Ebook: Wearable eHealth Systems for Personalised Health Management

The first International Workshop on New Generation of Wearable Systems for eHealth took place in Lucca, Italy, 11–14 December 2003. It is a significant milestone in the dissemination and promotion of this newmultidisciplinary area which is expected to play an important role in the evolving health care and health delivery sector, in Europe and world-wide.

The management and coordination of healthcare throughout the entire range of services, from primary to tertiary care, are undergoing fundamental changes such as, more emphasis on prevention and education of users, new ways of delivering care, integrated disease management, empowerment of individuals to manage their own health and overall provision of efficient and cost-effective services. The incentives arising from the need to optimise the use of healthcare budgets and provide quality services and equal access, contributed to the significant development of health telematics, telemedicine and eHealth during the last 15 years.

Extraordinary achievements in science and technology e.g. genomics-proteomics, micro- and nanotechnology, mobile communications, human-computer interface and knowledge management offer for the first time the possibility for new approaches in health, healthcaremanagement and services provision. This includes solutions to support personal health monitoring, early warning and timely intervention, lifestyle management and remote collaboration with health professionals. Daily life activities support and risk management for elderly people and chronic patients can also benefit by these ongoing technological developments.

The new generation of wearable personal eHealth systems has to be affordable, userfriendly, “invisible”, autonomous in terms of power consumption and able to assist individuals in their own health management. Major challenges are ahead such as further research and development, user acceptance and trust, cost effectiveness and business models. Intelligent Biomedical Clothing and biomedical sensors are becoming major driving forces for cutting edge developments. The synergy and close collaboration of all involved disciplines and sectors is of paramount importance.

The workshop on New Generation of Wearable Systems for eHealth was designed to fit the need of the international research community to share advances and brainstorm on future activities in the field. This book has its background in the workshop, and includes full papers describing developments and trends all over the world in the areas of smart wearable monitoring and diagnostic systems, smart treatment systems, biomedical clothing and smart fibres and fabrics. It also covers non-research aspects such as citizens' and patients' needs, interoperability, risk management and market perspectives. The chapters mirror the workshop and are preceded by a short executive summary which highlights the main issues, findings and conclusions for the convenience of the reader. The participation of the major actors involved in research, development, decision making and business should make this book unique and a pioneer in the field.

The Editors, Dr. Andreas Lymberis, Prof. Danilo De Rossi

The health sector today faces great challenges. Health is an information‐intensive sector where Information and Communication Technologies (ICTs) could significantly contribute to efficiency and productivity gains. European Union is looking at the different facets of eHealth and mainly at the following three:

a) Research and development, in particular to support the development of several regional health information networks, telemedicine services, and personal health systems for patients and citizens.

b) Regulatory framework and standardisation, which ensure competition, interoperability and, at the same time, the confidentiality of personal data.

c) Promotion of eHealth best practices through various eEurope 2002 and 2005 initiatives.

After the pharmaceutical and radiology industry, eHealth is now the third industrial pillar for health. This emerging sector forms the backbone for the reengineering of health systems. It actually improves the access to and quality of care and places citizens at the very centre of its concern.

The world is becoming more and more health conscious. Society, health policy and patients' needs are all changing dramatically. The challenges society is currently facing are related to the increase in the aging population, changes in lifestyle, the need for healthcare cost containment and the need for improvement and monitoring of healthcare quality. The emphasis is put on prevention rather than on treatment. In addition, patients and health consumers are waiting for non‐invasive or minimally‐invasive diagnosis and treatment methods, for home care, short stays in hospital, enhancement of rehabilitation, information and involvement in their own treatment. Progress in science and technology offers, today, miniaturization, speed, intelligence, sophistication and new materials at lower cost. In this new landscape, microtechnologies, information technologies and telecommunications are key factors. Telemedicine has also evolved. Used initially to exchange patients' files, radiographic data and other information between health providers, today telemedicine contributes to new trends in “hospital extension” through all‐day monitoring of vital signs, professional activities, entertainment and home‐based activities.

The new possibilities for home care and ambulatory monitoring are provided at 4 levels:

a) Microsensors. Microtechnologies offer the possibility of small size, but also of intelligent, active devices, working with low energy, wireless and non‐invasive or minimally‐invasive;

b) Wrist devices are particularly user friendly and combine sensors, circuits, supply, display and wireless transmission in a single box, very convenient for common physical activities;

c) Health smart clothes make contact with 90 % of the skin and offer many possibilities for the location of sensors. These sensors have to be thin, flexible and compatible with textiles, or made using textile technologies, such as new fibers with specific (mechanical, electrical and optical) properties;

c) Health smart homes. The aim of this method is to improve the patient's living conditions and to avoid the cost of long hospitalization. “Exosensors” are used for measurement of the activity and behavior of the patient. The field of applications is very large, e.g. continuous monitoring of elderly populations, professional and military activities, athletes performance and condition, and people with disabilities. This new healthcare approach has to take into account lifestyle for improving prevention. For the patient to be more and more involved in his/her own therapy, new responsibilities and ethics have to be defined. A “societal health education” has to be provided to physicians and to patients to get all the benefits of this new context.

MyHeart is an integrated project of the 6^th framework programme for research and development of the European Commission under Philips Research Aachen leadership for fighting Cardiovascular Diseases (CVD) by prevention and early diagnosis. The major goal of the project is to create business options using smart electronic systems and appropriate services that empower the users to take control of their own health status. MyHeart addresses a wide variety of applications in the cardiovascular disease space and intends to develop lifelong solutions for healthy people, at risk population as well for chronically ill patients.

The paper describes Health0: an innovative healthcare and lifestyle management wearable system that aims to bring an individual focused approach to healthcare. A modular architecture is proposed that combines a Linux‐based PDA with a distributed wireless sensor‐network and innovative bandage‐sized (2.5 cm²) sensor hardware. Real‐world scenarios that can use the Health0 system are discussed.

After four hundred years of delivering health care in hospitals, industrialized countries are now shifting towards treating patients at the “point of need”. This trend will likely accelerate demand for, and adoption of, wearable computing and smart fabric and interactive textile (SFIT) solutions. These healthcare solutions will be designed to provide real‐time vital and diagnostic information to health care providers, patients, and related stakeholders in such a manner as to improve quality of care, reduce the cost of care, and allow patients greater control over their own health. The current market size for wearable computing and SFIT solutions is modest; however, the future outlook is extremely strong. Venture Development Corporation, a technology market research and strategy firm, was founded in 1971. Over the years, VDC has developed and implemented a unique and highly successful methodology for forecasting and analyzing highly dynamic technology markets. VDC has extensive experience in providing multi‐client and proprietary analysis in the electronic components, advanced materials, and mobile computing markets.

People's desire is to stay healthy during the entire course of their live. Innovations in medicine in care and technology have always contributed significantly to meet this desire as close as possible. Today, healthcare systems are faced with huge additional challenges. The focus of nearly every healthcare debate is on costs. But is this debate target‐oriented and does it support the struggle for further enhancing the quality of care? The implementation of IT assisted workflow and knowledge supporting tools throughout the entire healthcare process ‐ prevention to cure – leads to care which would be much more focused on people's needs and efficiency. The information gained from monitoring and wearable devices has to be included to these tools for delivering comprehensive patient information to the point of care. Then the puzzle of the different components in healthcare linked by IT will be complete, and the care process could be continuously optimized in an efficient way.

The background of the development of i‐wear for health care and wellness are two actual trends: The wellness trend with its expectation to stay fit and healthy and the increasing life expectancy of the Europeans and the challenges, which are resulting thereof for the medicine and the technology that goes with it. Already in 2040 the amount of people over 60 years in Europe will amount to 40% of the entire population [1,2]. In recent years the co‐operation of physicians, biologists, physiologists, engineers for electronics and information technologies and textile scientists has produced a multitude of innovative applications for textiles, especially in the medical and wellness field. This presentation will cover the state of the art and some future aspects of textile‐integrated solutions for health and wellness services, with intelligent application forms or integrated electronics (i‐wear), which are an increasing market for textiles.

In order to make intelligent biomedical clothing a market reality, a critical mass of scientific, technical and industrial capacities from various disciplines and industries must be successfully brought together. The textiles and clothing sector, i.e. the industry that transform natural or man‐made fibres into yarns then with a myriad of processing options into complex tissues and finally into clothing, is undoubtedly a crucial element in such development. With Europe disposing of the world's most diverse, productive and innovative textiles and clothing industry, in addition to relevant expertise and resources in other scientific disciplines and industrial sectors, it could play a leading role in the advancement of the concept of intelligent biomedical clothing. In this process, a great number of challenges – firstly scientific and technical in nature ‐ still need to be overcome and support from public funding programmes could constitute the necessary trigger for research and industrial efforts to be seriously undertaken. In view of the great benefits of such new products for the individual consumer, national health care systems and the society as a whole, a concerted effort in private‐public partnership seems merited.

The EU support to R&D in eHealth over the last few years has addressed citizens, patients and health professionals needs in their activities. The societal challenges based on the principle of citizen‐centred care have found solutions in the many projects financed through the IST programme.

Major paradigm shifts have emerged e.g. from “hospital centred healthcare” to “patient/citizen centred health” and from “treatment” to “prevention”. Information technologies became one of the major driving forces for healthcare evolution, receiving acceptance by an increasing number of health professionals. In addition, a new industrial sector was clearly identified; the “Health Telematics Industry”.

This paper present the main research and development activities carried out in eHealth during the 5^th R&D Framework Programme and the future research and development activities in the 6^th R&D Framework Programme.

The purpose of this paper is to briefly summarize the basis of the U.S. Army's interest in Interactive Textiles and to describe some of the salient needs in the area of healthcare and E‐Textiles and finally to indicate the current and near term market for interactive textile solutions. The basis of current Army, indeed DoD interest in Interactive Textiles including E‐Textiles is found in the concept of Network‐Centric Warfare. The individual soldier in this concept is often at the hub of a vast information network than shares information across platforms such as vehicles and aircraft as well as across echelongs of command from the font line to the rearmost command and control centers. In order to realize the advantages of such a war fighting concept, E‐Textiles are required in a number of areas including soldier's uniforms, tentage and airdrop systems. With respect to healthcare, the Army's interest in E‐Textile solutions lie in the areas of human performance monitoring (broadly defined to include physiological states such as blood pressure and hydration as well as the more difficult to measure states of attentiveness and cognitive functioning), wound detection and treatment, energy harvesting and flexible displays.

Applications for ambulatory monitoring span the spectrum from fitness optimization to cardiac defibrillation. This range of applications is associated with a corresponding range of required detection accuracies and a range of inconvenience and discomfort that wearers are willing to tolerate. This paper describes a selection of physiological sensors and how they might best be worn in the unconstrained ambulatory environment to provide the most robust measurements and the greatest comfort to the wearer. Using wireless mobile computing devices, it will be possible to record, analyze and respond to changes in the wearers' physiological signals in real time using these sensors.

Decreased vigilance and fatigue are major factors accounting for driver error. Moreover, it is one of the most common causes of traffic accidents. The development and integration of non invasive systems to detect driver fatigue in real time is a challenging task for the near future. Smart systems promise new approaches to sensor development, signal processing and interpretation to asses the evolution of the physiological state of the driver. At the same time, however, driver monitoring should be realistic in terms of automotive constraints, price and robustness.

Can smart materials meet those requirements? Issues involved in driver monitoring will be discussed and an overview of the demands placed on smart materials by the automotive environment will be given.

Technology advancements are foremost on the minds of scientists and developers who are working to overcome the many hurdles associated with bringing consumers the enhanced benefits associated with next generation wearable health systems. Often the technology work takes a front seat to the basic requirements of traditional consumer apparel. The choices of what consumers elect to place and carry on their body can be practical, logical, emotional and sometimes seemingly random. By providing insights and data to support the claims, developers of wearable health systems of the future will be able improve their chance of consumer adoption and continued use by gaining a clearer picture of the people that will be wearing the systems. Results from 5 different consumer research studies are presented, examining consumer buying patterns, gender differences, regional differences, their receptivity to health benefits delivered via clothing and what they want from technology enhanced clothing. Market research related to biophysical monitoring utilizing smart fabrics or interactive textiles show a critical level of commercial activity. Medical applications focused on the aged, infant and critical patient care are taking the lead. This paper presents a look at the biophysical monitoring market and discusses new materials useful in garment systems and the challenges remaining for their development and integration with textiles. A new method of non‐invasive monitoring of periodic activity is discussed.

After decades of development of information systems dedicated to health professionals, there is an increasing demand for personalized and non‐hospital based care. An especially critical domain is cardiology: almost two third of cardiac deaths occur out of hospital, and victims do not survive long enough to benefit from in‐hospital treatments. We need to reduce the time before treatment. But symptoms are often interpreted wrongly. The only immediate diagnostic tool to assess the possibility of a cardiac event is the electrocardiogram (ECG). Event and transtelephonic ECG recorders are used to improve decision making but require setting up new infrastructures. The European EPI‐MEDICS project has developed an intelligent Personal ECG Monitor (PEM) for the early detection of cardiac events. The PEM embeds advanced decision making techniques, generates different alarm levels and forwards alarm messages to the relevant care providers by means of new generation wireless communication. It is cost saving, involving care provider only if necessary and requiring no specific infrastructure. This solution is a typical example of pervasive computing and ambient intelligence that demonstrates how personalized, wearable, ubiquitous devices could improve healthcare.

Despite advances made in health‐related ambulatory monitoring, medical practitioners and researchers have remained seriously constrained in their ability to acquire concurrent assessments of multiple physiological systems, as well as patient reports of symptoms and well being in daily life: Almost all past and current applications have been limited to the registration of a single variable (e.g. the electrocardiogram or blood pressure), and this has resulted in incomplete information about other relevant physiological and environmental factors likely to contribute to disease or its amelioration. Monitoring of multiple physiological functions has been too complicated to achieve and has required special measurement devices that have been unavailable, too expensive, or too cumbersome to effectively employ. Concurrent assessment of pertinent information about patient activities during monitoring has remained difficult to accomplish, although such information is likely to be crucial for the interpretation of physiological findings and patients' perceptions of improvement.

The LifeShirt^TM (Vivometrics, Inc., Ventura, CA, U.S.A.) is a multi‐function ambulatory device capable of simultaneously monitoring several physiological signals and patient reports of symptoms and well being. The LifeShirt system is an extensible data acquisition and processing platform consisting of a garment, a data recorder, and PC‐based analysis software. Sensors in the LifeShirt garment continuously monitor respiration, the electrocardiogram, activity and posture. Other functions are easily plugged into the system, including pulse oximetry, EEG/ EOG measurement, blood pressure, temperature, capnometry and acoustic monitoring. Subjective patient data may also be entered into the LifeShirt recorder, and all data are encrypted and written to a flash memory card. Vivologic^TM analysis software provides full‐disclosure analysis and display of high‐resolution waveforms and over 30 derived parameters; the software also produces summary reports for clinical diagnostic purposes. The LifeShirt has been rigorously tested for more than 38,000 hours in 90 studies with 1,750 subjects. The device has received all necessary regulatory approvals and is currently used in leading research institutions throughout the United States, Canada and Europe. Clinical applications include sleep diagnostics, heart disease, pulmonary disorders, cardiopulmonary rehabilitation, early hospital discharge and pre‐ and post‐operative monitoring, human‐factors in ergonomics and behavioral medicine.

The Body Area Network (BAN) extends the range of existing wireless network technologies by an ultra‐low range, ultra‐low power network solution optimised for long‐term or continuous healthcare applications. It enables wireless radio communication between several miniaturised, intelligent Body Sensor (or actor) Units (BSU) and a single Body Central Unit (BCU) worn at the human body. A separate wireless transmission link from the BCU to a network access point ‐ using different technology ‐ provides for online access to BAN components via usual network infrastructure. The BAN network protocol maintains dynamic ad‐hoc network configuration scenarios and co‐existence of multiple networks.

BAN is expected to become a basic infrastructure element for electronic health services: By integrating patient‐attached sensors and mobile actor units, distributed information and data processing systems, the range of medical workflow can be extended to include applications like wireless multi‐parameter patient monitoring and therapy support. Beyond clinical use and professional disease management environments, private personal health assistance scenarios (without financial reimbursement by health agencies / insurance companies) enable a wide range of applications and services in future pervasive computing and networking environments.

The Citizen Health System (CHS) is a European Commission (CEC) funded project in the field of IST for Health. Its main goal is to develop a generic contact center which in its pilot stage can be used in the monitoring, treatment and management of chronically ill patients at home in Greece, Spain, and Germany. Such contact centers, using any type of communication technology, and providing timely and preventive prompting to the patients are envisaged in the future to evolve into well‐being contact centers providing services to all citizens. In this paper, we present the structure of such a generic contact center and present its major achievements, and their impact to the quality of health delivery.

Continuous monitoring of physiological and physical parameters is necessary for the assessment and management of personal health status. It can significantly contribute to the reduction of healthcare cost by avoiding unnecessary hospitalisations and ensuring that those who need urgent care get it sooner. In conjunction with cost‐effective telemedicine platforms, ubiquitous health monitoring can significantly contribute to the enhancement of disease prevention and early diagnosis, disease management, treatment and home rehabilitation. Latest developments in the area of micro and nanotechnologies, information processing and wireless communication offer, today, the possibility for minimally (or non) invasive biomedical measurement but also wearable sensing, processing and data communication. Although the systems are being developed to satisfy specific user needs, a number of common critical issues have to be tackled to achieve reliable and acceptable smart health wearable applications e.g. biomedical sensors, user interface, clinical validation, data security and confidentiality, scenarios of use, decision support, user acceptance and business models. Major technological achievements have been realised the last few years. Cutting edge development combining functional clothing and integrated electronics open a new research area and possibilities for body sensing and communicating health parameters. This paper reviews the current status of research and development on smart wearable health systems and applications and discusses the outstanding issues and future challenges.