<title>1. INTRODUCTION</title> <p>The
growth in population ageing in most industrialized nations and the related
increasing percentage of chronic disease diffusion is posing several problems
at different levels of our society (political,
social, and familiar/personal
levels).</p> <p>Statistics
data provide a clear picture of the problem dimensions: according to recent results
of a survey funded by the European Commission [##UREF##0##1##], Europe
and Japan
will experience the most pronounced ageing trends up to 2050. The share of the
above 60 age group will be around 37% in Europe and even more in Japan, and
slightly lower in North America (27%). The percentage of the EU population over
the age of 65 is expected to reach more than 28% by 2050, with an estimated
group of 80 million people that will need care and assistance services, in
particular for chronic diseases [##UREF##0##1##].</p> <p>New
care models for chronic condition management have been proposed which define
guidelines for policy planning, as well as principles for social community and
health-care system organization and effort coordination. These models, usually
named continuous-care 
models,
promote home-based continuous care for chronic patients. They emphasize the
fact that the effectiveness and efficiency of long-term condition care depend
strongly on the capability of both the patients and their relatives to manage
their cases (self-management) and on the collaboration of all involved care
providers. Patients, family members, health-care teams (e.g., clinicians,
general practitioner, nurses, etc.), and social community members (e.g., social
workers, volunteers) should be properly informed, motivated, and prepared in
order to effectively collaborate together.</p> <p>One
of the first examples is the Chronic Care Model (CCM), which is a conceptual,
evidence-based framework developed in the USA
[##REF##15289634##2##]. This model proposes
innovative organizational aspects aiming at improving the effectiveness and
efficiency of assistance to patients affected by chronic conditions. The WHO
has recently proposed the Innovative Care for Chronic Conditions (ICCC)
framework, which widens the CCM in order to meet the needs of the international
community [##UREF##1##3##].</p> <p>Therefore,
advances in information and communication technologies (ICTs) and ambient intelligence
(AmI) context-aware system design are required in this framework in order to
address two main objectives. The final objective is to improve the quality of
life of both patients and their closest relatives. As a matter of fact, while
it is obvious that chronic conditions may cause limitations to a patient's
everyday activities, it should not be overlooked that they may dramatically
decrease the quality of life for a patient's family members as well [##UREF##2##4##]. In
order to care for the elder, relatives may be asked to make drastic life
changes, such as quitting their jobs and giving up their social lives. For such
a purpose, an ulterior objective is the implementation of ICT platforms capable
of supporting long-term care service provision while enabling cost savings and
effective heterogeneous resource management (e.g., professionals, biomedical
instruments, etc.).</p> <p>From
the viewpoint of AmI and context-aware system designers, home-based care models
pose several technology-oriented challenges. Services which should be provided
by an AmI system have been classified into the following categories [##UREF##3##5##]: (a) emergency treatment (services for
emergency detection and management); (b) autonomy enhancement, that is, user
assistance services for primary needs and/or everyday activities (nutrition,
taking medication, monitoring vital signs, etc.); comfort services, that is,
services enabling better life quality (e.g., education, socialization, etc.).</p> <p>These
services should be adaptive, easy to use, and strongly personalized according
to user requirements, needs, and disabilities. In most existing AmI
context-aware systems, the focus is on the requirements of the person needing
assistance (the “patient”), whereas requirements coming from the heterogeneous
community of people, who are involved to different extents in patient care and
assistance (the “caregivers”), are often not taken into account when designing
the system.</p> <p>In
this paper, we describe some results obtained through our current research on
the design and development of a service-oriented architecture for continuous
care provisions leveraging on context-aware and mobile technologies, called Emilia Romagna Mobile Health Assistance Network (ERMHAN). Its aim is to enable
the development and delivery of an extensible set of care services which allow
patients to be assisted at home in a familiar environment and support the
activity and mutual collaboration of care providers who are involved to a different
extent in patient care and assistance. Proper and effective information sharing
for action and cooperation support by involved care providers is specifically targeted,
due to their work in mobility conditions, their association to different
organizational domains (e.g., hospital and municipality), and their various
roles (such as general practitioner, specialist, nurse, family members, etc.).</p> <p>This
paper is organized as follows. In <xref ref-type="sec" rid="sec2">Section 2</xref>, we highlight the contribution of
our work and discuss existing related research activities. <xref ref-type="sec" rid="sec3">Section 3</xref> describes
the specific objectives of our work with special focus on the context-aware
approach and in <xref ref-type="sec" rid="sec4">Section 4</xref> we describe the ERMHAN system architecture and some
implementation details about the two main components, the Multichannel Health-Care Service Manager and the Context
Management System. In <xref ref-type="sec" rid="sec5">Section 5</xref>, we discuss some preliminary system
evaluation results and user testing activities. <xref ref-type="sec" rid="sec6">Section 6</xref> concludes the paper
by highlighting the most relevant results of our work and future research
directions.</p>
<title>6. CONCLUSIONS</title> <p>In
this paper, we have presented ERMHAN, a context-aware mobile service platform
supporting mobile caregivers in their daily activities. ERMHAN has demonstrated
its capability of providing an extensible set of services aiming at supporting
care networks in cooperating and sharing information for the goal of improving a
chronic patient's quality of life.</p> <p>ERMHAN
has been designed as a modular system, and its components have been implemented
by adopting standard technologies (e.g., Internet protocols, XML, Web services).
This approach makes the system easily extensible to match specific patient
requirements within an ambient intelligence environment.</p> <p>Future work will concentrate on
security and dependability issues as well as on extending the features provided
by the service platform. In the home domain, this will mainly consist in
deploying body and home sensor networks, and integrating input/output devices
for patients (e.g., alarm button and TV displays). As for the care centre
domain, the main developments will include designing graphical user interfaces
for system configuration and customization (e.g., customization of predefined
alarm management policies and patient case sheets for health centers providing
specialized services); adopting existing standards (e.g., HL7) for assuring
interoperability with hospital back-end systems.</p> <p>Leveraging
on the ERMHAN modular design, future work will also deal in analyzing and
integrating existing user interfaces and applications designed according to HCI
(Human Computer Interaction) principles, especially interfaces designed for
people with cognitive [##UREF##23##27##] and physical
impairments [##UREF##24##28##].</p> <p>Such
advancements, together with more extensive testing activities, including
patients' evaluation of system features, are needed for a final assessment of
the proposed platform.</p>
<p>Recommended by Frédérique Laforest</p> <p>Continuous care models for chronic diseases pose several technology-oriented challenges for home-based continuous care, where assistance services rely on a close collaboration among different stakeholders such as health operators, patient relatives, and social community members. Here we describe Emilia Romagna Mobile Health Assistance Network (ERMHAN) a multichannel context-aware service platform designed to support care networks in cooperating and sharing information with the goal of improving patient quality of life. In order to meet extensibility and flexibility requirements, this platform has been developed through ontology-based context-aware computing and a service oriented approach. We also provide some preliminary results of performance analysis and user survey activity.</p>
<title>2. RELATED WORK</title> <p>Several
research domains can be considered of interest in delivering AmI and pervasive
health services for chronic diseases, spanning from smart homes, assistive
technologies and home-based health monitoring, to context-aware hospitals.</p> <p>One of the first relevant contributions
has been provided by researchers working at the Georgia Tech Aware Home, a prototype of a smart home, where sensing
and perception technologies are used to gain awareness of inhabitant activities
and to enable services for maintaining independence and quality of life for an
ageing population [##UREF##4##6##]. The INHOME
project [##UREF##5##7##] aims at providing the means for improving the quality
of life of elderly people at home, by developing technologies for managing
their domestic environment and enhancing their autonomy and safety at home (e.g.,
activity monitoring, simple home environment management, flexible AV streams
handling, flexible household appliance access). Among more recent works, the
“ubiquitous home” is a real-life test-bed for home-based context-aware service
experiments [##UREF##6##8##] in Japan.
A set of implemented context-aware services has been evaluated by means of
real-life experiments with elderly people.</p> <p>In the field of assistive technologies
and home-based health monitoring systems, several examples exist: Vivago is an
alarm system which provides long-term user activity monitoring and alarm
notification [##UREF##7##9##]; the CareMedia system
[##UREF##8##10##] uses multimedia
information to track user activities.</p> <p>The “hospital of the future” prototype [##UREF##9##11##]
is an example of a context-aware computing system in a hospital environment. It
consists of a series of context-aware tools: an electronic patient record (EPR),
a pill container, and a hospital bed which displays relevant patient record
information, such as the medicine schema, according to contextual information (e.g.,
nurse position, patient, medicine tray). Muñoz et al. [##UREF##10##12##] have recently
proposed a context-aware mobile system where mobile devices are capable of
recognizing the setting in which hospital workers perform their tasks, and let
users send messages and access hospital services according to these contextual
elements.</p> <p>Despite
the multitude of relevant contributions in the above-mentioned research fields,
only recently research activities on pervasive services for ageing and chronic
disease management have begun addressing these requirements by means of a
holistic approach, taking systematically into account standard guidelines and
reference models for continuous care. Consolvo et al. [##UREF##2##4##] have applied
social network analysis methodology to the study of continuous care networks;
they conducted a series of interviews in order to explore the space of
eldercare (i.e., who was involved in the care, what types of care were needed,
and what types of care were being provided); based on user study results they
offer some design guidelines for the development of successful computer-supported
coordinated care (CSCC) systems.</p> <p>Pervasive
self care is a conceptual framework for the development of pervasive self-care
services [##UREF##11##13##]. This study has
been promoted in the framework of self care, an initiative by the Department of
Health in the UK
that aims at treating patients with long-term conditions near home. The
proposed reference model, inspired by the principles of service-oriented architecture
(SOA), distinguishes three main spheres: the body sphere (a body area network
supported by a router which interacts with body sensors and with the home
sphere); the home sphere (a home server that collects and preprocesses sensed
data), and the self-care service sphere (the data processing and sharing
subsystem).</p> <p>Some
experimentation results are given in [##REF##16871726##14##], where a telemedicine system is used
for the home care of patients suffering from chronic obtrusive pulmonary
disease (COPD); the integrated telemedicine system provides professionals with
shared and ubiquitous access to patient health records and patients with direct
access to nurse case manager, telemonitoring, and televisit services.</p> <title>2.1. Contribution of our work</title> <p>The
design of ICT tools for chronic disease management should take into account
flexibility and extensibility requirements. These requirements are common to
all kinds of distributed systems, but especially are applied to this
application domain, due to its intrinsic characteristics, such as different
national and local regulation frameworks, the heterogeneity of health centers
and communities involved in care service delivery, and the patient's health
status development over time. In such a complex and changing environment, cost-effective
solutions should be conceived as extensible and flexible service platforms. For
that reason, while the research activities surveyed above have focused on the
conceptual design or implementation of applications that target specific
chronic diseases and not on a specific chronic disease from the very beginning,
our approach has been to design and deploy a service platform that provides
general purpose services and could be easily extended and specialized in order
to match specific requirements of real cases.</p> <p>The
aim of our research has been to design and implement ERMHAN, an extensible
service platform supporting care teams in providing long-term assistance
services. Extensibility and flexibility of the ERMHAN service platform are mainly
achieved by means of modular and service-oriented design and the adoption of
open and standardized data formats and communication protocols.</p> <p>The platform design is based on the
definition of basic functional blocks and their interconnection by means of web
services standards. As a matter of fact, web services are recognized as an open
and standardized way of achieving interoperation between different software
applications, running on heterogeneous platforms and/or frameworks [##REF##18046939##15##].</p> <p>Semantic
web technologies have been applied to data representation and processing in
order to provide instruments that ease the development of pervasive and
personalized care services. More specifically, semantic web is used in order to
(a) represent knowledge by means of ontology-based formalisms; (b) reason over
knowledge using rule-based and ontology-based engines; (c) apply reasoning
techniques in order to implement personalized healthcare plans.</p> <p>The
prototype we have developed provides basic and general-purpose services for
information sharing, distributed, and multichannel personalized access to
patients' records and personalized real-time monitoring and alarm management on
a per patient basis. Implemented services include access to complete and
updated patient records (including patient health status, description of care
provider interventions), even in mobility conditions (at the hospital or at
patient's home) and through different devices (at least personal digital
assistants and desktop PCs); notification of patient health status conditions
and alarms, but without overwhelming care operators with too much information
(this might have the drawback of disturbing users and providing them with “no
information”). More effective information delivery could be achieved by routing
intervention requests according to patient health status gravity and required
expertise for intervention.</p> <p>Based
on its flexibility, the ERMHAN service platform can be specialized to address
the needs of specific patient cases. To achieve this objective, the basic
services provided by the ERMHAN platform can be integrated with those offered
by other systems, such as assistive technologies, home automation systems,
specific chronic disease prognoses, and diagnosis systems [##UREF##12##16##]. In the
following sections, we provide further details about the modeling approach and
system architecture of ERMHAN platform.</p> <title>3. CONTEXT-AWARE MODELING AND REASONING
FOR HOME-BASED CARE</title> <p>The
objective of this research is the design and prototypal development of a
context-aware mobile service platform (ERMHAN) for long-term home-based care
services delivery to chronic patients.</p> <p>ERMHAN
aims at supporting the main characteristics of emerging chronic care models: (a)
home-centered long-term patient followup; (b) shared care provided by a network
of heterogeneous care providers (named “continuous care network”); (c)
adaptation of care plans on a per patient basis.</p> <p>With
the term “continuous care network” we refer to the broad range of people
involved to different extents in the care of the elder, such as patient
relatives, the multidisciplinary teams at different health-care levels (e.g.,
general practitioners, specialists), social operators, volunteers, and so forth. They
belong to different organizations (e.g., hospitals, municipality, private
institutions), may work in more than a single location, and do not usually have
regular face-to-face contacts with other network members.</p> <p>Due
to the complexity of the care network, its ad hoc nature, and loosely coupled
structure, we have identified a set of basic services to be provided to care
providers: ubiquitous access to patient-health records (via mobile device or
desktop PC); role-based information sharing among different network members
belonging to different organizations; capability of adapting health plans on a per-patient basis. More
specifically, health-plan personalization is implemented in ERMHAN in terms of
personalized context-aware rules for alarm detection and management, as
described in the next paragraph.</p> <p>Even
if the aim of our work is to provide services to care providers, and
consequently developing assistive technologies are not the main target of this
work, ERMHAN provides some basic services for patient assistance, for example, medication
reminders, manual alarm activation, and communication request services. As the
focus of this work is on the architecture for service integration and delivery,
human computer interaction (HCI) issues, such as usability and accessibility,
have not been taken into account at this stage of our study.</p> <p>The
ERMHAN reference application scenario consists of two main domains (see ##FIG##0##Figure 1##):</p> <p>
<list list-type="alpha-lower"><list-item><p>the patient home, that is,
the environment where the patient lives, often with some relatives, and where
patient monitoring and assistive technologies would be deployed;</p></list-item><list-item><p>the care centre, that is,
the domain of the organization responsible for care service integration and
delivery (e.g., hospitals, nursing homes or municipalities). For the sake of
simplicity, in our scenario this is presented as a single logical point of
care, providing ICT services to care operators who can belong to different
organizations. Actors considered in our scenario are doctors (general
practitioners and specialists) and nurses. More complex scenarios involving
other organization domains (e.g., voluntary associations, pharmacies, etc.)
will be analyzed in future research activities.</p></list-item></list>
</p> <title>3.1. Context awareness</title> <p>This
paragraph describes what we do intend for “context awareness” in the framework
of home-based continuous care and the context model that has been adopted in
ERMHAN.</p> <p>Context
awareness is a general concept that refers to the capability of a system to be
aware of its physical and logical environment and to intelligently react
according to this awareness. The definition of context is likely to change
according to the application domain and related purposes [##UREF##13##17##].</p> <p>In
our application scenario, context awareness is meant as the capability of the
system to acquire and interpret relevant information with respect to the main
goal (patient quality of life) and to perform actions aiming at achieving such a
goal. Thus, the context may include information about patient health status,
inferred by sensed biomedical parameters (e.g., vital signs), and home
environment (e.g., temperature and relative humidity). Even social context
(i.e., information regarding people populating the patient care network) may be
considered as relevant information to be exploited for context-aware assistance
service delivery. The acquisition of these context data can be profitably
exploited by the system in order to infer relevant situations related to
patient status, (such as critical condition and alarm detection) and trigger
proper actions in order to facilitate the care providers' operations (i.e.,
alerting care providers for intervention).</p> <title>3.1.1. ERMHAN context model</title> <p>An
ontology-based context model, written in Web Ontology Language (OWL 
[##UREF##14##18##]), is employed
throughout the entire process of sensing, interpreting, managing, and
exchanging context information. We have extended a general purpose
ontology-based context model [##UREF##15##19##] with concepts
and relations describing the home care setting.</p> <p>The
OWL-based context model is used in order to represent system knowledge about
patient health status by means of ontology-based formalisms. The context model
provides a uniform representation of data coming from heterogeneous sources,
such as biomedical sensors, home monitoring systems and users' manual input.
Ontology and rule-based reasoning are applied over the context model in order
to check the consistency of context information and to infer further knowledge.
Rule-based reasoning is applied in the ERMHAN system in order to infer patient health
conditions, detect alarm conditions originating from a patient health status or
other events (e.g., the patient does not take medication), and select the
alerting policy which is most suitable according to alarm level and other
context information (e.g., availability of care providers for intervention).</p> <p>The
main advantage of this approach consists in representing the business logic of
the system in an explicit and declarative way. Thus, adaptation of health plans
on a per patient basis can be realized by allowing care providers to specify
rules tailored to the patient case.</p> <p>Hereafter
we describe the main features of the context modeling and reasoning
capabilities implemented in the ERMHAN system. A complete description of our
ontology-based context model for home health monitoring and alerting in patient
care networks is out of the scope of this article and is fully
described in [##UREF##16##20##].</p> <p>The
context model is composed of the following parts.</p> <p>
<list list-type="order"><list-item><p>The <italic>patient-domain ontology</italic> includes context items
about patient biomedical parameters, location, and activity. This information
is used by the system to automatically infer patient health status and detect
alarm situations by means of rule-based reasoning. Biomedical parameters
instances are represented together with some relevant properties, such as
measurement values and parameter ranges. Each range is specified in terms of
upper and lower thresholds and related alarm level; when a measured value falls
out of the thresholds, an alarm of the corresponding level is detected. Patient
health status is thus determined by comparing biomedical parameters' measured
values with a set of parameter ranges. We have specified four basic alarm
levels (very low, low, medium, high), but the model can be easily extended to
include further levels.</p></list-item><list-item><p>The <italic>home environment ontology</italic> includes
context data that describes the patient home environment. For instance,
monitoring environmental parameters (such as temperature and relative humidity)
are needed in order
to maintain a healthy environment and detect alarm situations. Alarm triggering
based on environment parameters is analogous to the one based on biomedical
parameters, described above.</p></list-item><list-item><p>The <italic>social context ontology</italic> represents
care network resources (health teams, social community members, etc.) and their
relations. Care network members that are represented as concepts in this
ontology include the patient, patient relatives, who take active part in
implementing the assistance plan, health operators (medical and paramedical
staff) who are in charge of patient care; social community organizations which
offer assistance services (e.g., transport and companion services). The social
context ontology is also used to represent other information which is
considered relevant to the ERMHAN application purposes, such as the
availability of a health operator for an intervention and the distance of a
relative from patient location (travel time). At present, users can provide
this information via a web form provided by the profile management services, by
choosing among predefined values (e.g., “available,” “busy,” “not available”).
As part of future work, we will investigate the use of context-aware systems
that can help in semi-automatically updating and managing such information (e.g.,
GPS positioning and inference mechanisms).</p></list-item><list-item><p>The <italic>alarm management ontology</italic> represents
the policy that should be instantiated to manage an alarm. Such policy
describes the steps that should be performed in the event of an incoming alarm.
Rule-based reasoning over this ontology model is used to select the suitable
alarm handling policy according to different context items, such as the
incoming alarm level, the patient identifier, and the availability of care team
members (i.e., the information represented by the social context ontology).</p></list-item></list>
</p> <title>3.1.2. Rule-based reasoning examples</title> <p>As
mentioned above, the ERMHAN system uses rule-based reasoning over the context
ontology instances for triggering alarms and defining policies for handling alarms.</p> <p>Alarm
triggering is based on the analysis of context data represented in the Patient
and home-domain ontologies.
We have defined a set of first-order rules so as to determine if an alarm has
to be triggered and which level should be activated according to measured
context data and corresponding thresholds. For instance, the following rule
triggers an alarm classified as “high” when the heart rate frequency is less
than 40 beat/minute and the systolic blood pressure is higher than 160 mm/Hg:</p> <p>Likewise,
when an alarm has been triggered, rule-based reasoning is used to determine
which alert policy should be actuated for handling the alarm situation. In
ERMHAN, an alert policy is represented as a set of instructions specifying whom
should be alerted and how (via SMS, mail, phone call) and if acknowledgment is
required. In ##TAB##0##Table 1##, we define a basic example policy for each alarm level.</p> <p>For
instance, we suppose that when a “MEDIUM” level alarm is detected, the system
should perform the following actions (see ##TAB##0##Table 1##).</p> <p>
<list list-type="alpha-lower"><list-item><p>Alerting
an operator via SMS or email. First, a general practitioner is alerted. If
he/she does not send the acknowledgment within a fixed-time interval, other operators (e.g.,
nurses) are alerted until one of them sends an acknowledgment. At the end, if
no acknowledgment is received, the system alerts an emergency operator,
available 24/24 and 7/7. The list of operators to be contacted is dynamically
created by the system by selecting the caregivers which are assigned to that
patient and are “available” for intervention.</p></list-item><list-item><p>At the same time at least
one of family members should be alerted, but acknowledge is not required.</p></list-item></list>
</p> <p>Adaptation
of system behavior on a per-patient
basis can thus be achieved by care providers by specifying personalized alarm
levels, parameter thresholds, and alert policies tuned to the individual's
conditions.</p> <title>4. ERMHAN SYSTEM ARCHITECTURE</title> <p>The
ERMHAN system architecture, shown in ##FIG##1##Figure 2##, is made of the following main
components.</p> <p>The Multichannel Health-Care Service Manager (MHSM). This component delivers mobile
health-care context-aware services to patients, relatives, and care providers,
targeting a variety of user devices. It is deployed in the care centre domain
and includes a front-end component deployed in the patient-home domain.</p> <p>The Context Management system.
This component deals with the acquisition of context data from heterogeneous
sources, the management, and storage of ontology-based context instances,
reasoning over context knowledge, and the delivery of relevant contextual
knowledge to context-aware applications (e.g., MHSM).</p> <p>MHSM and Context Management systems have
been designed as completely separate and independent modules. This has been
done in order to strongly decouple context data acquisition, management, and
context-aware service delivery. Communication among these components is based
on web service interfaces.</p> <title>4.1. Multichannel health-care service
manager</title> <p>The
Multichannel Health-Care Service Manager (MHSM) is the ERMHAN component that
provides mobile context-aware health-care services to end-users [##UREF##17##21##]. MHSM
provides end-users with proper services according to their roles and related
requirements. ERMHAN services are specifically targeted to care-provider
requirements. Thus, end-user roles which have been taken into account are
medical, paramedical, and the emergency centre staff. Nonetheless, we have also
considered some basic requirements for patients and patients' relatives.</p> <p>
<statement id="head1"><title>Medical staff</title><p>The medical staff must be constantly
informed about the patient's conditions. Each member can access ERMHAN services
remotely, via a desktop PC or a PDA. Available services include the following.</p><p>
<list list-type="simple"><list-item><label>(•)</label><p>Patient record management. Medical staff members can access and update the patient
record using a personal digital assistant (PDA) or desktop PC. Information
sharing among care professionals is achieved by providing them with the
capability of accessing a uniform view of patient information. Permission for
reading and modifying patient record fields is tailored according to the user's
role (e.g., general practitioner, specialists, etc.)</p></list-item><list-item><label>(•)</label><p>Alerts management service. When an alarm is triggered (manually by the patient or
automatically by the Context Management system), the alerts management service contacts
the staff through the appropriate channels (e.g., mail and/or SMS). As
specified by the alert policy, alerts can be sent as informative messages or as
intervention requests, depending on the alarm gravity level. In the latter
case, the caregiver is asked to acknowledge the alert reception and to confirm
the intervention request. More details about the alert policy are provided in
the next subsection.</p></list-item><list-item><label>(•)</label><p>Profile management service. The medical staff members can specify their own
availability for the intervention (e.g., available, not available, busy). This
information is taken into account by the rule-based reasoning process used to
select the operators which should be contacted in the alert policy.</p></list-item></list>
</p></statement>
</p> <p>
<statement id="head2"><title>Paramedical staff</title><p>The paramedical staff (e.g., general
assistance operators, nurses, etc.) can access the system remotely, by means of
a PC or a PDA. Similarly to the medical staff, but with different role-based
access rights, they can access the following services: patient record
management, alerts management services, and profile management services.</p></statement>
</p> <p>
<statement id="head3"><title>Emergency staff</title><p>The emergency staff is composed of “always
available” operators. They are notified by the alerts management service in
order to respond to emergency situations (highest critical alarm level) or when
other health operators have not responded to lower level alarms (e.g., medical
staff).</p></statement>
</p> <p>
<statement id="head4"><title>Patient</title><p>We considered the following patient requirements for
eliciting a basic set of services: the capability of easily communicating with
relatives or health operators, manually activating alarms, and having support for
implementing the health assistance plan. Requirements depending on specific
patient conditions (e.g., physical impairments, cognitive disabilities, etc.)
have not been considered in this study. The patient is equipped at home with a
Tablet PC and uses services through a Front-End available on the Tablet PC
touch screen. More specifically, services which are available to patients at
home include the following.</p><p>
<list list-type="simple"><list-item><label>(•)</label><p>Reminders service: the system alerts the patient that medication has to be taken. The alert
signal is an audio and video alarm which is remotely triggered on the front-end
deployed at patient home.</p></list-item><list-item><label>(•)</label><p>Help requests: the patient can manually generate an alarm, in order to request an
urgent intervention by the emergency staff.</p></list-item><list-item><label>(•)</label><p>Communication
requests: the patient can request to be contacted by some relatives.</p></list-item></list>
</p></statement>
</p> <p>
<statement id="head6"><title>Patient
relatives</title><p>The patient's
family members provide general assistance to the patient during daily routine
activities at home and should be kept informed about patient conditions when
outside the home (via the alert management service and profile management
service). </p><p>Services targeting relatives can be accessed via mobile devices with
minimal technical requirements (i.e., cell phones with an XHTML browser).</p></statement>
</p> <p>
<statement id="head7"><title>Multichannel health-care service manager implementation</title><p>The
MHSM has been designed and developed as a multichannel web application written
in Java language, leveraging the J2EE JSP/Servlet technology framework. The
MHSM has been developed as a 3-tier architecture including the following.</p><p>(1) 
A
back-end tier, named MHSM information management and storage, handles and
stores the following information resources: the patient record, containing
patient personal data, personal assistance plan, vital sign thresholds,
medical, sanitary and assistance diaries, and prescriptions (e.g., taking medication,
vital sign measurement scheduling); user profiles, containing end-user personal data,
organizational roles, caregiver availability status (for medical and
paramedical staff and patient relatives); organization models, representing the
care network structure, (i.e., care network members and patients under care).</p><p>(2) 
An
intermediate tier hosts
the business logic of the ERMHAN Services (patient record management, alerts
management, profile management, reminder management, patient help, and
communications request management).</p><p>(3) 
An
upper tier, composed of a multichannel front-end generation service, generates
user interfaces tailored to the capabilities of the different end-user mobile
devices (e.g., display size, resolution, memory and processing capabilities,
etc.). The target devices for this scenario are PDAs, Tablet PCs, cell-phones,
and laptops. The model view controller design paradigm [##UREF##18##22##] has been
adopted in order to properly manage user interface generation, business and
navigation logic, and content generation.</p><p>The
platform uses the web services technology standards (SOAP, WSDL) to interact
with external components, such as the Context Management system. The underlying
DBMS is MySQL. A communication management service implements an SMS gateway and
the SMTP protocol in order to provide SMS and e-mail alerts to care network
members (the adoption of further communication channels and protocols will be
evaluated in the future). This component has been designed and developed by the
industrial partner of the KAMER Project (HP Italy).</p></statement>
</p> <title>4.2. Context Management system</title> <p>This
section describes the Context Management (CM) system architecture that we have
developed to ease the implementation of context-aware assistance services for
chronic patients.</p> <p>The
CM system is based on a general-purpose framework providing basic features for
context data acquisition, reasoning, and delivery [##UREF##15##19##]. It is composed
of two different node types.</p> <p>
<list list-type="alpha-lower"><list-item><p>The Patient Context Manager (PatientCM). This node is deployed at the patient site.
It acquires data retrieved by biomedical and environmental sensor networks.
These data are preprocessed by the PatientCM in order to detect abnormal
conditions and are transmitted to the MHSM in order to update patient records
with new measurement values. Sensed data are injected into the patient and home-domain
ontology instances and rule-based reasoning processes are performed over this
context base in order to detect incoming emergency situations and trigger
corresponding alarms. The Central Context Manager is then notified of the
occurrence of an alarm.</p></list-item><list-item><p>The Central Context Manager
(CentralCM). This component is deployed in the care centre domain. When an
alarm situation has been detected by a PatientCM, the CentralCM processes
context information about patient health status and care team member
availability, in order to define an alert policy for informing care team members
and request their intervention in case of emergency. It handles the alarm
management and social context ontologies by creating related instances updated
with context information about patient health status, triggered alarm levels
and information about care team member availability. Based on this context
information, reasoning rules are applied in order to define the proper alert
policy for alarm handling. The resulting alert policy is then sent to the MHSM
for its implementation.</p></list-item></list>
</p> <p>Both
the Patient and the Central Context Managers include the following main blocks.</p> <p>Context data acquisition: this component receives context data from context providers
via SOAP messages (e.g., web service-enabled sensor networks), or via sensor
adapters.</p> <p>Context
knowledge base: this is a knowledge base composed of ontology-based context
models and instances stored in a database, a rule-based reasoner and rule
files. This component is based on Jena,
an open source Semantic Web framework [##UREF##19##23##].</p> <p>Context broker: this component distributes context data to external components by
notifying the interested applications when the context has changed or by
providing updated information in a request/response chain. Both notification
and request/response paradigms are implemented through a SOAP message exchange
[##UREF##20##24##].</p> <p>In each Context Manager, the
communication between internal components has been implemented according to the
observer design pattern, that is, through suitable EventListeners that listen
for events and encapsulate the information to be processed [##UREF##21##25##]. Therefore,
such decomposition allows each internal component to process its own specific
information independently.</p> <p>The CentralCM and PatientCM have been
implemented as J2EE web applications and their external interfaces are exposed
as web services.</p> <title>4.2.1.
Alarm
detection and management scenario
</title> <p>This
paragraph provides further insight into the Context Management system architecture
(see ##FIG##2##Figure 3##) by describing the system behavior in an alarm detection and
management scenario. ##FIG##3##Figure 4## provides a simplified graphical representation of
this scenario as a sequence of numbered steps.</p> <p>General
practitioners and nurses can access and modify patient health information through
the MHSM interface (Step 1). In particular, general practitioners can update
remote monitoring parameters, such as scheduling sensed data acquisition and
related alarm thresholds. For instance, a practitioner can specify that the
body temperature should be measured at 7 am and 5 pm every day, that a measured
value higher than 38°C should trigger a MEDIUM-level alarm if reached at 7 am, and a high-level alarm
if reached at 5 pm. The MHSM sends this information to the CentralCM which
routes the message to the proper PatientCM (Step 2).</p> <p>The <italic>CentralCM.PatientServiceManager</italic> component offers a web service interface which can be invoked by the MHSM in
order to communicate messages such as updates of patient diagnostic test
scheduling and vital sign alarm thresholds. The CentralCM manages a message
queue for each PatientCM and messages that come from the MHSM are then routed
to the proper message queue. The PatientCM.CentralCMClient component periodically polls the <italic>CentralCM.PatientServiceManager</italic> to request new messages.</p> <p>This
periodical polling is also used to monitor the status of both the PatientCM
operation and the connection between the PatientCM and the CentralCM. When the
CentralCM does not receive the expected periodical poll by a PatientCM (this
condition may be caused by connection failures or PatientCM malfunctions), it
triggers a corresponding alarm and the emergency staff is alerted to handle
this technical problem by activating the required procedures.</p> <p>The <italic>PatientCM.CentralCMClient</italic> parses the message payload and produces
suitable events, such as TimingEvents for scheduling biomedical data
acquisition.</p> <p>New
timing events are consumed by the <italic>PatientCM.DataAcquisitionScheduler</italic>.
According to the prescriptions contained in the TimingEvents objects, the
scheduler allocates corresponding timers triggering the patient's biomedical
data acquisition (e.g., body temperature, heart rate frequency) from web
service-enabled body sensor networks (Step 3).</p> <p>The <italic>PatientCM.DataCollector</italic> exposes a web
service interface which is invoked by the sensor networks to communicate new
acquired vital sign values. These data are then passed on to the DataDispatcher,
that notifies the MHSM of these data for patient record updating (Step 4) and
the OntoManager module for updating the Patient and home environment ontologies
instances. Rule based reasoning is then
applied to the knowledge base in order to detect possible alarms and produce
AlarmEvents. For instance, if the sensed body temperature is higher than 38°C a MEDIUM-level alarm is triggered. The <italic>PatientCM.AlarmNotifier</italic> notifies a new AlarmEvent to the CentralCM, by invoking the <italic>CentralCM.AlarmManager</italic> component (Step 5).</p> <p>The <italic>CentralCM.AlarmManager</italic> receives new
incoming alarms notified by the PatientCM and routes them to the <italic>CentralCM.OntoManager</italic> which has to create an alert policy
for alarm handling. Firstly, it feeds the knowledge base (composed of the alarm
management and social context ontologies) with instance data, such as
attributes of the AlarmEvent (patient identifier and alarm level) and updated
information about the patient social context (health operators availability)
which are made available by the MHSM. Then, it applies rule-based reasoning to
produce the alert policy.</p> <p>The <italic>CentralCM.PolicyNotifier</italic> is the
component which sends the alert policy to the MHSM, by invoking a specific web
service (Step 6). The MHSM then implements the policy 
by sending proper alerts to the contact lists (Step 7).</p> <p>Filtering
techniques are implemented by the <italic>CentralCM.AlarmManager</italic> to handle
sequences of alerts related to the same emergency situation. As a matter of
fact, while an alarm is being handled, notification related to the same
situation can be generated again by the PatientCM (e.g., because of new vital
sign measurements). The filtering technique is thus applied to avoid
overwhelming health operators with redundant alerts.</p> <title>5. SYSTEM EVALUATION AND TESTING ACTIVITIES</title> <p>This
section discusses the ERMHAN system results in terms of performance evaluation
and user testing activities.</p> <title>5.1. Context Management system
performance evaluation</title> <p>The
following considerations are concerned with a performance estimation of the
ERMHAN Context Management system obtained by collecting average alarm
generation and transmission times in a basic configuration. This configuration
is composed of one PatientCM and one CentralCM. The PatientCM is geographically
located 40 Km away from the CentralCM. The server hosting the CentralCM has an external IP
and accesses the Internet through the university wide area network. The
PatientCM can access the Internet through a standard low-band with DSL
connection (640 Kbps). More precisely, the PC hosting the PatientCM has a
wireless connection to an 802.11g DSL gateway. In particular, we have
considered the following hardware configuration.</p> <p>
<list list-type="order"><list-item><p>PatientCM:
AMD Athlon64 3200+, 1024 Mb RAM.</p></list-item><list-item><p>CentralCM:
Intel Pentium 4 2.0 GHz, 768 Mb RAM.</p></list-item></list>
</p> <p>The
performance measurement is based on the following parameters: the alarm detection time (<bold>T</bold>
<sub><bold>ALARM</bold></sub>) which is the time
interval between the acquisition of an out-of-range biomedical parameter value
and the triggering of the corresponding alarm obtained by means of rule-based
reasoning (<xref ref-type="sec" rid="sec3.1.2">Section 3.1.2</xref>); the transmission
delay (<bold>T</bold>
<sub><bold>TRANSM</bold></sub>) which is the time needed for transmitting
a message through the connection between PatientCM and CentralCM; the alert
policy time (<bold>T</bold>
<sub><bold>POLICY</bold></sub>), which is the time elapsing
at the CentralCM side between the reception of an incoming alarm originating from
the PatientCM and the generation of the corresponding alert policy. The sum of
these time intervals determines the overall time needed for the alert policy
generation from time the out-of-range biomedical parameter is acquired (<bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub>):

</p> <p>The
value of <bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub> does not vary significantly with respect to
alarm levels. Nonetheless, alarm levels influence the kind of alert policy
generated by the CentralCM and implemented by the MHSM. An evaluation including
also policy implementation and the notification to at least one care provider
should also take into account the following time intervals (see ##FIG##4##Figure 5##): the
time needed for transmitting the alert policy from the CentralCM to the MHSM (<bold>T</bold>
<sub><bold>TRANSM</bold><bold>2</bold></sub>); the time needed by the MHSM for
instantiating the alert policy (<bold>T</bold>
<sub><bold>MHSM</bold></sub>); the SMS latency (<bold>T</bold>
<sub><bold>SMS</bold></sub>) which is the delay for transmitting
SMSs to health operators; the delay for transmitting alert to the care centre
in order to notify emergency operators (<bold>T</bold>
<sub><bold>EM</bold></sub>).</p> <p>The
formula for calculating the global time interval (<bold>T</bold>
<sub><bold>GLOBAL</bold></sub>) from the alarm detection to the alert
notification to care providers differs according to the alarm level and
corresponding alert policy.</p> <p>For
VERY-LOW-
and LOW-level alarms, the following formula is applied:

</p> <p>For
MEDIUM-level alarms, the calculation has to take into account the fact that
health operators (general practitioners and nurses) are notified in sequence: a
first operator is alerted via SMS, if he/she does not respond within a
specified time interval (<bold>T</bold>
<sub><bold>TIMEOUT</bold></sub>),
another operator is notified. After <bold>N</bold> failed attempts (<bold>N</bold> is
specified in the alert policy), the alarm is communicated to an emergency
operator (<bold>T</bold>
<sub><bold>EM</bold></sub>).</p> <p>If
a care provider confirms the SMS reception after <italic>n</italic> attempts (<italic>n</italic> ≤ <italic>N</italic>),

otherwise

</p> <p>For
HIGH-level alarms
the following formula is
applied:

</p> <p>As mentioned above, this paragraph focuses on
performance estimation of the Context Management system in delivering the most
critical service (alarm detection and handling). Thus, our evaluation is based
on measured values of <italic>T</italic>
<sub>ALARM</sub>,
<italic>T</italic>
<sub>TRANSM</sub>, and <italic>T</italic>
<sub>POLICY</sub>. Values of further parameters (<bold>T</bold>
<sub><bold>TRANSM</bold><bold>2</bold></sub>
<bold>T</bold>
<sub><bold>MHSM</bold></sub>,<bold>T</bold>
<sub><bold>SMS</bold></sub> and <bold>T</bold>
<sub><bold>EM</bold></sub>) are not available for dissemination as they have been collected by the
industrial partner (HP Italy). Moreover, values of <bold>T</bold>
<sub><bold>SMS</bold></sub> and <bold>T</bold>
<sub><bold>EM</bold></sub> are dependent on the characteristics of the network infrastructure. In a real
implementation scenario, these parameters might be optimized according to
appropriate technological choices, such as using public or professional radio-mobile
networks for SMS delivery (i.e., GSM and TETRA, resp.) and a dedicated fixed line
for communicating with the emergency operators, as well as establishing proper service
level agreements with network operators.</p> <p>To
estimate the performance of the implemented system in detecting and managing
alarms, we have simulated the generation of 60 sample alarms for each of the
four alarm levels (“Very low,” “Low,” “Medium,” and “High”). Such samples have
been acquired by monitoring the activity of the Context Management system upon
an interval of five working days, during working hours, in order to stress the
system during worst traffic conditions (i.e., peak traffic hours). In more
detail, experiments were performed during two time slots: 10:00 A.M.–2:00 P.M. (<italic>Time
Slot 1</italic>) and 2:00 P.M.–6:00 P.M. (<italic>Time
Slot 2</italic>).</p> <p>
##TAB##1##Table 2## reports the mean and standard deviation values in
milliseconds of alarm detection time (<bold>T</bold>
<sub><bold>ALARM</bold></sub>), alert policy time (<bold>T</bold>
<sub><bold>POLICY</bold></sub>), and the overall alarm management
time (<bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub>),
which is calculated as the sum of <bold>T</bold>
<sub><bold>ALARM</bold></sub>, <bold>T</bold>
<sub><bold>POLICY</bold></sub>, and the transmission
delay (<bold>T</bold>
<sub><bold>TRANSM</bold></sub>).</p> <p>Measured
values of <bold>T</bold>
<sub><bold>ALARM</bold></sub> as well
as <bold>T</bold>
<sub><bold>POLICY</bold></sub> do not vary
significantly across alarm level. <bold>T</bold>
<sub><bold>POLICY</bold></sub> measured values are higher than <bold>T</bold>
<sub><bold>ALARM</bold></sub> ones as the major part of the processing load is leaning to the PatientCM side,
according to the architecture of the Context Managers.</p> <p>Measured values of the overall <bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub> vary significantly according to network
traffic conditions which directly influence <bold>T</bold>
<sub><bold>TRANSM</bold></sub> values. In this experiment, we can estimate an
overall alarm time swinging between 8 and 10 seconds, with a transmission delay
that can be evaluated in about 5 seconds. The higher values of the standard
deviation for alarm times can be charged on interferences in the PatientCM
wireless connection and on the network conditions in the restricted observation
window (five working days) considered for this evaluation.</p> <p>We
expect that a more performant connection would significantly improve the Alarm
Management Time, and a wider observation interval (i.e., one month) would
produce more uniform statistics for this indicator.</p> <p>In
order to minimize reasoning tasks execution time (inference on ontology
instances), we perform reasoning on small ontologies populated by a small
number of instances, since ontological reasoning execution times grow at least
linearly with respect to the ontology size [##UREF##22##26##]. This time
could be further optimized by performing part of the reasoning task before the
service request. Future research activities will thus focus on analyzing which
reasoning tasks could be performed prior to service requests and consequently
on reengineering the PatientCM and CentralCM.</p> <title>5.2 User trials</title> <p>As
ERMHAN services have been designed to support care networks and thus to address
requirements of care providers, testing is primarily to be focused on
evaluating health operators' acceptance of implemented features.</p> <p>A
trial has been performed in a nursing home in Piacenza
for system evaluation by
professional caregivers. Further trials are planned in a nursing home in Florence
in the near
future, for more extensive evaluations by chronic condition patients. For these
future tests, a sensing system for vital signs and environmental monitoring
will also be deployed. Testing activities will thus focus also on evaluating patient
acceptance with regard to deployed services (i.e., monitoring, medicine
reminder, help, and communication request services).</p> <p>In
the testing stage already conducted in Piacenza,
biomedical and environmental sensing was simulated by a web application.
Biomedical parameters that were represented in the model included heart rate
frequency, pulse oxymetry, systolic and diastolic blood pressure, body
temperature, and glycemia. The web application provides services for manual
input or predefined scenario simulation for context data acquisition.</p> <p>During
each session, practitioners were equipped with mobile devices and PCs. The
project staff took care of simulating the acquisition of biomedical and
environmental parameter values and the occurrence of alarms through the
dedicated web interface; health operators were asked to react to such events by
using the ERMHAN system as they were in the “real world,” such as ignoring
alerts or confirming the intervention request reception and taking charge of
the case. Practitioners were also asked to perform day-by-day operations through the system,
such as accessing and updating patient records, modifying the scheduling of
biomedical parameters acquisition and related alarm thresholds. At the end of
these trials, the testers' opinions about system features have been collected
through interviews and questionnaires.</p> <p>This
first trial session was conducted with 11 test users (including both general
practitioners and nurses). As a consequence, we are far from having
statistically significant data available, but we are able to illustrate some
preliminary results which can be drawn from questionnaire responses. A large
majority of users were quite satisfied by the system's overall features (more
than 60%). The capability of accessing patient health records has been judged
useful and easy to use (but some users had already tested similar features in
other experimental systems). The alarm management service and the capability of
specifying availability for intervention were judged especially useful (42% of
users) and useful (50% of users). Most users appreciated the capability of
remotely modifying the alarm thresholds and data acquisition scheduling on a
per-patient basis (18% expressed high appreciation, 73% good appreciation, 9%
were neutral). A group of users (30%) complained about some misalignment
between MHSM patient record presentation and paper-based records in use in
their nursing home (especially in terms of use, information organization and
classification). This aspect will be further investigated in future testing
activities and properly analyzed when defining a methodology for customized
deployment if ERMHAN is applied industrially.</p>
<title>ACKNOWLEDGMENTS</title> <p>The
KAMER Project is funded by the Regione Emilia Romagna, Italy. The partners are
Hewlett Packard Italy,
Cattolica University of Piacenza, and the Italian National Inter-University Consortium for Telecommunications
(CNIT). Technical assistance from Luca Capannesi, Department of Electronics and Telecommunications
of the University of Florence, is
gratefully acknowledged.</p>
<fig id="fig1" position="float"><label>Figure 1</label><caption><p>ERMHAN applications scenario.</p></caption></fig> <fig id="fig2" position="float"><label>Figure 2</label><caption><p>ERMHAN architecture.</p></caption></fig> <fig id="fig3" position="float"><label>Figure 3</label><caption><p>ERMHAN Context Management system.</p></caption></fig> <fig id="fig4" position="float"><label>Figure 4</label><caption><p>Alarm detection and management scenario.</p></caption></fig> <fig id="fig5" position="float"><label>Figure 5</label><caption><p>Time intervals for ERMHAN performance evaluation.</p></caption></fig>
<table-wrap id="tab1" position="float"><label>Table 1</label><caption><p>Alert policy examples.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Alarm level</th><th align="center" rowspan="1" colspan="1">Alert policies</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">VERY LOW</td><td align="left" rowspan="1" colspan="1">(i) SMS to
patient relative, no acknowledgement</td></tr><tr><td align="center" colspan="2" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">LOW</td><td align="left" rowspan="1" colspan="1">(i) SMS and
mail to general practitioner, no acknowledgement
</td></tr><tr><td align="left" rowspan="1" colspan="1">(ii) SMS and mail to relative, no acknowledgement</td></tr><tr><td align="center" colspan="2" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">MEDIUM</td><td align="left" rowspan="1" colspan="1">(i) SMS and
mail to general practitioner or nurse, acknowledgment required
</td></tr><tr><td align="left" rowspan="1" colspan="1">(ii) Send SMS and mail to relative, no acknowledgment</td></tr><tr><td align="center" colspan="2" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">HIGH</td><td align="left" rowspan="1" colspan="1">(i) Message to
emergency operator, acknowledgment required
</td></tr><tr><td align="left" rowspan="1" colspan="1">(ii) SMS to
patient relative, acknowledgement required</td></tr></tbody></table></table-wrap> <table-wrap id="tab2" position="float"><label>Table 2</label><caption><p>Mean and standard deviation values of alarm detection (<bold>T</bold>
<sub><bold>ALARM</bold></sub>), alert policy definition (<bold>T</bold>
<sub><bold>POLICY</bold></sub>)
and management, and overall alarm management times (<bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub>) in a basic Context Management configuration.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="3" colspan="1">Alarm level</th><th align="center" colspan="2" rowspan="1">
<bold>T</bold>
<sub><bold>ALARM</bold></sub>
</th><th align="center" colspan="2" rowspan="1">
<bold>T</bold>
<sub><bold>POLICY</bold></sub>
</th><th align="center" colspan="2" rowspan="1">
<bold>T</bold>
<sub><bold>MANAGEMENT</bold></sub>
</th></tr><tr><th align="center" rowspan="1" colspan="1">
<italic>Time slot 1</italic>
</th><th align="center" rowspan="1" colspan="1">
<italic>Time slot 2</italic>
</th><th align="center" rowspan="1" colspan="1">
<italic>Time slot 1</italic>
</th><th align="center" rowspan="1" colspan="1">
<italic>Time slot 2</italic>
</th><th align="center" rowspan="1" colspan="1">
<italic>Time slot 1</italic>
</th><th align="center" rowspan="1" colspan="1">
<italic>Time slot 2</italic>
</th></tr><tr><th align="center" colspan="2" rowspan="1">
<italic>Average</italic>
</th><th align="center" colspan="2" rowspan="1">
<italic>Average</italic>
</th><th align="center" colspan="2" rowspan="1">
<italic>Average</italic>
</th></tr></thead><tbody><tr><td align="left" rowspan="2" colspan="1">Very low</td><td align="center" rowspan="1" colspan="1">1567 ± 220</td><td align="center" rowspan="1" colspan="1">1358 ± 213</td><td align="center" rowspan="1" colspan="1">869 ± 203</td><td align="center" rowspan="1" colspan="1">843 ± 175</td><td align="center" rowspan="1" colspan="1">7728 ± 951</td><td align="center" rowspan="1" colspan="1">6814 ± 1303</td></tr><tr><td align="center" colspan="2" rowspan="1">1449 ± 238</td><td align="center" colspan="2" rowspan="1">854 ± 186</td><td align="center" colspan="2" rowspan="1">6196 ± 1247</td></tr><tr><td align="center" colspan="7" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">Low</td><td align="center" rowspan="1" colspan="1">1457 ± 207</td><td align="center" rowspan="1" colspan="1">1360 ± 217</td><td align="center" rowspan="1" colspan="1">879 ± 218</td><td align="center" rowspan="1" colspan="1">869 ± 203</td><td align="center" rowspan="1" colspan="1">8235 ± 618</td><td align="center" rowspan="1" colspan="1">6963 ± 1247</td></tr><tr><td align="center" colspan="2" rowspan="1">1409 ± 217</td><td align="center" colspan="2" rowspan="1">874 ± 210</td><td align="center" colspan="2" rowspan="1">7604 ± 1168</td></tr><tr><td align="center" colspan="7" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">Medium</td><td align="center" rowspan="1" colspan="1">1455 ± 178</td><td align="center" rowspan="1" colspan="1">1576 ± 220</td><td align="center" rowspan="1" colspan="1">865 ± 215</td><td align="center" rowspan="1" colspan="1">869 ± 232</td><td align="center" rowspan="1" colspan="1">8433 ± 652</td><td align="center" rowspan="1" colspan="1">7837 ± 680</td></tr><tr><td align="center" colspan="2" rowspan="1">1515 ± 208</td><td align="center" colspan="2" rowspan="1">867 ± 223</td><td align="center" colspan="2" rowspan="1">8137 ± 728</td></tr><tr><td align="center" colspan="7" rowspan="1">
<hr/>
</td></tr><tr><td align="left" rowspan="2" colspan="1">High</td><td align="center" rowspan="1" colspan="1">1402 ± 201</td><td align="center" rowspan="1" colspan="1">1576 ± 222</td><td align="center" rowspan="1" colspan="1">859 ± 221</td><td align="center" rowspan="1" colspan="1">855 ± 225</td><td align="center" rowspan="1" colspan="1">7481 ± 610</td><td align="center" rowspan="1" colspan="1">8848 ± 635</td></tr><tr><td align="center" colspan="2" rowspan="1">1489 ± 229</td><td align="center" colspan="2" rowspan="1">857 ± 222</td><td align="center" colspan="2" rowspan="1">8164 ± 925</td></tr></tbody></table></table-wrap>
<disp-formula id="eq1"><label>(1)</label><mml:math id="M1"><mml:mrow><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MANAGEMENT</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>=</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>ALARM</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TRANSM</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>POLICY</mml:mtext></mml:mrow></mml:msub><mml:mn>.</mml:mn></mml:mrow></mml:math></disp-formula> <disp-formula id="eq2"><label>(2)</label><mml:math id="M2"><mml:mrow><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>GLOBAL</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>=</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MANAGEMENT</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TRANSM</mml:mtext><mml:mn>2</mml:mn></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MHSM</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>SMS</mml:mtext></mml:mrow></mml:msub><mml:mn>.</mml:mn></mml:mrow></mml:math></disp-formula> <disp-formula id="eq3"><label>(3)</label><mml:math id="M3"><mml:mrow><mml:mtable columnalign="left" width="auto"><mml:mtr><mml:mtd><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>GLOBAL</mml:mtext></mml:mrow></mml:msub></mml:mtd><mml:mtd><mml:mo>=</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MANAGEMENT</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TRANSM</mml:mtext><mml:mn>2</mml:mn></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MHSM</mml:mtext></mml:mrow></mml:msub></mml:mtd></mml:mtr><mml:mtr><mml:mtd/><mml:mtd><mml:mi> </mml:mi><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:mi>n</mml:mi><mml:mo stretchy="false">(</mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>SMS</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TIMEOUT</mml:mtext></mml:mrow></mml:msub><mml:mo stretchy="false">)</mml:mo></mml:mtd></mml:mtr></mml:mtable></mml:mrow></mml:math></disp-formula> <disp-formula id="eq4"><label>(4)</label><mml:math id="M4"><mml:mrow><mml:mtable width="auto" columnalign="left"><mml:mtr><mml:mtd><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>GLOBAL</mml:mtext></mml:mrow></mml:msub></mml:mtd><mml:mtd><mml:mo>=</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MANAGEMENT</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TRANSM</mml:mtext><mml:mn>2</mml:mn></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MHSM</mml:mtext></mml:mrow></mml:msub></mml:mtd></mml:mtr><mml:mtr><mml:mtd/><mml:mtd><mml:mi> </mml:mi><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:mi>N</mml:mi><mml:mo stretchy="false">(</mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>SMS</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TIMEOUT</mml:mtext></mml:mrow></mml:msub><mml:mo stretchy="false">)</mml:mo><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>EM</mml:mtext></mml:mrow></mml:msub><mml:mn>.</mml:mn></mml:mtd></mml:mtr></mml:mtable></mml:mrow></mml:math></disp-formula> <disp-formula id="eq5"><label>(5)</label><mml:math id="M5"><mml:mrow><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>GLOBAL</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>=</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MANAGEMENT</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>TRANSM</mml:mtext><mml:mn>2</mml:mn></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>MHSM</mml:mtext></mml:mrow></mml:msub><mml:mo> </mml:mo><mml:mo>+</mml:mo><mml:mo> </mml:mo><mml:msub><mml:mrow><mml:mi>T</mml:mi></mml:mrow><mml:mrow><mml:mtext>EM</mml:mtext></mml:mrow></mml:msub><mml:mn>.</mml:mn></mml:mrow></mml:math></disp-formula>
<disp-quote><p>IF
(HeartRateFrequency&lt;40 AND SystolicBloodPressure&gt;160) THE HealthStatus
has AlarmLevel “HIGH.”</p></disp-quote>
<graphic xlink:href="IJTA2008-867639.001"/> <graphic xlink:href="IJTA2008-867639.002"/> <graphic xlink:href="IJTA2008-867639.003"/> <graphic xlink:href="IJTA2008-867639.004"/> <graphic xlink:href="IJTA2008-867639.005"/>
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Int J Telemed Appl. 2008 Aug 5; 2008:867639