University of Calgary

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2005-04-08

Telecardiological System CARDIO.NET: Promises and

Pitfalls

Rudowski, R.; Sierdzinski, J.; Grabowski, M.; Szymanski, F.

Presented at Med-e-tel 2005 Conference in Luxembourg.

http://hdl.handle.net/123456789/3559

Presentation

Downloaded from PRISM: https://prism.ucalgary.ca

TelecardiologicalTelecardiological System CARDIO.NET. System CARDIO.NET. PromisesPromises andand PitfallsPitfalls

R. R. RudowskiRudowski (1), J. (1), J. SierdzinskiSierdzinski (1), M. (1), M. GrabowskiGrabowski (1,2),(1,2),

F. F. SzymańskiSzymański (1,2)(1,2)

1 1 -- DeptDept. . ofof MedicalMedical InformaticsInformatics andand TelemedicineTelemedicine, , TheThe MedicalMedical UniversityUniversity ofofWarsawWarsaw

22-- CardiologyCardiology ClinicClinic, , II--stst FacultyFaculty ofof MedicineMedicine,,

TheThe MedicalMedical UniversityUniversity ofof WarsawWarsaw

OutlineOutline

BackgroundBackgroundAimAimElementsElements ofof thethe system: system:

-- EHR, EHR, -- DatabaseDatabase, , -- ExpertExpert system for system for riskrisk stratificationstratification

ResultsResultsRiskRisk stratificationstratification andand ethicsethicsPromisesPromises andand PitfallsPitfalls

Mortality rateMortality rate inin PolandPoland per 100 000 per 100 000 inhabitantsinhabitants

0

200

400

600

800

1000

1200

Mortality

Mortality caused by cardiovascular diseases

319

474557 537 530 513 505 503 469

813

9931056 1029 1020 1002 1001 998 987

1970 80 90 91 92 93 94 95 9996

Data from the Institute of Cardiology -2001

HemodynamicHemodynamic procedures procedures iin Poland 1999n Poland 1999--20022002

0

10000

20000

30000

40000

50000

60000

70000

80000

1999 2000 2001 2002

Coronarography

Coronary Angioplasty

46379

15453

65760

24326

76000

30000

58600

19580

From The Institute of Cardiology - 2001

MazoviaMazovia DistrictDistrict

HemodynamicHemodynamiclaboratorieslaboratories

Data from the Institute of Cardiology -2004

AcuteAcute CoronaryCoronary SyndromesSyndromes

The acute coronary syndromes (ACS) contain all three The acute coronary syndromes (ACS) contain all three clinical types of events (heart attack, unstable coronary clinical types of events (heart attack, unstable coronary heart disease, some cases of cardiac death) heart disease, some cases of cardiac death) andand are are one of the most frequent diagnoses of ischemic heart one of the most frequent diagnoses of ischemic heart disease. disease.

Credible epidemiological data on the incidence of ACS Credible epidemiological data on the incidence of ACS of all types in Poland is unavailable, but the estimate of all types in Poland is unavailable, but the estimate isis 250 000 cases per year. 250 000 cases per year.

AimsAims

TheThe designdesign andand implementationimplementation ofof prototypeprototypetelecardiologicaltelecardiological system system inin MazoviaMazovia DistrictDistrict..

ImporovementImporovement ofof cooperationcooperation amongamongcardiologicalcardiological centerscenters..

RationalizationRationalization ofof thethe specializedspecialized clinicalclinical resourcesresourcesandand accessaccess to to unifiedunified digitaldigital archivesarchives..

ReductionReduction ofof time time fromfrom symptomessymptomes to to interventionintervention((possiblepossible reductionreduction ofof mortalitymortality).).

The structure of The structure of Cardio.netCardio.net

Reference CenterLayer 1

Layer 2

Layer 3

Regional hospital 1

Regional hospital 2

Regional hospital n

AmbulanceAmbulance 11 AmbulanceAmbulance nnAmbulanceAmbulance 22

ToolsTools

ElectronicElectronic HealthHealth RecordRecord ((accesibleaccesible via Internet)via Internet)

RelationalRelational data data basebase MySQLMySQL

ExpertExpert System for System for riskrisk assessmentassessment

ElectronicElectronic HealthHealth RecordRecord ((accesibleaccesible via Internet)via Internet)

Pacjent -Elektroniczna

HistoriaChoroby

TerapiaD

iagn

osty

kaFa

rmak

oterap

ia

Lecz

enie

niefar

makolo

giczn

e

Rozpoznanie

wstępneBadanie

przedmiotowe

Badaniepodmiotowe

BadaniaEKG

Badania

biochemiczne

(Biomarkery)

Bada

niaob

razo

we

Roz

pozn

anie

osta

tecz

ne

- choroba wieńcow

a

- niewydolność serca

- zaburzenia rytmu

serca

- inne choroby

-szmery serca

-zastój w krążeniu

małym (Kilip)

-BMI

-RR (sk./rozk.)

- inne

-Bóle wieńcowe typowe

-Klasa CCS-Nietypowe bóle w klatce

piersiowej-Klasa NYHA

- inne czynniki

- EKG przy przyjęciu- EKG w trakcie leczania

- EKG przy wypisie

- Troponina

-CK

-CK-MB

- CK-MB

masa

- Kreatynina

- CRP-

ECHO

- cho

roba

wieńc

owa

- nie

wyd

olność

ser

ca- z

abur

zeni

a ry

tmu

serc

a- w

ady

serc

a-c

horo

by m

ięśn

ia s

erco

weg

ow

sier

dzia

i os

ierd

zia

- inn

e ch

orob

y

-Angioplastyka

-STEMI

-NSTEMI

- Zabieg kardiochirurgiczny - CABG

- Respirator

- Przeskórna ablacja

- inne

- t-PA

- Aspiryna

- Klopidogrel/Tiklopidyna

- Inhibitor ACE

- Statyna

- Antagonista GP IIb/IIIa

- inne

EElectroniclectronic formform 11

EElectroniclectronic formform 22

DatabaseDatabase

ClientClient--seversever architecturearchitecture withwith 3 3 layerslayers::

1. 1. ClientClient –– Internet Explorer min. Internet Explorer min. verver. 5.5.x. 5.5.x

2. 2. MiddlewareMiddleware –– PHPPHP3. 3. DatabaseDatabase serverserver -- MySQLMySQL

WWW ServerWWW Server

((ApacheApache))

ExpertExpert system (ES) for system (ES) for riskrisk stratificationstratification

InputInput datadata

BNPBNP

SIMPLESIMPLEOutputOutputVotingVoting

SystemSystemhighhigh riskriskoror lowlow risk

TIMITIMIrisk

GRACEGRACE

ZWOLLEZWOLLE

ES ES consultationconsultation –– finalfinal stepstep

BNP levels add additional prognostic BNP levels add additional prognostic information to risk scores in STEMI patients information to risk scores in STEMI patients

treated with PCItreated with PCI

MortalityMortality %%

ROC ROC curvescurves for for riskrisk scoresscores andand BNP BNP ininpredictionprediction ofof 3030--day day mortalitymortality

0,832

0,869

0,819

0,9

0,892

ES ES –– data data inputinput

ES ES –– resultsresults andand explanation moduleexplanation module

InterInter--rater agreement between rater agreement between realreal physician and physician and developed ESdeveloped ES Indication for pharmacotherapyIndication for pharmacotherapy

AspirinAspirin ACE inhibitorACE inhibitor BetaBeta--adrenoliticsadrenolitics

PhysicianPhysician PhysicianPhysician PhysicianPhysician

ESES YesYes NoNo SumSum YesYes NoNo SumSum YesYes NoNo SumSum

YesYes 5757 22 5959 123123 88 131131 102102 22 104104

NoNo 66 8484 9090 33 1515 1818 1515 3030 4545

SumSum 6363 8686 126126 2323 117117 3232

κκ 0,889 0,889 0,690 0,690 0,705 0,705

κκ < < 0,2 0,2 poorpoor

0,21 0,21 –– 0,4 fair0,4 fair

0,41 0,41 –– 0,6 0,6 moderatemoderate

0,61 0,61 –– 0,8 0,8 goodgood

0,81 0,81 –– 1,0 1,0 veryvery goodgood

Risk stratification in STEMI by different Risk stratification in STEMI by different strategiesstrategies

CClassificationlassification errorserrors

0,00%

2,00%

4,00%

6,00%

8,00%

10,00%

12,00%

BNP SIMPLE TIMI GRACE ZWOLLE Voting system

Cardio.netCardio.net -- resultsresults

EHR EHR hashas beenbeen createdcreated for for overover 100 100 patientspatients fromfrom SP SP CSK AM CSK AM HospitalHospital ((referencereference centercenter) ) andand for a for a fewfewpatientspatients fromfrom regionalregional centerscenters remotelyremotely. . ThisThis confirmedconfirmedfunctioningfunctioning ofof thethe system system andand verifiedverified appliedappliedsolutionssolutions..

PromisesPromises

2 2 mainmain elementselements ofof thethe system: EHR system: EHR andand databasedatabaseareare functioningfunctioning properlyproperly..

TheThe projectproject ofof presentedpresented telecardiologicaltelecardiological system system supportssupports ee--healthhealth strategystrategy for for PolandPoland for 2004for 2004--2006 2006 andand thethe NationalNational Program Program ofof HealthHealth. .

BothBoth initiativesinitiatives mentionmention thethe fightfight againstagainst coronarycoronarydiseasesdiseases as one as one ofof theirtheir strategicstrategic aimsaims..

PitfallsPitfalls

AmbulanceAmbulance networknetwork isis a a crucialcrucial factorfactor inin improvementimprovementofof healthhealth carecare ofof thethe ACS ACS patientspatients andand alsoalso itsitsintegrationintegration withwith regionalregional andand referencereference centerscenters

BetterBetter cooperationcooperation ofof ambulancesambulances withwith thethe regionalregionalandand refrencerefrence centerscenters isis requiredrequired ((organizationalorganizationalpitfallpitfall))

TheThe ambulancesambulances requirerequire newnew equipmentequipment for ECG data for ECG data transmissiontransmission overover mobile mobile phonesphones

Internet Internet connectionconnection inin regionalregional centerscenters isis a problem. a problem. TheThe staffstaff needsneeds trainingtraining inin EHR EHR andand databasedatabaseoperationoperation