The Neurogenic Bladder and Telemedicine: urologic history and physical exam development with a. Objectives

Transcription

1 The Neurogenic Bladder and Telemedicine: urologic history and physical exam development with a movement towards home monitoring. Lynn Stothers, MD, MHSc, FRCSC Prof. Urology University of British Columbia Objectives Understand the current way in which bladder physical exam and measurements are done with patient's in person List challenges in telemedicine which are specificto the neurogenic population Define near infrared spectroscopy (NIRS) 1

2 Personal Background Urology male urogenital tract / female urinary tract t Masters in Epidemiology / Public Health Subspecialty Neuro urology, Female Urology, UrinaryTract Infection, Urodynamics Home Monitoring / Electronic Medical Record (EMR) 1. Physician / Software and Hardware Interface 2. Physician Entry Errors 3. Patient Entry of Data 4. Physician and Patient Entry of Examination Findings 5. Technology that provides elements of the physical exam 2

3 Spinal Cord Injury Patient Population Neurogenic Bladder Multiple Sclerosis CVA Head / Spinal / Pelvic Trauma Parkinson s Disease Etc. (any neurologic condition that affects bladder control) Considerations: Home Monitoring Neurogenic Bladder Population A ibilit ilt f SCI i Accessibility specialty care for SCI is commonly in an urban centre Physical limitations in patient providing their own history Secondary party / caregiver Importance of physical exam and bladder function measurements Some risk factors for urinary tract complications are known 3

4 Home Monitoring Literature Review Approx. 25 articles on the subject of neurogenic bladder (SCI) and telemedicine More than 90% deal with the management of pressure ulcers A feasibility study of video-based home telecare for cleints with SCI Philips et al. J of Telemed and Telecare 1998 Telecare to promote skin and other self-care activites in sci population N=11 Trained driver who traveled to the subjects house to install video phone (Picasso AT&T) Weekly schedule Bladder outcome not specifically mentioned 4

5 Telehealth: Reaching out to Newly Injured spinal Cord Patients Phillips et al Public Health Reports 2001 RCT N=111 SCI patients Telemedicine vs telephone vs standard care (control) * first 2 groups also had educational component structured review of bladder routine Telehealth: Reaching out to Newly Injured spinal Cord Patients Phillips et al Public Health Reports 2001 Video x 9 weeks HRQuality of Life: no diff at 9 weeks HRQuality of Life: + diff at 1 year Hospital stays: 3 (video), 5.22 (telephone), 7.95 (standard care) 5

6 HOME SCI Research Projects Funded: Rick Hansen Institute + Ontario NIRS Bladder Technology Development Funded: Gates Foundation PRIME EMR Study Unfunded d Research Video Interface Unfunded Pilot Home Monitoring Overview of Research Studies 6

7 Home Monitoring Overview of Research Studies HOME SCI Study Home Monitoring Overview of Research Studies HOME SCI Study Optical Monitoring of Bladder Function 7

8 Home Monitoring Overview of Research Studies HOME SCI Study PRIME EMR Survey Research Video interface Optical Monitoring of Bladder Function Global Goals of our Projects 1. Reducing Errors in the physician / EMR interface 2. Explore the patient as an entry point of data into the EMR 3. Link via technology elements of the physical exam directly into the EMR 8

9 Urologic History the in person visit Urinaryfrequency (goingoften) often) Urinary urgency (hard to delay) Incontinence (leakage) Retention / obstructive voiding (hard to evacuate) Painful Urination History Standardized questionnaire for LUTS Validated Translated / reverse translated Patient enters the data 9

10 Male Symptom Score Example International Prostate Symptom Score (IPSS) International Prostate Symptom Score (I-PSS) Patient Name: Date of birth: Date completed In the past month: 1. Incomplete Emptying How often have you had the sensation of not emptying your bladder? 2. Frequency How often have you had to urinate less than every two hours? 3. Intermittency How often have you found you stopped and started again several times when you urinated? 4. Urgency How often have you found it difficult to postpone urination? 5. Weak Stream How often have you had a weak urinary stream? Not at All Less than 1 in 5 Times Less than Half the Time About Half the Time More than Half the Time Almost Always Your score 6. Straining How often have you had to strain to start urination? None 1 Time 2 Times 3 Times 4 Times 5 Times 7. Nocturia How many times did you typically get up at night to urinate? Total I-PSS Score Score: 1-7: Mild 8-19: Moderate 20-35: Severe Quality of Life Due to Urinary Symptoms Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

11 Women Symptom Score Examples UrogenitaldistressInventoryScore (UGDI) Pelvic Organ Prolapse (POP) (international Urogynecological Association) translated information Electronic Medical Record Urologic History (EMR) Physician / health professional data input of standardized questions Patient direct entry of historical data Research Purposes interfaces 11

12 Urologic Physical in person hands on exam Abdomen Uro Neurologic Genitalia Prostate Female Pelvic Exam Urologic Physical Challenges to consider for Telemedicine Some exam aspects are internal Even the external exam includes body areas which are highly private In person exam is typically done with positioning assistance 12

13 Tests to Measure Bladder Function Uroflow Urodynamics (UDS) Cystometrogram Pressure Flow study Residual Urine Uroflow How we measure bladder emptying Non invasive I.e. with the right equipment patients can do this at home Measures: How much you void The pattern of the urinary stream 13

14 Uroflow Image from Laborie Medical with permission 14

15 Cystometrogram How we measure bladder filling Gold Standard d Invasive Requires specialized equipment Requires technical staff Disposables Urodynamics Supplies Image from Laborie Medical with permission 15

16 Urodynamics Image from Laborie Medical with permission 16

17 Residual Urine Done by patient who use intermittent catheters to empty their bladder with their actual catheter Done using a small portable ultrasound Some units are approved for bladder volume measurements only 17

18 Image from Laborie Medical with permission Bladder Tests and Home Monitoring *Uroflow Bladder function *Residual Urine * Require technology to link these to upload into the EMR 18

19 Bladder Tests are critical to clinical decision making Known bladder storage pressures that can put the patient at risk for urologic complications Known voiding pressures which are considered to be obstructed and require action Key low pressure storage and low pressure emptying How else can we measure bladder function? - Use of light 19

20 Near Infrared Spectroscopy (NIRS) NIRS uses light in the near infra-red region of the spectrum ( nm) The physics that makes NIRS possible includes: -the transparency of tissue to NIR light - the absorption of NIR photons by naturally occurring compounds called chromophores 40 20

21 41 Non invasive NIRS Now Wirelessly 100 s of studies to learn the relationship between bladder function and the NIRS signal 21

22 Composite UDS/NIRS 22

23 Bladder Tests and Home Monitoring *Uroflow Cystometrogram Bladder function *NIRS Bladder function *Residual Urine * Require technology to link these to upload into the EMR Home Monitoring Overview of Research Studies HOME SCI Study 23

24 HOME SCI Grant Feasibility of Home Monitoring of spinal cord injured (SCI) patients related to the frequency and severity of UTI Include patients from BC with Ontario HOME SCI Period of run in without home monitoring Period of Home Monitoring 24

25 Home Monitoring what does this look like? Regularly scheduled telemedicine Patient enters data into a secure database History LUTS scores / frequency of UTI Physical Blood pressure Urine Dipstick NIRS data collection Home Monitoring what does this look like? Scheduled Telemedicine Visit (face to face) Review of patient entered history Review of patient entered physical findings Adding to the history by the health care provider Instructions on management of LUTS / UTI prevention 25

26 Home Monitoring Basic Science Information In the event of a urinary tract infection: Patient s urine samples will have further analysis of the bacteria NIRS will be converted to transmit the data electronically to us HOME SCI In the end we hope to determine if frequency telemedicine visits are feasible with regard to patient data entry / patient collection of physical exam related information Future extensions: Refine an EMR suited for this population Observe for any impact in prevention of urinary tract infection 26

27 Home Monitoring Overview of Research Studies HOME SCI Study Optical Monitoring of Bladder Function Home Monitoring in Developing Nations Concept Extend the idea of Less Invasive Bladder Monitoring to a Global Level Extra challenges 27

28 Home Monitoring in Developing Nations Uganda Population / Urologic Disease 2% of deaths Many early Incontinence due to obstructed labor (vesico vaginal fistula) serious problem 28

29 Grand Challenges Grant Evaluation of Novel Optical Technology (NIRS) to Screen for Bladder Problems Impacting Health Outcomes in Uganda Grand Challenges Grant Technology Development Grant Using Near Infrared Light to monitor the bladder Inexpensive light source Miniaturize Non invasive Extensive to use in labor / delivery / bladder complication (fistula) 29

30 PRIME Study PRIME EMR Study: PRevention and Identification of Mismatch Errors in EMR software objectives are: PRIME Study 1. To document current mechanisms in place to prevent lost and mismatched patient data errors in EMR programs in Canada. 2. To identify, through detailed interviews with 2. To identify, through detailed interviews with interface users, additional ways in which current EMR software could be modified to prevent lost and mismatched patient data. 30

31 PRIME EMR Study Standardized Interviews of N=60 physicians and interface developers Current status Conclusion Understand the current way in which bladder physical exam and measurements are done with patient's in person Define near infrared spectroscopy (NIRS) List challenges in telemedicine which are specificto the neurogenic population 31

32 Thank you My Conclusion 32