Proposals for a Strategic Partnership
Technology Bringing Change to Healthcare
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Table of Contents Message from Acting Director Paul Wright
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Medical Devices on Networked Systems
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Wireless Handheld Medical Devices
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Wireless Inertial Measuring System for Quantitative Diagnosis of Neurological Disease
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Primary Glaucoma and Diabetic Retinopathy Screening for Underserved Populations
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Energy Harvesting for Biomedical Devices and Health Care Intelligent Infrastructure
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Replicable IT-based Models for the Creation of Safe, Reliable, and Resilient Care Processes
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Public Health Assisting Smart Technologies
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The Universal Language of Health
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UC Davis Medical School
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Cell phone + Microscope = CellScope
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Virtual Stress Testing
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Affordable MRI Technology
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Message from Acting Director Paul Wright CITRIS: Using Information Technology to Improve Healthcare Greetings from Berkeley, California, headquarters of CITRIS, the Center for Information Technology Research in the Interest of Society. Since its inception, CITRIS has succeeded in channeling innovative research toward societal problems at each of our four University of California campuses (Berkeley, Davis and its Medical Center Campus, Merced, and Santa Cruz). In doing so, it has also served as the focal point of research collaboration between industry, academia and the public, as a conduit for educating a new wave of innovators to enter the workforce, and as a locus of intelligent discourse and innovation. For example, the contributions of CITRIS researchers to wireless sensor network technology have proven instrumental to creating a new industry in radio frequency identification technology (RFID), and we will continue to strive for success as we focus on our six major research initiatives in Energy and the Environment, Intelligent Infrastructures, Arts and Humanities, Healthcare, Services, and Technology for Emerging Economies. There is no doubt that healthcare is a societal-scale problem, and the CITRIS Healthcare thrust is an essential component of our mission. The capacities of healthcare systems nearly everywhere are strained due to demographic shifts, consumer trends, demand, labor force productivity, increasing costs, and societal forces, among other factors. Fundamental and applied research in science and engineering can greatly contribute to improving clinical care, care delivery, and quality of life for many affected individuals. Research in this fertile area brings together scientists, engineers and clinicians in the multidisciplinary spirit of CITRIS in such projects as • Information environments to improve the safety, quality and delivery of care; • Extending the reach of care through next-generation telemedicine technology and services; •Helping the elderly age in place through a variety of technologies and approaches including falls detection, sensor networks, and handheld devices; •Creating novel medical devices and tools to improve the costs, quality, safety and access to care. We have assembled this brochure, which highlights just a few of the healthcarerelated projects that we are working on, and hope that it can serve as a basis of discussion for finding mutual research interests that we can pursue together. I would also like to extend an invitation to you to visit (mostly) sunny California and visit us at CITRIS so that we can discuss these topics in person. Our mission is to engage in fundamental and applied research that will increase the capacity and lower the cost of the healthcare system not only in California, but throughout the world. We look forward to working with you to achieve this ambitious goal
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Medical Devices on Networked Systems To improve people’s long-term health, physicians would like to monitor and measure for the symptoms of serious medical conditions on a daily basis. CITRIS research on remote care addresses the needs of this field, and researchers, including John Canny at UC Berkeley, are working on diagnostic medical devices and their integration with network technologies. A device developed in the current research program monitors such important health markers as EKG, EMG (back muscle activation), GSR (Galvanic skin response, a stress marker), chest sound, temperature, and movement. The goal of this all-in-one device is specifically to provide longitudinal monitoring for the early warning of more serious conditions and, more generally, to discover the relationships between longterm wellness and health problems. As a Bluetooth device, it is designed to gather data without network connectivity for daily upload to another Bluetooth device. But it can also communicate with specific cell phones from BT for real-time monitoring. This device is quite useful in its current state, and can also be customized to other needs. The BID Lab has complete BT development capabilities (protocol and profile customization). Next Steps: The lab is actively seeking partners to explore home and clinical applications of the device. They plan to develop data analysis and visualization tools for these applications. Target users include both health providers and patients themselves (feedback for wellness improvement). We are specifically interested in: 1. Home wellness monitoring 2. Telemedicine in developing regions 3. Crisis reporting and analysis
Figure 1. Live output of the health sensor, recorded on a PC via the sensor’s Bluetooth radio.
Figure 2. Health sensor board top and bottom view. Size is 1.8x1.4 inches. The micro-SD data card is shown partially removed in the right image. 22| |Center Centerfor forInformation InformationTechnology TechnologyResearch Researchininthe theInterest InterestofofSociety Society
Wireless Handheld Medical Devices The Berkeley Institute of Design (BID) develops a wide variety of innovative healthcare-related technologies that can further the CITRIS mission of using information technology to benefit both physicians and patients. Current projects include point of care hand-held devices in which patient data can be quickly accessed, and diagnostic medical devices that are integrated into a network system. Physicians employ a wide variety of wireless handheld devices to improve the efficiency of their care delivery, including standard phones, smart-phones, and personal digital assistants. The BID Lab is creating related software applications on Adobe software’s Flash Lite, which is supported on a wide range of devices. The backend would respond to XML post queries. Currently, this project is being pursued though studies on both handheld devices and software for semi-skilled health workers in rural areas and also on phone-based exercise tools. Next Steps: CITRIS researchers are working to better understand the form and scope of the data sources to be accessed and how much work is involved in uniting them. Therefore, they are interviewing clinicians and other users about their needs, and will follow up with field tests with the prototype on several hardware platforms to elicit useful user feedback.
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Wireless Inertial Measuring System for Quantitative Diagnosis of Neurological Disease Simpler, cheaper analysis Doctors currently diagnose many neurological diseases by observing the gait of a patient; however, many patients feel uncomfortable in the medical surroundings and do not behave naturally. To remove this obstacle to diagnose, CITRIS researchers are developing an automated diagnostic system that will enable various gait and movement disorders to be quantitatively characterized. This system, which measures inertia, will allow patients to collect information at their home and at other locations that reflect their daily routine. The inertia measuring device works by detecting sudden movements of the upper body when it is out of phase with lower extremity movements. Arm measurements can be taken of patients with Parkinsonian syndromes and may help to reveal the unilateral predominance of any deficit. In patients who have suffered from a stroke, asymmetry of arm-swing may be characteristic, whereas in those with cerebellar disturbances or other non-Parkinsonian movement disorders, the arm movements may be chaotic and disorganized. The findings will thus help to identify the nature of the underlying problem. In addition, this simple and inexpensive device can be used by clinicians in remote areas without experienced experts available to provide diagnostic or prognostic assistance. The data can also be transmitted instantaneously over the Web to such an expert. The sternum sensor also allows the detection of actual falls of the user in “real time” in the home setting, and thus allow for dispatch of emergency medical services to the home when a patient may not be able to call for them by phone or even by a “lifeline” service.
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Primary Glaucoma and Diabetic Retinopathy Screening for Underserved Populations Telemedicine can have a significant impact on the health of underserved people, including improved eye care of California residents. Glaucoma and diabetic retinopathy cause most of the preventable blindness in the United States, and early detection and treatment can prevent blindness in up to 90 percent of patients. While many academic and service organizations have undertaken diabetic retinopathy screening using telemedicine, the cost of specialized digital retinal cameras, software, and personnel for performing retinal exams has kept retinopathy detection out of reach for many community clinics. UC Berkeley optometry professor Jorge Cuadros has delivered primary retinopathy for over ten years and has developed EyePACS , an open access system for clinical communication in eye care that has been used for teleconsultations, retinopathy screening, home care, education, digital grand rounds, and research with over 14,000 patients. While EyePACS has made significant cost gains, overall costs must decrease to make current screening models affordable to the large number of smaller clinics. As part of the CITRIS’s healthcare initiative, Cuadros proposes to validate new, inexpensive retinal imaging devices and computer applications against current methods to detect sight-threatening diabetic retinopathy and to detect and manage glaucoma in 100,000 patients in 100 community clinics throughout California over the next two years. The proposed work could produce a model for ubiquitous deployment of low cost systems for detection and treatment of sight-threatening conditions in community clinics and other locations. The impact of this work would be significant: it could eliminate up to 90 percent of blindness from diabetes and glaucoma, problems that disproportionately affect underserved, rural, and poor populations.
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Energy Harvesting for Biomedical Devices and Health Care Intelligent Infrastructure Body Powered Batteries An important aspect of the future of intelligent health care delivery lies with the promise of biomedical implants with extended wireless connectivity. These implants will provide therapy through both electrical stimulation and drug delivery and also serve as a gateway to enable personalized medicine. Batteries supply these implants with energy, but batteries are inherently limiting due to a fixed operating lifetime based on their fixed energy density and the strict constraints imposed by implantable devices. Rajeevan Amirtharajah, a professor of electrical and computer engineering at UC Davis, leads a multicampus group developing a miniaturize, rechargeable power supply that harvests energy from the movement and body temperature of the patient, stores the energy in printed batteries and capacitors, and regulates this energy into a stable voltage for running a number of diverse electronic subsystems. This research effort brings together mechanical engineers, electrical engineers, and clinicians to synthesize an integrated, reliable and biocompatible power supply solution that can both extend the lifetime and functionality of current implants and also enable a new generation of biomedical devices. Next steps: Over the next six months, the researchers will evaluate vibration harvesting at the meso and micro scale in relation to the needs of various implantable technologies; analyze circuit power requirements for biomedical applications including signal detection, computation, electrical tissue stimulation, and wireless communication; and create preliminary power supply conditioning circuits that maximize energy transfer efficiency from harvesters to storage and storage to load. Then, they will model, design, and prototype a thermal energy harvester for implantable medical devices.
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Replicable IT-based Models for the Creation of Safe, Reliable, and Resilient Care Processes Organizing the Hospital Information can impact the healthcare environment in many ways. Medical errors can disable and even kill patients. To prevent errors, many healthcare providers currently use or are implementing bar-code point-of-care (BPOC) medication administration systems. However, studies show that clinicians often override valid warnings, become habituated to warnings, and even administer doses that differ from the written order. Evidence also suggests that numerous inappropriate warnings may result in “warning fatigue” and that the large volume of warnings decreases productivity and provides incentives for dangerous workarounds. UC Berkeley IEOR Professors George Shanthikumar and Zuo-Jun Shen have proposed to develop an IT optimization model that will increase efficiency, effectiveness, and incentives of BPOC systems. Their dynamic method matches resources (e.g. nurses, beds, availability of equipment) to demand (patient load). This work aims to use models, populated with local facility data, to help create “clinician friendly” care environments and to engineer safe, resilient processes. Patients will benefit through safer, more effective care, and clinicians and staff will benefit through streamlined, safe and resilient processes. Further, this work will result in minimal disruption of care delivery since the impact of process changes can be studied before implementation. Other benefits include patient throughput increases and overtime reductions, and increasing profitability and capacity of safety-net providers. Next Steps Hospitals are being considered for research partners in this work, and provide real-world facility data from their extensive network of facilities, and provide clinical and operational expertise to inform modeling efforts. Cochran, G.L., et al. 2007. Errors Prevented by and Associated with Bar-Code Medication Administration Systems, The Joint Commission Journal on Quality and Patient Safety, v33:5 pp-293-301 Jones K., et al.: Prevalence of safe medication practices in small rural hospitals. Paper presented at the National Rural Health Association 29th Annual Conference, Kearney, Nebraska, May 18, 2006. http://www. rupri.org/healthpolicy/ (accessed Mar. 6, 2007).
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Public Health Assisting Smart Technologies (PHAST) Affordable MRI technology Public Health Assisting Smart Technologies (PHAST) CITRIS researchers are creating smart devices that promote awareness and understanding of personal activity spaces and how those spaces affect people’s health. The wearable devices will integrate datalogging global positioning system receivers with personal and environmental sensors. The data that these sensors provide can be used to address major public health problems, such as the relationship between physical exercise and obesity, social interaction and the spread of infectious diseases, and assessment of small-scale variations in exposures to airborne pollution. Such information has the potential to improve public health by altering environmental policies, community understanding and perceptions, and individual behaviors. Research on wearable computers has demonstrated the feasibility of designing purpose-built portable devices to collect personal data. For example, one health-related device is a wearable sensor for personal monitoring of vital signs and reporting of this data via wireless communication in case of emergencies. From a participant’s perspective, dosimeters are often acceptable because they are typically small devices that do not interfere with their normal activities. Recent research has explored the context behind exposures, by considering exposures in time and by location, by using the global positioning system (GPS). Such studies include exposures to pesticides, air pollutants, more general exposure, and most recently by our group, to assess activity associated with parasitic disease transmission. Next Steps: PHAST will develop linkages between public health and engineering faculty, students, and industry through the co-development of a core set of geopositioning prototype sensor devices, field testing of these devices, and joint exploration of how these may be applied to major public health problems. 8 | Center for Information Technology Research in the Interest of Society
The Universal Language of Health The health education of non-English speakers is an enormous Californiawide challenge, where roughly 40 percent of all Californians do not speak English at home. To address this opportunity, CITRIS remote-care researchers have developed a project that will use multi-lingual search, speech interfaces, and health dialogs on the Internet. Other projects include the use of cell phones to deliver culturally and linguistically validated health education material, published in collaboration with Hesperian Press. Also, researchers will enable clinicians and health care workers to provide follow-up services to patients through multi-lingual on-line surveys, questionnaires, and time-sensitive updates (outbreaks, warnings). The Web project could easily be incorporated into kiosks in rural and underserved clinics, while cell phones would provide access for difficult-to-reach groups, such as farm workers, offering broad reach and easy replication. By collaborating with the Central Valley Partnership for Citizenship, CITRIS scientists John Canny and Srini Narayan will first target Central Valley Spanish-speakers, including immigrant, high risk, rural poor, and indigent populations. These targeted groups face enormous challenges: 70 percent lack health insurance; 50 percent have multiple health problems; 40 percent have never seen a physician in their lives; and only 15 percent are literate in any language. To prove the extensibility of the work, the researchers will also develop and provide Web services for Mandarin Chinese, in addition to work currently being developed in Tamil. Next Steps: By working with corporate and foundation partners to extend work for Spanish and Mandarin materials, CITRIS researchers will work with programs through the California Telemedicine and E-Health Center (CTEC) as well as disseminating this work through programs such as Telemedicine Learning Centers, networks of rural and underserved programs, and special events.
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UC Davis Medical School The explosion of knowledge and information in the health sciences is ironically creating greater disparities in the quality of healthcare services. The Institute of Medicine 2001 report, “Crossing the Quality Chasm,” stated that “information technology must play a central role in the redesign of the health care system.” With this in mind, CITRIS, through its partners at the University of California, Davis, is developing technological healthcare solutions that have the power to fundamentally change medical education, healthcare delivery and clinical research. Through the current project pipeline, CITRIS aims to address these areas and improve the quality of healthcare throughout society. 1. Innovative Wireless, Wireline, and Optical Networking to Support Very High-Throughput and Mobile Applications: Applications In Patient Transportation 2. Enhanced RFID (Radio Frequency Identification) Technology for Disaster Preparedness and Hospital Surge Capacity The collaborative environment created within CITRIS—combining engineering, computer science and medicine—creates synergy to promote innovations in healthcare delivery. Such innovations will help to transform our current healthcare delivery model, current concepts in medical education, and how society views the intersection of medicine and technology. CITRIS engineers and medical professionals are dedicated to working together to help solve the healthcare issues that impact our society, from both individual and public health perspectives.
Researchers will emphasize the development of mobile ambulance networking nodes that are capable of deploying and configuring a high-performance network at any time. These mobile ambulances can be attached to vehicles or helicopters to allow high-end instrumentations and advanced medical treatments in real-time with gigabit connections to the medical facilities with much higher communications and data processing capabilities than is currently possible.
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Enhanced RFID Technology for Disaster Preparedness and Hospital Surge Capacity Patient tracking has long been a concern of medical community and runs hand in hand with patient data management. Recent experience from Hurricane Katrina and the 2004 Asian Tsunami show that widespread dispersal of patients to multiple sites within a region, sometimes at great distances from their home, lead to limited family assistance in care and delayed discharge. Clearly, this impeded the rapid movement of patients through the healthcare system, particularly those with chronic diseases such as diabetes, hypertension, and heart disease. Providing rapid patient tracking that can be centrally verified and viewed at all response facilities is paramount in a large regional surge response. and also enable a new generation of biomedical devices. Over the next six months, the researchers will evaluate vibration harvesting at the meso and micro scale in relation to the needs of various implantable technologies; analyze circuit power requirements for biomedical applications including signal detection, computation, electrical tissue stimulation, and wireless communication; and create preliminary power supply conditioning circuits that maximize energy transfer efficiency from harvesters to storage and storage to load. Then, they will model, design, and prototype a thermal energy harvester for implantable medical devices.
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Cell phone + Microscope = CellScope While telemedicine research continues to make remarkable strides in increasing access to care for underserved populations, obstacles such as cost, operation, and sustainability significantly limit its adoption and use. To improve the access of telemedicine, UC Berkeley Bioengineering Professor Daniel Fletcher has proposed CellScope, a revolutionary approach that turns a conventional cell phone into a compact, high-resolution, handheld microscope with the capability to capture, organize and transmit images. CellScope’s range of magnification (2x – 50x) makes standard cell phones broadly applicable. Low magnification can be used for imaging the ear canal, mouth, throat,, teeth and nasal cavities, with applications for primary care, teledentistry, and first responders. Medium and high magnification can be used to examine skin (teledermatology, wound care, home care) and even examine cells with appropriate reagents (telehematology, telepathology). Above: various configurations of Telemicroscopes CellScope allows telemedicine services to move with the care provider, enables infiltration of even small and frontier clinics due to its size and affordability, improves access to care by enabling telehealth services from nearly any location in the world, and can be used by a wide variety of providers in diverse sites of care. CellScope also leverages the security and audit trailing infrastructure of cellular service providers Samples of images of Sickle Cell Disease using a stanto provide regulatory compliance. dard microscope at 40X (black and white photo), and a Cell Phone Microscope at 40X (color photo). With Next steps: three million deaths per year (primarily in poor regions With under $75 in parts, Professor Fletcher in Sub-Saharan Africa), Microscopy is cheapest and and colleagues demonstrated the feasibility of most reliable diagnosis method. the first generation CellScope. Next, they will develop, test, and deploy a second-generation CellScope with an even greater magnification and with both transmitted and reflected light illumination that has the potential to enhance access to specialty health services.
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Virtual Stress Testing Putting Virtual Skeletons under Pressure One in three women will be affected by osteoporosis in their lifetimes, and detecting who is most at risk is part of UC Berkeley Mechanical Engineering Professor Tony Keaveny’s research. Keaveny and other CITRIS colleagues combine biomechanics with medical imaging to provide better diagnosis of osteoporosis risk of fracture. They are working in a new paradigm in healthcare—the seamless use of advanced physiological modeling of 3D medical images, or “virtual stress testing.” The new application will inform about a patient’s condition in a way that is scientifically accurate, intuitive, and compelling. The application for fracture risk assessment in osteoporosis is based on the basic biomechanical characteristics of bone at multiple physical scales. Patient-specific structural models are created for a bone using clinical CT scans to calculate the bone strength in a highly automated process. Studies have shown that these estimates of strength are superior to what can be provided with the current clinical standard, a DXA (dual energy X-ray absorptiometry) bone scan. With the addition of estimates of the in vivo forces that occur during strenuous activity, researchers can better estimate a biomechanical risk of fracture. Next Steps: Through collaboration with the UC Berkeley Parallel Computing Lab (Parlab), Professor Keaveny now plans to extend this technology to address coronary heart disease (CHD), which affects 16 million Americans annually and is associated with over 400,000 deaths per year. Their vision is that future radiological diagnostic procedures will be interpreted using such quantitative physiological patient-specific models, thus transforming The field of radiology and improving healthcare by better identifying those at high risk for various diseases.
Patient-specific finite element model using a clinical CT scan (from Keaveny lab’s work featured in the journal Bone, October 2003).
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Affordable MRI Technology Of the 1.6 million Californians with diabetes, fully half are low-income individuals and one third are elderly. Currently, using magnetic resonance imaging (MRI) is the preferred imaging way to diagnose infections of the diabetic foot, a common complication and major contributor to amputation, morbidity, and disability. However, the cost and availability of MRI for rural and underserved patients have limited its use in the treatment of diabetics, even though the practice of teleradiology has increased access to radiologists in most parts of the state. UC Berkeley Bioengineering Professor Steve Conolly has developed a novel method of MRI known as prepolarized MRI (PMRI) that offers high quality imaging at only one-tenth the cost of conventional MRI. PMRI uses two inexpensive electromagnets to create an MRI scan of the human body and brings the total scanner hardware cost to about $50,000, including materials, labor and manufacturer’s profit. When compared to $1.5M for conventional MRI, PMRI is much more affordable for rural and underserved clinics and safety net hospitals. Image quality obtained through PMRI now equals a 0.5T conventional MRI scanner and offers imaging near metallic implants that is superior to conventional MRI or CT.
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“The physical health of a country’s citizens is vital for the political and economic stability of the country. Unfortunately, healthcare is on a collision course with economic reality.” - Dave Gershon, MD, JD, The National Institute for Pharmaco-Economics & Healthcare 16 | Center for Information Technology Research in the Interest of Society