New frontiers of telemedicine systems for chronic patients monitoring: adaptive systems and multi-access services.

摘要

The management of chronic diseases is one of the most important health care problems in western countries. The increase in life expectancy due to improvements in economic and health care conditions has caused population ageing, and consequent increase in the incidence of chronic diseases. The joint concurrence of social and economical pressures has motivated the establishment of home care programmes, which involves primary and secondary care assistance. In this context, a careful management of the information flows between the different actors involved in home care is mandatory. Moreover, the capability of providing remote assistance in the home care monitoring activities may at the same time improve the quality and continuity of care and save the travel and personnel costs of home care programmes. Information and Communication Technology (ICT) is a natural solution for dealing with such problems. Several tools have been proposed to handle particular diseases, such as diabetes, or particular case management processes such as post-stroke patient rehabilitation. The kind of ICT support for home care varies widely. The first attempts resorted to the use of standardised databases, fax and e-mails to ensure co-ordination and data transfer. Then a large number of different systems have been tested for supporting home care, often exploiting technological solutions designed ad-hoc for data collection at home and data management system at the physician's side. Examples can be found in the area of Home Asthma Telemonitoring system, heart failure and ECG monitoring and diabetes. At the same time several works have been devoted to provide monitoring assistance through Interactive Voice Responders (IVR) integrated with a work-station through computer-telephony integration capabilities. Later, the availability of mobile technology and of the Internet has driven to test integrated solutions, able to conjugate the advantages of both technological platforms. Finally, all such technological experiences have been merged into a new concept, called Multi-Access Service (MAS). In a MAS a variety of access technologies, such as the Web, client-server applications on PCs or Palmtops, specialised devices for data collection and transmission, IVR and/or dialogue systems are integrated into one service. From a technological viewpoint, each access technology is managed through a software layer at the server side, which communicates with a middle-layer and with a data management layer. The middle-layer may implement some of the overall application logic, such as the capability of scheduling activities, like e-mail notifications or automated data analysis services. The MAS technology seems nowadays the most suitable solution for the implementation of the telemedicine services, thus allowing the provision of flexible instruments for communication. Within MAS, the user is not constrained to use the same technology for communication, but, on the contrary, may choose the access way in dependence on his preferences and needs, which may, of course, vary over time. A very interesting aspect of such services is represented by the capability of adapting the interactions in relationships with the user characteristics, i.e. to tailor and continuously adapt the system on the basis of a user profile which may be built during the monitoring process. Such ideas have been exploited in a couple of research projects, which will be described in this paper. In the next section we will briefly outline the basic characteristics of a MAS architecture and the possibility of adapting of such architecture to the user profile; then we will highlight the adaptation problems in the project HOMEY, aimed at managing hypertensive patients and in the project M2DM, aimed at managing diabetic patients.