The 5th IEEE International Conference on E-Health and Bioengineering - EHB 2015 Grigore T. Popa University of Medicine and Pharmacy, Iaşi, Romania, November 19-21, 2015
Bluetooth devices for the optimization of patients’ workflow in a radiation oncology department Mario Magliulo1, Laura Cella1 and Roberto Pacelli2
1: Italian National Research Council - Institute of Biostructures and Bioimaging Naples, Italy,
[email protected],
[email protected] 2: Dept. OfAdvancedBiomedicalSciences,UniversityofNaples“Federico II”, Naples,Italy,
[email protected]
Abstract—The costs of healthcare administrations are continuously increasing and techniques able of reducing costs and optimizing systems are necessary. The use of information and communications technology (ICT), such as Bluetooth (BT) Activity Tracker (ACT) devices, can expand and improve the capabilities of the management structures. We propose to extend the application of this widespread technology even in the medical environment. The aim of our work is to apply BT-ACTs for workflow management and patients’ performance monitoring in a Radiation Oncology Department. Indeed, in such medical department working on outpatients based regimen, workflow and clinical control may be complex. Our preliminary experience in using ACT in a Radiation Oncology Department of an Academic Institution is described. The integration of ACT with a novel electronic medical record archiving and retrieving system is implemented. We show that using BT-ACT is possible to successfully monitor patient workflow and biometric data during radiation treatment. Keywords: e-health, wearable sensors, heath record, presence detection systems.
I.
INTRODUCTION
Information and communication technology (ICT) is widely proposed in health care facilities in order to reduce operating costs and to improve patient safety and medical services[1-3]. In Diagnostic Imaging and Radiation Oncology Departments the patients flow is often composed by a mix of emergency and ambulatory patients and the application of integrated management is expected to improve health care organizations and overall the sector efficiency. The public health sector is subject to budget constraints, requiring innovative solutions aimed to increase the efficiency of the caring system. Information about patients’ behavior inside the hospital, for example, may help to better point out the critical problems of the workflow management and improve the hospital services. Furthermore, for research activity in academic and scientific institution, the simplification of data management is even more strongly advocated. In the care process of patients undergoing radiation therapy, information about the health of patients, not only when they are under treatment, but also when they spend their
normal life at home, may contribute to more appropriate and timely interventions in the case of health problem occurrence. Patients’ status outside the hospital, reported by the patients themselves or by a caregiver, may offer an approximate and deficient information with the loss of topic statistics relevant to the clinical evaluation of patients status. In this context, the use of ICT, such as Activity Tracker (ACT) and Bluetooth (BT) technology can help to retrieve clinical information useful for practical optimization of patients’ management and for scientific purpose. By ACT, known also as Fitness Trackers, it is possible to monitor the exercises capacity or the calories burned through the motion/exercise. However, these wearable calculators could be suitable for biometric monitoring in environments other than fitness such as the medical one. An ACT is a processing device wearable, typically as a stripe with biometrical and/or motion sensors. Modern devices have generally biometrical sensors able to monitor and record the heart rate, the galvanic skin response, the skin temperature, the warm flow, the sleep cycle, and the motion, using a high precision 3-axis accelerometer. Some trackers have a built-in altimeter or other sensors on the shoes, which give a more accurate information about the activity you are doing. Usually the ACT has 2-4 sensors for direct measurements, while supplementary information are obtained from those measurements using processing algorithms. A smartphone or a computer application synchronizes all these data to analyze the personal habits, in order to know the health and the wellness of the monitored person. Bluetooth is a telecommunications industry specification that describes how mobile phones, computers and other electronic devices, can be easily interconnected using a shortrange wireless connection. One of the last version of this standard, named BT 4.0 is compliant with BLE (Bluetooth Low Emission) and allows some special features that can be used for presence detection [4, 5]. One of the main features is the very low power consumption that makes possible to realize small devices that can work few (2-4) days without battery charging. The aim of our work is to realize a management system dedicated to clinical research structures. We show how BLE
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and ACT technologies are able to manage patient workflow and monitor biometric parameters of patients during their life outside hospital [2]. We also show how their use may optimize the handling of the daily clinical workload of a Radiation Oncology Department of an academic institution [6]. II. MATERIALS AND METHODS A. Environment description The medical environment is a complex one because the main user is a patient. The typical patient of a Radiation Oncology Department is subjected to treatments that imply the coming daily in the department for a given period. We select as medical testing environment the Diagnostic Imaging and Radiation Oncology Department of “University Federico II” of Naples. In this Department, the Radiation Oncology section provides complete treatments for cancer affected patients. A hospital information system (HIS) is used to store patients’ personal information. A picture archiving and communication system (PACS), DICOM compliant, manages the entire imaging database. This system manages the imaging studies of the whole hospital (more than 120.000 studies each year) and connects together more than 50 modalities and reporting workstations. The Radiation Oncology section workflow is a standard radiation therapy workflow of which we analyze two specific sub-phases that are: 1. 2.
treatment plan definition patient treatment.
In the Radiation Oncology section, more than 500 patients per year are treated. The treatment can last on average 20 days and a queue management is required to increase efficiency and reduce human errors. Furthermore, the addition of objective biometric data continuously collected during the treatment period is of great utility for the clinical performance and outpatients quality of life monitoring [7]. B. Platform Description In our application, we focused on an ACT able to measure SpO2, acceleration and temperature. We selected a particular type of ACT produced by Amiigo Inc. (California, USA) that provides a set of APIs for direct readout of sensor data, making the raw data available. This is a comfortable non-invasive bracelet with total absence of vibrations or display. In addition, due to the special waterproof design, the patient can perform all usual activities, such as shower, without having to remove it from the wrist. These features allow the objective monitoring of clinical parameters without distracting the patients or changing their lifestyle. Amiigo ACT has sensors for SpO2, temperature and has an accelerometer able to record the patient movements highlighting any alarm situations such as spills or acceleration of movement due to sleep disturbances. The heart rate is calculated from the SpO2 measurements. The SpO2 sensor is
constituted by a dual wavelength pulse oximeter, able to detect the oxygen saturation on the wrist and not on the index finger, as in standard medical pulse oximeters. The sensor, embedded in the bracelet, is easily wearable and has a very low invasiveness allowing the application even on patients who may be psychologically stressed. Although the performed measurement is less accurate compared with the one that can be obtained from finger type oximeter, the handling is easier and the efficiency of data collection, with more than 50% of valid measurement, is sufficient to obtain information about the trend of the SpO2 in a period of 24-48 hours. A software named HealthSystem on purpose designed and commissioned to a software house (Dotit, Italy) manages all the collected ACT data. Interestingly, the software can directly query the ACT raw data making them available for subsequent analysis. Furthermore, the above software coupled with ACT BLE device, can detect the presence of the holder (i.e. the patient) in the waiting room. In this way, a queue management system monitoring the patient flow can be implemented. The ACT can be configured in stand-alone mode, so that SpO2, heart rate and temperature are monitored at variable intervals from 50 minutes to 2 hours during the day, while the accelerations are continually recorded at intervals of 10 ms. The overall result of the monitoring process is a log file in which all the motion and biometric parameters are stored in an internal memory. C. Patient Flow and Biometrical Data The HealthSystem software can manage, patients medical information during their stay in the hospital and their vital parameters during the treatment (1 to 7 weeks) generating a complete data warehouse. In this management system, we store all the collected data. Thanks to the software architecture, many dedicated queries can be executed. The process starts when the patient arrives at the Radiation Oncology ambulatory, a specialist fill in some anamnestic data and decides the type of treatment. The physician request a Computed Tomography (CT) exam that permits the treatment plan definition. At the end, the HIS generates a booking request and give an appointment to the patient. Some days later (1-5 days), the patient comes at the hospital acceptance office with administrative and clinical documents (accepting phase) [8]. When the patient enters in the ambulatory, the physician collects all the anamnestic data and fill in the required field and other necessary information in HealthSystem. At the end of CT exam, before the patient leaves, the personnel give to the patient the ACT. The bracelet has an ID associated to the hospital patient ID code. The patient can leave the department and return the day after to start the therapy. The patient path information are stored in HealthSystem. Amiigo device starts to record biometric data in stand-alone mode. During this period, thanks to the ACT, the medical staff have immediate access to the patient data and can update
therapy if a new event occurs. Two Bluetooth receivers are installed in the Radiation Oncology Section (Fig. 1). A server computer receives data that are stored in bracelets and manages queues. The software has a web based (Java) architecture and allows queue and data display. The first receiver is located near the waiting room and is able to detect the ACT presence and to download the parameters file at the specialist’s console, showing patients name and arrival time. The second receiver is in the accelerator room. This locates the patient inside the accelerator room and highlights the name of the patient actually treated avoiding patient exchange and treatment errors. The location system continuously analyzes data and stores each timestamp giving precise information on the time of treatment, on the average waiting time and patient’s delays. The collected data are sent to a Matlab R2014b server that processes them into graphic form, showing sensors signals that are subsequently displayed on patient medical record (Fig. 2). The HealthSystem software is dynamically interconnected to the HIS in order to obtain clinical reports and laboratory results from other Departments upon request. In addition to basic database operations, the software allows query customization. To develop the system we used relational database design technique. The internal tables’ structure can be changed adding new data categories and can dynamically be connected to other similar information systems. Some functions can be added upon request of the medical staff. The system could be configured to pop up window allowing the medical staff to see special prescriptions related to patient in queue. A “reminder pop up” can highlight special request and document integration related to a specific patient. Since the application is web-based and completely designed in Java, the system is highly scalable and is not tied to specific hardware architectures. Furthermore, different statistical function can be implemented using both Java and Matlab.
Fig. 1. System Architecture, wireless connections between subsystems
Fig. 2. Software displays patient info and on the left the patient queue
III. RESULTS The overall system test installation was completed recently and the system is starting to produce a good quantity of data. In the first testing phase 5 patients (2 females and 3 males) were selected to experiment the ACTs. All patients confirmed that the bracelets do not permit any setting changes and resulted extremely comfortable. The continuous presence in the Department, due to the daily treatment, allows good patient interaction and collaboration. The data were collected without interruptions with a continuous feedback about system application criticisms. Of note, none of the devices was lost by the Department. The adoption of this system resulted in a positive feedback from all patients that feel more monitored during the whole treatment, increasing the hospital confidence. Regarding data collection performance, some adjustments have to be made. Analyzing SpO2 readings, we note that the presence of hair on the male arm can interfere with SpO2 sensor producing noisy readings. In addition, some still undefined behaviors, leading to wrong bracelet positioning, cause SpO2 disturbed measurements. To this end, a band pass filter was designed in Matlab for data denoising. The skin temperature sensor gives robust and precise measurements although they are highly individual dependent. Thanks to standard technology, the accelerometer produces also regular and precise readings. These preliminary results are encouraging. The biometric data collected from the patients overall reflect their life style and the changes due to the radiation therapy treatment. Regarding the presence detection, the queue system implemented using BT technology successfully informs the physicians on the actual patient queue and on average waiting time. The receiver placed in the accelerator room univocally identify the patient ID and the related treatment plan to be delivered avoiding possible patient exchange and treatment errors. The statistical analyses of the recorded waiting times represent a helpful suggestion for possible new reorganization
and optimization of the Department. The medical staff showed high satisfaction for this new organization tool. IV. CONCLUSION The aim of the present study is the workflow monitoring and optimization in a typical clinical research structure, including monitoring of patient vital parameters during a medical treatment that lasts few weeks. We implemented a clinical data warehouse, without interfering with the daily hospital personnel work according to the Pervasive Computing Paradigm. We coupled monitoring technology with medical records management system. Data mining techniques, instead of traditional statistical analysis, are applied. The implementation of a user-friendly system, able to manage heterogeneous data, allows prediction of events, pathology evolution and quality of life variation enabling the positive impact of care treatment. From the medical point of view, the implemented system could be relevant for general improvement in the medical research. The data, acquired using noninvasive techniques, show a snapshot of the patient home life. These data can help the radiation oncologist to understand better the impact that the radiation therapy treatment could have on the patient also outside the hospital. The analyses of biometric data, compared with information given by the patients or by the caregivers, provide precise information about patient’s lifestyle outside the hospital. The presence detector helps to avoid patient exchange and improve the quality assurance of the service. This technique can also support the research on the prediction of acute toxicity risk of radiation therapy treatment or the treatment efficiency [8]. We use pervasive computer techniques allowing minimizing patient collaboration, human intervention, and consequently errors. We show that using common technologies, such as ACT and BT, is possible to obtain patient identification in medical setting and to monitor patient biometric data during the treatment. These results are promising for both clinical and research activities, thanks to the implementation of minimal errors affected data warehouse. Increasing the number of BT receiver detectors and installing them in different hospital areas may help hospital staff to locate efficiently patients and to manage their flow inside the whole structure, realizing an even more efficient management. It must be noted that the used ACT devices in some cases cannot correctly read parameters, but we have to highlight their use is not intended for emergency scope. The collected data are adequate to describe mean patient activity and main criticisms, just to reveal possible life style variations during the radiation or any treatment. Our preliminary results are promising and show that, coupling commonly available and cheap technologies, it is possible to obtaining systems that manage heterogeneous data. Activity tracker appears to be good device to monitor
patient quality of life. Further work is necessary to improving system functionalities, developing new filters for more robust acquisition of data and realizing the integration with other hospital system and sensors for a global radiotherapy network. ACKNOWLEDGMENTS The authors wish to thank Mr. David Scott of Amiigo Inc. for his technical contribution to this project. He has been all the time very kind to give us all the necessary support to interface the device. REFERENCES [1]
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