Download QHome telecare technologies for the elderly

RESEARCH
Original article
.................................................................................................................................
Q Home telecare technologies for the elderly
Taxiarchis Botsis*, George Demiris†, Steinar Pedersen‡ and
Gunnar Hartvigsen*‡
*MI&T Group, Department of Computer Science, University of Tromsø, Norway; †Biomedical and Health Informatics, University of
Washington, Seattle, Washington, USA; ‡Norwegian Centre for Telemedicine, Tromsø, Norway
Summary
There are many home telecare technologies which have been developed specifically for chronic diseases and there are
some more generic technologies that could be used as well. For home telecare, the equipment must be certified, the
operational routines must be reformed, the infrastructure must be in place, the market must be prepared, the health
authorities must be convinced that the system will work and the cost-effectiveness must be evaluated. Organizational and
societal changes, such as cost reduction policies and an aging population, are the main driving forces for the development
of home telecare, especially for elderly patients. At the moment there is no holistic model for scientific evaluation from
different perspectives (e.g. clinical, legal, technical). We suggest that more research on home telecare and its effects needs
to be conducted, in order to provide evidence for optimizing the use of this promising technique.
Introduction
(1)
..............................................................
The need for health care increases with age1 – four times as
many elderly people of 85 years or over need daily care
compared with those aged 65– 74. At the same time, it is
unlikely that in the near future there will be enough nurses
to support them adequately2 and it is also possible that
there will be a lack of facilities to accommodate them. This
international trend has already been described as a crisis
in care.3 One approach to solving the problem is the
application of telemedicine in the home environment,
i.e. home telecare, also known as home-based e-health4
or telehomecare.5
Home telecare was first developed for patients with
chronic diseases such as heart failure, diabetes, asthma
and chronic obstructive pulmonary disease (COPD).6
Thereafter, its application was expanded to other vulnerable
populations.7 Home telecare has the potential to increase
independence and quality of life for elderly people who
prefer to live in their own homes, while also producing cost
savings for the health-care system.
Telemedicine in elderly patients’ homes
..............................................................
Most elderly patients wish to spend their old age in their own
home. By supporting them in their homes it is possible to:
Accepted 6 July 2008
Correspondence: Taxiarchis Botsis, Medical Informatics and Telemedicine Group,
Department of Computer Science, University of Tromsø, 9037 Tromsø, Norway
(Fax: þ47 7764 4580; Email: [email protected])
Journal of Telemedicine and Telecare 2008; 14: 333– 337
(2)
(3)
provide frequent access to their care from different
groups (health-care staff, family and friends);
obtain cost-effective results, including time-savings for
service providers and shorter treatment periods;
detect health abnormalities at an early stage through
the frequent monitoring of physiological data.
Furthermore, health-care providers can use home telecare to
supply more education and counselling, social support,
disease monitoring and management than elderly patients
could obtain by visits to hospital. More clinical observations
can be recorded and there is the potential for more frequent
follow-up. Other functions could include diagnosis,
prescriptions and various other aspects of care (e.g.
institutional, acute, chronic, rehabilitative, continuing,
preventive and self-care).
Restrictions
It is obvious that not all chronic diseases or medical
conditions are suitable for home telecare, such as those that
require the permanent presence of health-care personnel or
life-critical monitoring equipment. Suitable conditions
include stable chronic diseases such as COPD, asthma,
cardiovascular disease, diabetes, dementia and mobility
impairment. All home telecare systems for the elderly
should fulfil the following requirements:
(1)
(2)
they must be simple to use and user-friendly;
they must be stable, interoperate without interruption
and provide reliable monitored values;
DOI: 10.1258/jtt.2008.007002
T Botsis et al. Home telecare devices
(3)
(4)
they must ensure computer security and data
confidentiality;
the service should be continuously available.
Users
It is not only patients who use a home telecare system, but
also health-care providers. It is quite probable that both
kinds of users have to deal with similar situations. It could
be argued that few elderly patients will be familiar with
technology, but it is reasonable to believe that most patients
will be in the near future.8 Some staff members will be
comfortable about using computer-based applications and
will not be easily deterred when new technical problems
arise, but others may not.9 In any case, all users will require
training for using each system, taking into account the level
of their expertise.
Methods
..............................................................
There are many home telecare technologies which have
been developed specifically for chronic diseases and
there are some more generic technologies that could be
used as well. The range is quite extensive, so only some
representative examples are presented here. The selection
criteria were based on covering a wide range of home
telecare technologies from the simple to the complex and
from the popular to the less well-known. Some equipment
with limited implementation but a promising future was
also included. All these technologies have been exhibited at
conferences, such as the American Telemedicine
Association meeting in the US.
Home telecare technologies for chronic
diseases
..............................................................
Asthma and COPD
One of the first telespirometry procedures was described
by Bruderman and Abboud.10 Here the patient made
measurements with a portable spirometer, transmitting
them to a remote monitoring centre via the telephone
network and receiving online advice on medication. The
MIR-Medical International Research Company (Rome, Italy)
has recently developed a spirometer (Spirolab III), which
measures various respiratory variables and is designed for
telemedicine applications.
Patients with asthma or COPD often need long-term
oxygen therapy and must use supportive devices at home.
The HELiOS oxygen system (Tyco Healthcare, Mansfield,
Massachusetts, USA) is equipped with a built-in oxygen
content telemonitoring device. This makes it possible to
follow the patient’s reactions to treatment.11
334
Cardiovascular diseases
Intensive home-based monitoring reduces hospital
admissions and inpatient time for patients suffering from
severe congestive heart failure.12 Ades et al. indicated that
the quality of life of patients with heart disease was
improved when such patients used electrocardiogram (ECG)
transmission during their rehabilitation at home.13 An
example of an ECG recorder is the CardioConcept PC-based
system (MedIT, Oslo, Norway) that performs 12-channel
recording of ECG signals and transmits them through the
Internet or by email. In addition, the ambulatory blood
pressure device of the same company measures blood
pressure and can be connected to a PC.
Apart from the devices mentioned above, some more
generic applications are used for cardiac patients. The
Health Buddy System (Health Hero Network, Redwood City,
California, USA) for people with chronic diseases is a home
telecare application which has been used in studies with
elderly people after coronary artery bypass grafting.14,15
Another example is the Med-eMonitor System (Infomedix,
Rockville, Maryland, USA) that comprises a portable patient
interface device with automated data transmission
capabilities when it is connected to the patient’s telephone
line. This system has been used to improve care for
patients with cardiovascular disease.16 The device can be
programmed remotely via the Internet and gives health-care
providers secure access to patient data.
Diabetes
There is a range of technologies for diabetes care from
patients accessing web-based education to video visits at
home. In earlier studies, invasive glucose meters were
connected to a telephone line to communicate data and even
provide patients with feedback in some cases.17 – 20 In recent
studies, hand-held devices have become more popular, such
as a computer with glucose meter21 and an advanced
messaging device with two-way audio-video functions.22
Non-invasive glucose meters (that measure blood glucose
without penetrating the skin) or low-invasive systems are
already available commercially. An example is the GlucoWatch
(Animas Technologies, West Chester, Pennsylvania, USA)
which is like a wristwatch. The MiniMed Paradigm realtime
system (Medtronic Minimed Inc., Northridge, California,
USA) combines a low-invasive insulin pump with realtime
continuous glucose monitoring. The GlucoDay (Menarini,
Florence, Italy) is also low-invasive and can provide reliable
online glucose values during recording.23
There are many glucose meters available. The devices
mentioned above indicate that apart from collecting blood
samples to measure blood glucose manually, there are
several new technologies that provide more automated and
non-invasive methods of monitoring.
Dementia
A common difficulty for people with dementia is verifying
their location. One solution is offered by Wherify Wireless
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T Botsis et al. Home telecare devices
Inc. (Redwood Shores, California, USA) that combines a
satellite global positioning system and a mobile phone in a
wristwatch. When the patient wears such a watch, it can be
traced by Wherify’s global location service centre. The
relatives and/or the caregivers can either call the global
location service centre or connect to the company’s web
page and locate the patient on a map.
Other equipment
Other home telecare equipment includes:
(1)
(2)
(3)
(4)
Health watches measure blood pressure, pulse,
temperature and skin moisture. They then transmit the
measurements to a health-care centre. In 2001, at the
retirement home Lötsjögården in Sundbyberg, Sweden,
a pilot project studied information technology in
homecare. Among the devices that were introduced
were health watches for all residents;24
Homelab. Point-of-care testing is possible in the home
using equipment like the i-STAT device (Abbott
Laboratories, Abbott Park, Illinois, USA). This allows
samples such as urine or blood to be taken at home and
analysed automatically. The accuracy of the blood
gas analysis performed by the i-STAT portable device
is similar to that performed in a conventional
laboratory.25 Another kind of home testing includes
the ‘smart’ toilets that were introduced in Japan in the
1980s. They are equipped with sensors that can analyse
urine and stool samples in order to identify health
problems at a prodromal phase. A smart toilet has been
developed by Matsushita Electric Industrial Co. (Osaka,
Japan). This toilet measures a person’s temperature,
blood pressure and urine glucose. The measurements
can then be sent to health personnel who can monitor
the person’s state of health continuously;26
Sensors at home. Fall sensors that register acceleration
and position can provide rapid notification of a fall and
the possible extent of any injury. In addition, sensors
that measure weight automatically can be used for
several purposes, such as the Sonoton Avantek
(Porsgrunn, Norway) weight sensor that activates an
alarm when the patient deviates from his/her normal
weight. Other sensors detect inactivity during a
specified period. When they are placed in different
rooms of a dwelling, it is possible to perform trend
analyses of the activity in each room and detect falls,
reduced nutrition or sleeping disorders;27
Sensors in clothing. Avariety of sensors can be embedded
in clothes for monitoring purposes. For example, the
LifeShirt System (VivoMetrics Inc., Ventura, California,
USA) monitors physiological variables, enabling
the subject to carry out normal activities without
interruption. The LifeShirt is currently being used in
research institutions in the US, Canada and Europe.28 In
addition, Sensatext (Bethesda, Maryland, USA) has
developed the SmartShirt that can monitor biometric
information in an easy and comfortable manner;29
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Medication control. Elderly patients often receive
numerous prescriptions for medications with different
dosages and instructions, and in many cases from
several health-care professionals. They may therefore
have difficulties with medication management and
compliance. Intelligent pillboxes may be useful to
warn against or prevent the intake of incompatible
medication. An example is the Pillbox (e-pill,
Wellesley, Massachusetts, USA) that has a built-in
modem and can be remotely controlled. A more
complete system for the remote control of medication
has been tested in Norway.30 The system utilizes a
pillbox that is connected to the patients’ electronic
health record. Compliance data are transferred to the
electronic health record regularly and can be examined
by the patients’ doctor at the next visit.
Future technologies
In the future, simple supervision tasks may be handed
over to robots. The ‘Wakamaru’ robot (Mitsubishi Heavy
Industries, Shinagawa, Japan) is equipped with cameras
and can be controlled by voice. The pictures collected by
the robot can be transmitted to mobile phones and
computers.31 The Wakamaru robot can monitor elderly
patients and their health conditions, report deviation from
daily activities and oversee security in the house. Other
robots are the ‘Asimo’ (Honda Motor Co. Ltd., Tokyo,
Japan), an advanced humanoid robot that can respond to
voice control messages and ‘Dr Robot’ (InTouch Health Inc.,
Santa Barbara, California, USA), operated by a doctor, that
can conduct a ward round and check up on patients.32
Through the implantation of miniature electronic devices
(MEMS – Micro Electro-Mechanical Systems), it is possible to
observe various biological functions. The company
CardioMEMS (Atlanta, Georgia, USA) produces MEMS
monitoring equipment that can be implanted in the body for
transmitting information about blood flow and pressure
wirelessly to computer equipment located outside and near
the body. Finally, Radio Frequency Identification (RFID)
technology offers the possibility of monitoring food, clothes
and the articles that a person uses at home by marking each
item with an RFID tag. The RFID tags can be made thin
enough to be embedded in labels and tickets, and it is possible
to both read and write data to an RFID tag on the move.
Discussion
..............................................................
In our experience, the time elapsing between pilot systems
and their final implementation in the health service
may be long. For home telecare, the equipment must be
certified, the operational routines must be reformed, the
infrastructure must be in place, the market must be
prepared, the health authorities must be convinced that the
335
T Botsis et al. Home telecare devices
system will work and the cost-effectiveness must be
evaluated. This is a cumbersome process, which requires
that much of the infrastructure must be in place at the start.
The main problems in establishing home telecare systems
are the lack of:
(1)
(2)
(3)
(4)
standards to combine incompatible information
systems;
an evaluation framework which considers the legal,
ethical, organizational, economical, clinical, usability,
quality and technical aspects;
guidelines for the practical implementation of
potential home telecare applications;
scientific evidence to demonstrate the effectiveness of
home telecare applications.
procedures. In August 1996, Norway became the first
country to implement an official telemedicine fee schedule
making certain telemedicine services reimbursable by the
National Health Service. Partial reimbursement was
authorized in the US in 1997.36
Organizational and societal changes, such as cost
reduction policies and an aging population, are the main
driving forces for the development of home telecare,
especially for elderly patients. At the moment there is no
holistic model for scientific evaluation from different
perspectives (e.g. clinical, legal, technical). We suggest that
more research on home telecare and its effects needs to be
conducted, in order to provide evidence for optimizing the
use of this promising technique.
Acknowledgments: This work was partly funded by the
Research Council of Norway ( project no 174934). It was
carried out during TB’s tenure of an ERCIM ‘Alain
Bensoussan’ Fellowship.
In 1998, the American Telemedicine Association developed
the first home telecare clinical guidelines to assist
health-care providers in making decisions about purchasing
different technologies and implementing telehealth
programmes;33 these guidelines were revised in 2001. The
success of home telecare systems depends, among other
factors, on the degree of their usability for all users involved
and their introduction into daily clinical practice.
Usability also becomes important for home telecare
applications that require operation by the patient and/or
their family members. The design of an information
system for healthy users who are familiar with computer
technology is a challenge. When a system needs to address
age-related constraints and potential inexperience with
technology, the design becomes obviously much more
difficult. Designers of home telecare systems that include
the elderly should aim to increase the system’s functional
accessibility and address the needs of their users, while
following guidelines for the implementation of information
technology applications for the elderly.34
While several home telecare initiatives have
demonstrated the potential of the technology in the home
for older adults, most work has been of a pilot nature with
relatively small sample sizes. There have been a few large
scale clinical trials exploring the use of home telecare for
older patients, but there is a gap in the scientific literature
which is at odds with the call for evidence-based tools in
health care.
An important question is whether there should be a
special legal framework for health care administered at a
distance. The characteristics, limitations and permissions in
home telecare for elderly patients should be stated clearly in
advance. Other legal risks associated with the use of home
telecare, such as liability for malfunctioning equipment
need to be addressed.35 It is also important to explore
the possible ethical problems that such systems might
introduce, e.g. can telecare equipment replace the nurse’s
touch?
Another barrier to the greater integration of home
telecare services into daily practice is the absence of
consistent reimbursement policies. In order to solve this
problem, some countries have established appropriate
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