A paradigm shift in diagnosis and in e-health systems – A possible CHIRON scenario

In CHIRON detection and diagnosis are based on the analysis of heterogeneous medical data originating from historic data, medical knowledge sources, imaging systems, collection of vital sign data by sensors and handheld devices that are performed anytime and anywhere. Medical doctors will have remote access to the person’s health file (the Virtual Patient Repository) and will be able to take a more proactive role in prevention of diseases, guided by alerts and data coming from sensory networks and high quality medical images.

This is a significant innovation compared to the currently used approaches that are based on values of health-related parameters only, often monitored instantaneously and episodically (during clinical center visits). In addition, the correlation across physiological, psycho-emotional, environmental parameters, as well as the use of relevant data derived from non-medical applications (such as a patient’s physical activities or stress levels), contributes to innovations in the development and use of e-health systems.
Please note that such a correlation model does not exist in practice. Presently, diagnosis of a disease depends largely on the experience of the individual doctors. The typical models for diseases only predict mortality or morbidity in long term but never identify “when actually” the person is at risk.

A possible CHIRON scenario

Peter is 65 years old and he lives with his wife in a small village close to Wien.

Since 12 years he is suffering from Congestive Heart Failure (CHF); his doctor explained him that his heart is unable to pump enough blood to meet the needs of the tissues of his body. For Peter the most common signs of the disease are swollen legs and ankles and sometime difficulty of breathing.

Periodically he is subject to degenerative episodes often combined and preannounced by retention of fluids and weight gain.

It is not easy for the doctor to prevent these situations; he visits Peter every two weeks and usually he ask him how he felt since last visit, but often the answer are vague and declared changes in the general health status are not contextualized and linked to specific events / situations.

The therapeutic program of Peter is based on drugs such as ACE (angiotensin-converting enzyme) inhibitors, diuretics and vasodilators and also on the adherence to healthier lifestyle (proper diet, rest and a regular – even if limited – physical activity).

The health status of Peter became worst in the last 18 months; his CHF was classified by the doctors as class III according to the New York Heart Association (NYHA) classification method; in fact Peter has marked limitation of any activity and he feels comfortable only at rest.

During the last year he was obliged to regular visits and examinations at the hospital (in total 12) and he was forced to be hospitalized for ten days.

Since six months Peter is participating on a voluntary basis to an experimental program suggested by his doctor and based on the use of ICT technology as support to patients with chronic diseases and specifically with diagnosed CHF.

The solution includes the monitoring through sensors and the measurement of some parameters such as heart rate, blood pressure, change in the potassium level, liquid retention and body weight. Additionally of Peter’s overall functional health status is assessed on the base of monitoring activities of daily living with ambient and unobtrusive sensors in his home environment.

Environmental parameters such as ambient temperature and humidity are monitored too with the intent of exploring possible links between environment and CHF. Moreover data on air pollution of the area where Peter lives are collected by accessing a specialized web site.

The measurement methods are not invasive and novel techniques are employed to combine unobtrusiveness with enough accuracy in the measurements. As an example, intelligent algorithms are deriving the blood pressure, the level of liquid retention and the level of blood serum potassium from the electrocardiogram.

All the data are transmitted wirelessly to a mobile device that makes a first elaboration and then sends the data to a remote medical center.

Peter’s doctor was authorized by Peter to access these data via Internet; in such way he can have an exhaustive and up-to-date picture of the Peter’s health status and he is able to detect on time critical trends of the mostly relevant parameters. The intelligent system elaborates and keeps up-to-date the personalized risk profile of Peter. The doctor is able to change the therapeutic program accordingly and – if necessary – to pay an earlier visit to Peter or to prescribe him some new laboratory analyses.

In case of sudden occurrence of a critical, degenerative episode, the system automatically activates alarm mechanisms addressed to the doctor and/or to the emergency health service depending on the seriousness of the situation.

It happened six months ago that Peter was seized by a sudden illness while he was driving his car; fortunately he was able to stop and automatically an emergency call was sent together with the localization of the patient, made possible through a GPS-based solution integrated into the Peter’s mobile phone.

During the day Peter is supported and motivated by his mobile device to comply with the therapeutic plan prescribed by the doctor. A personalized application reminders him to take the medicines and coaches him towards healthier habits in terms of dietary, resting and physical activity.

The psychological profile built into the system and kept up-to-date through periodic questionnaires allows adopting the most suitable motivational model.
It is out of discussion that a key role is that of Mary, the Peter’s wife. Continuously she is watching at the husband health status and she is supported by the mobile device in performing her role of informal caregiver. Before the starting of this experimental program she had a short training together with Peter.

Two months ago Peter was hospitalized while visiting his daughter living in another town. Worsening symptoms were detected by the remote monitoring system and a message was automatically sent to the hospital to prepare the doctors to perform examinations through imaging techniques quite soon at the arrival of the patient.

Although the doctors were able to access the Health Profile of Peter and to get information on his clinical history, on the trends – during the last period – of the relevant physiological parameters, on the prescribed therapy and on other elements important to shape an exhaustive picture of the situation, it was difficult for them to take a firm decision on the cause of the current CHF crisis and hence on the right treatment strategy.
In these cases medical imaging plays an essential role by definitively determining the actual cause (e. g. presence of possible ischemia) through anatomical images of heart tissues and blood vessels and thereby dictating the necessary intervention procedure.
If the CHF is due to coronary artery disease, previous myocardial infarction or remodelling of the left ventricle then there is a high risk of ischemia.

Peter was subject to Cardiovascular Magnetic resonance (CMR) examination and the images of cardiac and major vessel anatomy were analysed by using novel and powerful algorithms for feature extraction; the images were visualized by using an advanced high resolution and high dynamic range display developed in the CHIRON project and supporting the radiologist in detecting even very fine details.
The needed set of equipment was localized within the hospital and collected to be ready for the examination and the following interpretation of the outcomes.
The new display helps the doctor in a fast and accurate diagnosis; it is used in critical tasks when the image interpretation is not so easy. When the display was brought to the Cardiovascular Department, its position was automatically tracked and it was automatically set for the optimization of cardiac images.

The advancements in computer science, image processing and display technology now permit previously unattainable rapid, robust assessment of a diverse spectrum of functional and physiological parameters from the medical images.

In the case of Peter, they indicated that he had an ischemia and the extension of the damage in the myocardial tissue was detected more precisely.

To have a further confirmation of the existence of transient regional myocardial ischemia the doctors subjected Peter to an examination using a novel imaging method termed as “PRIME Delta Map” where displaying ischemia involves taking the ST-segment input of ECG and displaying only ST change in pain and out of pain as colour on a torso. The method was enhanced through an improved automated software analysis tool.

All the new data collected at the hospital were uploaded in the Peter’s Health Profile and the Peter’s doctor was able to stay informed on the evolution of the situation and to interact with the colleagues of the hospital to agree with them the treatment plan.
After seven days of hospitalization Peter was in the condition of being discharged and to continue the rehabilitation at home.