Taking technology to the people

For those who do not or have not read Telecare Aware (http://www.telecareaware.com/), I would recommend it for all the latest in news on telecare and telehealth, mhealth etc.  

A recent soapbox on telecare aware struck a chord with me. In this soapbox (http://www.telecareaware.com/index.php/telehealth-soapbox-when-the-elephant-in-the-room-has-no-smartphone.html) Carolyn Thomas, whose blog Heart Sisters (http://myheartsisters.org/2012/10/10/no-smartphone/)  proposes that evidence suggests older and disabled people are the least likely to engage with or use mobile technologies such as smartphones. My own experience of working with people over the age of seventy also bears this out. For many smartphones are too complex to understand, have too poor screens with too small fonts and do not have ringers that they can hear. In fact, it was precisely this reason why I wrote a book on mobile phones specifically designed for seniors (http://www.amazon.co.uk/GUIDE-BUYING-MOBILE-PHONE-ebook/dp/B007U5VG0G), which features easy to use phones by emporia and Doro among others manufacturers. 

The emporia Elegance easy to use phone

Easy to use mobile phones have large fonts, loud ringers and are as they say on the box, easy t use. For many people who are venturing in to the mobile phone market an easy to use mobile is the best introduction to a no-nonsense phone.

Returning to what Carolyn Thomas was saying in her soapbox for Telecare Aware her main thrust was that the UK, and in fact many other countries as well, current health policy relies on the introduction of health apps or widgets to enable the person to monitor their own health and control their own health.  The soapbox suggests that if the people to be targeted and of most need are the older and disabled then these are precisely the people who will miss out as a result.  Older and disabled people do not, by and large, use smartphone or tablets and therefore do not use apps/widgets.

I appreciate the argument that in due course, the older population will be from our age group who are a little more tech savvy but I think this is a little short sighted as an argument. I am all for mhealth and the use of apps/widgets but only as applied appropriately to ensure that each app/widget meets the needs (be they health or whatever).  This made me think of the DTA tool (Dependability Telecare Assessment) and how this can be applied to this form of technology.

DTA

If the DTA tool is used to consider health related apps/widgets for older and disabled people then this app/widget would most likely fail the first box of Fitness for Purpose. Health apps or widgets cannot meet the broad needs of and older or disabled person unless said person has a platform to run the app on which they are confident to use.

I would suggest that many apps/widgets that I have tried actually fail the second category or Trustworthiness as many offer generic platitudes rather than bespoke advice or information. For example If I look up Multiple Sclerosis on many health apps/widgets, I get a lovely article on the origins of the condition and often some rather worrying lists of possible symptoms and how it is diagnosed etc, but there is little written on having MS and fatigue.  For this, you tend to get referred to the fatigue section that talks generically about fatigue. Now, for anyone who experiences fatigue, I am certain that most will recognise that there is a spectrum of fatigue from the “I am tired” stage through to the “so exhausted I cannot press a button”.  Within this spectrum there is a possible infinite number other forms of fatigue.  Some are a direct result of the MS possibly, whereas others are might be as a result of the medication that a person is taking.  I have not seen an app/widget that asks for your full medical history and can compute the possibilities of having multiple conditions and how they interrelate to each other.

Health apps and health widgets

A further problem with many apps/widgets I have tested is that they often over egg the pudding, by which I mean they can make simple conditions into mammoth issues for the person, by instructing them to seek medical assistance immediately.  For many people this is very distressing and can make the use of such apps/widgets less likely in the future, but for people who already have conditions which are debilitating this can be the last thing they need to hear.  Moreover, for the doctor/health professional who actually sees the person as a result of the app/widget this is extra avoidable work that could and should have been avoided. So we have stressed out the patient and the doctor... not a great start.  This means that many apps/widgets are less than 100% reliable and could be classified possibly as dangerous as they will raise the blood pressure when a false positive is received.

Moving to the third column of DTA I would also argue that many of the apps/widgets are unacceptable and not very usable for older or disabled people, so we have some serious flaws in the over reliance on mHealth for this client group.  In fact I would suggest that this might increase risks of premature fatality if rolled out to older and disabled people on mass without a proper trial of each app/widget.

David Shaywitz seems on the right track in a recent article he asserts:

“The danger is that if we don't find a way to recognize, express, and capture the value of the human connection in medicine, we are unlikely to preserve it, and it will become engineered out of healthcare - at least until an entrepreneurial, humanistic developer appreciates just how important and valued such connection can be.”

http://www.theatlantic.com/health/archive/2012/10/humanism-in-digital-health-do-we-have-to-sacrifice-personal-connections-as-we-improve-efficiency/264325/

  

I must admit I personally do believe the only way forward with health is through the appropriate adoption of telehealth and mhealth, but I stress the word appropriate. In the same way that telecare should be personalised to the individual’s needs and wants; mhealth should take this same baseline.  I am a techie person; I own a smartphone, a tablet, a laptop, MP3 player etc, but I want technology to support me to achieve the best from my life, not dictate to me my life.  I want apps and widgets that are bespoke to me and my personal situation/condition, not some generic half baked app/widget that fails to diagnose.

We need to stop focussing on what technology can do and start thinking how technology can be of use to us in supporting and promoting our lives without us modifying how we live to any great extent.

Why don't we have interoperability of telecare devices... yet?

One of the old chestnuts within the telecare arena is the idea of interoperability.  Interoperability simply means that technologies can work together, thus a product by one manufacturer can be used with another manufacturers kit. A simple analogy would be that a Microsoft Word document could be edited on on a PC as well as a Mac computer.

In telecare terms this would mean that I could buy a fall detector from one manufacturer and it should still be configurable with another manufacturer's alarm system. In reality, this can usually be simply done through the purchase of a bridging device, but interoperability should mean that this device is no longer required.

I am mindful of the recent courtroom battle between Apple and Samsung which upheld Apple in the US but nowhere else in the world as the designers of the iPhone and iPad appearance and software. It is interesting to me as I am writing this on a netbook with Windows XP installed, whilst having an Apple device flash emails arriving to me.  I also have an Android smartphone and and Android tablet on this same desk providing further alerts and noises.  I know I will never miss any critical information with all this technology, but the time spent sifting through the rubbish to find the golden nugget is considerable. It is questionable whether this venture  is actually worth the effort.

I stray to illustrate that today we have a range of technological options open to us and we have to decide how we progress down the technological route.  For computers to write type on  I prefer Microsoft products but I also have a  keyboard for the tablet computer  and occasionally use that to edit things on.  The tablet has its own excellent touchpad keyboard as does the smartphone so I can actually edit documents and other things without the need for an external keyboard.

I use the cloud providers of free storage to store current active documents so they can be accessed anywhere on any of my wireless device. I also use the cloud to share documents with other people I work with, so they can edit them or review them. Thus if I am in McDonald's I can still access my email and edit a paper whilst sipping my Coke.

So what does this say about interoperability? Well it is interesting, to me, that although the devices are not per se interoperable, certain things on them are.

One source of interoperability is Bluetooth, which enables all my devices to link together or link to portable devices such as keyboards, mice etc.

A second interoperable source is the cloud providers allowing access to all my stored files on any device, as long as the operating system is compatible with the cloud software.

I have similar software on all my devices and Skype is a great example of a cross platform software that operates on almost all platforms.

So I am thinking to myself, I have a mobile phone that can communicate with everything else, I have an Apple product that does this as well and a netbook that also does this, and a Nokia Symbian smartphone that also does this, that I no longer use,so why can simple telecare devices not make use of the advances in technology to allow proper interoperability?

I am fully aware of the Continua group and think what they are doing is great, but it is no longer rocket science.  Devices can communicate through Bluetooth or Zigbee, or infra red or wirelessly. Software can be made to be cross platform so each operating system can use it, so why can I not use the fall detector I think is best with the dispersed alarm unit I think is best and add the best peripherals to this?  Why are we still faced with no choice? we are committed to buying a system from one manufacturer and then we must purchase on their peripherals with the limitations that they have.

The customer is left with little or no choice.

I am staggered that the mobile product market is rapidly expanding but the telecare marketplace appears stagnating in comparison.

How can we reverse this state of affairs?


How can we make telecare interoperable and usable?

DTA a working example - falls

DTA - an illustration of how it can be used

The problem
Mrs J has recently had a stroke which has left her with a weakness on one side. She has limited capacity to comprehend the consequences of this weakness and falls a lot whilst trying to do normal activities. She recently fell getting out of bed on the way to the toilet at night and also in the bathroom whilst getting off the toilet. Mrs J wants to be independent and feel safer whilst undertaking her daily routines.

The solution
Mrs J was given a bed occupancy sensor, pendant, pull cord in the toilet and a smoke alarm.

Rationale behind solution
This is a simple case in many ways, the main presenting issue is that of falls as a result of weakness resulting from the stroke. If we consider DTA we can see that we are meeting the dependability criteria by offering this solution.

(Click on Picture to make bigger)

The solutions provided are fit for purpose; they are portable, when necessary, comfortable, will work as expected in the appropriate manner and in the correct time. They are trustworthy as they are reliable, will promote safety and not cause danger and are simple to service and maintain. The solutions were acceptable to Mrs J who does not want to be bothered with technology but is happy to wear a pendant. The solutions are practical, require no learning apart from the pressing of the button on the pendant or pulling of the cord in the toilet; and the solutions are compatible as they are all provided from one manufacturer. Mrs J was concerned about the aesthetics of the pull cord but considered that her safety was of more importance than the look of the cord in the toilet and was happy that the placement of the cord was exactly right for her to use if she had difficulties in the toilet in the future.

This example ticks all the boxes for each product. The smoke detector was added as Mrs J could be compromised in the event of a fire in her home. She might fall whilst trying to vacate her house in an emergency situation. The replacement smoke detector replaces her current smoke detector but is positioned in the correct place in her hallway and provides an audible alert as well as alerting the response centre that there is a potential fire in Mrs J’s property.

Note: this page originally appeared on  Friday, 7 August 2009 and has reappeared through demand. If you want to know more about DTA please contact Guy on gdewsbury @ yahoo.co.uk for more information.

More on gdewsbury

The gdewsbury freelance consultancy and writing service (www.gdewsbury.com) has now been in business for a while and is pleased to announce it is registered with the Assistive Technology Practitioner Society as a Specialist Assistive Technology Practitioner.

As a consultancy gdewsbury work with small telecare and Assistive technology companies to develop their business plans and strategies. We are also developing Telecare training courses which are designed for care organisations.

The consultancy still writes articles such as the TechTalk column for Disability Magazine and various other journals and websites.

If you think gdewsbury could be of help to you or your organisation please get in touch by emailing gdewsbury@yahoo.co.uk.

Tick Box Telecare - its coming to you...

Tick boxes are a standard method used when undertaking large surveys.  In research, the tick box serves as a method of gaining quick opinion on a certain subject.  This opinion is then translated into some form of quantitative statistics and presented in a report.  Tick boxes are not the most reliable form of data but they are a quick form of gathering statistical data.

 

The tick box approach is really useful in other circumstances.  When undertaking a new task, a tick box or checklist is a useful memory aid to ensure you have completed everything you need to do.  Just as we use shopping lists to help us shop the checklist is a useful prompt.  The tick box also can be used as a form of evidence, demonstrating someone has completed all the stages of something, although it does not show the quality of how they completed it.

In a telecare assessment, the tick box can be really useful as a guide to the things you need to discuss and consider in the assessment.  It can serve as a memory jog or prompt as well as a tool to ensure you have covered all bases. 

The tick box is of course not without its limitations and problems. 

One clear issue is that the tick box will focus the assessor’s attention on the elements mentioned on the list and therefore the assessor could fail to think outside of these elements.

An OT colleague mentioned one of the benefits of the tick box assessment enables detailed information in a short format but it should always have the space to provide additional information to give a full picture. This is the qualitative material, such as the client has stairs but no stair rail or bannister.  These important factors could have significant bearing in an  assessment for telecare.

This is an interesting point.  A standard tick box approach often leaves little or no space for the extra information.  The rationale for this is that this information cannot be coded so it is best omitted. 

point 1 - This is the real core information that should be recorded, so any tick box approach to telecare must have boxes for providing extra information.

The recording of information is often based on ease of processing rather than ease of collection.  So although a tick box might have additional space for comments, there is no guarantee that these comments will be used at a later stage.

point 2 – all comments boxes should be given equal weight in the processing of the information. 

Thus, armed with a tick box telecare assessment which has space for comments, the assessor begins the assessment. Where are they? Are they in the office speaking to someone on the phone or are they are actually at the client’s house? 

I suggest that it is almost impossible to undertake a telecare assessment over the phone. No matter how detailed your questions are, you will never get the level of information required to complete a true full assessment.  You will not, for example,  be able to accurately determine if a person has difficulty walking – I accept that you can ask the person – but many people are unable to rate themselves accurately.  People tend to over or under exaggerate their abilities.   It is difficult for the most experienced OT or social worker to determine accurately whether someone does or does not have mobility issues over the phone.

I accept that the current culture suggests that the responses of the client are often all that is required as proof, so if a person does not have insight they require assistance with mobility then , according to this argument, they do not... until they are found in a heap on the floor, suffering from hypothermia. This attitude is similar to asking a person over the phone whether they attacked their partner – I doubt many social workers would be happy to accept the response over the phone.

point 3 – Telecare assessments must be completed face to face, in the property the client resides. 

Face to face interviews must be at the client’s residence so the assessor can see how the person moves around their home and how they get in and out of bed or the bath etc.  Home visits allow the assessor to assess the client’s capacity and possible difficulties around their home.These assessments and observations could also trigger other referrals.

By face to face, I mean in visual contact, not staring at a person! I also mean not staring into a computer screen where the tick box form is being completed.  Eye contact, observation and listening are essential to any good assessment.

That ticks the box

The take away message is relatively simple, Use tick boxes sparingly and appropriately and with due caution. 

What we need to avoid are crass statements such as:

Have you fallen in the last 6 months?

If the answer is yes then consider a fall detector (which is one of the myriad of possibilities and does not get the assessor to consider other options). 

Have you left the bath tap on? .... ...consider a flood sensor. 

A good assessment would explore (amongst other things):

• If a person has fallen, why and where have they fallen?  
• What other factors contributed to the fall?   
• A lapse in medication perhaps or sudden onset of dizziness etc?  
• Has the person noticed a reduction in their general mobility? 

The reason why someone has fallen could be for a number of contributory reasons.  A full exploration could justify a number of other referrals to services such as GP, Physio, OT or falls clinic.

Telecare needs to be truly person-centred.

point 4 - Tick box telecare could be useful if used as part of a range of tools to assess a person but not as the assessment per se. 

It is clear that in the cost-saving culture, councils and health authorities will be advocating a tick box approach to telecare in the future, but in the long-term this is false economics.  A thorough assessment might trigger additional referrals to other services and might appear to cost more, but the saving is in the client, a person, actually getting the help they need to be able to respond to and manage their condition.

This post was spurred into life by an article in  Telecare Aware.

Update

Since this article was written gdewsbury, the consultancy I work for has produced a person centred telecare assessment tool called DTA: the Dependability Telecare Assessment tool manual. This is available from www.gdewsbury.com/dta only. It takes the user through the process of using the tool to ensure person centred telecare assessments. 
 
 

Moving upwards and onwards

The Telecare Blog is undergoing some major changes and will have some posts removed and others changed.  The mother site www.smartthinking.ukideas.com is also undergoing refurbishment, so the main site for information on telecare etc will be www.gdewsbury.com.

This blog will continue, just change a little.

Reopening the hornets’ nest - the terminology of telecare – the ongoing debate...

It has been some time since I wrote about terminology (http://thetelecareblog.blogspot.com/2010/01/language-of-telecare.html) but it’s funny that in the time since that piece was written things have moved on and new services have developed. I do not intend to repeat that blog entry but I think we need to have some common sense when it comes to the terms and their usage.  Maybe the discussion on terminology is old hat and not of great worth at this time.  Maybe the time is right to open the chest and peek inside....

I have already pointed out (in various papers) that the term ‘assistive technology’ has a range of meanings depending on where you live in the world.  In the USA, assistive technology is focused on the technologies that can be used to assist children in schools and with their education in general.  The UK meaning is very different.  Similarly, telecare in the USA is known as ‘Personal Emergency Response System’ (PERS) or ‘medical alerts’, whereas the actual term ‘telecare’ refers to a range of technologies relating to medical/health at a distance (which in the UK is defined as telemedicine and telehealth).

Telecare seems to be a catchall term. Breaking the word down, there is tele (distant) and care (the act of caring, providing care, providing a caring service, providing care for a person, caring for a person, showing you care). This can be contrasted with the word ecare, which has the same second half but the ‘e’ stands for electronic.  To contrast these two words, telecare and ecare we need to see the differences as one is care at a distance and the other is care provided through electronic means. Similarly, ehealth and mhealth differ by health being provided electronically (e) or via mobile services (m).

A key feature of telecare is remote monitoring, this involves people and technology (i.e. people who monitor the alerts and call the person generating the alert).  I consider a simple automated telephone service that has a set of predetermined responses is not telecare; this is ecare. Strictly speaking, it should not even count as ecare, but emonitoring as much of telecare and ecare is concerned with monitoring. 

The public need to be assured that what they are purchasing provides value for money and does what they expect. In ecare systems there are potentially no human interventions, whereas in telecare systems there are. Does the system have call centres where people speak to the person who has triggered the alert?  Do the call centres operatives also make decision on the best course of action (response unit, friends, family, emergency services, doctor, etc)?  The way that a service is described needs to be clear for the customer as their purchases result in a long-term commitments and cash outlays.

Current regulations do not cover the differing types of service and legislation fails to differentiate between the differing aspects of monitoring available.

I can see the benefits of all the differing types of monitoring on the market and strongly believe they each have a place and a level of merit.  What I am concerned about is that the language that is used does not allow for the differentiation that there is between these services.

Personally, I am not bothered what category a service fits under rather I am more concerned about the service they provide. Where I do get concerned is when services are portrayed as belonging to something they do not belong to, as this is a misrepresentation to the public.  The people purchasing a telecare service are expecting care at a distance, whereas when people are  purchasing ecare they should be aware it is all electronic.

I understand why the name telecare was derived, but I also think that this name should be changed to emonitoring or telemonitoring.   This way it says what it does on the packet.  I can also accept that if a telecare service has a full response unit that will be attending people in their home as part of the package then it might deserve the term telecare, but many services currently fail to even offer this basic service.

As a potential purchaser of telecare, for my mother, I suspect that when I look for the company that will be providing the monitoring and technology, one of the first questions I will be asking is does the services do what it says on the packet?  Is this a real telecare service?

I know the currently the UK Government is endorsing telecare through the Whole Systems Demonstrators and the 3millionlives initiative has spent considerably large amounts of money on developing and deploying telecare in the UK and there are now over 1 million people with the service, I suspect that if we redefined telecare to make it more realistic we will find the figures are very different. 

Taking Telecare to a new level

With the beginning of a new year, after considerable thought I have decided to take telecare activities to the next level. Having spent three years as a Telecare Coordinator for a London Borough and obtained excellent CQC reports for the service whilst in charge, and having worked as an academic for over ten years working in the field of telecare, assistive technology, smart homes, telehealth, ambient technologies, ubiquitous technologies, eHealth, mHealth, mobile technologies in addittion to my other interests in architecture and building design, health in general and of course people with long term conditions and disabled people, I now feel that the time is right for something new.

The Whole Systems Demonstrators (WSD) by the UK’s Dpeartment of Health (DH) has recently reported on its headline findings which clearly indicate a positive use of technology can save lives and save resources. There is little doubt that these findings will be scrutinised fully once the full reports are available, and at this point the headlines might not reveal the whole picture, but they are very encouraging.

We can now be confident that technology can save lives and resources, but we also need to ensure that the technology meets the needs and expectations of the people requiring it. It is important that as a result of using technology the person is not expected to become a machine, operating in unreasonable and predictive manners.

If you have a long term condition, your life is punctuated by regular events, such as taking medication, medical appointments, all the way through to the more chronic who might require assistance in all activities of daily living. What I consider unacceptable, is that technology designed to assist becomes the problem. This could be through making assumptions about people’s lifestyles and expecting unreasonable interactions such as checking-in every hour, or pressing a button regularly to stop an alert. This could also be through false alerts or just the technology not meeting operational expectations.

We are in a era which is really exciting. Technology is evolving faster than ever before and we should be able to harness this technology to enhance people’s live by removing barriers of distance, by producing virtual communities, and bringing virtual services through the cloud to people anywhere in the world.

My current concern is that although some electronic devices benefit from the advances in modern technologies, (eg mobile phones, tablets etc) other more mundane technologies, such as pendant alarm based systems or wandering sensors are failing to think beyond the standard.

We are entering a new year, 2012, and we have the chance to begin to create the world we want. A world where distance is not an issue, where access to products and services is far easier through modern technology. My hope for this new year is that we can get together and design products that will last, which have relevance and meaning to those we design for. This year could and should be the year of personalisation and innovation.

We need to stop waiting for tomorrow to create what is needed to today. We need to act now!

We need to change the way we think about products.

We need to change the way we think about services and service provision.

We need to change the way we think about technology and we need to change the way we think about people.

We need to step away from the tick box solution.

Let’s make Person-Centred Design truly person-centred!

It is with these messages in mind that I have started a new business called gdewsbury which is a Freelance Specialist Technology Writing Service and Consultancy (gdewsbury.com) with which I wish to work with the cutting edge businesses to assist in the build and design or truly exeptional products and help small or new businesses become great through expert input.

This is the year to take telecare to a new level.