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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 Journal of Telemedicine and Telecare Volume 14 Number 7 2008 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 Journal of Telemedicine and Telecare Volume 14 Number 7 2008 (5) 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 1 Tahkokallio P. Smart houses. 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