Invited presentation by MN Kamel Boulos at http://www.aal-europe.eu/innovate-uk/ (12 March 2013) - (C) The eCAALYX Project Consortium - http://ecaalyx.org/

1. @
Telehealthcare for older people with
comorbidity: lessons from eCAALYX
and project walk-through
Maged N. Kamel Boulos, MBBCh, MSc, PhD, SMIEEE
Plymouth University, UK
mnkboulos@ieee.org

2. Agenda
• Introduction: about comorbidity in older people
and the eCAALYX project
• Lessons learned during the course of the project*
• Project walk-through
• Evaluation (brief notes)
• Acknowledgments
* For a much more detailed discussion of these lessons, see: Gálvez-Barrón
CP, Kamel Boulos MN, Prescher S, Abellán Cano C, Suárez Ortega E, Font Tió
A, Morales Gras J, O'Donovan K, Díaz Boladeras M, Köhler F, Rodríguez-
Molinero A. Telemedicine scenario for elderly people with comorbidity.
Book chapter to appear in: Garcia NM, Rodrigues JPC, Sales Dias M, Elias D
(Editors). Ambient Assisted Living. Taylor and Francis / CRC Press (USA), due
2013. http://allab.it.ubi.pt/images/documents/aalbook2011.pdf

3. Introduction—comorbidity
• The negative social and economic impacts of population
ageing are mainly due to the concurrent comorbidity in older
people rather than to ageing per se.

4. Introduction—comorbidity
• A comorbid condition is defined as either a medical condition
existing simultaneously but independently with another
condition in a patient, or as a medical condition in a patient
that causes, is caused by, or is otherwise related to another
condition in the same patient.
• According to Valderas et al. (2009), the mechanisms that
underlie the coexistence of two or more conditions in a
patient include direct causation, associated risk factors,
heterogeneity, and independence.
• Comorbidity is associated with worse health outcomes, more
complex clinical management, and increased healthcare
costs.*
Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for
understanding health and health services. Annals of Family Medicine. 2009; 7 (4):357–63.
http://dx.doi.org/10.1370/afm.983

5. Introduction—comorbidity
• The interplay between different conditions – often apparently unrelated
(e.g., arthritis and heart disease) – may have consequences that are not
always simply summational (e.g., worse motor disability or reduced
mobility in the case of arthritis coexisting with heart disease).
• Healthcare costs increase with the increase in age and number of
coexisting diseases; however, the increase is very much higher in persons
with chronic conditions compared to persons without chronic conditions.
• The number of conditions coexisting in a person influences healthcare
costs more than age; thus, healthcare costs for a relatively young person
aged 65-69 with two associated chronic conditions are significantly higher
than those for a person over 85 years with one associated chronic
condition. In other words, healthcare costs for a person aged 65-69 with
one associated chronic condition rise more when the person develops a
second associated chronic condition than as the person just gets older.
Thus, the comorbidity affecting a person as they get older is more relevant
than their natural ageing per se.*
* Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple
chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269-2276.

6. Introduction—eCAALYX
• The European-funded eCAALYX project (Enhanced Complete
Ambient Assisted Living Experiment, 2009 – 2012; funded
under the Ambient Assisted Living Joint Programme -
http://ecaalyx.org/) is building on the strengths and
experience acquired in the original European-funded CAALYX
project (Complete Ambient Assisted Living Experiment, 2007 –
2008; funded under the Sixth Framework Programme).
• eCAALYX takes the 24/7 monitoring of the health and well-
being of healthy older people that was developed in CAALYX
(with special emphasis on outdoors/mobile scenarios) one
step further by refining it and making it available to older
people with comorbidity (with additional strong emphasis on
home-based care and lifestyle management components).

7. CAALYX (2007-2008, FP6) and eCAALYX (2009-2012, AAL) are two recent
examples of EU-funded e/mHealth projects to develop next-generation
home and outdoors 24/7 health telemonitoring/telehealthcare services
for older people, including, (in eCAALYX), older patients with
comorbidity.
The Internet and smarphones are central to delivering these services.
Sensors
http://caalyx.eu/
http://ecaalyx.org/ ECG Sensor GPS
Web
Services
http://caalyx-mv.eu/
(2011-2014, FP7) Caretaker Site
Blood Pressure Meter
Internet
Internet
Bluetooth
Fall Sensor
Plymouth University (PU) is full research partner in both
projects (PU P.I.: MN Kamel Boulos, grant holder of a total
of €173,005.00 for PU’s involvement in both projects).

8. • In services such as CAALYX and eCAALYX, the main
process consists of periodically (or continuously, as
necessary):
– acquiring vital signs (body temperature, pulse and
respiratory rates, blood pressure) and other clinical and
non-clinical signals and data (e.g., ECG, blood glucose
level, saturation of peripheral oxygen, body weight,
activity monitoring, person’s location via GPS, etc.),
– recording them locally (while the user is at home or
outdoors),
– analysing them, and
– communicating them as necessary (e.g., when the
system suspects an unfolding emergency) to a remote
telehealthcare centre, where the data are made
available to a specialist or healthcare professional for
further action.

9. • The devices used most frequently in such applications
to measure clinical/biochemical parameters and
signals are pulse oximeters, blood pressure meters,
ECG monitors, glucose meters, digital scales,
movement and fall detection sensors (accelerometers),
etc.
• These devices can be fixed somewhere at home, but it
is increasingly common for them these days to be
made wireless or “wearable” (with sensors
incorporated into clothing, bracelets, etc.), which
makes their use more comfortable and transparent.
• These collections of sensors around a person or patient
make up what we call a Body Area Network (BAN) or
Personal Area Network (PAN).

10. Lessons learned
• In the next slides we will briefly present some practical
lessons we have learned during the course of the eCAALYX
project that could also be generalised to other telehealthcare
solutions to ensure their success.
• The lessons cover the clinical scope and requirements of
telehealthcare services for older people with comorbidity;
service configurability (clinical) on a per-individual-patient
basis; clinical information management; user-centred design
(for older patients, their carers and clinicians); and service
sustainability, interoperability and expandability as part of a
growing telehealthcare ecosystem; among other clinical,
technological and organisational issues (that are not fully
covered in these slides, e.g., patient privacy issues).

11. Desirable clinical scope of telehealthcare
services for older people with comorbidity
• Currently, many telehealthcare projects are exclusively
aimed at monitoring a single disease such as diabetes,
cardiac insufficiency or chronic respiratory disease.
• However, such an approach is not practical, cost effective
or sustainable, as one of the characteristics of older
populations is that they often suffer from more than one
chronic, major illness (pluripathology).
• This means that telehealthcare systems must be able to
monitor several major diseases simultaneously (if they
are to become viable and sustainable solutions).

12. Desirable clinical scope of telehealthcare
services for older people with comorbidity
• Cardiovascular, chronic respiratory and osteoarticular
diseases have the greatest impact on the elderly in terms of
survival, dependency and hospitalisation, and should thus be
considered ‘high priority’ when deciding on conditions to
cover by a given telehealthcare service.
• Telehealthcare systems must be principally aimed at the
secondary and tertiary prevention of disease.
• The elderly population’s demand for assistance or healthcare
services may increase through reasons that are not strictly
clinical but are rather of a social nature. In this regard,
telehealthcare services can and should be conceived as a
useful tool for integration and cooperation between
healthcare and social care services (this integration also
requires significant organisational changes/change mngmnt).

13. Other desirable clinical requirements in
telehealthcare services for older people with
comorbidity
• The telehealthcare service should be available continuously for patients on a
24/7 basis.
• The relevant clinical information required to monitor the health of an older
person includes not only vital physiological signs (heart and respiratory
rates, blood pressure, body temperature, etc.), but also information about
the person’s functional status, affective state, and pain levels, amongst other
data. This equally important information can be gathered through
questionnaires or rating scales normally used in clinical practice, but
administered in a telematic manner.
• Telehealthcare systems must have great plasticity, flexibility and
configurability due to the wide variability within patients’ clinical profiles
and diseases. A patient’s doctor should be able to configure the system
according to the patient’s (and doctor’s) choice of devices/sensors,
observation schedules (or patterns) and alert levels.

14. Clinical configurability: 1
Observation Template
remotely editing ObservationSteps
*
observation patterns on a Observation
Template
per-patient basis and Get User Profile
prescribing/configuring Send Observation
new sensors in eCAALYX Medical Observation Type
+Report
+Health State Classification
Observation
+Measurements that lead to Conclusion Caretaker Site
Observation
Measurements
1 *

15. Other desirable clinical requirements in
telehealthcare services for older people with
comorbidity
• Clinical information management: Submission and assessment of “raw”
measurements obtained through the devices can result in information
overload or raise false alarms among healthcare providers. Telehealthcare
systems should therefore carry out a preliminary processing of the
information gathered by sensors (e.g., through the use of properly
validated medical algorithms), so that they may only warn of relevant
clinical situations.
• Telehealthcare systems should be viewed, designed and promoted not as
replacing clinicians, but as a tool to aid them in their work and one that
seamlessly integrates into their existing clinical workflows rather than
disrupts them. This is necessary to manage the inevitable change as these
services are introduced and to reduce the resistance of some clinicians to
change, which might be encountered.
• This implies that users (clinical, but also non-clinical: organisations,
patients and lay carers) must be properly heard, represented and
involved in all the design and development phases of the service.

16. Catering for older people’s usability
requirements
Examples of ageing-related limitations (visual, auditory,
cognitive) that have usability design implications:
Ageing can be associated with a decline in the abilities of colour discrimination and contrast
Visual limitations
sensitivity (= designers should use high-contrast colour schemes), as well as with limitations in
motion perception and peripheral vision.
Ageing can affect the hearing function (esp. for higher frequencies, so designers should use
Auditory limitations
lower frequencies and avoid sound effects/background noise) as well as the ability to
concentrate on audio and text at the same time. There could also be impairments in sound
localisation and speech recognition.
Ageing can affect the information-processing capacity of a person (processing speed, longer
Cognitive impairments
thinking time, memory loss) and reduce the abilities of information selection and extraction
from displays (= designers should use simple, low-hierarchy menus and only show essential
information in a very clear language). Ageing can also be associated with declining spatial and
working memory, which may lead to troubles in learning.
However, devices and software should be carefully designed in a way
that does not stigmatise older patients, as this could significantly
influence their acceptance of the system. The ‘design for all’ strategy
should be kept in mind.

17. Catering for older people’s usability
requirements
• The usability design for the eCAALYX mobile platform caters
for older users’ needs in two main areas, namely physical
handling and maintenance of the smartphone, and the usage
of the phone software itself.*
• Regarding physical handling and maintenance, the following
practical solutions were adopted:
– Use of dock-stations to simplify the battery charging of the mobile device;
– Use of a mobile phone without buttons and with large touch-screens, which
allows the building of virtual buttons as large as needed, instead of the small
buttons available on commercial mobile phones with conventional keypads
and keyboards; and
– All maintenance actions are performed either remotely and transparently to
the user, or locally, by technicians.
* Kamel Boulos MN et al. How smartphones are changing the face of mobile and participatory healthcare: an
overview, with example from eCAALYX. BioMed Eng OnLine. 2011; 10:24. http://www.biomedical-engineering-
online.com/content/pdf/1475-925x-10-24.pdf

18. Catering for older people’s usability
requirements
• Concerning smartphone software usage, the following
practical solutions were adopted in eCAALYX:
– The phone runs autonomously without the need of any mandatory interaction
from the user from the time it is powered on. This includes the suppressing of
all enquiries of the operating system, such as pin negotiation and the
automation of all necessary processes;
– Rebooting has to be avoided, because it can be a difficult task to perform by
the target users. The phone must therefore support prolonged periods of
operation without the need to reboot the system;
– All error pop-ups were suppressed, to avoid showing any system errors to the
user.
http://www.youtube.com/watch?v=iwuP5EeNH4c

19. Video demonstration
• http://www.youtube.com/watch?v=iwuP5EeNH4c
• http://www.youtube.com/watch?v=sct566oMsCc

20. Service sustainability, interoperability
and expandability as part of a growing
telehealthcare ecosystem
See: Kamel Boulos MN. eHealth
service interoperability: Paying
attention to interfaces! Lessons
from CAALYX and eCAALYX
(invited keynote speech). In:
Proceedings of the Third Middle
East Conference of Health
Informatics, Beirut, Lebanon, 31
March-1 April 2010 - organised
by the Lebanese Medical
Informatics Association in
collaboration with MEAHI, the
Middle East Association for
Health Informatics within IMIA.
http://ecaalyx.org/index.php?opt
ion=com_content&view=article&
id=50:lebanon&catid=35:confere
nce-papers&Itemid=37

21. A typical personal telehealth ecosystem
Source: Carroll R et al. Continua: An Interoperable Personal
Healthcare Ecosystem. IEEE Pervasive Computing. 2007; 6(4): 90-94.

22. Personal e/mHealth services ecosystem/value chain:
complex interfaces and layers building on one another;
many device vendors and value-added service providers.

23. • Portability: a device/system can be seamlessly connected to
other devices/different systems/different service providers to
provide additional, complementary functionality; and
• Interoperability:
medical/health applications
in different clinical
and care environments
can securely and reliably
exchange useful information
between devices connected
to, or worn by the person, as necessary.
Source: Galarraga M et al. Telemonitoring systems interoperability challenge: an updated review of
the applicability of ISO/IEEE 11073 standards for interoperability in telemonitoring. Conf Proc IEEE
Eng Med Biol Soc. 2007;2007:6161-5.

24. eCAALYX interoperability approaches
• Continua Version One standard, incorporating ISO/IEEE 11073 and
Bluetooth standards (for plug-and-play interoperability); and
• Broadband Forum TR-069 CWMP* specification (used by eCAALYX in
a completely novel way for auto-configuration, remote
troubleshooting and customisation of the home healthcare system).
* Technical Report 069 CPE (Customer-Premises Equipment) WAN (Wide Area Network) Management Protocol
Health
Device Profile Spec (not yet)
http://www.continuaalliance.org/
http://www.broadband-forum.org/

26. The Continua End-to-End reference architecture (v1 scope)
Source: Carroll R et al. Continua: An Interoperable Personal Healthcare
Ecosystem. IEEE Pervasive Computing. 2007; 6(4): 90-94.

27. From: Douglas P. Bogia DP, Cnossen RA (Intel Corp). Continua |
Health Alliance and Associated Standards--Design and More >
Developer Forum on Telemedicine Systems: Issues, Design,
|
Development and Standardization. Presented at: Globecom
2008, December 2, 2008, New Orleans, Louisiana, USA.

28. Integrating the Health-
care Enterprise
http://www.ihe.net/

29. Demonstrations/
plugfests
Source: Douglas P. Bogia DP, Cnossen RA (Intel Corporation). Continua Health Alliance and
Associated Standards--Design and Developer Forum on Telemedicine Systems: Issues,
Design, Development and Standardization. Presented at: Globecom 2008, December 2,
2008, New Orleans, Louisiana, USA.

30. Demonstrations/
plugfests
Source: Douglas P. Bogia DP, Cnossen RA (Intel Corporation). Continua
Health Alliance and Associated Standards--Design and Developer
Forum on Telemedicine Systems: Issues, Design, Development and
Standardization. Presented at: Globecom 2008, December 2, 2008,
New Orleans, Louisiana, USA.

31. Project walk-through
WBS = Wearable Body Sensors

32. Equipment for the patient:
note smart garments

33. Location of the temperature
sensor in the smart garment
The smart garment
MINI DIN connection to the ECU (Electronic Control Unit)
in the smart garment
Front side of the ECU
From left to right the indicators are:
1. BT link established (blue LED); only when connected
2. Low battery LED, 20% left (red LED); only when low battery
3. HR and RR display (yellow LED blinking with the rate of the sensor)
4. HR and RR circuit ok (green LED)
5. ON/OFF interrupter
6. MINI DIN connector (interface with the Smart Garment)
7. MINI USB interface to charge the battery
8. 100% charged battery LED (green LED fully charged, red LED
charging, only while charging) ECU

34. LEDs indicating connection via the Bluetooth link LEDs indicating system working but not
connected via a Bluetooth link
Communication implementation between the
Fall Sensor/Fall and Activity Sensor and the
mobile smartphone through the ECU

35. < System overview of Fall and Activity Sensor
Sample of the activity classification algorithm
in operation over a 144 seconds. A series of 4
stand-sit-stand, 6 stand-lie-stand and 3 stand-
walk-stand activities were performed >

37. ISS device: The ISS (Intelligent
Sensor System) is a portable
physiological monitor that combines
the most relevant sensors for
monitoring the prevalent chronic
conditions and health risks of
elderly people, such as
cardiovascular diseases,
hypertension, stroke and congestive
heart failure

38. Power supply
Connection to mains power is
indicated by the plug symbol at
the battery status icon
ISS plugs

39. The cable connections from the sensors to the ISS

42. Administrator
Instruct the user on how to use the blood glucose meter.
Connection with the home system router and
communication is achieved automatically via a Bluetooth
link when powered up.

43. Home system (STB + TV)
STB = TV Set-Top-Box

44. Usability tip:
The remote
control should
be more
tailored for
eCAALYX
scenarios, with
only the
necessary
buttons offered.
At home:
TVBox (STB)
and TV interface
screens

45. User Selection interface Health Menu
Reminders interface Notification interface

46. Vital Sign selection menu Blood Pressure graph
eCAALYX Agenda menu Medical appointment

47. Medication event Measurement event
Health Videos interface eCAALYX playing video screen

48. eCAALYX video full screen mode Questionnaires menu
Question interface Finished questionnaire

49. eCAALYX emergency call and incoming call
interfaces
eCAALYX video-conference call

50. At home: TVBox (STB) and TV interface screens
N.B.: STB also acts as sensor gateway for immediate visualisation
of measurement values on the TV after using a sensor.
Support for the future (Kinect NUI navigation):

51. eCAALYX settings menu (administrator) General Settings interface
Network Settings interface Connection between the Home Gateway
router and a laptop, as recommended for the
installation check-up
Browser location bar pointing to the check-up webpage

52. Home Gateway check-up webpage view
HG System and Remote Servers Functionality test

53. Mobile system overview and the deployment
diagram of the mobile smartphone, which
includes the LG-P990 handset equipped with a
SIM Card, and the eCAALYX software with its
configuration files

54. eCAALYX mobile platform and app
• The eCAALYX mobile app has beendeveloped as a key and central
component of eCAALYX.
• The main functionality of the eCAALYX mobile platform and app is to
act as a seamless “informed” intermediary between the wearable
health sensors (in a ‘smart garment’) used by the older person and
the health professionals’ Internet site, by reporting to the latter (but
also to the patients, as appropriate) alerts and measurements
obtained from sensors and the geographic location (via smartphone
GPS) of the user.
• Additionally, the mobile platform is also able to reason with the raw
sensor data to identify higher level information, including easy-to-
detect anomalies, such as tachycardia and signs of respiratory
infections, and some more complex ones, based on established
medical knowledge.

55. eCAALYX mobile platform and app
• A user interface is also provided, which allows the user to evaluate the
most recent medical details obtained from sensors, perform new
measurements, and communicate with the caretakers/clinicians.
• The technological platform in the current prototype is the Google
Nexus, running the Android 2.1 platform, with 1 GHz processor and 512
MB RAM memory; however, it can
be easily ported to a newer Android version, or even
to another Android phone.
• The software itself is written in JAVA. The interface with the
Caretaker/Clinicians’ site is accomplished using the W3C Web Services
technology, while the interface with the health sensors (in a ‘smart
garment’ worn by the patient) is realised using Bluetooth wireless
technology.
• Access to necessary resources, such as GPS, Bluetooth, and the Internet
(3G/WiFi), is also provided through the Android Platform.

56. eCAALYX mobile platform and app: Major challenges
• There were many challenges to the development of the mobile platform.
Most importantly, the mobile platform must be seamless and autonomous in
its operation (e.g., in raising alerts), in order to provide a usable service to a
target group that usually does not have any familiarity with technology and
might even be unconscious during times of medical emergency and not able
to manually operate any device or software.
• System and service reliability is also an important issue to take into account,
firstly due to the possible negative sensation that the application may give to
the user in the case of malfunctioning, and, secondly, due to the physical
distance between the technical maintenance teams and the users.

57. Major challenges (eCAALYX mobile) – Cont’d
• From an implementation point of view, the issues regarding the
development of intelligent mechanisms in a mobile, resource-
limited and battery-powered device should also be considered.
• Usability issues are discussed in earlier slides of this presentation.
Usability is a critical issue for the target group of eCAALYX as, usually,
users in this target group do not have any familiarity with technology
and this is also often compounded by a range of physical (e.g., poor
eyesight) and/or cognitive disabilities (e.g., dementia) that such
users might be suffering from, which can further limit their use of
the technology.
• Due to these facts, the eCAALYX mobile platform was designed to be
completely transparent to the user, and the necessary interface
functionality to be as accessible as possible.

58. Functionality provided by the mobile smartphone

59. The Physical Activity, Respiratory
Rate and Temperature screens >
Vital Signs screens of the mobile
application >

60. The status window, with several
possible statuses >
The communication implementation between
the different sensors and the mobile
smartphone through the Electronic Control
Unit (ECU)

62. (all user types)
< Select user type:
Doctor, caretaker,
Patient, or Family
member
eCAALYX Server
Administrator’s portal >
Create new user
(steps 1-4)

63. Administrator portal: Managing doctors
Administrator portal: Patient management

65. Selection of Doctors to add to a patient
Blank User profile

66. Now that the Doctor is added, you can also add a Kit using the “select kit” option:
Kit management view
Add the appropriate kit:
Kit selection Kit management updated profile
You need to note the “idkit” and “idbiokit” for the hardware devices
that you will be providing to the patients:
Kit: ALAN21KIT Password : Alan21Kit idkit: 26 idbiokit: 147
Hospital Unit: Primary Care eCAALYX
Gateway: gtnew with Hardware Id 112233
Device List
Hardware details for the Kit
The patients profile will then be updated accordingly.

68. Adding devices to a patient profile
Doctor’s view

70. Caretaker portal - Measurements
ECG

71. Search for a patient
Doctor/caretaker portal: Searching for
a particular patient
Doctor/caretaker portal: Selecting patient’s
measures (date range)

77. Caretaker portal - Respiratory rate

79. Caretaker portal – weight (multiple persons at same patient home used the scale)

80. Caretaker portal – blood pressure

81. Caretaker portal – temperature

83. Doctor portal: Agenda for GP /
Selection of informational videos
for patients

84. Doctor’s portal: Patient’s Agenda > New Appointment
Video selection menu

85. Interface to adding a new treatment
or measure

88. A physician is also able to choose and send clinical questionnaires
to a patient through the caretaker/doctor’s portal. Questionnaires
are classified as new ‘Biomeasure Treatment’.

89. Caretaker portal – English questionnaires

90. Questionnaires (Fragebogen) - caretaker portal

92. Caretaker portal – Observation Pattern/setting Measures Limits
Caretaker portal – single Alert

93. Alerts in caretaker portal (caretaker view)

94. Fall alert in caretaker portal (patient view)

95. Fall alert in caretaker portal (caretaker view)

96. Source: Kamel Boulos MN, Anastasiou A, Bekiaris E, Panou M. Geo-enabled technologies for independent living: examples
from four European projects. Technology and Disability. 2011; 23(1):7-17. http://dx.doi.org/10.3233/TAD-2011-0300

97. Source: Kamel Boulos MN, Anastasiou A, Bekiaris E, Panou M. Geo-enabled technologies for independent living: examples
from four European projects. Technology and Disability. 2011; 23(1):7-17. http://dx.doi.org/10.3233/TAD-2011-0300

98. Evaluation
• The eCAALYX project comprised
two phases of
field trials with 10 patients.
• In the first phase, a limited set of
features was tested, focusing the
tests more on usability and
stability.
• The second phase of the trials
took place in Germany in March
and April 2012, and included a
larger set of features.
• More extensive field trials, with
80-100 patients, are taking place
in the different countries already
running the CAALYX-MV follow-on
project.
eCAALYX Trial 2 synopsis

99. Acknowledgments
• This work has been conducted
within the eCAALYX project,
which is supported in part by the
Ambient Assisted Living (AAL)
Joint Programme, a joint
research and development
funding activity by 20 European
Member States and 3 Associated
States, with the financial support
of the European Community (EC)
based on article 169 of the EC
treaty.
• The eCAALYX Project Consortium
includes 11 member
organisations in five European
countries.