Health Emergency Event Notification System, Towards to the Seamless Service Mobility Juli´an A. Garibaldi Beltr´an, Mar´ıa Cos´ıo Le´on, Ana I. Grimaldo Mart´ınez, Juan I. Nieto Hip´olito Autonomous University of Baja California Ensenada, Baja California, M´exico Email:
[email protected],
[email protected],
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[email protected]
Abstract—In this paper we present a Health Emergency Event Notification system, which is intended to support the monitorization of the elderly health care; focusing on seamless service mobility paradigm. The system is composed by five features: i) the vital signs recording, ii) emergency contact phone numbers register (for SMS – Short Message Service and phone calls), iii) monitorization profile creation, iv) messages notification management, and v) local mobile storage service. Our architecture was designed to drive information through the WiFi / Cellular network from a WSN (Wireless Sensor Network) even when there is not real-time connection. This proposal considers as restriction connectivity costs. The proposal was designed considering the Scenario-Based Design methodology. In formation is related to a proyect conducted a long one year in Harmony house. Meanwhile, we were designing the communication infraestructure. Our architecture was evaluated by 2 caregivers and 2 nurses from Harmony house. The results showed high scores in analyzed aspects: perceived ease of use, usefulness and intended use. We conclude that in order to complement and enhance the initial design, it is necessary to carry out an in-site evaluation. Our future work includes to analyze the architecture performance under different connectivity scenarios. Index Terms—Caregivers, Elderly, Seamless Service Mobility, WSN
I. I NTRODUCTION According to [1], in the more developed regions, the population aged 60 or over is increasing at the fastest pace ever (growing at 2.4 percent annually before 2050 and 0.7 percent annually from 2050 to 2100) and is expected to increase by more than 50 per cent over the next four decades, rising from 274 million in 2011 to 418 million in 2050 and in 433 million in 2100. Compared with the more developed countries, the population of the less developed regions is ageing rapidly. Over the next three decades, the population aged 60 or over in the developing world is projected to increase at rates far surpassing 3 percent per year and its numbers are expected to rise from 510 million in 2011 to 1.6 billion in 2050 and to 2.4 billion in 2100 [1]. In intention to cover care requirements from the aforementioned population group, the worldwide trend about response emergency systems, is to be embedded in the telecommunications system platform. In the less developed regions, the cost of enabling pervasive communication services, represents an important part of elderly people budget [2]. An approach
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to reduce costs, is the use of technologies that enable local networks using shared access points to the internet. Mobile devices have features that allow continuous health monitoring services; the term used to define this kind of services is mobile health, mostly called mHealth, a field of electronic health (eHealth), that involves the use of mobile networks as GSM (Global System for Mobile communications), 3G (Third Generation), LTE (Long Term Evolution), in mobile devices as smartphones, tablets and other electronic gadgets [3]. Along with the aforementioned mobile networks, there are technologies as Wi-Fi, Bluetooth and WSN (Wireless Sensor Networks) that supports the seamless service mobility; defined as the ability of a mobile user to access the particular subscribed services any time and anywhere, [4]. Another term in the same context is seamless mobility, defined as the capability to manage connectivity, so that the user is “always best connected.” However, this problem is complex in practice and the user’s definition of “the best connected” depends on cost, performance, location, and other factors. We are proposing a seamless service mobility, based on an infraestructure which has the capability to merge into existing emergency management systems. Focusing to optimize monitoring tasks by nurses, caregivers, and emergency management systems despite the connectivity restrictions. The service proposed in this paper was tested in Harmony house.1 This paper is organized as follow: Section II describes the state of art, and our proposal; Section III presents the guidelines in the design process of the infraestructure proposed; Section IV presents the seamless service mobility proposed; Section V describes an exploratory assessment with caregivers using the infraestructure proposed; Section VI shows a contrast between our contribution and the existent system in Harmony house. Finally, Section VI presents the conclusion and future work. II. S TATE OF A RT The raison d’etre of a health emergency event management system is the notification, besides to provide information about the event and people who is being monitored. Works as [5], its main contribution is to demonstrate the present scope and future potential of mobile communications in telemedicine; 1 http://
www.serenatijuana.com
allowing to show the importance of developing systems such as below is described. Authors in [6], propose a middleware; it is located between mobile device and the mobile intelligent server. The middleware allows to provide a service considering minimal connectivity resources and once the system is no connected waits for re-connecting to bring the monitoring service. The ultimate goal the authors in [7] is an architecture, that provides a consistent user experience for all services, independent of how the user connects to the network. Some features from abovementioned proposal are shared by the system in intention to notify health emergency events.
(a) The necklace with a push button.
The prototype senSAVE (“Sensor Assistance for Vital Events”) was developed by a consortium of five Fraunhofer Institutes [8]. The prototype can be run on any mobile device that uses Windows Mobile 5 and that is able to read date streams in parallel from two Bluetooth channels, but there are not considerations about data transmission to the emergency centre. Another work dealing with monitoring health systems is [9], although authors propose key features; if a communication channel to the medical server is available, the personal server (PS) establishes a secure link to the medical server and sends reports that can be integrated into the user’s medical record. However, if a link between the PS and the medical server is not available, the PS should be able to store the data locally and initiate data uploads when a link becomes available. In intention to have monitoring data available, enabling access to patient health records regardless patient location; some proyect as in [10] propose a mobile ehealth records system (mEHR-System); it complements a typical ehealth records system (EHR-System). A mEHR-System uses the Internet and Web services to provide pervasive interaction among doctors and patients. Another authors as [11][12][13] propose monitoring system oriented to patients and their care provider, considering mEHR-System, besides seamless conectivity. With similar aim authors in [14], propose a monitoring system providing through the mobile phone an interfaces for the users to check and learn about their own health statuses. We gathered contributions and lacks from the above described works; it allowed us to include in our proposal enhanced features as: mEHR-database, “best connected” average user definition towards to the seamless service mobility. Adding specific features for caregivers working with seniors with cognitive decline. The main feature is the decision module to send notification, based on connectivity scenarios. This characteristic allows to the proposal be operational in local networks with null connectivity; it is achieved by a local warning when internet connection is no available for caregivers about an emergency event besides to sent it to the central unit through cellular communication services. In the next section, we provide detail about the Health Emergency Event Notification System functionalities.
(b) The central unit.
Fig. 1: Technology in scenario A.
III. G UIDELINES TO S EAMLESS S ERVICE M OBILITY DESIGN
Our approach is user-centered design, specifically scenariosbased design. This methodology the focus of design work from defining system operations (i.e., functional specification) to describing how people will use a system to accomplish work tasks and other activities [15]. The decision to use user-centered design techniques was based on the experience gained through out one year working in the scenary. Although the scenario-based design is a relatively lightweight method for envisioning future use possibilities, our expertise about Harmony house scenario allow us to gather enough data to design an initial proposal to cope with connectivity failures in emergency notification systems. In order to describe the different stages in the target scenario throughout the time working in Harmony house; the following paragraph shows three scenarios to illustrate how caregivers use technology to develop care tasks. The scenario A, illustrates the initial environment that we found before we introduce the FIAD monitoring architecture proposal. Subsequently in B scenario, the monitoring architecture prototype was introduced to describe how caregivers interacted in them. A. Initial scenario A Adriana is a caregiver in Harmony house. As all caregivers in Harmony house, Adriana is responsible to take care of about 5 seniors. Her daily journey begins at 7:00 o’clock. Her first task is to visit the seniors to take the vital signs. It is important that Adriana be punctual, because the seniors use to take breakfast once she finished this task. Adriana could
h
Therefore, Adriana does not need to write the data, thus she can talk with the seniors. When the senior pushes the button on the necklace the device sends a message to the central unit and automatically Adriana receives a message in her mobile device warning her about the help request and who is requesting for help. However, sometimes, the Internet connection fails and data from bracelet is not sent to the central unit. Therefore, is difficult to attend efficiently a notification, especially in case of emergencies. Central data server Traffic flow
Fig. 2: Bracelet.
face some difficulties some mornings (i.e. senior waking up in a really bad mood, sick and different issues about their cognitive decline). In order to support the Adriana’s work, the seniors uses a technology; it is a necklace with a push button (see Figure 1a). When the senior pushes the button on the necklace the device, sends a message to the central unit (see Figure 1b) in the nursery room. When a notification is received, Adriana goes to check who the senior requiring help is. Once she identifies the senior requiring help, she goes to search where the patient is (i.e. garden, living room, reading room, etc.). Finally, she can bring the care to the patient in needing. 1) Discussion of scenario A: The scenario A shows in the process important issues about bringing care. The first one is the time that senior must wait to be checked according to the visit sequence. This time is related to the difficulties facing for the cognitive decline (i.e. mood of seniors). In addition, when a notification is presented the caregivers spend time going to the nursery room to check which senior needs for help. Besides they require looking for the senior and attending them. This is the best scenario for a help requirement, because the senior has the capabilities to push the button. However, when an emergency is presented, and the senior can’t push the button, the time to attend an emergency is longer than usually. Considering the issues identified in the scenario A, we introduce the monitoring architecture prototype intended to improve the emergency notification process as well as to increase the caregivers quality service to the seniors. As follows, we present the scenario B to illustrate how the technology changes scenario A.
Mobile device
WSN IEEE 802.15.4
Internet WSN medical device sensors
Gateway GWFIAD
Fig. 3: The FIAD infrastructure. 1) Discussion: Considering the improvements in the scenario B compared with A, the mainly advantage is data gathering automation. However, when there is not internet connection the care efficiently is decreased; due to data loses. So there is important to introduce the concept of seamless services. The next section describes our proposal to provide a seamless service mobile in intention to mitigate disconnection environments failures. IV. S YSTEM D ESCRIPTION We base our proposal on the FIAD monitoring architecture, see Figure 3, which was previously developed and stated the directives at the CONACYT-Serena senior care project. The FIAD architecture provides an open platform for monitoring services that are connected to the Internet both at home and at the assistant geriatric house. Central data server
Emergency response service
Traffic flow
WSN IEEE 802.15.4
B. Final scenario B Adriana is a caregiver in Harmony house. As all caregivers in Harmony house, Adriana is responsible to take care of about 5 seniors. Her daily journey begins at 7:00 o’clock. Her first task is to use her mobile device to check the vital signs of the seniors under her responsibility. Usually, she goes to visit the seniors based on attention priorities identified through the physiological records about the vital signs. The technology supporting Adriana’s work is a bracelet with a push button that each senior has (see Figure 2). The bracelet automatically checks the vital signs and datum is sent to the central unit.
WiFi IEEE 802.11
WSN medical device sensors
Gateway GWFIAD Mobile server (Local storage)
Fig. 4: The seamless mobility in FIAD infrastructure. The FIAD infrastructure consists of an in-home wireless sensor network (WSN); expanding the WSN coverage FIAD architecture uses a gateway; the gateway takes data from WSN and retransmits to WiFi/Ethernet network. There exists
Call to family
Visual and audible alarms
SMS
Emergency
Ambulance call
work as short message service (SMS), although, it is possible not cellular network access, the worse connectivity condition; therefore, we propose two kinds of local notifications: audible and visual, see Figures 6b, and 6c in intention to provide information for caregiver or alien people near of the person who is being monitored.
User controlled events
Nonemergency
Storage Unit
A. User interface description Data message processing unit reception/transmission IP sockets
Configuration modules
Connection management
emergency contact phone numbers
Fig. 5: System components.
a central data server and processing platform; a web based service portal. The FIAD architecture infrastructure has a restriction about mobility; their services are restricted to WiFi/IEEE 802.15.4 gateway coverage area. In intention to add mobility to the architecture; we propose a mobility module. This module adds two characteristics to FIAD architecture: mobility and disconnection aware. Both characteristics allow continuous monitoring, see Figure 4. The module system is embedded in the FIAD architecture through IP sockets and short message service (SMS). It was developed in the IDE Eclipse in Java programming language, intended to use in devices with operating system Android. The application was executed in a smartphone Samsung Galaxy S III mini, running Android Jelly Bean, version 4.1.2 and a tablet device Samsung Galaxy Tab 2.0, Android Jelly Bean, version 4.2.2. However, the application could be run on any Android device, with minimal changes in the user interface. The mainly system modules are: i) reception/transmission IP sockets; ii) the data message processing unit; and iii) the storage unit; to provide continuous monitoring. Around them, the user has access to configure the service, through configuration modules: i) emergency contact phone numbers; ii) remote server storage; and iii) thresholds for emergency event management (patient monitoring profiles), see Figure 5. While designing the system, it was considered the concept the seamless service mobility before defined. We define “the best connected” as: low cost of monitoring non-emergency conditions; while there are not restrictions for communicating emergency events. Therefore, the system offers the seamless service mobility, through a disconnected initial state moving to connected state considering the notification type (either emergency or non-emergency.) Data gathered from medical device sensors are stored in the local mobile database. If there exists a WiFi service for access, and the device can do it; data are sent to the remote server. On the other hand, if there it is not possible to have access to WiFi services; the storage process remains, until the connectivity condition is available. Emergency event notifications are sent by the cellular net-
The system has four mainly displays. The first one, see Figure 6a, shows the main screen; the system gathers data from a mobile medical sensing device connection (bracelet). It also shows the picture of a person which is being monitored; caregivers or nurses can see the data, and send samples by a SMS, or make a call through pressing one button. When the user has an emergency situation; he/she can use the bracelet button (the panic button) to ask for help; in the mobile device, an audible and visual advertising is displayed, see Figure 6b; as well as, if the user has a fall, Figure 6c in the mobile device; besides an SMS will be sent to the emergency contact phone numbers. The user from interface shown in Figure 6d, gathers information about mHealth database; records in the database, storage capacity, and energy remained. V. E XPERIMENTAL EVALUATION In order to analyze the impact of using the integrated module system to support the development of taking care activities for the elderly, an exploratory assessment was conducted, in intention to evaluate the use of the application in the smartphone. In order to simulate an scenario, one researcher was using the bracelet, performing activities that usually the elderly people do. The participants were evaluating the application through interacting with the smartphone. During the interaction with the smartphone, the participants were receiving information about the patient: i) ID; ii) temperature; and iii) outside temperature (see Figure 6a). In addition, emergencies events as user fall and panic button notifications were used. In order to analyze the perception of using the system to support the elderly people care; the following aspects were evaluated: i) perceived ease of use; ii) perceived usefulness; and iii) perceived intended use with nurses and caregivers. A 5-Likert TAM-based questionnaire was used to measure the perception of the participants. In addition, open questions were applied to gather feedback. Participants: 4 participants from Harmony, geriatric care home were invited to take part in the evaluation. All of them female, 2 nurses and 2 caregivers. Their average age was 36 years old (SD = 14 years old). Method: First, participants filled a demographic survey. Then, they were explained about the function and operation of the integrated system (the bracelet, the gateway and the smartphone). Participants were interacting with the smartphone by receiving information about the patient and emergencies events as user fall and panic button notifications. When they received notifications, they decided about the action to perform (e.g. send a SMS or call for an ambulance) just by pressing a
(a) Main display.
(b) Emergency event.
(c) Fall detection.
(d) mHealth database.
looked interested in the interaction with the smarthphone “...it is very useful to have the vital signs of patients remotely...” [Nurse 1], “...it is very important to check the health status just by looking at my phone...” [Caregiver 2]. Nevertheless, some participants were concerned about using the system during the assessment compared with the real situations ...“ I would like to use the system for a long time and then, I could tell you my opinion about the usefulness...” [Nurse 2]. “...I prefer to use the system while I am developing my job, I think I could have a better idea about the difficulties because at this time, everything is easy...” [Caregiver 2]. In addition to the quantitative results, at the end of the session, participants answered open questions about their experience. Q1: What do you enjoy most while using the system?: all participants looked interested mainly about the automatization of the system during the monitorization of vital signs of patients “...the system could help me a lot with the constant monitoring...” [Nurse 2]. Q2: Would you like to include additional elements?: although participants looked satisfied, they made some recommendations “...I would like to include more vital signs...”[Caregiver 1]. Q3: What was the easiest element to use during the interaction with the system?: due to the experience of the participants in the use of the actual system, they looked as “ease” the interaction with our system. “...I understood everything because it was easy...”[Caregiver 1]. VI. D ISCUSSION
Fig. 6: Emergency Event Notification System displays and advertising.
button in the application. Finally, they were asked to complete a TAM-based questionnaire and some open questions about their experience. Quantitative Results: We analyze the data obtained from the TAM-based questionnaire. The results indicate a high perception of ease of use, usefulness and intended use of all the participants (see Table I). TABLE I: Perceived usefulness, ease of use and intended use. Aspect analyzed Perceived usefulness Perceived ease of use Intended use
Nurses 5/5 5/5 5/5
Caregivers 5/5 5/5 5/5
According to the table above-mentioned there is no difference between scores of nurses and caregivers. The possible explanations of this results are the small sample of participants and the automation in gathering data and the easy access to the information through the smarthphone, allowed them to know the health status of the elderly at any time. Qualitative Results: During the evaluation, participants
In the state of the art, we found monitoring mobile health systems, intended for specific population groups; in this paper we shown a Health Emergency Event Notification System, consisting of the architecture, described on section IV, the system is oriented to caregivers and nurses; it was tested in a geriatric care home, where the caregivers and nurses uses an application like is shown in Figure 8. We developed a system considering the concept of seamless service mobility, continuous monitoring, automatic filling of medical forms in real time, and emergency notifications. This system has the capability to create a monitoring configuration profile by adjusting the threshold, and notification frequency. According to exploratory evaluation described in section V, the users present high perception of ease of use, usefulness, and intended use. In addition, they looked very interested in the “real-time connection” to the senior health data. This is denoted by the user’s comments “...it is very useful to have the vital signs of patients remotely...” [Nurse 1], “...it is very important to check the health status just by looking at my phone...” [Caregiver 2]. This research was exploratory about the use of the module described in this paper; we present preliminary results that allowed formalize a vision of the use of this system with potential users. The system provides a solution to the seamless service mobility problem. Users’ evaluation did not visualize any problem in the application presented. However, we observed deficiencies in
Fig. 7: Configuration module problems.
is achieved through a mHealth database, and SMS messages to preconfigure destinations. The evaluation results shows a positive perception from potential users. However, it is necessary to improve configuration modules in intention to avoid wrong predefined messages or calls. Our system has features that improve by far the actual system in the Harmony, geriatric care home; specifically about the most important task: monitoring vital signs automatization base on personalized monitoring profiles, as we shown in the “Experimental evaluation” section . As a future work our proposal will be evaluated in-situ by more participants, including additional medical sensing devices, as well as disconnection scenarios; it is considering observations from initial evaluation. ACKNOWLEDGMENT The authors would like to thank Serena Senior Care S.A. de C.V., http://www.serenaseniorcare.com. Their caregivers gave us feedback about our solution. Furthermore, they shown us their mobile monitoring application; it allowed us to gather relevant information about a base solution versus our proposal. R EFERENCES
(a) Main menu.
(b) Sample register.
Fig. 8: Serena senior care system.
the configuration, (see Figure 7); the initial observation lead us to conclude that: the configuration module was not intuitive, since users do not configure by themselves. This condition open the opportunity to carry out a second evaluation; it must cover all features, with the aim to solve detected deficiencies. Furthermore, the evaluation was not oriented to make comparisons between the existing system and the ours; therefore, the participants detected favorable features as: i) automatized vital signs monitoring; ii) targeted messages; and iii) monitoring profiles in their smartphone, which were not include in the existing system. Users conclude that using this application could impact significantly the reduction of times in important daily activities. VII. C ONCLUSION AND FUTURE DIRECTIONS The raison d’etre of a health emergency event management system is notification; therefore, the seamless service mobility problem must be considered. Solutions in the literature relates ubiquitous services; although authors do not have serious consideration to resolve problems due to disconnection scenarios. In this work, we propose a system managing notifications from emergency events, while the seamless service mobility
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