醫學與工程---資訊工程在醫學上的應用

智慧醫療

Smart Healthcare

臺北市立聯合醫院仁愛院區家庭醫學科

郭冠良

Kuan-Liang Kuo, MD, PhD

2020-03-18

Ver. 0317 1

Contents

• 醫療資訊之歷史演進

• 智慧醫療

2

歷史演進

3

~2000

• 管理資訊系統 (Management Information

System)

– 藥品、衛材、帳務

– ERP

• HIS (Hospital Information System)

– 用途演進?

4

ERP

BPR

ERP*

EA

CRM

KM

EA

EA

EA

供應商

經銷商

SCM SCM

客戶

EAI EAI

ERP: Enterprise Resource Planning

BPR: Business Process Reengineering

SCM: Supply Chain Management

EA: Enterprise Application

EAI: EA Integration

CRM: Customer Relationship Management

5

6

RIS

LIS

ERP

PACS Clients

CPOE

狹義的 HIS

廣義的HIS ~2000

住院、急診、門診

CPOE: Computerized Physician Order Entry

2000~

• HIS

– 整合各部門系統 (廣義的HIS)

– 結合CDSS (Clinical Decision Support System)

7

Quiz

• 廣義的HIS包含哪些子系統?

8

2010~

• EMR (Electronic Medical Record)

• Wireless network

• Wearable device

• Smart phone

• IoT (Internet of Things)

9

EMR

• EMR (Electronic Medical Record)

– 電子簽章

– 無紙化

10

2010~

Meaningful Use (2010~)

11

2010~

MIPS (2015~) (Merit Based Incentive Payment System)

• MIPS harmonizes existing CMS quality programs – Meaningful Use

– Physician Quality Reporting System

– Value-Based Payment Modifiers

• MIPS consolidates multiple, quality programs into a single program to improve quality care

12

2010~

https://www.healthit.gov/topic/meaningful-use-and-macra/meaningful-use

MIPS (2015~) (Merit Based Incentive Payment System)

• The Four Pillars of MIPS Reporting

• Using Certified EHR Technology

13

2010~

https://www.healthit.gov/topic/federal-incentive-programs/MACRA/merit-based-incentive-payment-system

RIS

LIS

PACS

Gateway:

•XML

•Signature

ERP

CPOE

EEC

EMR

Data source

電子病歷 2010~

14

衛福部提供軟體:

EEC Gateway

EEC Lite Gateway

15

Quiz

• 電子病歷與病歷電子化的不同?

16

Wireless network

2010~

17

功耗、傳輸速度、傳輸距離

Wearable Device

2010~

http://www.c-sharpcorner.com/UploadFile/f88748/internet-of-thingsiot-part-4-network-protocols-and-arc/

18

IoT (Internet of Things)

• IoT layers

2010~

https://www.c-sharpcorner.com/UploadFile/f88748/internet-of-things-part-2/

19

IoT (Internet of Things)

• IoT ontology hierarchy

2010~

http://www.c-sharpcorner.com/UploadFile/f88748/internet-of-things-iot-part-3/

20

IoT (Internet of Things)

2010~

http://dx.doi.org/10.4236/ait.2016.62002

21

Quiz

• IoT的網路需求

– 網路傳輸頻寬

– 網路傳輸距離

– 功耗

22

2015~

• Smart Healthcare

– ICT integration with healthcare

• Smart Hospital

– Smart healthcare

– Smart environment / building

• IoT

• AIoT

ICT: Information communication technology

AI: Artificial Intelligence 23

2015~

• AI in medicine

– ML

– DL

– …

• Blockchain

– Cryptography

AI: Artificial Intelligence

ML: Machine Learning

DL: Deep Learning

24

智慧醫療 Smart Healthcare

25

Get Smart for Healthcare

• Terms

– Connected health

– Digital health

– eHealth

– mHealth

– iHealth

– Smart healthcare

– Digital Medicine

26

• 2018年我國65歲以上人口達14%，依據WHO定義，已邁入「高齡社會」

27

https://www.ndc.gov.tw/Content_List.aspx?n=695E69E28C6AC7F3 (2019-02-10擷取自國家發展委員會)

Motivation Smart

Healthcare

• 出生數下降

– 1968: 40萬

– 2018: 18萬

• 照顧負擔快速升高

28

https://pop-proj.ndc.gov.tw/download.aspx?uid=70&pid=70 (2019-02-10擷取自國家發展委員會)

Motivation Smart

Healthcare

Motivation

• Sickcare or

Healthcare

• Health Cost

– 健保預算

?/年

Smart

Healthcare

• Unfortunately, our healthcare system is a

system for the sick

29

Marvasti FF, Stafford RS. From

“Sick Care” to Health Care:

Reengineering Prevention into the

U.S. System. The New England

journal of medicine.

2012;367(10):889-891.

doi:10.1056/NEJMp1206230.

Motivation

Smart

Healthcare

Increasing complexity of

healthcare system

Big data

Medical science

becomes

Data-intensive science

Smart healthcare 30

Motivation Smart

Healthcare

• P4-medicine (Lee Hood, MD, PhD)

31

Big data tracking multiple

dimensions of individual

health

Ongoing systems

analytics

(Systems biology)

Personalized, actionable

health information

Data Method P4-medicine

Motivation Smart

Healthcare

• P4-medicine

32

Big data tracking multiple

dimensions of individual

health

Ongoing systems

analytics

(Systems biology)

Personalized, actionable

health information

Data Method P4-medicine

Motivation Smart

Healthcare

• Systems biology

1

2

Biology

information technology

Molecular, cellular, and phenotypic data

Information-based

Systems approaches

Holistic understanding of complex biological

systems 3 Systems biology

Comprehensive, dynamic analyses of

the components of a system

Disease and wellness as a continuum of network states unique in time and space to each

individual human being

33

Big data tracking multiple

dimensions of individual

health

Ongoing systems

analytics

(Systems biology)

Personalized, actionable

health information

Data Method P4-medicine

Motivation Smart

Healthcare

• P4-medicine願景

– Personalized actionable information

• De-identified

• Aggregated

– Physicians

• Make more cost-effective diagnosis and treatments

– Patients (sick people) and consumers (healthy people)

• Live healthier, more productive lives

34

Motivation Smart

Healthcare

35

Get Smart for Healthcare

• Information at point-of-care (POC)

• Guidelines embedded workflow

• Ubiquitous computing

– Network, sensor, mobile device, …

• Measurable healthcare

– Data, data, data

How to?

36

• Seamless sensors and interactive

technologies

• Offer personalized and context-

adapted medial support

– Assistance to carry out everyday activities

– Monitoring personal health conditions

– Enhancing patient safety

– Getting access to social medical and

emergency systems on demand

Ubiquitous Computing Smart

Healthcare

Comfort,

Autonomy,

Detection,

Prediction,

Prevention

Context data, data, data

37

Ubiquitous Computing Smart

Healthcare

http://lmeasy.blogspot.tw/2015/11/ubiquitous-computing-ubicomp.html

38

• Ubiquity

• Natural

interaction

• Proactivity

Ubiquitous Computing Smart

Healthcare

http://blogs.parc.com/2010/03/defining-ubiquitous-computing-vs-augmented-reality/

39

• Cognitive science(人) + Computer science(機)

• Role of humans

– Human as operator

– Human as data source

• Cyber-physical system(CPS)

– Interact seamlessly

• 人、機、物的無縫融合計算

• 實體裝置的互動網路

– Adaptive behavior of all

– Intelligence of all

Human-in-the-loop Smart

Healthcare

40

Human-in-the-loop Smart

Healthcare

Generate

rules

Holzinger, Andreas, Carsten Röcker, and Martina Ziefle. "From smart health to smart

hospitals." Smart health. Springer International Publishing, 2015. 1-20.

41

Cyber-physical system

(CPS)

Smart

Healthcare

42

• Mobility

• Invisibility

• Natural communication

Technological Challenges Smart

Healthcare

43

• Hardware

• Network

• Software

• Data

• Service

Components of

Smart Healthcare

Smart

Healthcare

44

• Device (or sensor)

– Connectivity

– Data capture

• Clinical data

• Operational data

– Mobility (miniature, light-weight)

– Low power consumption

– Low cost

– FDA approved (medical device)

Hardware Smart

Healthcare

45

• Smart healthcare is built on smart networks

– Ubiquitous

– Combination of multiple protocols

– Q&A: Bandwidth issue, security issue

Network Smart

Healthcare

46

See next slide

• Scenario example:

– Range vs energy consumption

•BLE

•Xenon •Wi-Fi

•LAN

Internet

•GPRS

•3G/4G

BLE: Bluetooth Low Energy

LAN: Local Area Network

Network Smart

Healthcare

47

Combination of multiple protocols

Network

• Range, Power, and

Data rates

– 4G/Wi-Fi/BLE

48

http://embedur.com/blogsandnews/Choosing-the-right-wireless-tech-for-IoT.html

BLE: Bluetooth Low Energy

• 智慧醫療最重要，最核心部分

• Software

– 1.應用程式

– 2.背景服務程式 (伺服器)

– 3.批次處理程式

– 4.API程式

Software Smart

Healthcare

49 API: Application Programming Interface

• 應用程式

– User Interface

• Data

• Control

• POC

– Logic

• Workflow

• CDSS

– Database

Software Smart

Healthcare

MVC Model

50

1.應用程式

51

• Types of application framework

– Standalone

– Client-server

• Thin-client

• Fat-client

Software Smart

Healthcare

52

1.應用程式

• Thin-client

– Server-based computing

• Web-based computing

• Cloud-computing

– Virtual desktop

Software Smart

Healthcare

53

Client-server

• Thin-client

• Fat-client

http://www.atlanticcs.net/cloudcomputing.html

http://www.sfsolutions.co.th/solutions/virtual-desktop-vdi

1.應用程式

• Fat-client

– PC-based

Software Smart

Healthcare

54

Client-server

• Thin-client

• Fat-client

1.應用程式

• Thin-client v.s. Fat-client

Software Smart

Healthcare

55

Client-server

• Thin-client

• Fat-client

http://paransilverlight.tistory.com/258

Pros and

Cons?

1.應用程式

• 背景服務程式

– 作業系統 (OS)

– 伺服器 (server)

– 排程啟動程式 (cron)

Software Smart

Healthcare

56 https://msdnshared.blob.core.windows.net/media/2017/01/servers.jpg

2.背景服務程式

• 批次處理程式

– 資料處理

– 與排程啟動程式結合

Software Smart

Healthcare

57

https://image.slidesharecdn.com/april131220dataartisanscelebi-

160425200014/95/unified-stream-and-batch-processing-with-apache-

flink-7-638.jpg?cb=1461614428

3.批次處理程式

• API程式

– 分散式計算的解決方案

• 平行計算 /計算量分工

– SaaS (Software as a

service)

• Web service

• 例:

– AWS (Amazon web

services)

– Google cloud

Software Smart

Healthcare

58

4.API程式

https://image.slidesharecdn.com/april131220dataartisanscelebi-

160425200014/95/unified-stream-and-batch-processing-with-apache-flink-7-

638.jpg?cb=1461614428

https://coderwall.com/p/klzs5a/hello-distributed-computing

• Source – HIS

– Medical device / IoT

• Type – Clinical data

– Operational data

• Applications – Alarm management

– Patient surveillance

– Asset management (Extended ERP)

• Purpose – Improve clinical outcome

– Enhance workflow and operational efficiency

Data Smart

Healthcare

59

Medical Science

vs

Data Science

• AI in medicine – Rule-based

• Expert system

– Statistical method • Bayesian network

– Neural network (1943~) • Machine learning

• Deep learning

• Clinical Decision Support System – Alert

– Reminder

– Workflow

Data Smart

Healthcare

60

Data Science

Data Smart

Healthcare

61 Public Key Encryption and Digital Signature: How do they work?

2004 by CGI Group Inc.

• Blockchain

– Chain and data

Data Smart

Healthcare

62

Data Smart

Healthcare

63

• Blockchain

– Security

• Blockchain Technology – Distributed network

– Shared ledger

– Digital transaction

• Healthcare blockchain advantages – Open standard

– For researchers, healthcare providers, care givers, and individuals

– Fault tolerance and disaster recovery

– Lifetime data

– From guideline to personalized treatment path

Data Smart

Healthcare

64

• Scalibility

• Access security and data

privacy

• Based on

– Humanity

– Person-centered

• HCAHPS (Hospital Consumer Assessment

of Healthcare Providers and Systems)

• http://www.hcahpsonline.org

Service Smart

Healthcare

65

Comfort,

Autonomy,

Detection,

Prediction,

Prevention

• For

– Point-of-care

• Patient

• Clinician / Healthcare provider

– Institute

– Public health

– Policy

Service Smart

Healthcare

66

• Scenarios

– Medical education

• Simulation

– Patient care

• CDSS

• Workflow

• Outcome

Service Smart

Healthcare

67

• Scenarios

– Research

• Clinical data

• Operational data

– Hospital operation

• Quality and efficiency

Service Smart

Healthcare

68

• 健檢中心

– 預約

• 建議客戶需要健檢

– 現場

• 受檢者進度

– 定點掃描: RFID、barcode

– 室內定位技術

• 動態排程

Service Smart

Healthcare

69

• Learning Health System

(LHS)

– Rapid Increasing

Complexity

– Achieving Greater Value in

Health Care

– Capturing Opportunities

from Technology, Industry,

and Policy

Service Smart

Healthcare

70

• Learning Health System

(LHS) (李友專)

– Data to Knowledge

– Knowledge to Practice

– Practice to Consumer

– Consumer to Data

Service Smart

Healthcare

71

期程 易感受期 臨床前期 臨床期 殘障期 生命末期與臨終期

初段 次段 三段 四段

級別 第一級 第二級 第三級 第四級 第五級 第六級 第七級

健康促進

特殊防護

早期診斷

早期治療

限制殘障

居家照護

緩和醫療

安寧照護

介入方案

健康促進活動 勞工健檢 健康檢查 慢性病個案管

理 居家復健 居家安寧 在宅臨終

營養衛教 特殊族群健檢 四癌篩檢 失智照護 居家照護 圓夢計畫 悲傷輔導

健康識能 居家防跌 失智篩檢防治 用藥整合 在宅服務

預防注射 老人憂鬱篩檢 住院治療

輔具運用 出院準備

推展政策

家庭責任醫師 家庭責任醫師 家庭責任醫師 家庭責任醫師 居家醫療整合

(S0, S1, S2)

居家醫療整合

(S3)

居家醫療整合(S3)

ACP/AD ACP/AD

SDM

ACP/AD

開放醫院

SDM

ACP/AD

PAC

SDM

ACP/AD

SDM

DNR/AD

SDM

DNR

四段七級的預防醫學 Smart

Healthcare

期程 易感受期 臨床前期 臨床期 殘障期 生命末期與臨終期

初段 次段 三段 四段

級別 第一級 第二級 第三級 第四級 第五級 第六級 第七級

健康促進

特殊防護

早期診斷

早期治療

限制殘障

居家照護

緩和醫療

安寧照護

介入方案

健康促進活動 勞工健檢 健康檢查 慢性病個案管

理 居家復健 居家安寧 在宅臨終

營養衛教 特殊族群健檢 四癌篩檢 失智照護 居家照護 圓夢計畫 悲傷輔導

健康識能 居家防跌 失智篩檢防治 用藥整合 在宅服務

預防注射 老人憂鬱篩檢 住院治療

輔具運用 出院準備

推展政策

家庭責任醫師 家庭責任醫師 家庭責任醫師 家庭責任醫師 居家醫療整合

(S0, S1, S2)

居家醫療整合

(S3)

居家醫療整合(S3)

ACP/AD ACP/AD

SDM

ACP/AD

開放醫院

SDM

ACP/AD

PAC

SDM

ACP/AD

SDM

DNR/AD

SDM

DNR

四段七級的預防醫學 Smart

Healthcare

減重、營養、衛教(EQ App鼓勵互動)

戒菸(IoT，EQ App鼓勵互動)

預注提醒

跌倒(平衡、環境)監測IoT

特殊工作環境IoT

智慧輔具

期程 易感受期 臨床前期 臨床期 殘障期 生命末期與臨終期

初段 次段 三段 四段

級別 第一級 第二級 第三級 第四級 第五級 第六級 第七級

健康促進

特殊防護

早期診斷

早期治療

限制殘障

居家照護

緩和醫療

安寧照護

介入方案

健康促進活動 勞工健檢 健康檢查 慢性病個案管

理 居家復健 居家安寧 在宅臨終

營養衛教 特殊族群健檢 四癌篩檢 失智照護 居家照護 圓夢計畫 悲傷輔導

健康識能 居家防跌 失智篩檢防治 用藥整合 在宅服務

預防注射 老人憂鬱篩檢 住院治療

輔具運用 出院準備

推展政策

家庭責任醫師 家庭責任醫師 家庭責任醫師 家庭責任醫師 居家醫療整合

(S0, S1, S2)

居家醫療整合

(S3)

居家醫療整合(S3)

ACP/AD ACP/AD

SDM

ACP/AD

開放醫院

SDM

ACP/AD

PAC

SDM

ACP/AD

SDM

DNR/AD

SDM

DNR

四段七級的預防醫學 Smart

Healthcare

健檢篩檢提醒

失智、憂鬱監測IoT、EQ App

互動

慢性病監測IoT

用藥監測IoT

智慧輔具

Future

• Smart healthcare perspective in hospital

information management

– BPR(Business Process Re-engineering)

Q & A

Smart

Healthcare

75

趨勢

76

趨勢

• 2017台大

– 生物資訊學國際研究生博士學位學程

– 資料科學碩博士學位學程

• 2018成大

– 數據科學研究所

77

Thanks for Your Attention

78