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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 173-179

The role of a disruptive digital technology for home-based healthcare of the elderly: Telepresence robot


1 USC Business School, University of the Sunshine Coast, Maroochydore, Queensland, Australia
2 Department of Neuromedicine and Movement Science, Faculty of Medicine and Health, Norwegian University of Science and Technology and Norwegian Centre for eHealth Research, University Hospital of North Norway, Tromsø, Norway
3 UM-SJTU Joint Institute, China and WHO Collaborating Centre on eHealth, University of New South Wales, Australia

Date of Web Publication28-Dec-2018

Correspondence Address:
Donald Kerr
USC Business School, University of the Sunshine Coast, Maroochydore, Queensland
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_20_18

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  Abstract 


Many elderly people prefer to live at home independently. They and their relatives face challenges with respect to physical and mental health care in this environment. In addition, the traditional model of hospital-based centralized healthcare is now under stress due to the ageing population worldwide, especially in countries, such as Japan, China and Europe. Robots are now being used extensively for many different applications in business (e.g., materials handling) and homes (e.g., floor cleaning). On the other hand, researchers all over the world have been investigating the use of robots (e.g., PARO the therapeutic baby seal robot) to provide emotional support and well-being for the elderly. The EU project VictoryaHome was designed to trial telepresence robots for the care, safety and emotional well-being of the elderly across four countries in Europe and Australia. This paper examines the potential of integrated care of the elderly in their own homes and is based on the findings of the VictoryaHome project.

Keywords: Aged care, emotional well-being of elderly, integrated care at home, seniors, telepresence robots, welfare technology


How to cite this article:
Kerr D, Serrano J A, Ray P. The role of a disruptive digital technology for home-based healthcare of the elderly: Telepresence robot. Digit Med 2018;4:173-9

How to cite this URL:
Kerr D, Serrano J A, Ray P. The role of a disruptive digital technology for home-based healthcare of the elderly: Telepresence robot. Digit Med [serial online] 2018 [cited 2019 Mar 20];4:173-9. Available from: http://www.digitmedicine.com/text.asp?2018/4/4/173/248979




  Introduction Top


To maintain their independent lifestyles, many frail elderly people prefer to live alone at home rather than in nursing homes. However, family members often worry about their elderly relatives' well-being and feel insecure leaving them unsupervised at home. Additionally, due to the geographical distances, family members are often unable to visit their relatives frequently, leading to a loss of bond with family and friends that in turn leads to frustration and loneliness amongst the elderly.

A variety of solutions (e.g., smart home sensors and fall detection pendants) are available to address some of the safetyconcerns, but such technologies lack the “human touch” of the near and dear that is missed very much by older people. Elderly people now live longer, and loneliness is a major emotional health problem for them.[1],[2] These health problems can have major long-term implications on a person's life expectancy with issues such as bad sleeping patterns, deteriorated physical conditions and low level of energy during daytimes,[3] high or low blood pressure[4] and mental health concerns.[5]

More and more people have functional dependencies, multiple chronic diseases and advanced stage incurable conditions that are in need of new approaches from the point of view of social and health care. Today many IT solutions for older adult care at home, designated as tele-care technologies, are already available in the market. However, they raise many questions, such as how are these technologies supporting older adults at home in their daily activities? What about the integration with their informal caregivers like family and friends? Are such technologies giving them peace of mind and lightening their burden? There is a large gap separating real needs and the promoted products.

Telepresence robots allow family members and caregivers to provide some virtual company to the elderly while attending to their care needs remotely. Therefore, it maybe possible to overcome some of above issues based on the recent advances in telepresence robot systems and accessories. An EU Project VictoryaHome[6] investigated this problem through a multi-country collaborative project on telepresence robots for home-based care of the elderly in 20 sites (private homes of elderly users) in five countries (Netherlands, Norway, Sweden, Portugal and Australia).

This paper reports on the Australian part of the project with a view to designing the next phase of this application for the elderly in developing countries, such as China and Bangladesh. The paper is organized as follows; the next Section discusses the background, followed by a discussion of the Telepresence Robot originally designed by the Swedish company Giraff and further developed within the VictoryaHome project. We then discuss the initial testing of the robot with the elderly. Finally, we discuss the issues faced in Australia with a view to developing a more cost-effective telepresence robot as part of our future work.


  Background to the Research Top


Researchers have been investigating the use of robots to aid the elderly in various types of applications, such as communication with relatives and friends at a distance, transportation of medical supplies and equipment across healthcare/aged care facilities, surgical procedures etc.[7],[8] Robotic technologies used to help older adults with their problems can be divided into nine categories; companion, telepresence, manipulator service, rehabilitation, health-monitoring, reminder, domestic, entertainment and fall detection/prevention robots.[9] This paper will focus on telepresence robots.

Telepresence robots are robots that provide two-way communication between two people, and this may assist in aiding the maintenance of social networks for older adults. The provision of a telepresence device as distinct from a telephone offers an easy to use means of providing rich communications and has been shown as beneficial in bringing together distant grandchildren with their grandparents.[10] This may also be beneficial to people who have lower levels of hearing as they can supplement the spoken word with lip movement, facial expression and gestures to aid understanding. Some telepresence robots have in-home navigation abilities that can provide another care function for a remote user.[11] One of the most important aspects of communication is a sense of connectedness, which helps individuals not to feel lonely. Robots could also benefit people with cognitive impairment problems and help them to stay in their homes longer. This monitoring approach offered by the telepresence robot implies that family members living away from the person can still play a role in their day-to-day care and allows the older person to play an active role in their extended family life. The use of these devices may allow seniors to safely stay in their own homes and the communities within which they have existing social links. The VictoryaHome project created an integrated architecture combining telecare supporting devices, such as a fall detector and a smart medication dispenser, with a telepresence robot and an Android-based App for remote monitoring.

A description of the original idea of the VictoryaHome project as provided by[12] is shown in [Figure 1]. Within the scope of the VictoryaHome project and in collaboration with various partners, the Swedish company Giraff developed a robot specifically for this application. A photo taken during the Norwegian test site located in Odda is reproduced in [Figure 2].
Figure 1: The architecture of VictoryaHome (©2015 VictoryaHome consortium)

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Figure 2: Giraff Robot with an Elderly (©2015 VictoryaHome consortium)

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Formal caregivers would be further helped by technology in the care they currently offer, while the informal caregivers can again be closer to their loved ones providing care to them but also receiving their wise advice; the daughter checking if her mother is fine by using the “serenity button” and also verifying that the right medicines have been taken for the day [Figure 3]; and just after that, the grandchild asking her grandmother for advice in a cosy and involving conversation using the tele-presence feature and showing the afternoon pictures taken at school, with the facilities built in Victorya. Both sides are closer again as it was in previous generations where extended families were the norm. Victorya can bring together formal care givers, informal caregivers and most of all, give older adults the possibility of engaging in her or his own care. This could result in a real network of care. A possible disadvantage of the scenario outlined above could be reduced visits from family living close to the older person. In other words, they could use the telepresence robot as an alternative to direct, personal visits. However, given the modern trend of geographically dispersed families whereby visits may involve hours of road travel or even international travel, for the majority of situations, this would not be a problem. Even in situations of close family access, the fact that the technology facilitates immediate access if needed in the case of a fall or other adverse situation can also negate possible disadvantages with respect to less person to person visits.
Figure 3: Picture of remote young Caregiver on Giraff as seen by the elderly in Australia

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The project aims at much more than helping the older adults with formal caregivers. It also focuses on the informal caregivers, the family, the friends, and those close to the older adults entrusted with the burden of giving daily care the best they can. In many cases this takes energy and time from their already busylife. For the first time they will be supported by IT and caring from a distance, with the help of specially designed tools such as dehydration prevention, medication adherence, activity monitoring and fall detection, and a video and voice communication mechanism, which until now has only been available on PCs and sometimes mobile phones. Never before have these tools been simultaneously accessed by both sides (end-user and care giver).

VictoryaHome benefits both the older adults being cared for and their informal caregivers. Consequently, the care organization (e.g., the aged care provider) also benefits through the active support of informal caregivers through this system, thus reducing the care burden and cost by the care organization (e.g., fewer professional caregiver visits being required, etc).


  Telepresence Robots Top


There are several telepresence robots[13] now being used for people to attend meetings remotely. However, the VictoryaHome project needed to test several functions (not available in commercial telepresence robots) of elderly care, such as the remote administration of medications and the detection of falls. Within the scope of the VictoryaHome project and in collaboration with various partners, the Swedish company Giraff developed a robot specifically for this application. More than 30 robots were produced of which 22 were tested at private homes of elderly users across the Netherlands, Norway, Sweden, Portugal and Australia, during the project trials. As part of this research, the authors carried out a systematic survey of the adoption of assistive robots (of which telepresence is a type) for elderly people.[7]

This paper mainly discusses VictoryaHome from the perspective of aged care in the Australia, involving subjects on the Sunshine Coast in Queensland (the largest concentration of retired people in Australia) and in Sydney-NSW, Australia. The project specifically looked at the performance usefulness of the telepresence robot for the elderly being cared for at home through remote informal caregivers (e.g., family members) and remote and visiting formal caregivers (e.g., aged care providers) in the context of a well-being check

The Giraff robot

The Giraff robot was originally created by Giraff Technologies AB, a small to medium enterprise (SME) based in Sweden, and later further developed within the scope of the VictoryaHome project. The Giraff robot is a large machine, which includes a full-size desktop computer tower plus batteries. It has the ability to raise and lower the interaction screen, change the screen angle (like nodding the head of the Giraff), zoom the camera on a specific area, switch to night vision for dark rooms, and finely control the speed and manoeuvrability of the machine.

Evaluations of the device were in the form of a controlled research trial with the results meant to inform further development of the device in order to provide a solution that would, as closely as possible fit the needs of older people living in their own homes. The trial was extensive with 20 private homes of elderly users, across Europe and two more in Australia. As the trial was designed to determine the usefulness of the Griaff robot, a series of questions were asked both from the primary user (the elderly) and the secondary users (the caregivers) perspective.

The Giraff can be remotely activated by a ‘secondary user’ (care workers and loved ones who want to contact the primary user using the telepresence robot) to request a visit to the ‘primary user’ (the older person). The primary user can see an image of the caller on the Giraff screen and can either accept or reject the incoming call. Some secondary users can also be given permissions that allow them to make ‘emergency’ calls, where they can activate the Giraff and start a visit without any intervention by the primary user, in order to check the well- being of the primary user as may be the case with a suspected fall.

The Giraff robot has been evaluated in various sites in Europe[14] and at two sites in Australia.


  Findings Top


The VictoryaHome project conducted a multisite trial study involving 22 older adults (primary users), 29 informal carers and 5 professional carers (secondary users), in the following countries: The Netherlands, Norway, Sweden, Portugal and Australia.

The study focused on:

  1. Effects on wellbeing, independence and safety of both primary and secondary users–the older adults and their carers respectively;
  2. Impact on the care system processes;
  3. Usability and technology acceptance.[15],[16]


The project investigated whether the services provided by VictoryaHome would improve the wellbeing of both the older adults (primary users) and their family members (secondary users).

The European project

The results from the European trials are shown below:

In general data seems to indicate that primary users are more positive to VictoryaHome than the secondary users. In fact, there were measured increased feelings of happiness, self-esteem and reduced levels of frustration. The indication is that peace of mind was positively influenced for primary users, whereas the inverse effect was registered for secondary users.

Measures of social contact of the primary users were obtained for both contacts with relatives and friends. Results indicate that, when compared the situation before and after the intervention, the contact with family remained the same but there was a slight increase of contacts with friends. This might be a result of an interest in the fact that the primary user is participating in a test. Another interesting result is the fact that there is a difference in contact with family and friends to ask for help and the contact for talking about private matters. The respondents prefer the family to talk about private matters rather than friends but in relation to asking for help, the respondents only gave a slight preference to family in comparison to friends.

The introduction of a telepresence device in the home has produced some positive feelings of interest, reactiveness and trust and, inversely, concerns about sociability and liveliness. The lack of feeling of touch was reported but as compensation, the feeling of direct interaction and a real sense of meeting the communication partner was mentioned by the primary users.

Data indicates a general positive attitude of the users in relation to their abilities. Opinions about the effectiveness of the VictoryaHome services are divided. Users who had a negative opinion about the safety mention that this is due to malfunctioning of the service, as especially the fall detection device was having many errors which causes even more worries for some secondary users. At the same time, many secondary users were looking forward to this service most compared to others, as falling of the primary users is one of their main concerns related to the primary users' health. A working fall detection device might reduce the fear on both primary and secondary user, as some already mentioned that in case the fall detection device was working, users felt safe knowing that someone would come and help directly.

In general, not many users mentioned the effectiveness of the pill dispenser, despite that quite a lot of primary users forget their medication intake. This might be because some already use a similar device. Some are however finding the pill dispenses effective, as they were not using such device yet, and it helped the secondary user to take away the feeling of constantly having to remind the primary users.

The project investigated whether the services of VictoryaHome would be accepted by its users and how they would perceive its usability. In general, the experienced usability by primary users was very low; acceptance among primary users, but also among family and friend seems questionable or neutral.

Users do believe that the services offered by the VictoryaHome system are good, and users have the feeling that it would be good for others if they would use the service. However, primary users did not express interest in continuing to use the VictoryaHome system after the study period. Most likely this is due to the robot not being enjoyable, primary users experiencing anxiety feelings, or just believing that it is not convenient for them. The reason why it is not convenient could be the technical problems which could have caused confusion among primary users. Although a different measurement for acceptance was used among secondary users, their intention to use the VictoryaHome service is neutral, which is contradictory to the primary users.

Usability was only measured among primary users, who rated the usability as low. This low usability can most likely be explained by the errors that users experienced as a consequence of technical problems. In fact, many informal caregivers mentioned that the design problems should be improved before testing the system with older adults. Some mention that they like most of the features, a non-working product causes a lot of fear and anxiety and would have a negative impact on its usability. The complete set of results from the VictoryaHome studies have been published in.[17]

The Australian project

The Australian extension of the VictoryaHome project had to disable two key features that were part of the add on benefits in using the Giraff, namely the fall detector and the medicine dispenser. In the case of the fall detector, it could not be activated and was unable to be used because the European version had direct access to a call center which was not available in Australia. In the case of the medicine dispenser, we could not obtain ethics approval for such a device as it contravened the Therapeutic goods administration's Australian standards for the dispensing of medicines. The omission of these two components of the robot usage effectively meant that the Giraff robot in Australia was a telepresence device without the extra benefits associated with the European study.

The two sites in Australia were in the Sydney and Sunshine Coast regions. The Sydney participant was a 63 years old male living on the second-floor of a house, with his carers living on the ground floor of the same house. His main communication device was making calls with a smartphone and email. After using the Giraff, an interview was carried out by a family member who is in contact with the participant. The ability to navigate through the home assisted in monitoring was considered to be the most positive facet of using Giraff compared to Skype and Facetime for this family member acting as an informal caregiver. They also appreciated the ability to see when their family member had returned home from an outing. The Sunshine Coast site participant was a 65-year-old male with limited mobility and living alone.


  Observations Top


The main problems encountered by the research team were of technical nature and are summarized as below:

Firewall issues: The Giraff uses quite a complex network architecture, with a central directory server in Norway, a driving-commands server in Norway, plus a third-party video-conferencing protocol from a USA provider. For the Giraff to work correctly, several network ports are required to be open, to establish these connections and to ensure fast peer-to-peer video and driving control. However, in some environments, especially in public buildings, it is not easy to have access to existing firewalls. For example, the Giraff could not be accessed from outside the University, due to strict firewall rules.

Video Freezing: This was the major problem with using the Giraff in Australia - the video frame rate would drop making the Giraff impossible to drive. Usually the audio would freeze as well, which made communication impossible. Detailed network traffic investigation showed that the video and audio traffic was being routed via the USA, rather than peer-to-peer, so was often subject to intermittent lag and packet loss problems.

Driving Lag: We encountered significant lag in the left/right driving controls, which made it difficult to control the Giraff. Detailed investigation of the network traffic with Wireshark showed that this was because the driving commands were going via a server in Norway, with around 500m sec lag.

In summary, the large distance from Australia to the Giraff servers located in Norway and the USA created severe lags in the communication; security infrastructure (firewall) related to the fact that University settings were being used to control the Giraff and this resulted in access problems; standards from other countries not being compliant to those in Australia meant that some components of the VictoryaHome platform could not be used. An example of this was the medicine dispenser that was a part of the Giraff robot but could not be used in Australia.[14] It is also accepted that the communication infrastructure in Australia (especially on the Sunshine Coast) was limiting at the time of the trial and the Sunshine Coast site did also suffer from intermittent communication problems as well reduced performance during peak times. We were fortunate that the research participant on the Sunshine Coast was a technology enthusiast and was willing to re-boot the device when asked.

It is hoped that this paper can also assist future researchers who may have had the same objectives as our research team, namely simply testing the technology for usage and acceptance. However, the technology is evolving rapidly and there is a need to ensure the systems are working correctly in the chosen environment before even considering the implementation of usability and acceptance studies. We are confident that the technology will improve, and the objectives and goals of this original research can be met as the technology improves and evolves.


  Conclusion and Future Work Top


This paper has discussed the concept of integrated care for the elderly living independently, involving family members (informal carers) at remote locations and aged care providers in contact with the elderly (through remote communication and visits). The scenarios for care include some significant ones, such as medication dispensing and fall detection and reporting. The project team developed a special telepresence robot with the features for these functions in collaboration of a Swedish robot company called Giraff. The system was trialled as part of the EU VictoryaHome project at more than 20 sites in five countries (Netherlands, Norway, Sweden, Portugal and Australia) on elderly people and their caregivers. The basic idea was liked by all. However, the robot had too many technical problems related to software and medical device laws in different countries, such as Australia. Besides, the robot was found too expensive for the required functions. The team is now working as part of the mHealth for Belt and Road Region Initiative involving seven countries including China and Bangladesh to address these problems through robots made in China and Bangladesh. This newer technology should offer improved, more cost-effective robots with more battery capacity and improved communication practices using accepted, international protocols. It would be a major disservice to the aged care community if this research was discontinued due to an early adoption setback and immature communication protocols. This research needs to evolve to meet the needs of the ever-increasing costs of aged care across all countries in the world. One of the most effective ways society can reduce these increasing costs is to help older people stay at home longer and technology can play a very important role in this endeavour.

Acknowledgement

The work reported in this project was partly funded by the EU Victoryahome project, Smart Services CRC and CEPAR in UNSW-Australia and the University of Sunshine Coast, Australia. The authors wish to thank all participants of the Victoryahome project, especially to Arni Ariani of UNSW, Mark Utting and Jacqueline Blake from the University of Sunshine Coast, Australia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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