between the maximum and minimum values of kinetic energy observed during the cardiac cycle.

Integrating Medical Images and Clinical Information

The Heart Institute (InCor) of Sao Paulo has been committed to the goal of integrating all clinical information within the institution. In the last few years, InCor has successfully created a system for transmission, archiving, retrieval, processing and visualization of Medical Images and also a Hospital Information System that stores the administrative and clinical information. These integrated subsystems form InCors Electronic Patient Record (EPR). This work describes the experience in the effort to develop a functional and comprehensive EPR, which includes access control, lab exams, images (static, dynamic and 3D), clinical reports, documents and even real-time vital signals. Currently, more than 13TB of DICOM images have been stored using the proposed architecture. The EPR stores more than 5 GB/day of integrated data and presents more than 1400 hits per day. The proposed storage subsystem allows six months of visibility for rapid retrieval and more than two years for automatic retrieval using a jukebox.

Georeferenced and secure mobile health system for large scale data collection in primary care

INTRODUCTION Mobile health consists in applying mobile devices and communication capabilities for expanding the coverage and improving the effectiveness of health care programs. The technology is particularly promising for developing countries, in which health authorities can take advantage of the flourishing mobile market to provide adequate health care to underprivileged communities, especially primary care. In Brazil, the Primary Care Information System (SIAB) receives primary health care data from all regions of the country, creating a rich database for health-related action planning. Family Health Teams (FHTs) collect this data in periodic visits to families enrolled in governmental programs, following an acquisition procedure that involves filling in paper forms. This procedure compromises the quality of the data provided to health care authorities and slows down the decision-making process. OBJECTIVES To develop a mobile system (GeoHealth) that should address and overcome the aforementioned problems and deploy the proposed solution in a wide underprivileged metropolitan area of a major city in Brazil. METHODS The proposed solution comprises three main components: (a) an Application Server, with a database containing family health conditions; and two clients, (b) a Web Browser running visualization tools for management tasks, and (c) a data-gathering device (smartphone) to register and to georeference the family health data. A data security framework was designed to ensure the security of data, which was stored locally and transmitted over public networks. RESULTS The system was successfully deployed at six primary care units in the city of Sao Paulo, where a total of 28,324 families/96,061 inhabitants are regularly followed up by government health policies. The health conditions observed from the population covered were: diabetes in 3.40%, hypertension (age >40) in 23.87% and tuberculosis in 0.06%. This estimated prevalence has enabled FHTs to set clinical appointments proactively, with the aim of confirming or detecting cases of non-communicable diseases more efficiently, based on real-time information. CONCLUSION The proposed system has the potential to improve the efficiency of primary care data collection and analysis. In terms of direct costs, it can be considered a low-cost solution, with an estimated additional monthly cost of U

Wigner-Ville distribution applied to cardiac motion estimation

0.040 per inhabitant of the region covered, or approximately U

Functional bull's eye based on three dimensional velocity information to quantify left ventricle motion in gated-SPECT

0.106 per person, considering only those currently enrolled in the system.

Implementation of an integrated hospital information system using an open-source three-tier architecture

Some heart abnormalities like ischemia and infarction of myocardium can produce significant changes in cardiac wall motion and decrease severely the cardiac function. For this reason the cardiac motion estimation and quantification have been the focus of many investigations. The aim of this work is to study cardiac motion by means a dense velocity vector field based on the computation of the Wigner-Ville distribution, a common transformation used in the spatiotemporal-frequency (STF) analysis. The major motivation for considering the use of STF comes from observations in mammalian vision. This paper describes a method to obtain a 3D-frequency spectrum, based on the computation of the Wigner-Ville distribution, and a procedure to determine, automatically, the velocity of pixels in a temporal series of images. The method is also applied to synthetic images and real images obtained from gated-SPECT.

Development of a mobile HIS/PACS workstation to assist critical cardiac patients in an intensive care unit

The description and quantification of the regional function of the cardiac left ventricle (LV) involve making quantitative measurements of the heart movement. In this work we present a functional bulls eye or polar map that depicts three dimensional coded velocity information from gated-SPECT images. The polar map is built based on the standards defined by the AHA and comprises 17 segments. The use of the proposed map was tested in images from 5 normal subjects and 4 patients with intraventricular dyssynchrony submitted to cardiac resynchronization therapy. Preliminary results have shown good indications of potential application of the technique to the diagnosis and the follow up of such patients. The functional polar map is independent of the heart size, so it makes possible the creation of normal pattern standards. Such standards would allow the application of the method in a broad range of applications involving the analysis of the heart movement.

Segmentation of left ventricle myocardium in MRI using endocardium layer expansion model

The goal of the current study is to describe the experience of the Heart Institute (InCor) in the implementation of a patient-oriented Hospital Information System (HIS) integrated with the Radiology Information System (RIS) and the Picture Archiving and Communication System (PACS) in an open-source three-tier architecture. The system was designed in modules that permits patient admission, discharge and transfer (ADT), registration of medical activities, registration of diagnoses and therapy, order entry and access of all patient data, including vital signals, images and lab tests. The modules are integrated in a single Web-based application allowing easy and fast navigation through the application. In order to provide high quality of patient care in an efficient and cost-effective manner, thin clients workstations in a Linux environment were used. To access the patient information users have to perform an authentication procedure that uses LDAP protocol, which also defines a profile to the users. The system is fully integrated to the InCors PACS, allowing instant access to the image database from applications that requires this information, such as diagnostic reports. For displaying the images a Java DICOM viewer was implemented. On the server side, a Java DICOM server was designed to allow communication with all DICOM modalities.