Mobile Applications in Health Care - a Regional

Perspective

Ingrid Rügge1, Markus Behrens1

1
Universität Bremen, Center of Computing Technologies (TZI), [wearLab], 28359 Bremen,
Germany
{ruegge, skid}@tzi.de
http://www.wearlab.de

Abstract. Mobile and wearable ICTs are new technologies which are able to
support mobile activities and mobile work processes in a new unobtrusive man-
ner. The results of a measure for mobile eHealth applications are represented.

1 Introduction

Mobile and wearable information and communication technologies (mobile ICT) have
reached a stage where they can be widely employed and offer economic benefit. In
order to profit from the potential of these arising technologies, existing working and
business processes have to be analyzed with respect to their proportion of mobile ac-
tivities. For mobile activities and mobile working processes appropriate application-
oriented mobile solutions beyond desktop computing have to be developed. The over-
all aim is the support of activities which do not take place at the desk but, for exam-
ple, while moving around, and which require the full attention of the user.

Fig. 1. Wearable Computer from Symbol Technologies

One application area with an evidently high proportion of mobile working proc-
esses is health care, e.g. on-the-spot emergency and home care nursing as well as the
work of hospital staff. Although computers and communication technologies along
with mobile devices, e.g. pagers, have been used in this domain for a long time, there
is still a considerable potential of working processes which could be supported by
mobile solutions.
Quite early, the state of Bremen and a multitude of small and medium enterprises in
Bremen became aware of the economic potential of mobile solutions. Bremen de-
clared itself to be “mobile city” [1]. It undertakes a lot of effort to regionally
strengthen the competences within this topic and to become nationwide well-known
for mobile solutions. One of the means to push further development and application
of mobile ICT-solutions was the execution of the measure “Mobile Solutions in
Health Care”. A concept to sensitize actors from all areas of health care for these new
technologies has been conceived and realised. This project and the results achieved
are presented in the following.

2 Course of the measure

Proceeding from an overview of current tendencies of development and application

potentials, the aim of the measure was to identify those groups which are actively in-
volved in health care and in the field of mobile solutions and services for health care
including the roles they play and their chances within this network. Special attention
was given to a study of suppliers and service providers in and around Bre-
men/Bremerhaven, and to the identification of future users, with priority on regional
fields of application.

Fig. 2. Prototype of a wristwatch-computer from IBM/Citizen

Through systematically sensitizing users and providing them with specific informa-
tion on new mobile and wearable computing technologies possible fields of applica-
tion for this arising technology will be discovered. The initiation of a dialogue be-
tween users in health care and developers of mobile ICT-solutions which would
eventually lead to a development of innovative projects was the essential objective of
this measure. The project was carried out in two phases.
During the first phase, a study about existing mobile solutions was carried out [2].
Another task was to identify actors of the mentioned target groups. The following
groups were discovered:
- users in health care (experts in the application domain)
 - developer of conventional ITC-solutions for health care
- producer of medicine technology
- developer of mobile ITC-solutions (experts in developing mobile solutions
for other application domains)
In addition, possible users were interviewed about their mobile activities, needs of
communication, and situation-based information. The aim was to ascertain the spe-
cific requirements for mobile solutions. During these interviews the interlocutors
talked about their fields of activities and their general working environment. They
were asked about the actual state of (mobile) ICT systems being used in their daily
work routine and about useful possibilities to establish new mobile applications or
how to basically improve the overall efficiency of important and often accomplished
tasks. Also, the conversations led to further contact persons.

Fig. 3. Head-Mounted Display from MicroOptical

In the second phase, the results were used to motivate representatives of each actor
group for a discussion about ideas for mobile solutions gathered from the interviews
and from the results of the study. This information was used to invite prospective us-
ers and developers to seven events: one start-up presentation to introduce the purpose
of the measure and the forthcoming events, and six topic-centered workshops which
were organised according to the requirements of the participants. Invitations were sent
out to further contacs resulting from interviews. 101 persons altogether attended the
events, to exchange thoughts about mobile solutions for rescue, mobile monitoring of
patients or new ways of home-care, among others. Several scenarios mentioned dur-
ing the interviews were reasoned, ideas and options for new mobile technologies were
discussed, and new contacts could be established.
The measure was completed by the end of 2003. In the final survey the participants
expressed themselves positively about the initiation of this kind of discussion on an
adequate user-centered support of mobile activities and work processes in health care.
They praised the participative approach of the measure. They are very interested in
the perpetuation of the dialog about this trend-setting technological topic. The results
of the study, which are continuously updated, are available online [2]. Based on the
experience gained from the measure, three regionally relevant follow-up actions were
initiated. One recommendation is to carry on with the measure by integrating similar
topic-centered and application-oriented events into the further education of health
care professionals. The contents of these events have to be tuned to the special needs
of the members of the different actor groups (medicals, paramedicals, nurses etc.)
In the following chapter, an overview of the results of the study is given. Subse-
quently, one example from the analysis of the interviews and workshops is described
in detail. It illustrates which conditions and constraints will have to be met in order to
eventually develop an adequate mobile solution.

3 Study about mobile e-health applications

In the application of new technologies, medical science often led the way, as, e.g. in
the field of information- and communication-applications. A lot of hospital sections
and also a few physician’s practices are equipped with a high degree of technology.
Even the first expert systems (MYCIN [16], INTERNIST [17]), computer graphics
solutions for medicine [18], and virtual reality applications [19] were investigated and
developed within the medical domain. This cutting-edge position is especially true for
“stationary” solutions, but it also applies to the deployment of mobile solutions.

Fig. 4. Paper-based input-technology from Anoto

Mobile activities in health care cover all working processes and activities which are
carried out while in motion, and, in addition, those which take place at changing loca-
tions. The most important characteristic of mobile activities, however, is the fact that
the primary task and attention of the executing person are situated in the real world. In
health care for example, home care is a mobile activity, just like a house call or the
use of an ambulance. Medical staff in hospitals also do a lot of mobile work, e.g. an-
aesthetists visit their patients in their respective rooms to record their anamnesis. Fur-
thermore, patients who live a relatively normal life at home, but are monitored by
body-mounted vital-sensors, in this respect, are mobile, too. There are a lot of possi-
bilities to support these activities and work processes and there remains a lot of re-
search and development to be done.
 Even though the survey of the [wearLab] brought up information about more than
50 projects, services and products, there still is a lack of diversity in mobile solutions.
Most examples are prototypes or projects still under development, and in some cases
so-called “mobile” solutions are nothing else than desktop programmes running on a
notebook or handheld PC. Innovative ideas are quite the minority. Exceptions are e.g.
a support-system for Parkinson patients [14] and further approaches to improve the
individual qualitiy of life by using computer-aided prothetics, a speech-controlled
clinical documentation system or a knowledge-based support system for medication.
The purpose of the study was to put together an overview of up-to-date product-,
initiative- and project-trends. Special attention was given to regional (Bremen) and
national (Germany) proposals and activities in this specific technological domain.

3.1 Emergency scenarios

Several research institutions already deal with the support of rescue forces focusing
on mobile ICT-technology used in emergency medical aid. The main focus lies on
standard situations with emergency ambulances. Mobile devices used in such situa-
tions are PDAs, robust web pads, state-of-the-art input devices like the paper-based
technology of the Anoto Pen [3] or a complete wearable computer produced i.e. by
Xybernaut [4].

Fig. 5. NOAH-Vest from University of Regensburg

Most of these projects have in common that the main task is to collect important
patient-data during an emergency call and to submit those data wirelessly and without
loss of time for coordination to e.g. emergency headquarters. Thus, the treatment of
the patient can be prepared well before the actual admission at the hospital which
might be crucial for the patient’s life. Further references: [5], [6]
3.2 Mobile telemonitoring and emergency services

Monitoring of risk patients and emergency services includes different applications

ranging from telemonitoring and telediagnosis-methods to preventive measures for
so-called risk-groups like diabetics and heart-attack patients. Patient monitoring for
therapeutical or diagnostical reasons is costly because it is done in the hospital. Now,
wearable devices can be used to monitor them at home or outside. This “advantage of
playing at home” increases the well-being of the patient and also provides more “real-
istic” conditions for the measures than under the artificial conditions in a hospital.
Furthermore, treatment costs can be reduced.

Fig. 6. Smart Shirt from Sensatex [21]

The aim of mobile solutions is the patient’s more or less unrestricted freedom of
movement, however, these mobile solutions could also be realised in a hospital or in a
nursing home. Common to all projects is the measuring of patient’s vital functions
with sensor systems, status monitoring and the triggering of an action as soon as non-
standard values are observed. The difference lies in the mobile devices used, the
monitored vital signs, and the responsible authorities. [7], [8], [9]

3.3 Support of working processes in hospitals

The majority of the projects dealing with mobile solutions are found inside the clini-
cal environment. Although at the first glance this may seem unexpected, since hospi-
tals are “stationary”, their infrastructure is well equipped with conventional ICT, and
they have only non-mobile facilities, nevertheless, a lot of mobile aspects were identi-
fied. These mainly deal with documentation which is essential for such institutions.
As hospitals are generally equipped with a clinical information system, some pro-
jects are concerned with mobile attachments for the desktop-computing software in
order to support the staff with location-independent access to the patients’ records. In
order to avoid errors, e.g. during the transfer of data from paper to the information
system, and to minimize administrative expenses, the necessary documentation should
be supported on the spot by a mobile solution. [10], [11]

Fig. 7. Mobile Voice EPA from COMPARAT GmbH

3.4 Mobile Solutions for Home Care and Doctor’s house calls

A large number of nursing activities, from the provision of basic needs to therapeutic
measures, may be described by the term “home care”. During a house call the nursing
staff is on its own, so they might miss important information, e.g. about former ill-
nesses of the patient. To solve such problems, there are projects like “LOTSE” [12].
One purpose of this project is the development of health care applications for mobile
devices based on web pads, to record and review patient records, and to perform re-
mote diagnostics. A system with wireless connectivity will be developed to make the
required information available to persons working in home care independent of the
location. In an analogous scenario, emergency doctors, hospital staff, and nurses
could be permanently connected to each other through a mobile equipment and thus
would be able to exchange current information.
The only project to support doctors while on house call is a software solution called
“Medical PAD Visite” by Wenk, Inc. [13]. It provides physicians with the possibility
to access their complete ITCpracticesystem even while at a patient’s. A PDA is used
as interaction device, but without a wireless connection.

3.5 IT-prosthetics for an improved quality of life

While the research for mobile solutions was carried out, there was one fact which at-
tracted attention: many institutions are already working on mobile applications to im-
prove the overall quality of life for ill or handicapped people. But most mobile de-
vices used in those projects are prototypes.
One project in this field of mobile activities is called “PARREHA”. It is aimed at
supporting patients suffering from Parkinson’s disease [14]. As a basis for the devel-
opment, a wearable computer with a head-mounted display from Xybernaut Corp. [4]
is used. Virtual reality exercises, audio-visual communication between patients and
doctors as well as videoconferencing are utilised for the evaluation of motorical func-
tions and for the conception of therapeutical measures. Although the project is de-
signed exclusively for Parkinsonpatients, it might also - with some slight modifica-
tions - be used as visual or aural aid.

Fig. 8. PARREHA with a wearable computer

3.6 Anamnesis support

Anamnesis support means a technical solution for one special medical documentation
process. One example is a project realised at the university hospital in Regensburg
[15] where a mobile solution for answering an extensive questionaire was devides in
order to support psychosomatic diagnosis. For a diagnosis the doctor has to include
information about the personality of the patient who consequently has to fill out a
large number of forms. An electronic form allows the patient to fill in the required
data regardless of her/his location. A computer-supported analysis of the given infor-
mation can instantly be utilised for diagnosis by the physician in charge. The ques-
tions can be selected beforehand by the doctor at her/his desktop PC. The prepared
PDA is handed out to the patient who can then answer the questions without time
pressure. The answers are put directly into the PDA and are then transferred directly
via wireless connection to the computer system of the doctor. The medical staff re-
quires no further manual data acquisition.

Fig. 9. Pocket PC with questionnaire, University of Regensburg

As mobile solutions keep progressing this overview of existing mobile solutions

only shows a temporary state of 2003. There are permanently new developments and
there is no end in sight. This is partly because many of the mobile solutions developed
until now are not designed properly to meet the user’s needs. Therefore, within the
scope of the project “Mobile Solutions in Health Care” a requirement analysis has
been conducted. The interviews and workshops gave an insight into those areas of
health care where mobile solutions would be meaningful and desirable. In the follow-
ing chapter, the identified areas are listed. Some requirements on an adequate mobile
solution for “mobile documentation” are exemplarly described below. But such a mo-
bile solution has still to be developed.

Fig. 10. Affective Computing System at MIT [7]

4 Results from the interviews and workshops

As regionally relevant applications were to be preferred, explorative interviews were

made with representatives from the identified actor groups. The results served as input
for the topic-centered workshops with regionally motivated thematic emphases. The
following aspects were identified as being important or as application domains for
mobile solutions:
- faciliating documentation in home care, in doctors’ practices, hospitals, etc.
- standardisation and semantic integration of data to faciliate access to distrib-
uted information
- electronic storage of all documents,
- localizing people (confused persons, important team members of an operat-
ing team etc.)
- mobile tele-monitoring of the vital parameters of patients
- computer-supported co-operation between all sections and professions in a
general and comprehensive health care process

The following example shows in detail the concrete requests of the users in the area
of documentation.

4.1 Reduction of the required effort for documentation

Documentation is indispensable in all fields of health care. They serve different pur-
poses depending on the area:
- data collection for invoicing,
- data collection for the insurance,
- acquisition of process-supporting data, and
- gathering of medical and nursing-relevant data.
From the staff’s (doctors, nurses or technicians) point of view, the first two bullets
are additional tasks which do not support their original, primary assignments and are
often looked on as inconvenient and redundant.
An estimation for health care has shown that more than 40 minutes of nursing
staff’s daily working time is used for documentation only. This may increase depend-
ing on the distances between the location where the data has been collected and that
where these are stored or where an input terminal is located. The introduction of suit-
able mobile devices could augment the quality of any care facility, assuming that such
developments are more than only conversions of already existing desktop-computing
documentation systems to handheld PCs.
The digitalisation of documentation and the introduction of mobile devices makes
the information everywhere accessible thus reducing considerably communication by
phone. Overall communication, however, has to be maintained, as especially in health
care inter-human, non-technically mediated communication is essential. Some events
like e.g. change of shifts cannot and should not be redeemed, whereas individual note
taking during staff meetings thus will become obsolete. Individual access to com-
monly-used data and a common “virtual information room” could be the solution.
One important precondition for the acceptance and utilisation of such an application
would be to design the required interaction as simple and easy as possible. A casual
interaction method for the use of mobile and wearable computing systems will have to
be developed. Involving the users into the design process of mobile solutions would
be a good way to gain their acceptance. If users participate early in the project, it will
be a lot easier for them to become familiar with the use of the developed mobile solu-
tion and even to help to improve it.

5 Conclusion and Future work

This article reported on the measure “Mobile Solutions in Health Care“ which was
carried out with a regional focus on Bremen. The goals of the measure were to initiate
a dialogue between representatives of the regional health care community on the one
hand and mobile technology companies on the other hand and to foster the initiation
of successful projects in mobile health care. The study of existing projects in this area
revealed a spectrum of six different classes of applications. Projects exist in the fields
of emergency, mobile tele-monitoring, and the support of working processes in hospi-
tals. Other projects were conducted in the fields of home care, IT-prosthetics, as well
as anamnesis support. The measure also comprised interviews and workshops with
representatives of the target groups.
The development process of mobile solutions in health care is far from being com-
pleted. Several additional application-centered technologies are required for their re-
alisation. It is important to analyse the mobile working processes of the user in order
to develop successful applications. Also, their active participation is indispensable.
It is planned to continue the measure with specific training offers involving a vari-
ety of local facilities. In Bremen, the development of new mobile solutions will pre-
sumably be focussing on home care.

Fig. 11. Keybord independent input of text [20]

References

1. Bremen Mobile City http://www.mobilecity.org (seen: 20.01.2004)

2. Study „Technological and Application-orientated Potential of Wearable Computing“.
http://www.wearlab.de/DOCS/studie/studie.html (seen: 20.01.2004)
3. Anoto AB, Lund, Sweden. http://www.anoto.com (seen: 30.01.2004)
4. Xybernaut Corporation. http://www.xybernaut.com (seen : 30.01.2004)
5. 6WINIT - IPv6 Wireless Internet Initiative. http://www.6winit.org (seen: 30.01.2004)
6. T-Systems Nova, Germany. Project: “xMotion - eMObile Testbed for InterOperabil-
ity of Networks in eLogistics”. http://www.t-systems.de (seen 30.01.2004)
7. MIT Media Laboratory, Cambridge, MA, USA. Project: “Affective Medicine: Tech-
nology with Emotional Intelligence”. http://affect.media.mit.edu (seen: 30.01.2004)
8. Ericsson, Stockholm, Sweden. Project: “Blue Wireless Heart Monitor”.
http://www.ericsson.com,
 http://2002.istevent.cec.eu.int/2002exhibition/exhib/index_en.asp?id=314 (both seen:
30.01.2004)
9. TMS Telemedizinische Systeme GmbH, Chemnitz, Germany.
http://www.aerztezeitung.de/docs/2002/11/23/4m0501.asp, http://www.telemedsys.de
(both seen: 30.01.2004)
10. Institut für Angewandte Pflegeforschung der Uni Bremen (iap), Bremen, Germany.
Project: „Apenio“. http://www.iap.uni-bremen.de, http://www.gesundheitswirtschaft-
bremen.de/project_detail.jsp?primaryKey=5, http://www.iap.uni-
bremen.de/Projekte/proj_25.htm (all seen: 30.01.2004)
11. BIBA, Bremen, Germany. Project: “CAREN”. http://www.caren.biba.uni-bremen.de/
(seen: 30..01.2004)
12. BIBA, Bremen, Germany. Project “LOTSE”. http://www.biba.uni-
bremen.de/projects/lotse/ (seen: 30.01.2004)
13. Wenk Systems, Hamburg, Germany. Project “Medical PAD Visite”.
http://www.wenk.com (seen: 30.01.2004)
14. Oxford Computing Consultants Ltd, Oxford, UK. Project “PARREHA”.
http://www.oxfordcc.co.uk, http://www.parreha.com (both seen: 30.04.2004)
15. Universitätsklinikum Regensburg, Regensburg, Germany. http://www-cgi.uni-
regensburg.de/Klinik/Klinikum/, http://www.hewlett-
packard.de/mobile/download/cpq_UniklinikRegensburg_06_020311_final.pdf (seen:
30.01.2004)
16. E. Shortliffe and B. Buchanen, “A Model of Inexact Reasoning in Medicine, Math.
Bioscience 23, 1975, pp. 351-379.
17. R. Miller, H. Pople, and J. Myers, “IINTERNIST1, an Experimental Computer-Based
Diagnostic Consultant for General Internal Medicine”, New England Journal of
Medicine 307, 1982, pp 468-476.
18. H.-O. Peitgen, D. Saupe, “The Science of Fractal Images”, Springer-Verlag New
York, 1988
19. Medicine and Virtual Reality: A Guide to the Literature,
http://www.hitl.washington.edu/kb/medvr/medvr.html (seen: 30.01.2004)
20. The Kitty Project http://www.kittytech.com/default.html (seen: 30.01.2004)
21. The Georgia Tech Wearable Motherboard http://www.gtwm.gatech.edu/,
http://www.sensatex.com/smartshirt/ (seen: 30.01.2004)