Telehealthcare for older people with comorbidity: lessons from eCAALYXand project walk-through
@Telehealthcare for older people with comorbidity: lessons from eCAALYX and project walk-throughMaged N. Kamel Boulos, MBBCh, MSc, PhD, SMIEEE Plymouth University, UK firstname.lastname@example.org
Agenda• Introduction: about comorbidity in older people and the eCAALYX project• Lessons learned during the course of the project*• Project walk-through• Evaluation (brief notes)• Acknowledgments * For a much more detailed discussion of these lessons, see: Gálvez-Barrón CP, Kamel Boulos MN, Prescher S, Abellán Cano C, Suárez Ortega E, Font Tió A, Morales Gras J, ODonovan K, Díaz Boladeras M, Köhler F, Rodríguez- Molinero A. Telemedicine scenario for elderly people with comorbidity. Book chapter to appear in: Garcia NM, Rodrigues JPC, Sales Dias M, Elias D (Editors). Ambient Assisted Living. Taylor and Francis / CRC Press (USA), due 2013. http://allab.it.ubi.pt/images/documents/aalbook2011.pdf
Introduction—comorbidity• The negative social and economic impacts of population ageing are mainly due to the concurrent comorbidity in older people rather than to ageing per se.
Introduction—comorbidity• A comorbid condition is defined as either a medical condition existing simultaneously but independently with another condition in a patient, or as a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient.• According to Valderas et al. (2009), the mechanisms that underlie the coexistence of two or more conditions in a patient include direct causation, associated risk factors, heterogeneity, and independence.• Comorbidity is associated with worse health outcomes, more complex clinical management, and increased healthcare costs.*Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications forunderstanding health and health services. Annals of Family Medicine. 2009; 7 (4):357–63.http://dx.doi.org/10.1370/afm.983
Introduction—comorbidity• The interplay between different conditions – often apparently unrelated (e.g., arthritis and heart disease) – may have consequences that are not always simply summational (e.g., worse motor disability or reduced mobility in the case of arthritis coexisting with heart disease).• Healthcare costs increase with the increase in age and number of coexisting diseases; however, the increase is very much higher in persons with chronic conditions compared to persons without chronic conditions.• The number of conditions coexisting in a person influences healthcare costs more than age; thus, healthcare costs for a relatively young person aged 65-69 with two associated chronic conditions are significantly higher than those for a person over 85 years with one associated chronic condition. In other words, healthcare costs for a person aged 65-69 with one associated chronic condition rise more when the person develops a second associated chronic condition than as the person just gets older. Thus, the comorbidity affecting a person as they get older is more relevant than their natural ageing per se.* * Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269-2276.
Introduction—eCAALYX• The European-funded eCAALYX project (Enhanced Complete Ambient Assisted Living Experiment, 2009 – 2012; funded under the Ambient Assisted Living Joint Programme - http://ecaalyx.org/) is building on the strengths and experience acquired in the original European-funded CAALYX project (Complete Ambient Assisted Living Experiment, 2007 – 2008; funded under the Sixth Framework Programme).• eCAALYX takes the 24/7 monitoring of the health and well- being of healthy older people that was developed in CAALYX (with special emphasis on outdoors/mobile scenarios) one step further by refining it and making it available to older people with comorbidity (with additional strong emphasis on home-based care and lifestyle management components).
CAALYX (2007-2008, FP6) and eCAALYX (2009-2012, AAL) are two recent examples of EU-funded e/mHealth projects to develop next-generation home and outdoors 24/7 health telemonitoring/telehealthcare services for older people, including, (in eCAALYX), older patients with comorbidity. The Internet and smarphones are central to delivering these services. Sensorshttp://caalyx.eu/http://ecaalyx.org/ ECG Sensor GPS Web Serviceshttp://caalyx-mv.eu/ (2011-2014, FP7) Caretaker Site Blood Pressure Meter Internet Internet Bluetooth Fall SensorPlymouth University (PU) is full research partner in bothprojects (PU P.I.: MN Kamel Boulos, grant holder of a totalof €173,005.00 for PU’s involvement in both projects).
• In services such as CAALYX and eCAALYX, the main process consists of periodically (or continuously, as necessary): – acquiring vital signs (body temperature, pulse and respiratory rates, blood pressure) and other clinical and non-clinical signals and data (e.g., ECG, blood glucose level, saturation of peripheral oxygen, body weight, activity monitoring, person’s location via GPS, etc.), – recording them locally (while the user is at home or outdoors), – analysing them, and – communicating them as necessary (e.g., when the system suspects an unfolding emergency) to a remote telehealthcare centre, where the data are made available to a specialist or healthcare professional for further action.
• The devices used most frequently in such applications to measure clinical/biochemical parameters and signals are pulse oximeters, blood pressure meters, ECG monitors, glucose meters, digital scales, movement and fall detection sensors (accelerometers), etc.• These devices can be fixed somewhere at home, but it is increasingly common for them these days to be made wireless or “wearable” (with sensors incorporated into clothing, bracelets, etc.), which makes their use more comfortable and transparent.• These collections of sensors around a person or patient make up what we call a Body Area Network (BAN) or Personal Area Network (PAN).
Lessons learned• In the next slides we will briefly present some practical lessons we have learned during the course of the eCAALYX project that could also be generalised to other telehealthcare solutions to ensure their success.• The lessons cover the clinical scope and requirements of telehealthcare services for older people with comorbidity; service configurability (clinical) on a per-individual-patient basis; clinical information management; user-centred design (for older patients, their carers and clinicians); and service sustainability, interoperability and expandability as part of a growing telehealthcare ecosystem; among other clinical, technological and organisational issues (that are not fully covered in these slides, e.g., patient privacy issues).
Desirable clinical scope of telehealthcareservices for older people with comorbidity• Currently, many telehealthcare projects are exclusively aimed at monitoring a single disease such as diabetes, cardiac insufficiency or chronic respiratory disease.• However, such an approach is not practical, cost effective or sustainable, as one of the characteristics of older populations is that they often suffer from more than one chronic, major illness (pluripathology).• This means that telehealthcare systems must be able to monitor several major diseases simultaneously (if they are to become viable and sustainable solutions).
Desirable clinical scope of telehealthcareservices for older people with comorbidity• Cardiovascular, chronic respiratory and osteoarticular diseases have the greatest impact on the elderly in terms of survival, dependency and hospitalisation, and should thus be considered ‘high priority’ when deciding on conditions to cover by a given telehealthcare service.• Telehealthcare systems must be principally aimed at the secondary and tertiary prevention of disease.• The elderly population’s demand for assistance or healthcare services may increase through reasons that are not strictly clinical but are rather of a social nature. In this regard, telehealthcare services can and should be conceived as a useful tool for integration and cooperation between healthcare and social care services (this integration also requires significant organisational changes/change mngmnt).
Other desirable clinical requirements in telehealthcare services for older people with comorbidity• The telehealthcare service should be available continuously for patients on a 24/7 basis.• The relevant clinical information required to monitor the health of an older person includes not only vital physiological signs (heart and respiratory rates, blood pressure, body temperature, etc.), but also information about the person’s functional status, affective state, and pain levels, amongst other data. This equally important information can be gathered through questionnaires or rating scales normally used in clinical practice, but administered in a telematic manner.• Telehealthcare systems must have great plasticity, flexibility and configurability due to the wide variability within patients’ clinical profiles and diseases. A patient’s doctor should be able to configure the system according to the patient’s (and doctor’s) choice of devices/sensors, observation schedules (or patterns) and alert levels.
Clinical configurability: 1 Observation Template remotely editing ObservationSteps *observation patterns on a Observation Template per-patient basis and Get User Profile prescribing/configuring Send Observation new sensors in eCAALYX Medical Observation Type +Report +Health State Classification Observation +Measurements that lead to Conclusion Caretaker Site Observation Measurements 1 *
Other desirable clinical requirements in telehealthcare services for older people with comorbidity• Clinical information management: Submission and assessment of “raw” measurements obtained through the devices can result in information overload or raise false alarms among healthcare providers. Telehealthcare systems should therefore carry out a preliminary processing of the information gathered by sensors (e.g., through the use of properly validated medical algorithms), so that they may only warn of relevant clinical situations.• Telehealthcare systems should be viewed, designed and promoted not as replacing clinicians, but as a tool to aid them in their work and one that seamlessly integrates into their existing clinical workflows rather than disrupts them. This is necessary to manage the inevitable change as these services are introduced and to reduce the resistance of some clinicians to change, which might be encountered.• This implies that users (clinical, but also non-clinical: organisations, patients and lay carers) must be properly heard, represented and involved in all the design and development phases of the service.
Catering for older people’s usability requirementsExamples of ageing-related limitations (visual, auditory,cognitive) that have usability design implications: Ageing can be associated with a decline in the abilities of colour discrimination and contrastVisual limitations sensitivity (= designers should use high-contrast colour schemes), as well as with limitations in motion perception and peripheral vision. Ageing can affect the hearing function (esp. for higher frequencies, so designers should useAuditory limitations lower frequencies and avoid sound effects/background noise) as well as the ability to concentrate on audio and text at the same time. There could also be impairments in sound localisation and speech recognition. Ageing can affect the information-processing capacity of a person (processing speed, longerCognitive impairments thinking time, memory loss) and reduce the abilities of information selection and extraction from displays (= designers should use simple, low-hierarchy menus and only show essential information in a very clear language). Ageing can also be associated with declining spatial and working memory, which may lead to troubles in learning.However, devices and software should be carefully designed in a waythat does not stigmatise older patients, as this could significantlyinfluence their acceptance of the system. The ‘design for all’ strategyshould be kept in mind.
Catering for older people’s usability requirements• The usability design for the eCAALYX mobile platform caters for older users’ needs in two main areas, namely physical handling and maintenance of the smartphone, and the usage of the phone software itself.*• Regarding physical handling and maintenance, the following practical solutions were adopted: – Use of dock-stations to simplify the battery charging of the mobile device; – Use of a mobile phone without buttons and with large touch-screens, which allows the building of virtual buttons as large as needed, instead of the small buttons available on commercial mobile phones with conventional keypads and keyboards; and – All maintenance actions are performed either remotely and transparently to the user, or locally, by technicians.* Kamel Boulos MN et al. How smartphones are changing the face of mobile and participatory healthcare: anoverview, with example from eCAALYX. BioMed Eng OnLine. 2011; 10:24. http://www.biomedical-engineering-online.com/content/pdf/1475-925x-10-24.pdf
Catering for older people’s usability requirements• Concerning smartphone software usage, the following practical solutions were adopted in eCAALYX: – The phone runs autonomously without the need of any mandatory interaction from the user from the time it is powered on. This includes the suppressing of all enquiries of the operating system, such as pin negotiation and the automation of all necessary processes; – Rebooting has to be avoided, because it can be a difficult task to perform by the target users. The phone must therefore support prolonged periods of operation without the need to reboot the system; – All error pop-ups were suppressed, to avoid showing any system errors to the user. http://www.youtube.com/watch?v=iwuP5EeNH4c
Video demonstration• http://www.youtube.com/watch?v=iwuP5EeNH4c• http://www.youtube.com/watch?v=sct566oMsCc
Service sustainability, interoperability and expandability as part of a growing telehealthcare ecosystemSee: Kamel Boulos MN. eHealthservice interoperability: Payingattention to interfaces! Lessonsfrom CAALYX and eCAALYX(invited keynote speech). In:Proceedings of the Third MiddleEast Conference of HealthInformatics, Beirut, Lebanon, 31March-1 April 2010 - organisedby the Lebanese MedicalInformatics Association incollaboration with MEAHI, theMiddle East Association forHealth Informatics within IMIA.http://ecaalyx.org/index.php?option=com_content&view=article&id=50:lebanon&catid=35:conference-papers&Itemid=37
A typical personal telehealth ecosystem Source: Carroll R et al. Continua: An Interoperable PersonalHealthcare Ecosystem. IEEE Pervasive Computing. 2007; 6(4): 90-94.
Personal e/mHealth services ecosystem/value chain:complex interfaces and layers building on one another;many device vendors and value-added service providers.
• Portability: a device/system can be seamlessly connected to other devices/different systems/different service providers to provide additional, complementary functionality; and• Interoperability: medical/health applications in different clinical and care environments can securely and reliably exchange useful information between devices connected to, or worn by the person, as necessary. Source: Galarraga M et al. Telemonitoring systems interoperability challenge: an updated review of the applicability of ISO/IEEE 11073 standards for interoperability in telemonitoring. Conf Proc IEEE Eng Med Biol Soc. 2007;2007:6161-5.
eCAALYX interoperability approaches• Continua Version One standard, incorporating ISO/IEEE 11073 and Bluetooth standards (for plug-and-play interoperability); and• Broadband Forum TR-069 CWMP* specification (used by eCAALYX in a completely novel way for auto-configuration, remote troubleshooting and customisation of the home healthcare system). * Technical Report 069 CPE (Customer-Premises Equipment) WAN (Wide Area Network) Management Protocol Health Device Profile Spec (not yet) http://www.continuaalliance.org/ http://www.broadband-forum.org/
The Continua End-to-End reference architecture (v1 scope)Source: Carroll R et al. Continua: An Interoperable Personal Healthcare Ecosystem. IEEE Pervasive Computing. 2007; 6(4): 90-94.
From: Douglas P. Bogia DP, Cnossen RA (Intel Corp). Continua |Health Alliance and Associated Standards--Design and More >Developer Forum on Telemedicine Systems: Issues, Design, |Development and Standardization. Presented at: Globecom2008, December 2, 2008, New Orleans, Louisiana, USA.
Integrating the Health-care Enterprisehttp://www.ihe.net/
Demonstrations/plugfestsSource: Douglas P. Bogia DP, Cnossen RA (Intel Corporation). Continua Health Alliance andAssociated Standards--Design and Developer Forum on Telemedicine Systems: Issues,Design, Development and Standardization. Presented at: Globecom 2008, December 2,2008, New Orleans, Louisiana, USA.
Demonstrations/plugfests Source: Douglas P. Bogia DP, Cnossen RA (Intel Corporation). Continua Health Alliance and Associated Standards--Design and Developer Forum on Telemedicine Systems: Issues, Design, Development and Standardization. Presented at: Globecom 2008, December 2, 2008, New Orleans, Louisiana, USA.
Project walk-through WBS = Wearable Body Sensors
Location of the temperature sensor in the smart garment The smart garmentMINI DIN connection to the ECU (Electronic Control Unit)in the smart garment Front side of the ECU From left to right the indicators are: 1. BT link established (blue LED); only when connected 2. Low battery LED, 20% left (red LED); only when low battery 3. HR and RR display (yellow LED blinking with the rate of the sensor) 4. HR and RR circuit ok (green LED) 5. ON/OFF interrupter 6. MINI DIN connector (interface with the Smart Garment) 7. MINI USB interface to charge the battery 8. 100% charged battery LED (green LED fully charged, red LED charging, only while charging) ECU
LEDs indicating connection via the Bluetooth link LEDs indicating system working but not connected via a Bluetooth link Communication implementation between the Fall Sensor/Fall and Activity Sensor and the mobile smartphone through the ECU
< System overview of Fall and Activity SensorSample of the activity classification algorithmin operation over a 144 seconds. A series of 4stand-sit-stand, 6 stand-lie-stand and 3 stand- walk-stand activities were performed >
ISS device: The ISS (IntelligentSensor System) is a portablephysiological monitor that combinesthe most relevant sensors formonitoring the prevalent chronicconditions and health risks ofelderly people, such ascardiovascular diseases,hypertension, stroke and congestiveheart failure
Power supply Connection to mains power is indicated by the plug symbol at the battery status iconISS plugs
The cable connections from the sensors to the ISS
AdministratorInstruct the user on how to use the blood glucose meter.Connection with the home system router andcommunication is achieved automatically via a Bluetoothlink when powered up.
Usability tip: The remote control should be more tailored for eCAALYX scenarios, with only the necessary buttons offered.At home:TVBox (STB)and TV interfacescreens
User Selection interface Health MenuReminders interface Notification interface
Vital Sign selection menu Blood Pressure grapheCAALYX Agenda menu Medical appointment
Medication event Measurement eventHealth Videos interface eCAALYX playing video screen
eCAALYX video full screen mode Questionnaires menuQuestion interface Finished questionnaire
eCAALYX emergency call and incoming callinterfaceseCAALYX video-conference call
At home: TVBox (STB) and TV interface screensN.B.: STB also acts as sensor gateway for immediate visualisationof measurement values on the TV after using a sensor. Support for the future (Kinect NUI navigation):
eCAALYX settings menu (administrator) General Settings interfaceNetwork Settings interface Connection between the Home Gateway router and a laptop, as recommended for the installation check-upBrowser location bar pointing to the check-up webpage
Home Gateway check-up webpage viewHG System and Remote Servers Functionality test
Mobile system overview and the deploymentdiagram of the mobile smartphone, whichincludes the LG-P990 handset equipped with aSIM Card, and the eCAALYX software with itsconfiguration files
eCAALYX mobile platform and app• The eCAALYX mobile app has beendeveloped as a key and central component of eCAALYX.• The main functionality of the eCAALYX mobile platform and app is to act as a seamless “informed” intermediary between the wearable health sensors (in a ‘smart garment’) used by the older person and the health professionals’ Internet site, by reporting to the latter (but also to the patients, as appropriate) alerts and measurements obtained from sensors and the geographic location (via smartphone GPS) of the user.• Additionally, the mobile platform is also able to reason with the raw sensor data to identify higher level information, including easy-to- detect anomalies, such as tachycardia and signs of respiratory infections, and some more complex ones, based on established medical knowledge.
eCAALYX mobile platform and app• A user interface is also provided, which allows the user to evaluate the most recent medical details obtained from sensors, perform new measurements, and communicate with the caretakers/clinicians.• The technological platform in the current prototype is the Google Nexus, running the Android 2.1 platform, with 1 GHz processor and 512 MB RAM memory; however, it can be easily ported to a newer Android version, or even to another Android phone.• The software itself is written in JAVA. The interface with the Caretaker/Clinicians’ site is accomplished using the W3C Web Services technology, while the interface with the health sensors (in a ‘smart garment’ worn by the patient) is realised using Bluetooth wireless technology.• Access to necessary resources, such as GPS, Bluetooth, and the Internet (3G/WiFi), is also provided through the Android Platform.
eCAALYX mobile platform and app: Major challenges• There were many challenges to the development of the mobile platform. Most importantly, the mobile platform must be seamless and autonomous in its operation (e.g., in raising alerts), in order to provide a usable service to a target group that usually does not have any familiarity with technology and might even be unconscious during times of medical emergency and not able to manually operate any device or software.• System and service reliability is also an important issue to take into account, firstly due to the possible negative sensation that the application may give to the user in the case of malfunctioning, and, secondly, due to the physical distance between the technical maintenance teams and the users.
Major challenges (eCAALYX mobile) – Cont’d• From an implementation point of view, the issues regarding the development of intelligent mechanisms in a mobile, resource- limited and battery-powered device should also be considered.• Usability issues are discussed in earlier slides of this presentation. Usability is a critical issue for the target group of eCAALYX as, usually, users in this target group do not have any familiarity with technology and this is also often compounded by a range of physical (e.g., poor eyesight) and/or cognitive disabilities (e.g., dementia) that such users might be suffering from, which can further limit their use of the technology.• Due to these facts, the eCAALYX mobile platform was designed to be completely transparent to the user, and the necessary interface functionality to be as accessible as possible.
Functionality provided by the mobile smartphone
The Physical Activity, RespiratoryRate and Temperature screens > Vital Signs screens of the mobile application >
The status window, with several possible statuses > The communication implementation between the different sensors and the mobile smartphone through the Electronic Control Unit (ECU)
(all user types) < Select user type: Doctor, caretaker, Patient, or Family membereCAALYX Server Administrator’s portal > Create new user (steps 1-4)
Selection of Doctors to add to a patientBlank User profile
Now that the Doctor is added, you can also add a Kit using the “select kit” option: Kit management view Add the appropriate kit: Kit selection Kit management updated profile You need to note the “idkit” and “idbiokit” for the hardware devices that you will be providing to the patients: Kit: ALAN21KIT Password : Alan21Kit idkit: 26 idbiokit: 147 Hospital Unit: Primary Care eCAALYX Gateway: gtnew with Hardware Id 112233 Device List Hardware details for the Kit The patients profile will then be updated accordingly.
Adding devices to a patient profile Doctor’s view
Fall alert in caretaker portal (caretaker view)
Source: Kamel Boulos MN, Anastasiou A, Bekiaris E, Panou M. Geo-enabled technologies for independent living: examplesfrom four European projects. Technology and Disability. 2011; 23(1):7-17. http://dx.doi.org/10.3233/TAD-2011-0300
Source: Kamel Boulos MN, Anastasiou A, Bekiaris E, Panou M. Geo-enabled technologies for independent living: examplesfrom four European projects. Technology and Disability. 2011; 23(1):7-17. http://dx.doi.org/10.3233/TAD-2011-0300
Evaluation• The eCAALYX project comprised two phases of field trials with 10 patients.• In the first phase, a limited set of features was tested, focusing the tests more on usability and stability.• The second phase of the trials took place in Germany in March and April 2012, and included a larger set of features.• More extensive field trials, with 80-100 patients, are taking place in the different countries already running the CAALYX-MV follow-on project. eCAALYX Trial 2 synopsis
Acknowledgments• This work has been conducted within the eCAALYX project, which is supported in part by the Ambient Assisted Living (AAL) Joint Programme, a joint research and development funding activity by 20 European Member States and 3 Associated States, with the financial support of the European Community (EC) based on article 169 of the EC treaty.• The eCAALYX Project Consortium includes 11 member organisations in five European countries.