Ebook: Handbook of Ambient Assisted Living

What is the state of healthcare worldwide today?

Some things are certain. We know that the worldwide population is aging dramatically. We know that the cost of care in most countries is rising rapidly, fueled by the introduction of effective but expensive new drugs and equipment. We know that in many countries there will be far fewer medical professionals to care for people who are sick, and we know that as people live longer, they will be required to manage a greater number of chronic conditions for longer periods of time. We know that in some countries there is resistance to paying for additional care. We know that many industrialized health systems are biased toward “sick” care, helping people once they develop a problem, versus helping people stay well throughout their lifespan and minimizing the onset of conditions that are costly to treat and diminish quality of life. We know that individuals now survive traumatic events such as a heart attack or stroke that would have killed them in the past – a medical success story – but then live until old age when the cost of care skyrockets.

In short, we know that all of these pressures mean that we must change the way we deliver healthcare. We need better, more holistic, life-long care at lower cost.

It is for these reasons that the scientific and engineering contributions described in the Handbook of Ambient Assisted Living: Technology for Healthcare, Rehabilitation and Well-being are so important and timely. Innovative use of new technologies may be the only way to provide care affordably, and to scale that care to hundreds of thousands or millions of people, as our societies adapt to the changes mentioned above. The 45 technical chapters presented here together summarize achievements of an accomplished group of researchers around the globe taking a wide-range of approaches to improving health using technology. The chapters provide a thought-provoking framework in which to consider how healthcare might – and must – change in the future. I anticipate that this volume will inspire other researchers to explore how technologies ranging from in-home sensors to wearable systems to game-like interfaces might be used for elder care, wellness promotion, assistive aids, early diagnosis, coping systems, and rehabilitation. In ten or twenty years, the work described here is likely to be mainstream – incorporated into the way we receive daily care and taken for granted. We won't think twice about sensors in our homes or worn on our bodies to help our computers keep us healthy, and we will expect that computers help us to better manage our care when we get sick. Today, however, the research described here is pushing the limits of what we can do with technology and shows the value of transdisciplinary work that merges the latest advances in computing with solid medical research and practice.

Here's to a healthy, technology-aided future.

Stephen Intille

Ph.D., Assoc. Prof., College of Comp. and Inf. Science & Dept. of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA

Exemplars of operational AAL deployment in the healthspace are relatively few but increasing. This short reflective piece considers the reasons why, notes underpinning drivers for the future, outlines the increasing research-based activity and sets the context for the following papers that consider the current field from different perspectives across the globe. Firstly research-based (O'Kane, O'Donoghue, Gallagher, Aftab, Caseyand Courtney), then Zayas-Caban and colleague propose a methodology for design and implementation, followed by a description of operational piloting (MacGinnis). The next two papers look at progress – in Taiwan (Tsai-Ya and Jenn-Hwan) from the historic development forwards, and comparatively (Shao-Huai and Jui-Chen) in Japan describing a novel incentivisation model. Both of these papers make observations that could be applied globally, as do all the contributors in this section. Wild and Boise then conclude the section by focusing on attitudes to and uses of AAL for a particular target group of potential recipients of assistive technology, Older Persons. Evaluated AAL practical applications are emerging in the health space but the pace of roll-out could be speeded up if frequently observed constraints and some practical lessons learnt from deployment, which have been brought into focus by these papers, were addressed more effectively. There are however some additional refreshing and emerging European and global eHealth initiatives that look set to also facilitate progress.

It is now well established that many patients in hospital can suddenly become acutely ill but experience delayed recognition of their physiological deterioration resulting in late referral to critical care, or in some cases death. In recent years there has been significant growth in the use of scorecards to assist with the detection of increasing patient morbidity, but even though a scorecard may be well-constructed and its parameters carefully chosen, the usefulness of any scorecard is only as good as the accuracy and timeliness of the data that is used to populate it.

The scorecard in this chapter referrers to the Modified Early Warning Scorecard (MEWS) which is a paper-based clinical scorecard, intended to provide clinicians with an early warning of acute patient deterioration. While this paper based approach is a significant advance in patient care, major data capture and processing deficiencies still exist.

To overcome these limitations an electronic-Modified Early Warning Scorecard (e-MEWS) was designed and developed in collaboration with the staff at St. Luke's General Hospital, Kilkenny, Ireland. The e-MEWS is an intelligent rule-based clinical decision support system designed to automatically perform frequent wireless monitoring of a patient's vital signs, and to record and process the data to calculate and display a MEWS score and other valuable patient information.

This research demonstrates how an existing real-world paper based approach can be greatly enhanced through the application of intelligent Clinical Decision Support Systems (CDSS). In turn the adoption of wireless Body Area Network (BAN) technologies within a clinical environment highlights how Ambient Assisted Living (AAL) solutions can play a significant role in patient care delivery.

The use of consumer health informatics (CHI) interventions is proliferating rapidly with little consensus about how CHI interventions should be designed or implemented. While CHI interventions have been shown to improve clinical outcomes, barriers to their use remain. This chapter describes a well-developed conceptual model for program evaluation and suggests how it can be used to guide the design and implementation of CHI interventions, with the goal of supporting the intended outcomes of these interventions and minimizing the unintended outcomes. The chapter then provides an overview of how knowledge from three human factors domains can inform the CHI interventions design and implementation components of the evaluation model. By integrating human factors principles and methods into the evaluation model, developers can reduce barriers to use and minimize resulting unintended consequences of CHI interventions.

The UK has been an early adopter in the use of ambient assisted living technology for social care and this experience has helped to shape the approach to the use of technology in healthcare. The National Health Service (NHS) in England has benefited from a series of policy measures, supported by grant funding, that have resulted in a significant uptake of ambient assisted living technologies in both health and social care. Over the period 2005–2010 the NHS has moved from a few small scale pilots toward a situation where a growing proportion of local health authorities have implemented some form of service, and a few have moved on to plan or deploy technology on a large scale.

The paper examines the operational use of assisted living technologies, highlighting the pivotal place of the ‘Whole System Demonstrators’ which have been established to generate the evidence needed to support a move towards mainstream adoption. It also examines a number of other operational implementations of assisted living to identify trends in the technologies and draw out lessons for the deployment and use of these technologies as mainstream services.

This article is introducing the current development of telehealthcare and reviewing the past history and effect in Taiwan. Since 2006, the government has deployed several projects to facilitate the development of telehealthcare, which including U-Care (2006), 10 year projecton long term care (2007), Taiwan 12 construction project (2008), and six emerging industries (2009). The currently running project, Telehealthcare Service Development Program, started in 2007. This project is targeting Diabetes Mellitus and the population with Hypertension and also developing two models of service delivery, a Homecare/Community service model and an Institutional Care service model. Seven services are delivered in Homecare/Community service model, which are tele-physiological monitoring, member health management, tele-consulting, tele-health education, medication safety services, living resource referral, and emergency management; five services are delivered in Institutional Care service model, which are tele-consultation, tele-physiological monitoring, tele-visiting for family members, medication safety services, and tele-health education. The significant benefit outcomes for members in this project relate to hospitalization rate, ER admission rate, self-care monitoring, institutional infection rate, unexpected readmission rate, and redundant medication rate, and also the acceptance rate and satisfaction for both members and caregivers and reductions in the burdens on members' family are also relatively high. In the future, development of telehealthcare service will rely on amendment of the current legislation/decree by government, incentivizing of the services by healthcare/insurance providers, and introduction of new business models by all involved industries.

As Taiwan steps into an aging society, it faces problems of shortage of caregivers in aging society and an increased variety of care demands for elders, even those with serious disabilities. Considering Japan has similar cultural background as Taiwan, this study attempted to introduce an assistive technology rental system in Japan, where long-term care insurance and a rental service of assistive technology has been implemented since 2000. The use of assistive technology could reduce the caregivers' burden, and help elders to become more independent and active. As a result, Japan, the first aging country in the world, is able to reduce the waste of medical resources for the end of life.

A burgeoning area of investigation in the wake of advances in in-home technology has been the application of those new technologies to enhance the health and independence of older adults without the constraints and expenses of the traditional health care system. Increasingly, researchers are using home monitoring and assistive technologies to identify changes in health and behavior in home settings, and to facilitate successful adaptation to those changes. The successful application of assistive and monitoring technologies depends on receptivity of potential users, i.e. the older adults, family members, health care providers and others. In this chapter, we will review the current state of research in older adults' perceptions, attitudes, and priorities regarding in-home technology designed for health monitoring and/or maintenance of independence. Further, we will summarize current thoughts regarding ethical issues in the application of these technologies to older adults as end users.

This section explores technology used to identify an individual in their environment, promote their safety and wellness at home and beyond and support rehabilitation. All three aspects need to be addressed if AAL is to flourish.

Digitization of the healthcare sector has been a major impetus for rapid adoption of biometric technologies, ranking it only behind the financial sector in consumer facing applications. The highly critical nature of healthcare records, the legal and medical risks associated with mis-identification, and the requirement of quick access to user information makes biometrics a preferred technology. The body of research supporting the theoretical effectiveness and efficiency of biometric technologies is quite substantial but users, the deployment environment and the type of biometric technology heavily impact its actual effectiveness and efficiency. Biometric technologies open up unprecedented opportunities in ambient assisted living (AAL) applications, but they also raise some unanswered questions. The aim of this chapter is to provide its readers with a basic understanding of biometric technologies and processes, discuss research in this area, and future challenges and use of biometric technologies in the healthcare environment, and specifically AAL applications.

Face recognition is certainly the most natural approach to person recognition in smart home environments. The extreme variability of faces in such applications, due to continuous changes in terms of pose, illumination and subject appearance (hairstyle, make-up, etc.), requires very robust and fast algorithms to be developed. Moreover the variations of the subject's face cannot usually be adequately encoded in the initial user template, typically created starting from a few example images, thus making necessary to continuously update the templates on the basis on new inputs. After a review of the state of art of video-based face recognition approaches, suitable for home environments, a semi-supervised video-based template updating approach introduced by the authors is presented.

This chapter presents a novel framework for dynamic biometric monitoring of behaviour towards user authentication, utilizing dynamic and static anthropometric information. The recognition of the performed activity is based on Generalized Radon transforms that are applied on spatiotemporal motion templates. User authentication is performed exploiting the behavioural variations between different users, regardless of small variations in the interaction setting. The upper body limb anthropometric information is extracted for each user and an attributed body-related graph structure framework is employed for the detection of static biometric features of important discrimination power. Finally, a quality factor based on ergonomic criteria evaluates the recognition capacity of each activity. Experimental validation illustrates that the proposed approach for integrating static anthropometric features and activity-related recognition, advances significantly the authentication performance. In this concept, a series of possible applications of the proposed system is also presented.

This chapter discusses the feasibility of using the Electrocardiogram (ECG) for human identification. ECG falls under the umbrella of medical biometrics, i.e., physiological signals that are typically used for disease diagnosis, but also carry subject discriminative information. As opposed to traditional static biometric modalities like the iris, the fingerprint or the face, ECG is a time dependent signal affected both by physical and emotional activities. Therefore, one of the challenges that are studied in this work is the design of permanent and, at the same time discriminative features, which are robust to heart rate changes.

A feature extraction methodology based on the autocorrelation of ECG recordings is presented and evaluated on a public database. In addition, the advantages of using the standard 12 lead ECG system in the recognition process are discussed, and various fusion strategies are presented. Experimental results indicate increased recognition accuracy for the fused case (100% for 14 subjects).

Furthermore, this chapter advocates ECG biometrics as a natural choice for handling medical information. Given the medical origin of the signal and the fact that in a clinical setting this measurement is collected irrespective of the recognition task, an ECG based biometric signature can be used to manage the patient's information. A body area network (BAN) is described as the application environment, while the findings can be generalized for a wide range of clinical settings.

This chapter introduces the idea of a smart living environment in which the home tracks and supports happy healthy living for the residents. We start with the introduction of the concepts of wellness and the Aware Home Research Initiative at Georgia Institute of Technology. We then present several interesting projects to illustrate the approaches and implementations toward health, awareness and entertainment and conclude with some reflections and discuss possible future research directions.

Air travel is becoming increasingly more accessible to people both through the availability of low cost flights. Health problems may arise due to anxiety and unfamiliarity with airport departure procedures prior to flying, whilst during the air travel, problems may arise as a result of the food served on board, differences in the environmental conditions inside the cabin, the risk of cross-infection from fellow passengers, seat position, posture adopted and duration of the flight. These can be further compounded by changes in time zones and meal times, which may continue to affect an individual's health long after arrival at the final destination. The aircraft passenger comfort depends on different features and the environment during air travel. Seat comfort is a subjective issue because it is the customer who makes the final determination and customer evaluations are based on their opinions having experienced the seat. The aircraft passenger seat has an important role to play in fulfilling the passenger comfort expectations. The seat is one of the important features in the passenger aircraft and is the place where the passenger spends most of time during air travel. This chapter describes the development of adaptive neck support system to improve the wellbeing experience during air travel for economy class aircraft passenger. Design concept, prototyping, system implementation, experimental testing and design evaluation in an aircraft cabin simulator developed at Eindhoven University of Technology will be presented in the chapter.

This chapter discusses gait monitoring and why it is important to the health and wellbeing of individual, at any time of their life. It then describes a range of medical conditions which affect a person's gait and gait monitoring could be used to improve the outcomes following rehabilitation. Different techniques for monitor gait are also discussed, together with their relative merits and limitations. Finally, examples where monitoring has been used to help the treatment and rehabilitation processes have been provided.

This section explores AAL from a gerontological perspective, both in terms of the types of AAL systems and applications that have been developed for older users and the contributions that technology can make to their health, independence and quality of life. The six chapters are representative of the range of research and development activities focusing on meeting the needs of older people and are organized in three themes: monitoring activity and health; AAL and dementia; market and policy issues.

This chapter describes a state of the art AAL project in Kaiserslautern, Germany, which aims at monitoring inactivity patterns under real-world-conditions. Twenty flats have been inhabited by approximately 26 individuals since the end of 2007. The flats are equipped with several home automation sensors and actuators, thus allowing the collection of extensive data sets representing the typical user behaviour over long periods of time. Inactivity is the focus of the presented approach since it is assumed that inactivity and not activity is indicative of potential emergencies. The ultimate goal of the system is supporting senior citizens with modern home automation technology and thus helping them to maintain their independence and self-determination. In addition, illnesses and medical emergencies are to be detected by analysing and interpreting the captured sensor data. Based on this automated reasoning, appropriate help is administered to the persons affected. It is important to note that the development procedure of the Kaiserslautern AAL environment had been implemented from the onset as an evolutionary, user-centred design process to ensure user feedback and to allow easy identification of potential shortcomings or flaws of the developed solutions. Choosing such a user-centred design process facilitated meeting one of the paramount objectives of the AAL project, viz., that the AAL technology satisfies the users' needs and wants.

In an increasingly ageing population, solutions are being sought to enable older people to live independently in their own homes. Assistive technology has the potential to develop supportive environments for older people through “ambient assisted living”. This chapter is based on results from the implementation of an assistive technology project designed to provide formal carers with patient information to support them in their case management. The study followed the trial use of a telecare system, capturing the experiences of formal carers and documenting the impact of assistive technology. The findings identify that assisted living devices have the potential, once trust is established, to support formal carers to undertake their role more effectively. However, in accepting assistive technology as part of an integrated care solution, there are implications on the role and responsibilities of the formal carer, existing mechanisms for delivering community care and the quality of the relationship between the carer and the cared for. The paper concludes by considering the challenges for assistive technology if it is to be directly supportive of formal care-givers.

In this chapter we discuss efforts to measure natural human movement and describe a novel location aware technology to study the relationship of movement to health changes. Several syndromes whose understanding may be increased by a more thorough analysis of movement are identified. We conclude with a discussion of how location aware technologies can play a role in identifying problems and solutions in the design of living spaces for the elderly.

Ambient-assisted living services are slowly but surely making their way into daily practice and life. At the same time, levels of uptake both in Europe and North America remain low and the deployment of services that are fit for this complex market remains a challenge and often fails. The present chapter provides an overview of the market for AAL services in the world and gives some guidance from practice on how these markets can be reached.