医療関連ソフトウェア¶

// ICU患者監視システムの実装例
interface VitalSigns {
  patientId: string;
  timestamp: Date;
  heartRate: number;
  bloodPressure: {
    systolic: number;
    diastolic: number;
  };
  spO2: number; // 酸素飽和度
  temperature: number;
  respiratoryRate: number;
  consciousness: ConsciousnessLevel;
}

interface PatientAlert {
  id: string;
  patientId: string;
  alertType: AlertType;
  severity: AlertSeverity;
  message: string;
  timestamp: Date;
  parameters: {
    measured: number;
    threshold: number;
    trend?: string;
  };
  acknowledged: boolean;
  responseActions?: string[];
}

enum AlertType {
  BRADYCARDIA = 'bradycardia',
  TACHYCARDIA = 'tachycardia',
  HYPOTENSION = 'hypotension',
  HYPERTENSION = 'hypertension',
  HYPOXEMIA = 'hypoxemia',
  ARRHYTHMIA = 'arrhythmia',
  TEMPERATURE_ABNORMAL = 'temperature_abnormal'
}

enum AlertSeverity {
  LOW = 'low',
  MEDIUM = 'medium',
  HIGH = 'high',
  CRITICAL = 'critical'
}

class ICUMonitoringSystem {
  private patients: Map<string, PatientMonitor> = new Map();
  private alertManager: AlertManager;
  private trendAnalyzer: TrendAnalyzer;
  private mlEngine: MachineLearningEngine;

  constructor() {
    this.alertManager = new AlertManager();
    this.trendAnalyzer = new TrendAnalyzer();
    this.mlEngine = new MachineLearningEngine();
    this.setupRealtimeMonitoring();
  }

  // リアルタイム監視の設定
  private setupRealtimeMonitoring(): void {
    // 1秒間隔での生体情報取得
    interval(1000).pipe(
      mergeMap(() => this.collectAllVitalSigns()),
      tap(vitalSigns => this.processVitalSigns(vitalSigns)),
      catchError(error => {
        console.error('Vital signs collection error:', error);
        // 重要：監視システムの障害は即座に報告
        this.alertManager.createSystemAlert({
          type: 'SYSTEM_ERROR',
          message: 'Vital signs monitoring interrupted',
          severity: AlertSeverity.CRITICAL
        });
        return of([]);
      })
    ).subscribe();

    // アラート状態の監視
    this.monitorAlerts().subscribe(alert => {
      this.handleAlert(alert);
    });
  }

  // 生体情報の処理と解析
  private processVitalSigns(vitalSigns: VitalSigns): void {
    // 個別患者の監視設定を取得
    const monitor = this.patients.get(vitalSigns.patientId);
    if (!monitor) return;

    // 異常値の検知
    const alerts = this.detectAbnormalVitals(vitalSigns, monitor.thresholds);
    alerts.forEach(alert => this.alertManager.addAlert(alert));

    // トレンド分析
    const trendAnalysis = this.trendAnalyzer.analyze(vitalSigns, monitor.history);
    if (trendAnalysis.hasSignificantChange) {
      this.alertManager.addAlert({
        id: generateUUID(),
        patientId: vitalSigns.patientId,
        alertType: AlertType[trendAnalysis.parameter.toUpperCase() as keyof typeof AlertType],
        severity: trendAnalysis.severity,
        message: `${trendAnalysis.parameter} showing ${trendAnalysis.trend} trend`,
        timestamp: new Date(),
        parameters: trendAnalysis.parameters,
        acknowledged: false,
        responseActions: trendAnalysis.recommendations
      });
    }

    // 機械学習による予測
    const prediction = this.mlEngine.predictDeterioration(vitalSigns, monitor.history);
    if (prediction.riskLevel > 0.7) {
      this.alertManager.addAlert({
        id: generateUUID(),
        patientId: vitalSigns.patientId,
        alertType: 'DETERIORATION_RISK' as any,
        severity: AlertSeverity.HIGH,
        message: `High risk of clinical deterioration detected (${(prediction.riskLevel * 100).toFixed(1)}%)`,
        timestamp: new Date(),
        parameters: {
          measured: prediction.riskLevel,
          threshold: 0.7,
          trend: prediction.trendDirection
        },
        acknowledged: false,
        responseActions: prediction.interventions
      });
    }

    // 履歴の更新
    monitor.addVitalSigns(vitalSigns);
  }

  // 異常値検知アルゴリズム
  private detectAbnormalVitals(vitals: VitalSigns, thresholds: PatientThresholds): PatientAlert[] {
    const alerts: PatientAlert[] = [];

    // 心拍数チェック
    if (vitals.heartRate < thresholds.heartRate.min) {
      alerts.push(this.createAlert(vitals.patientId, AlertType.BRADYCARDIA, 
        `Heart rate: ${vitals.heartRate} bpm (below ${thresholds.heartRate.min})`,
        vitals.heartRate, thresholds.heartRate.min));
    } else if (vitals.heartRate > thresholds.heartRate.max) {
      alerts.push(this.createAlert(vitals.patientId, AlertType.TACHYCARDIA,
        `Heart rate: ${vitals.heartRate} bpm (above ${thresholds.heartRate.max})`,
        vitals.heartRate, thresholds.heartRate.max));
    }

    // 血圧チェック
    if (vitals.bloodPressure.systolic < thresholds.bloodPressure.systolic.min ||
        vitals.bloodPressure.diastolic < thresholds.bloodPressure.diastolic.min) {
      alerts.push(this.createAlert(vitals.patientId, AlertType.HYPOTENSION,
        `Low blood pressure: ${vitals.bloodPressure.systolic}/${vitals.bloodPressure.diastolic} mmHg`,
        vitals.bloodPressure.systolic, thresholds.bloodPressure.systolic.min));
    }

    // 酸素飽和度チェック
    if (vitals.spO2 < thresholds.spO2.min) {
      alerts.push(this.createAlert(vitals.patientId, AlertType.HYPOXEMIA,
        `Low oxygen saturation: ${vitals.spO2}% (below ${thresholds.spO2.min}%)`,
        vitals.spO2, thresholds.spO2.min));
    }

    return alerts;
  }

  // アラート処理
  private handleAlert(alert: PatientAlert): void {
    // アラートの優先度に基づく処理
    switch (alert.severity) {
      case AlertSeverity.CRITICAL:
        this.sendEmergencyNotification(alert);
        this.activateEmergencyProtocol(alert);
        break;
      case AlertSeverity.HIGH:
        this.notifyMedicalStaff(alert);
        this.logHighPriorityAlert(alert);
        break;
      case AlertSeverity.MEDIUM:
        this.addToAttentionList(alert);
        break;
      case AlertSeverity.LOW:
        this.logAlert(alert);
        break;
    }

    // アラートの記録
    this.alertManager.logAlert(alert);
  }

  // リアルタイムダッシュボードの更新
  getRealTimeDashboard(): Observable<ICUDashboard> {
    return combineLatest([
      this.getPatientSummaries(),
      this.getActiveAlerts(),
      this.getSystemStatus()
    ]).pipe(
      map(([patientSummaries, alerts, systemStatus]) => ({
        timestamp: new Date(),
        patientSummaries,
        activeAlerts: alerts,
        systemStatus,
        totalPatients: this.patients.size,
        criticalPatients: patientSummaries.filter(p => p.severity === 'CRITICAL').length,
        staffNotifications: this.getStaffNotifications()
      }))
    );
  }

  // 機械学習による改善
  optimizeThresholds(patientId: string): Promise<OptimizedThresholds> {
    const monitor = this.patients.get(patientId);
    if (!monitor) throw new Error('Patient not found');

    return this.mlEngine.optimizeAlertThresholds(
      monitor.history,
      monitor.thresholds,
      monitor.alertHistory
    );
  }
}

interface PatientMonitor {
  patientId: string;
  thresholds: PatientThresholds;
  history: VitalSigns[];
  alertHistory: PatientAlert[];
  addVitalSigns(vitals: VitalSigns): void;
}

interface PatientThresholds {
  heartRate: { min: number; max: number };
  bloodPressure: {
    systolic: { min: number; max: number };
    diastolic: { min: number; max: number };
  };
  spO2: { min: number; max: number };
  temperature: { min: number; max: number };
  respiratoryRate: { min: number; max: number };
}

interface ICUDashboard {
  timestamp: Date;
  patientSummaries: PatientSummary[];
  activeAlerts: PatientAlert[];
  systemStatus: SystemStatus;
  totalPatients: number;
  criticalPatients: number;
  staffNotifications: StaffNotification[];
}

// 麻酔監視システムの実装例
interface AnesthesiaData {
  patientId: string;
  timestamp: Date;
  anesthetics: {
    isoflurane?: number; // vol%
    sevoflurane?: number;
    propofol?: number; // mg/kg/h
    remifentanil?: number; // μg/kg/min
  };
  gasMonitoring: {
    etCO2: number; // End-tidal CO2
    fiO2: number; // Fraction of inspired oxygen
    respiratoryRate: number;
    tidalVolume: number;
  };
  hemodynamics: VitalSigns;
  depthOfAnesthesia: {
    bis: number; // Bispectral Index
    entropy?: number;
  };
}

class AnesthesiaMonitoringSystem {
  private currentPatient?: string;
  private anesthesiaData: Map<string, AnesthesiaData[]> = new Map();
  private protocolManager: ProtocolManager;

  // 麻酔深度の自動調整提案
  suggestAnesthesiaAdjustment(data: AnesthesiaData): AdjustmentSuggestion | null {
    const bis = data.depthOfAnesthesia.bis;
    const hemodynamics = data.hemodynamics;

    // BIS値による麻酔深度判定
    if (bis < 40) {
      return {
        type: 'REDUCE_ANESTHESIA',
        reason: 'Deep anesthesia detected (BIS < 40)',
        suggestion: 'Consider reducing anesthetic agents',
        urgency: 'MEDIUM',
        parameters: {
          currentBIS: bis,
          targetBIS: '40-60',
          adjustment: 'Reduce by 10-20%'
        }
      };
    } else if (bis > 60) {
      // ただし、血行動態の安定性も考慮
      if (hemodynamics.heartRate > 100 || hemodynamics.bloodPressure.systolic > 140) {
        return {
          type: 'INCREASE_ANESTHESIA',
          reason: 'Light anesthesia with hemodynamic instability',
          suggestion: 'Consider increasing anesthetic depth',
          urgency: 'HIGH',
          parameters: {
            currentBIS: bis,
            targetBIS: '40-60',
            hemodynamics: `HR:${hemodynamics.heartRate}, BP:${hemodynamics.bloodPressure.systolic}/${hemodynamics.bloodPressure.diastolic}`
          }
        };
      }
    }

    return null;
  }

  // 術中覚醒の早期検知
  detectIntraoperativeAwareness(data: AnesthesiaData): AwarenessRisk {
    const bis = data.depthOfAnesthesia.bis;
    const heartRate = data.hemodynamics.heartRate;
    const bloodPressure = data.hemodynamics.bloodPressure.systolic;

    // 覚醒リスクの総合評価
    let riskScore = 0;

    // BIS値による評価
    if (bis > 60) riskScore += 3;
    else if (bis > 50) riskScore += 1;

    // 血行動態による評価
    if (heartRate > baseline.heartRate * 1.2) riskScore += 2;
    if (bloodPressure > baseline.systolic * 1.3) riskScore += 2;

    // 麻酔薬濃度による評価
    const totalAnestheticConcentration = this.calculateTotalAnestheticLoad(data.anesthetics);
    if (totalAnestheticConcentration < 0.8) riskScore += 2;

    return {
      riskLevel: this.calculateRiskLevel(riskScore),
      score: riskScore,
      factors: this.identifyRiskFactors(data),
      recommendations: this.generateRecommendations(riskScore, data)
    };
  }
}

interface AdjustmentSuggestion {
  type: 'INCREASE_ANESTHESIA' | 'REDUCE_ANESTHESIA' | 'MAINTAIN_CURRENT';
  reason: string;
  suggestion: string;
  urgency: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  parameters: Record<string, any>;
}

interface AwarenessRisk {
  riskLevel: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  score: number;
  factors: string[];
  recommendations: string[];
}

// DICOM画像管理・処理システム
interface DICOMStudy {
  studyInstanceUID: string;
  patientID: string;
  patientName: string;
  studyDate: Date;
  studyDescription: string;
  modality: Modality;
  series: DICOMSeries[];
  aiAnalysis?: AIAnalysisResult;
}

interface DICOMSeries {
  seriesInstanceUID: string;
  seriesNumber: number;
  seriesDescription: string;
  images: DICOMImage[];
  reconstructions?: ReconstructionData;
}

interface DICOMImage {
  sopInstanceUID: string;
  imageNumber: number;
  pixelData: ArrayBuffer;
  metadata: DICOMMetadata;
  annotations?: Annotation[];
}

enum Modality {
  CT = 'CT',
  MRI = 'MR',
  XRAY = 'CR',
  ULTRASOUND = 'US',
  MAMMOGRAPHY = 'MG',
  PET = 'PT',
  SPECT = 'NM'
}

class DICOMImageSystem {
  private pacs: PACSRepository;
  private aiEngine: MedicalAIEngine;
  private viewer: MedicalImageViewer;
  private reportingSystem: ReportingSystem;

  // AIによる画像解析
  async performAIAnalysis(study: DICOMStudy): Promise<AIAnalysisResult> {
    const analysisResults: AIAnalysisResult = {
      studyInstanceUID: study.studyInstanceUID,
      analysisDate: new Date(),
      findings: [],
      confidence: 0,
      recommendations: []
    };

    switch (study.modality) {
      case Modality.CT:
        analysisResults.findings.push(...await this.analyzeCTScan(study));
        break;
      case Modality.MRI:
        analysisResults.findings.push(...await this.analyzeMRIScan(study));
        break;
      case Modality.XRAY:
        analysisResults.findings.push(...await this.analyzeXRay(study));
        break;
      case Modality.MAMMOGRAPHY:
        analysisResults.findings.push(...await this.analyzeMammography(study));
        break;
    }

    // 総合的な信頼度の計算
    analysisResults.confidence = this.calculateOverallConfidence(analysisResults.findings);

    // 臨床的推奨事項の生成
    analysisResults.recommendations = this.generateClinicalRecommendations(analysisResults.findings);

    return analysisResults;
  }

  // CT画像の解析
  private async analyzeCTScan(study: DICOMStudy): Promise<AIFinding[]> {
    const findings: AIFinding[] = [];

    for (const series of study.series) {
      // 肺結節の検出
      const nodules = await this.aiEngine.detectPulmonaryNodules(series);
      findings.push(...nodules.map(nodule => ({
        type: 'PULMONARY_NODULE',
        location: nodule.location,
        confidence: nodule.confidence,
        measurements: {
          diameter: nodule.diameter,
          volume: nodule.volume,
          hounsfield: nodule.hounsfield
        },
        malignancyRisk: nodule.malignancyProbability,
        description: `${nodule.diameter}mm pulmonary nodule`,
        followUpRecommendation: this.getNodulelFollowUp(nodule)
      })));

      // 脳出血の検出（頭部CT）
      if (series.seriesDescription.includes('BRAIN') || series.seriesDescription.includes('HEAD')) {
        const hemorrhages = await this.aiEngine.detectICH(series);
        findings.push(...hemorrhages.map(hemorrhage => ({
          type: 'INTRACRANIAL_HEMORRHAGE',
          location: hemorrhage.location,
          confidence: hemorrhage.confidence,
          measurements: {
            volume: hemorrhage.volume,
            type: hemorrhage.subtype
          },
          severity: hemorrhage.severity,
          description: `${hemorrhage.subtype} hemorrhage in ${hemorrhage.location}`,
          followUpRecommendation: 'Immediate neurosurgical consultation'
        })));
      }

      // 肺塞栓の検出（造影CT）
      if (series.seriesDescription.includes('PE') || series.seriesDescription.includes('PULMONARY EMBOLISM')) {
        const emboli = await this.aiEngine.detectPulmonaryEmbolism(series);
        findings.push(...emboli.map(embolus => ({
          type: 'PULMONARY_EMBOLISM',
          location: embolus.location,
          confidence: embolus.confidence,
          measurements: {
            clotBurden: embolus.clotBurden,
            artery: embolus.affectedArtery
          },
          severity: embolus.severity,
          description: `Pulmonary embolism in ${embolus.location}`,
          followUpRecommendation: 'Immediate anticoagulation consideration'
        })));
      }
    }

    return findings;
  }

  // 重要所見の自動通知システム
  setupCriticalResultNotification(): void {
    this.aiEngine.onCriticalFinding().subscribe(finding => {
      // 緊急度の評価
      const urgency = this.evaluateUrgency(finding);

      if (urgency === 'CRITICAL') {
        // 即座の通知（5分以内）
        this.sendUrgentNotification(finding);

        // 自動的に放射線科医にアラート
        this.alertRadiologist(finding);

        // 主治医への緊急通知
        this.notifyAttendingPhysician(finding);

        // 緊急プロトコルの起動
        if (finding.type === 'INTRACRANIAL_HEMORRHAGE') {
          this.activateStrokeProtocol(finding);
        } else if (finding.type === 'PULMONARY_EMBOLISM') {
          this.activatePEProtocol(finding);
        }
      }
    });
  }

  // 3D画像再構成
  async generate3DReconstruction(series: DICOMSeries): Promise<ThreeDReconstruction> {
    // ボリュームレンダリング
    const volumeData = await this.processVolumeData(series.images);

    // サーフェスレンダリング
    const surfaceModel = await this.generateIsosurface(volumeData);

    // VR（バーチャルリアリティ）対応
    const vrCompatibleModel = await this.optimizeForVR(surfaceModel);

    return {
      volumeData,
      surfaceModel,
      vrModel: vrCompatibleModel,
      measurements: await this.generate3DMeasurements(surfaceModel),
      annotations: []
    };
  }

  // マルチモダリティ画像融合
  fuseMultimodalityImages(
    anatomicalSeries: DICOMSeries, // CT/MRI
    functionalSeries: DICOMSeries   // PET/SPECT
  ): Promise<FusedImageSet> {
    return this.aiEngine.performImageFusion({
      anatomical: anatomicalSeries,
      functional: functionalSeries,
      registrationMethod: 'RIGID_BODY',
      fusionMode: 'OVERLAY'
    });
  }
}

interface AIFinding {
  type: string;
  location: AnatomicalLocation;
  confidence: number;
  measurements: Record<string, any>;
  severity?: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  malignancyRisk?: number;
  description: string;
  followUpRecommendation: string;
}

interface AIAnalysisResult {
  studyInstanceUID: string;
  analysisDate: Date;
  findings: AIFinding[];
  confidence: number;
  recommendations: string[];
}

interface ThreeDReconstruction {
  volumeData: VolumeData;
  surfaceModel: SurfaceModel;
  vrModel: VRModel;
  measurements: ThreeDMeasurement[];
  annotations: Annotation[];
}

// 電子カルテシステムの実装例
interface ElectronicHealthRecord {
  patientId: string;
  medicalRecordNumber: string;
  encounters: Encounter[];
  diagnoses: Diagnosis[];
  medications: Medication[];
  allergies: Allergy[];
  vitalSigns: VitalSigns[];
  labResults: LabResult[];
  imaging: ImagingResult[];
  procedures: Procedure[];
  clinicalNotes: ClinicalNote[];
  advanceDirectives?: AdvanceDirective[];
}

interface Encounter {
  encounterId: string;
  patientId: string;
  encounterType: EncounterType;
  admissionDate: Date;
  dischargeDate?: Date;
  attendingPhysician: Physician;
  location: Location;
  chiefComplaint: string;
  status: EncounterStatus;
}

enum EncounterType {
  INPATIENT = 'inpatient',
  OUTPATIENT = 'outpatient',
  EMERGENCY = 'emergency',
  SURGERY = 'surgery',
  CONSULTATION = 'consultation'
}

class ElectronicHealthRecordSystem {
  private ehrRepository: EHRRepository;
  private clinicalDecisionSupport: CDSEngine;
  private interoperabilityEngine: InteroperabilityEngine;
  private auditLogger: AuditLogger;

  constructor() {
    this.ehrRepository = new EHRRepository();
    this.clinicalDecisionSupport = new CDSEngine();
    this.interoperabilityEngine = new InteroperabilityEngine();
    this.auditLogger = new AuditLogger();
    this.setupClinicalDecisionSupport();
  }

  // 臨床意思決定支援システム
  private setupClinicalDecisionSupport(): void {
    // 薬物相互作用の監視
    this.clinicalDecisionSupport.onMedicationOrder().subscribe(order => {
      const patient = this.ehrRepository.getPatient(order.patientId);
      const interactions = this.checkDrugInteractions(order, patient.medications);

      if (interactions.severity === 'HIGH' || interactions.severity === 'CRITICAL') {
        this.sendClinicalAlert({
          type: 'DRUG_INTERACTION',
          severity: interactions.severity,
          message: interactions.description,
          patientId: order.patientId,
          physianId: order.prescriberId,
          recommendations: interactions.alternatives
        });
      }
    });

    // アレルギー反応の監視
    this.clinicalDecisionSupport.onMedicationOrder().subscribe(order => {
      const patient = this.ehrRepository.getPatient(order.patientId);
      const allergyCheck = this.checkAllergies(order.medication, patient.allergies);

      if (allergyCheck.hasContraindication) {
        this.sendClinicalAlert({
          type: 'ALLERGY_CONTRAINDICATION',
          severity: 'CRITICAL',
          message: `Patient has known allergy to ${allergyCheck.allergen}`,
          patientId: order.patientId,
          physianId: order.prescriberId,
          recommendations: ['Consider alternative medication', 'Verify allergy history']
        });
      }
    });

    // 異常検査値の監視
    this.clinicalDecisionSupport.onLabResult().subscribe(result => {
      const abnormalValues = this.identifyAbnormalValues(result);

      abnormalValues.forEach(abnormal => {
        if (abnormal.severity === 'CRITICAL') {
          this.sendClinicalAlert({
            type: 'CRITICAL_LAB_VALUE',
            severity: 'CRITICAL',
            message: `Critical ${abnormal.test}: ${abnormal.value} ${abnormal.unit}`,
            patientId: result.patientId,
            recommendations: abnormal.recommendations
          });
        }
      });
    });
  }

  // 薬物相互作用チェック
  private checkDrugInteractions(newOrder: MedicationOrder, currentMedications: Medication[]): DrugInteractionResult {
    const interactions: DrugInteraction[] = [];

    for (const currentMed of currentMedications) {
      if (currentMed.status === 'ACTIVE') {
        const interaction = this.clinicalDecisionSupport.checkInteraction(
          newOrder.medication.code,
          currentMed.code
        );

        if (interaction) {
          interactions.push(interaction);
        }
      }
    }

    // 最も重篤な相互作用のレベルを採用
    const severity = this.getHighestSeverity(interactions);

    return {
      hasInteractions: interactions.length > 0,
      severity,
      interactions,
      description: this.generateInteractionDescription(interactions),
      alternatives: this.suggestAlternatives(newOrder.medication, interactions)
    };
  }

  // 総合的な患者リスク評価
  assessPatientRisk(patientId: string): Promise<RiskAssessment> {
    return this.ehrRepository.getCompleteRecord(patientId).then(ehr => {
      const riskFactors = [];

      // 年齢リスク
      const age = this.calculateAge(ehr.patient.birthDate);
      if (age > 65) riskFactors.push({ factor: 'ADVANCED_AGE', score: Math.min((age - 65) / 5, 5) });

      // 併存疾患リスク（Charlson Comorbidity Index）
      const charlsonScore = this.calculateCharlsonScore(ehr.diagnoses);
      riskFactors.push({ factor: 'COMORBIDITIES', score: charlsonScore });

      // 薬剤リスク
      const medicationRisk = this.assessMedicationRisk(ehr.medications);
      riskFactors.push({ factor: 'MEDICATIONS', score: medicationRisk.score });

      // 最近の検査値異常
      const recentLabs = this.getRecentLabResults(ehr.labResults, 30); // 30日以内
      const labRisk = this.assessLabRisk(recentLabs);
      riskFactors.push({ factor: 'LABORATORY', score: labRisk.score });

      // 入院歴
      const hospitalizationRisk = this.assessHospitalizationRisk(ehr.encounters);
      riskFactors.push({ factor: 'HOSPITALIZATION_HISTORY', score: hospitalizationRisk });

      const totalScore = riskFactors.reduce((sum, rf) => sum + rf.score, 0);

      return {
        patientId,
        assessmentDate: new Date(),
        totalRiskScore: totalScore,
        riskLevel: this.categorizeRiskLevel(totalScore),
        riskFactors,
        recommendations: this.generateRiskRecommendations(riskFactors),
        nextAssessmentDate: this.calculateNextAssessmentDate(totalScore)
      };
    });
  }

  // 医療品質指標の監視
  monitorQualityIndicators(): Observable<QualityMetric> {
    return interval(3600000).pipe( // 1時間間隔
      mergeMap(() => this.calculateQualityMetrics())
    );
  }

  private async calculateQualityMetrics(): Promise<QualityMetric[]> {
    const metrics: QualityMetric[] = [];

    // 30日再入院率
    const readmissionRate = await this.calculate30DayReadmissionRate();
    metrics.push({
      type: 'THIRTY_DAY_READMISSION',
      value: readmissionRate.rate,
      target: 15.0, // 目標値15%未満
      period: { start: readmissionRate.period.start, end: readmissionRate.period.end },
      trend: readmissionRate.trend
    });

    // 院内感染率
    const infectionRate = await this.calculateInfectionRate();
    metrics.push({
      type: 'HEALTHCARE_ASSOCIATED_INFECTION',
      value: infectionRate.rate,
      target: 2.0, // 目標値2%未満
      period: infectionRate.period,
      breakdown: infectionRate.byType
    });

    // 薬剤有害事象
    const adeRate = await this.calculateADERate();
    metrics.push({
      type: 'ADVERSE_DRUG_EVENT',
      value: adeRate.rate,
      target: 5.0, // 目標値5%未満
      period: adeRate.period,
      severity: adeRate.severityDistribution
    });

    return metrics;
  }

  // FHIR準拠データ交換
  exportFHIRResource(patientId: string, resourceType: FHIRResourceType): Promise<FHIRResource> {
    return this.interoperabilityEngine.convertToFHIR(patientId, resourceType);
  }

  importFHIRResource(fhirResource: FHIRResource): Promise<ImportResult> {
    // FHIR形式データを内部形式に変換
    const convertedData = this.interoperabilityEngine.convertFromFHIR(fhirResource);

    // データ検証
    const validationResult = this.validateIncomingData(convertedData);
    if (!validationResult.isValid) {
      throw new Error(`Invalid FHIR data: ${validationResult.errors.join(', ')}`);
    }

    // データの統合
    return this.ehrRepository.mergeExternalData(convertedData);
  }
}

interface DrugInteractionResult {
  hasInteractions: boolean;
  severity: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  interactions: DrugInteraction[];
  description: string;
  alternatives: AlternativeMedication[];
}

interface RiskAssessment {
  patientId: string;
  assessmentDate: Date;
  totalRiskScore: number;
  riskLevel: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  riskFactors: RiskFactor[];
  recommendations: string[];
  nextAssessmentDate: Date;
}

interface QualityMetric {
  type: string;
  value: number;
  target: number;
  period: { start: Date; end: Date };
  trend?: 'IMPROVING' | 'STABLE' | 'WORSENING';
  breakdown?: Record<string, number>;
  severity?: Record<string, number>;
}

// 遠隔医療プラットフォームの実装例
interface TelehealthSession {
  sessionId: string;
  patientId: string;
  providerId: string;
  sessionType: SessionType;
  scheduledTime: Date;
  actualStartTime?: Date;
  endTime?: Date;
  status: SessionStatus;
  connectionQuality: ConnectionQuality;
  recordedData?: RecordedSessionData;
  clinicalNotes?: string;
  followUpRequired?: boolean;
}

enum SessionType {
  CONSULTATION = 'consultation',
  FOLLOW_UP = 'follow_up',
  MEDICATION_REVIEW = 'medication_review',
  THERAPY = 'therapy',
  EMERGENCY = 'emergency',
  MONITORING = 'monitoring'
}

enum SessionStatus {
  SCHEDULED = 'scheduled',
  WAITING = 'waiting',
  IN_PROGRESS = 'in_progress',
  COMPLETED = 'completed',
  CANCELLED = 'cancelled',
  NO_SHOW = 'no_show'
}

interface RemoteMonitoringDevice {
  deviceId: string;
  patientId: string;
  deviceType: DeviceType;
  lastSync: Date;
  batteryLevel: number;
  connectionStatus: 'CONNECTED' | 'DISCONNECTED' | 'LOW_SIGNAL';
  calibrationDate: Date;
  nextMaintenanceDate: Date;
}

enum DeviceType {
  BLOOD_PRESSURE_MONITOR = 'blood_pressure',
  GLUCOSE_METER = 'glucose_meter',
  PULSE_OXIMETER = 'pulse_oximeter',
  WEIGHT_SCALE = 'weight_scale',
  ECG_MONITOR = 'ecg_monitor',
  ACTIVITY_TRACKER = 'activity_tracker',
  MEDICATION_DISPENSER = 'medication_dispenser'
}

class TelehealthPlatform {
  private sessionManager: SessionManager;
  private deviceManager: DeviceManager;
  private clinicalAI: ClinicalAIEngine;
  private emergencyProtocol: EmergencyProtocol;

  constructor() {
    this.sessionManager = new SessionManager();
    this.deviceManager = new DeviceManager();
    this.clinicalAI = new ClinicalAIEngine();
    this.emergencyProtocol = new EmergencyProtocol();
    this.setupRemoteMonitoring();
  }

  // リモート監視の設定
  private setupRemoteMonitoring(): void {
    // デバイスデータの自動収集
    this.deviceManager.onDataReceived().subscribe(deviceData => {
      this.processRemoteMonitoringData(deviceData);
    });

    // 緊急事態の自動検知
    this.clinicalAI.onCriticalAlertGenerated().subscribe(alert => {
      this.handleCriticalAlert(alert);
    });

    // 薬剤遵守の監視
    this.monitorMedicationAdherence().subscribe(adherenceData => {
      if (adherenceData.adherenceRate < 0.8) { // 80%未満
        this.scheduleAdherenceCounseling(adherenceData.patientId);
      }
    });
  }

  // リモート監視データの処理
  private processRemoteMonitoringData(deviceData: DeviceData): void {
    // データの妥当性検証
    const validationResult = this.validateDeviceData(deviceData);
    if (!validationResult.isValid) {
      this.logDataError(deviceData, validationResult.errors);
      return;
    }

    // 患者の基準値と比較
    const patientBaseline = this.getPatientBaseline(deviceData.patientId, deviceData.type);
    const analysis = this.analyzeAgainstBaseline(deviceData, patientBaseline);

    // 傾向分析
    const trendAnalysis = this.analyzeTrends(deviceData);

    // 臨床的意思決定支援
    const recommendations = this.clinicalAI.generateRecommendations({
      deviceData,
      baselineComparison: analysis,
      trendAnalysis,
      patientHistory: this.getPatientHistory(deviceData.patientId)
    });

    // 必要に応じてアラート生成
    if (analysis.isSignificantDeviation || trendAnalysis.hasWorseningTrend) {
      this.generateClinicalAlert({
        patientId: deviceData.patientId,
        alertType: 'REMOTE_MONITORING_ALERT',
        severity: this.determineSeverity(analysis, trendAnalysis),
        message: this.generateAlertMessage(deviceData, analysis, trendAnalysis),
        recommendations: recommendations,
        requiresImmediateAction: analysis.isCritical || trendAnalysis.isCritical
      });
    }

    // データストアに保存
    this.storeMonitoringData(deviceData, analysis, trendAnalysis);
  }

  // バーチャル診療の実施
  async conductVirtualConsultation(sessionId: string): Promise<ConsultationResult> {
    const session = await this.sessionManager.getSession(sessionId);

    // 患者の事前問診データを取得
    const preVisitData = await this.getPreVisitQuestionnaire(session.patientId);

    // リモート監視データの統合
    const recentMonitoringData = await this.getRecentMonitoringData(session.patientId, 7); // 7日間

    // AI支援診断の準備
    const aiPreliminaryAssessment = await this.clinicalAI.generatePreliminaryAssessment({
      patient: await this.getPatientRecord(session.patientId),
      preVisitData,
      monitoringData: recentMonitoringData,
      chiefComplaint: preVisitData.chiefComplaint
    });

    // セッション開始
    await this.sessionManager.startSession(sessionId);

    // リアルタイム支援情報を医療従事者に提供
    const supportData: RealTimeSupportData = {
      patientSummary: this.generatePatientSummary(session.patientId),
      aiSuggestions: aiPreliminaryAssessment.suggestions,
      differentialDiagnoses: aiPreliminaryAssessment.differentialDiagnoses,
      recommendedQuestions: aiPreliminaryAssessment.recommendedQuestions,
      riskFactors: aiPreliminaryAssessment.riskFactors
    };

    return {
      sessionId,
      duration: Date.now() - session.actualStartTime!.getTime(),
      clinicalFindings: aiPreliminaryAssessment.findings,
      diagnosis: aiPreliminaryAssessment.workingDiagnosis,
      treatmentPlan: aiPreliminaryAssessment.treatmentPlan,
      followUpRequired: this.assessFollowUpNeed(aiPreliminaryAssessment),
      prescriptions: aiPreliminaryAssessment.prescriptions,
      nextAppointment: this.scheduleNextAppointment(session.patientId, aiPreliminaryAssessment)
    };
  }

  // 在宅モニタリングアラートシステム
  private handleCriticalAlert(alert: CriticalAlert): void {
    switch (alert.severity) {
      case 'CRITICAL':
        // 即座の介入が必要
        this.emergencyProtocol.activate(alert);
        this.notifyEmergencyServices(alert);
        this.alertPrimaryCareProvider(alert);
        break;

      case 'HIGH':
        // 24時間以内の評価が必要
        this.schedulePriorityConsultation(alert.patientId);
        this.alertPrimaryCareProvider(alert);
        break;

      case 'MEDIUM':
        // 医療従事者による評価が必要
        this.addToProviderReviewQueue(alert);
        break;

      case 'LOW':
        // 継続監視
        this.logForTrendAnalysis(alert);
        break;
    }
  }

  // 遠隔リハビリテーション支援
  async supportRemoteRehabilitation(patientId: string): Promise<RehabilitationPlan> {
    const patient = await this.getPatientRecord(patientId);
    const condition = patient.primaryCondition;
    const functionalStatus = await this.assessFunctionalStatus(patientId);

    // 个人化されたリハビリプログラムの生成
    const programs = await this.clinicalAI.generateRehabProgram({
      condition,
      functionalStatus,
      patientPreferences: await this.getPatientPreferences(patientId),
      homeEnvironment: await this.getHomeEnvironmentData(patientId)
    });

    // VR/ARを活用したエクササイズの提案
    const immersiveExercises = await this.generateImmersiveExercises(condition, functionalStatus);

    // 進捗追跡システムの設定
    this.setupProgressTracking(patientId, programs);

    return {
      patientId,
      programs,
      immersiveExercises,
      milestone: this.defineMilestones(condition, functionalStatus),
      trackingMetrics: this.defineTrackingMetrics(programs),
      reviewSchedule: this.createReviewSchedule(condition)
    };
  }

  // 薬剤遵守監視
  private monitorMedicationAdherence(): Observable<MedicationAdherenceData> {
    return interval(86400000).pipe( // 24時間間隔
      mergeMap(() => this.calculateAdherence())
    );
  }

  private async calculateAdherence(): Promise<MedicationAdherenceData[]> {
    const activePatients = await this.getActivePatientsWithMedications();
    const adherenceData: MedicationAdherenceData[] = [];

    for (const patient of activePatients) {
      const expectedDoses = await this.getExpectedDoses(patient.id, 30); // 30日間
      const actualDoses = await this.getRecordedDoses(patient.id, 30);

      const adherenceRate = actualDoses.length / expectedDoses.length;
      const missedDoses = expectedDoses.filter(expected => 
        !actualDoses.some(actual => 
          this.isWithinTimeWindow(actual.timestamp, expected.timestamp, 3600000) // 1時間の許容範囲
        )
      );

      adherenceData.push({
        patientId: patient.id,
        period: { start: new Date(Date.now() - 30 * 86400000), end: new Date() },
        adherenceRate,
        expectedDoses: expectedDoses.length,
        actualDoses: actualDoses.length,
        missedDoses: missedDoses.length,
        patterns: this.identifyNonAdherencePatterns(actualDoses, expectedDoses),
        interventions: this.suggestAdherenceInterventions(adherenceRate, missedDoses)
      });
    }

    return adherenceData;
  }
}

interface DeviceData {
  deviceId: string;
  patientId: string;
  type: DeviceType;
  timestamp: Date;
  values: Record<string, number>;
  qualityIndicators?: QualityIndicator;
}

interface ConsultationResult {
  sessionId: string;
  duration: number;
  clinicalFindings: ClinicalFinding[];
  diagnosis?: string;
  treatmentPlan: TreatmentPlan;
  followUpRequired: boolean;
  prescriptions?: Prescription[];
  nextAppointment?: Date;
}

interface CriticalAlert {
  alertId: string;
  patientId: string;
  deviceType: DeviceType;
  alertType: string;
  severity: 'LOW' | 'MEDIUM' | 'HIGH' | 'CRITICAL';
  message: string;
  detectedAt: Date;
  requiresImmediateAction: boolean;
  suggestedActions: string[];
}

interface MedicationAdherenceData {
  patientId: string;
  period: { start: Date; end: Date };
  adherenceRate: number;
  expectedDoses: number;
  actualDoses: number;
  missedDoses: number;
  patterns: NonAdherencePattern[];
  interventions: AdherenceIntervention[];
}

// 救急指令システムの実装例
interface EmergencyCall {
  callId: string;
  timestamp: Date;
  callerInformation: CallerInfo;
  location: EmergencyLocation;
  incidentType: IncidentType;
  severity: TriageSeverity;
  symptoms: string[];
  dispatchedUnits: DispatchedUnit[];
  status: EmergencyCallStatus;
  clinicalNotes?: string;
  outcome?: EmergencyOutcome;
}

interface EmergencyLocation {
  address: string;
  coordinates: { latitude: number; longitude: number };
  landmark?: string;
  accessInstructions?: string;
  hazards?: string[];
}

enum IncidentType {
  CARDIAC_ARREST = 'cardiac_arrest',
  BREATHING_DIFFICULTY = 'breathing_difficulty',
  CHEST_PAIN = 'chest_pain',
  STROKE = 'stroke',
  TRAUMA = 'trauma',
  UNCONSCIOUS = 'unconscious',
  ALLERGIC_REACTION = 'allergic_reaction',
  OVERDOSE = 'overdose',
  PSYCHIATRIC = 'psychiatric',
  BURNS = 'burns',
  OTHER = 'other'
}

enum TriageSeverity {
  RED = 'red',      // 生命に関わる緊急事態
  ORANGE = 'orange', // 重篤、迅速な対応が必要
  YELLOW = 'yellow', // 緊急だが安定
  GREEN = 'green',   // 非緊急
  BLACK = 'black'    // 救命不可能
}

class EmergencyDispatchSystem {
  private callCenter: CallCenter;
  private dispatchManager: DispatchManager;
  private triageAI: TriageAIEngine;
  private resourceManager: EmergencyResourceManager;
  private hospitalNetworkManager: HospitalNetworkManager;

  constructor() {
    this.callCenter = new CallCenter();
    this.dispatchManager = new DispatchManager();
    this.triageAI = new TriageAIEngine();
    this.resourceManager = new EmergencyResourceManager();
    this.hospitalNetworkManager = new HospitalNetworkManager();
    this.setupEmergencyResponse();
  }

  // 緊急通報の受付と処理
  async handleEmergencyCall(incomingCall: IncomingCall): Promise<EmergencyCall> {
    // 即座の位置特定
    const location = await this.determineLocation(incomingCall);

    // AIによる初期トリアージ
    const aiTriage = await this.triageAI.performInitialTriage({
      callerInput: incomingCall.audioTranscript,
      location,
      callerDemographics: incomingCall.callerInfo
    });

    // 緊急通報の作成
    const emergencyCall: EmergencyCall = {
      callId: generateUUID(),
      timestamp: new Date(),
      callerInformation: incomingCall.callerInfo,
      location,
      incidentType: aiTriage.incidentType,
      severity: aiTriage.severity,
      symptoms: aiTriage.identifiedSymptoms,
      dispatchedUnits: [],
      status: EmergencyCallStatus.RECEIVED,
      clinicalNotes: aiTriage.notes
    };

    // 緊急度に基づく即座の対応
    if (aiTriage.severity === TriageSeverity.RED) {
      this.activateImmediateResponse(emergencyCall);
    }

    // 最適な緊急車両の選択と派遣
    const dispatchDecision = await this.optimizeDispatch(emergencyCall);
    emergencyCall.dispatchedUnits = dispatchDecision.units;

    // 病院への事前連絡
    await this.notifyReceivingHospitals(emergencyCall, dispatchDecision);

    // コールの記録と追跡開始
    await this.callCenter.recordCall(emergencyCall);
    this.startCallTracking(emergencyCall.callId);

    return emergencyCall;
  }

  // AIによるトリアージシステム
  private async performAITriage(callData: CallData): Promise<TriageResult> {
    // 音声認識による症状抽出
    const symptoms = await this.triageAI.extractSymptoms(callData.audioTranscript);

    // 症状ベースの重症度評価
    const severityScore = this.triageAI.calculateSeverityScore(symptoms);

    // 年齢・性別・既往歴を考慮した修正
    const adjustedScore = this.adjustForRiskFactors(severityScore, callData.demographics);

    // 緊急度の決定
    const triageSeverity = this.determinePriority(adjustedScore);

    // 推奨プロトコルの生成
    const protocol = this.triageAI.getRecommendedProtocol(symptoms, triageSeverity);

    return {
      incidentType: this.classifyIncident(symptoms),
      severity: triageSeverity,
      identifiedSymptoms: symptoms,
      severityScore: adjustedScore,
      confidence: this.triageAI.getConfidenceLevel(),
      recommendedProtocol: protocol,
      notes: this.generateTriageNotes(symptoms, triageSeverity)
    };
  }

  // 最適化された救急車の派遣
  private async optimizeDispatch(emergencyCall: EmergencyCall): Promise<DispatchDecision> {
    // 利用可能な救急車両の取得
    const availableAmbulances = await this.resourceManager.getAvailableAmbulances(emergencyCall.location);

    // 各車両の到着予想時間計算
    const arrivalEstimates = await Promise.all(
      availableAmbulances.map(ambulance => 
        this.calculateArrivalTime(ambulance, emergencyCall.location)
      )
    );

    // 最適化アルゴリズム（時間、専門性、装備を考慮）
    const optimization = this.optimizeAmbulanceSelection({
      call: emergencyCall,
      ambulances: availableAmbulances,
      arrivalTimes: arrivalEstimates,
      hospitalDistances: await this.calculateHospitalDistances(emergencyCall.location)
    });

    // 最適救急車の選択
    const selectedAmbulance = optimization.primaryAmbulance;
    const backupAmbulance = optimization.backupAmbulance;

    // 救急車の派遣
    await this.dispatchManager.deployAmbulance(selectedAmbulance, emergencyCall);

    // 必要に応じてバックアップも派遣
    if (emergencyCall.severity === TriageSeverity.RED && backupAmbulance) {
      await this.dispatchManager.deployAmbulance(backupAmbulance, emergencyCall);
    }

    return {
      units: [
        {
          ambulanceId: selectedAmbulance.id,
          role: 'PRIMARY',
          estimatedArrival: optimization.primaryArrival,
          dispatchTime: new Date()
        },
        ...(backupAmbulance ? [{
          ambulanceId: backupAmbulance.id,
          role: 'BACKUP',
          estimatedArrival: optimization.backupArrival,
          dispatchTime: new Date()
        }] : [])
      ],
      route: optimization.optimalRoute,
      specialInstructions: optimization.instructions
    };
  }

  // リアルタイム追跡と監視
  setupRealTimeTracking(): void {
    // 救急車の位置追跡
    this.resourceManager.trackAmbulanceLocations().subscribe(locationUpdate => {
      this.updateETACalculations(locationUpdate);
      this.notifyStakeholders(locationUpdate);
    });

    // 病院受け入れ準備状況の監視
    this.hospitalNetworkManager.monitorBedAvailability().subscribe(availability => {
      this.updateHospitalRecommendations(availability);
    });

    // 交通状況の監視
    this.monitorTrafficConditions().subscribe(trafficData => {
      this.adjustRoutesForTraffic(trafficData);
    });
  }

  // 病院ネットワークとの統合
  private async selectOptimalHospital(emergencyCall: EmergencyCall): Promise<HospitalSelection> {
    const criteria = {
      incidentType: emergencyCall.incidentType,
      severity: emergencyCall.severity,
      patientLocation: emergencyCall.location,
      specialtyRequired: this.determineSpecialtyNeeds(emergencyCall)
    };

    // 利用可能な病院の取得
    const availableHospitals = await this.hospitalNetworkManager.getAvailableHospitals(criteria);

    // 各病院の評価
    const hospitalScores = availableHospitals.map(hospital => ({
      hospital,
      score: this.scoreHospital(hospital, criteria),
      eta: this.calculateHospitalETA(emergencyCall.location, hospital.location),
      bedAvailability: hospital.currentCapacity,
      specialistAvailability: hospital.specialistCoverage
    }));

    // 最適病院の選択
    const optimalHospital = hospitalScores.reduce((best, current) => 
      current.score > best.score ? current : best
    );

    return {
      primaryHospital: optimalHospital.hospital,
      alternativeHospitals: hospitalScores.slice(0, 3).map(hs => hs.hospital),
      estimatedArrival: optimalHospital.eta,
      notificationSent: await this.notifyHospital(optimalHospital.hospital, emergencyCall)
    };
  }

  // 大規模災害対応モード
  activateDisasterResponse(disasterEvent: DisasterEvent): Promise<DisasterResponse> {
    return new Promise(async (resolve) => {
      // 災害対応モードの有効化
      this.resourceManager.activateDisasterMode();

      // 追加リソースの要請
      const additionalResources = await this.requestAdditionalResources(disasterEvent);

      // トリアージプロトコルの変更
      this.triageAI.switchToDisasterTriage();

      // 病院ネットワークの協調
      const hospitalCoordination = await this.coordinateHospitalNetwork(disasterEvent);

      // 代替医療施設の活用
      const fieldHospitals = await this.setupFieldHospitals(disasterEvent);

      // リソース配分の最適化
      const resourceAllocation = this.optimizeDisasterResources({
        event: disasterEvent,
        additionalResources,
        hospitalCoordination,
        fieldHospitals
      });

      resolve({
        mode: 'DISASTER_RESPONSE',
        additionalResources,
        hospitalCoordination,
        fieldHospitals,
        resourceAllocation,
        activatedAt: new Date()
      });
    });
  }

  // パフォーマンス指標の監視
  monitorPerformanceMetrics(): Observable<EmergencyPerformanceMetrics> {
    return interval(300000).pipe( // 5分間隔
      map(() => ({
        averageResponseTime: this.calculateAverageResponseTime(),
        callVolume: this.getCurrentCallVolume(),
        triageAccuracy: this.calculateTriageAccuracy(),
        resourceUtilization: this.calculateResourceUtilization(),
        hospitalDiversionRate: this.calculateDiversionRate(),
        patientOutcomes: this.analyzePatientOutcomes()
      }))
    );
  }
}

interface TriageResult {
  incidentType: IncidentType;
  severity: TriageSeverity;
  identifiedSymptoms: string[];
  severityScore: number;
  confidence: number;
  recommendedProtocol: EmergencyProtocol;
  notes: string;
}

interface DispatchDecision {
  units: DispatchedUnit[];
  route: RouteInformation;
  specialInstructions: string[];
}

interface DispatchedUnit {
  ambulanceId: string;
  role: 'PRIMARY' | 'BACKUP' | 'SPECIALTY';
  estimatedArrival: Date;
  dispatchTime: Date;
}

interface EmergencyPerformanceMetrics {
  averageResponseTime: number; // minutes
  callVolume: number;
  triageAccuracy: number; // percentage
  resourceUtilization: number; // percentage
  hospitalDiversionRate: number; // percentage
  patientOutcomes: OutcomeAnalysis;
}