Ambient Intelligence in Health Care

GIUSEPPE RIVA PhD

ABSTRACT

Ambient Intelligence (AmI) is a new paradigm in information technology in which peopleare empowered through a digital environment that is aware of their presence and contextand is sensitive adaptive and responsive to their needs habits gestures and emotions Themost ambitious expression of AmI is Intelligent Mixed Reality (IMR) an evolution of tradi-tional virtual reality environments Using IMR it is possible to integrate computer interfacesinto the real environment so that the user can interact with other individuals and with theenvironment itself in the most natural and intuitive way How does the emergence of the AmIparadigm influence the future of health care Using a scenario-based approach this paperoutlines the possible role of AmI in health care by focusing on both its technological and re-lational nature In this sense clinicians and health care providers that want to exploit AmIpotential need a significant attention to technology ergonomics project management humanfactors and organizational changes in the structure of the relevant health service

295

CYBERPSYCHOLOGY amp BEHAVIOR

Volume 6 Number 3 2003copy Mary Ann Liebert Inc

INTRODUCTION

HUMANndashCOMPUTER INTERACTION has come a longway since the early days when computer users

working in the DOS environment copied files on adisk by typing instructions like ldquoDIRprdquo or ldquoCOPYmyfileexe ardquo In fact during the past 15 yearstechnologyrsquos focus has gradually been shifting awayfrom the computer as such to the user12 Clear signsof this transformation were the development of themodern graphical user interface and the emergenceof totally new interactive communication environ-ments such as Computer Mediated Communication(CMC) and Computer Supported CollaborativeWork (CSCW)3 However a series of new technologyadvancement are providing the background for anew change According to different analysts IT worldis now in the middle of two concurrent trends4

Pervasive diffusion of intelligence in the spacearound us through the development of wirelessnetwork technologiesmdashWiFi and Bluetoothmdashad-vanced mobile communicationmdash25 G and 3Gnetworksmdashand intelligent sensors

Increase of richness and completeness of com-munications through the development of multi-media technologies towards ldquoImmersive VirtualTelepresencerdquo (IVT) including an increased at-tention to the aspects of human perception andof person-machine interaction

The possible result of these converging trends isAmbient Intelligence (AmI Fig 1) AmI is a newparadigm in information technology in which peo-ple are empowered through a digital environmentthat is aware of their presence and context and issensitive adaptive and responsive to their needshabits gestures and emotions is the next logicalstep of this process45

In fact as underlined by the AMBIENCE ProjectAmI can be defined as the merger of two importantvisions and trendsmdashldquoubiquitous computingrdquo andldquosocial user interfacesrdquo

It builds on advanced networking technologieswhich allow robust ad-hoc networks to be formedby a broad range of mobile devices and otherobjects (ubiquitous- or pervasive computing) By

Istituto Auxologico Italiano Applied Technology for Neuro-Psychology Laboratory Milan Italy

adding adaptive user-system interaction methodsbased on new insights in the way people like to in-teract with computing devices (social user inter-faces) digital environments can be created whichimprove the quality of life of people by acting ontheir behalf These context aware systems combineubiquitous information communication and enter-tainment with enhanced personalization naturalinteraction and intelligence

mdashwwwitea-officeorgprojectsfacts sheetsambience fact sheethtm

How does the emergence of the AmI paradigminfluence our vision of health care This paper willtry to answer to this question Specifically using ascenario-based approach the paper will outline apossible role of AmI in health care

THE EMERGENCE OF AMI SPACE

To date some e-health applications have im-proved the quality of health care and later theywill lead to substantial cost savings67 For instancephysicians can review radiological films and pa-thology slides in remote sites or assist and performsurgery via remote robotics

However most of these applications are used fordiscrete clinical activities such as scripting lab-test-ing patient monitoring and condition-specific di-agnostics and treatment8 As recently noted by Fiferand Thomas9 ldquothe new question about E-medicinepractice may be not lsquowhen will it happenrsquo butwhen will the fragmented E-health systems be con-nectedrdquo

A possible solution to this question comes fromAmI According to the vision of AmI provided bythe Information Society Technologies AdvisoryGroup (ISTAG) to the European Commission allthe environment around usmdashhomes and offices

cars and citiesmdashthrough AmI will collectively de-velop a pervasive network of intelligent devicesthat will cooperatively gather process and trans-port information10 As noted by the ISTAG group10

Such an environment is sensitive to the presence ofliving creatures (persons groups of persons andmaybe even animals) in it and supports their activ-ities It ldquoremembers and anticipatesrdquo in its behaviorThe humans and physical entitiesmdashor their cyberrepresentativesmdashtogether with services share thisnew space which encompasses the physical andvirtual worldrdquo

AmI can be seen as the integration of functions atthe local level across the various environments Onone side this enables knowledge content organiza-tion and processing On the other side it also en-ables the direct natural and intuitive interaction ofthe user with applications and services spanningcollections of environments including the cyber-space level In this sense the AmI paradigm canbe seen as the direct extension of todayrsquos conceptof ubiquitous computing the integration of micro-processors into everyday objects However AmIwill also be more than this a pervasive and unob-trusive intelligence in the surrounding environ-ment supporting the activities and interactions ofthe users4

The most ambitious expression of AmI is Intelli-gent Mixed Reality (IMR) Using IMR it is possibleto seamlessly integrate computer interfaces into thereal environment so that the user can interact withother individuals and with the environment itselfin the most natural and intuitive way

Within IMR a key role will be played by MobileMixed Reality (MMR) the enhancement of infor-mation of a mobile user about a real scene throughthe embedding of any objects (eg 3D imagesvideos text computer graphics sound) within his

296 RIVA

FIG 1 Converging technologies in the Ambient Intelligence paradigm(Adapted from Davide et al4)

adding adaptive user-system interaction methodsbased on new insights in the way people like to in-teract with computing devices (social user inter-faces) digital environments can be created whichimprove the quality of life of people by acting ontheir behalf These context aware systems combineubiquitous information communication and enter-tainment with enhanced personalization naturalinteraction and intelligence

mdashwwwitea-officeorgprojectsfacts sheetsambience fact sheethtm

How does the emergence of the AmI paradigminfluence our vision of health care This paper willtry to answer to this question Specifically using ascenario-based approach the paper will outline apossible role of AmI in health care

THE EMERGENCE OF AMI SPACE

To date some e-health applications have im-proved the quality of health care and later theywill lead to substantial cost savings67 For instancephysicians can review radiological films and pa-thology slides in remote sites or assist and performsurgery via remote robotics

However most of these applications are used fordiscrete clinical activities such as scripting lab-test-ing patient monitoring and condition-specific di-agnostics and treatment8 As recently noted by Fiferand Thomas9 ldquothe new question about E-medicinepractice may be not lsquowhen will it happenrsquo butwhen will the fragmented E-health systems be con-nectedrdquo

A possible solution to this question comes fromAmI According to the vision of AmI provided bythe Information Society Technologies AdvisoryGroup (ISTAG) to the European Commission allthe environment around usmdashhomes and offices

cars and citiesmdashthrough AmI will collectively de-velop a pervasive network of intelligent devicesthat will cooperatively gather process and trans-port information10 As noted by the ISTAG group10

Such an environment is sensitive to the presence ofliving creatures (persons groups of persons andmaybe even animals) in it and supports their activ-ities It ldquoremembers and anticipatesrdquo in its behaviorThe humans and physical entitiesmdashor their cyberrepresentativesmdashtogether with services share thisnew space which encompasses the physical andvirtual worldrdquo

AmI can be seen as the integration of functions atthe local level across the various environments Onone side this enables knowledge content organiza-tion and processing On the other side it also en-ables the direct natural and intuitive interaction ofthe user with applications and services spanningcollections of environments including the cyber-space level In this sense the AmI paradigm canbe seen as the direct extension of todayrsquos conceptof ubiquitous computing the integration of micro-processors into everyday objects However AmIwill also be more than this a pervasive and unob-trusive intelligence in the surrounding environ-ment supporting the activities and interactions ofthe users4

The most ambitious expression of AmI is Intelli-gent Mixed Reality (IMR) Using IMR it is possibleto seamlessly integrate computer interfaces into thereal environment so that the user can interact withother individuals and with the environment itselfin the most natural and intuitive way

Within IMR a key role will be played by MobileMixed Reality (MMR) the enhancement of infor-mation of a mobile user about a real scene throughthe embedding of any objects (eg 3D imagesvideos text computer graphics sound) within his

296 RIVA

FIG 1 Converging technologies in the Ambient Intelligence paradigm(Adapted from Davide et al4)

or her sensorial information11 In this scenario theembedded information is based on factors like lo-cation and direction of view user situationcontextaware (eg day of the time holidays of business re-lated) user preferences (ie preference in terms ofcontent and interests) terminal capabilities andnetwork capabilities

Moreover following the AmI paradigm any em-bedded object is context aware and based on fac-tors like location direction of view user situationuser preferences terminal capabilities and net-work capabilities

The possibilities offered by MMR are huge Byintegrating within a common interface a wirelessnetwork connection wearable computer and head-mounted display MMR virtually enhances usersrsquoexperience by providing information for any objectsurrounding them They can manipulate and exam-ine real objects and simultaneously receive addi-tional information about them or the task at hand

Moreover using augmented or mixed realitytechnologies the information is presented three-di-mensionally and is integrated into the real worldRecently Christopoulos12 identified the followingapplications of MMR

Smart signs added to the real world Smart signsoverlaid on user real world may provide infor-mation assistance and advertisement based onuser preferences

Information assistant (or ldquovirtual guiderdquo) The virtualguide knows where the user is his or her headingas well as the properties of the surrounding envi-ronment interaction can be through voice or ges-tures and the virtual guide can be an animatedguide and provides assistance in different scenar-ios based on location and context information

Augmented reality or virtual reality combined withconversational multimedia (or ldquovirtual immersivecooperative environmentsrdquo) Conversational multi-media can be also added to a VR or an aug-mented reality scenario where a user can see theavatar of another user coming into the scene anda 3D video conference is carried on If we useVR given the position and orientation informa-tion of the first user in the world the second usercan put the first one (or his or her avatar) in a 3Dsynthetic world

In the future the terminal will be able to sense thepresence of a user and calculate hisher current sit-uation Throughout the environment bio sensingwill be used to enhance person-to-person and per-son-to-device communications Biometrics technol-ogy will be used to enhance security by combiningstatic (facial recognition) and dynamic information(voice and lip movement uncontrolled user ges-tures) as well as userrsquos habits which the networkwill be able to acquire and maintain

Further developing these points ISTAG intro-duced the concept of AmI Space The Ami Space iscomposed of networked (using a changing collec-tion of heterogeneous network) embedded systemshosting services that are dynamically configureddistributed components (Fig 2) The AmI Spacecan be seen as the integration of functions at thelocal level across the various environments and en-ables the direct natural and intuitive dialogue ofthe user with applications and services spanningcollections of environmentsmdashas well as at the cy-berspace levelmdashallowing knowledge and contentorganization and processing13

In particular the Ami Space should offer capabil-ities to accomplish the following

AMBIENT INTELLIGENCE IN HEALTH CARE 297

FIG 2 The AmI space (Adapted from ISTAG13)

Model the environment and sensors available toperceive it to take care of the world model Thisdeals with the list of authorized users availabledevices active devices state of the system andso on

Model the user behavior to keep track of all therelevant information concerning a user Also itautomatically builds the user preferences fromits past interactions and eventually abstracts theuser profile to more general community profiles

Interact with the user by taking into account theuser preferences Natural interaction with theuser replaces the keyboard and windows inter-face with a more natural interface like speechtouch or gestures

Control security aspects to ensure the privacyand security of the transferred personal dataand deal with authorization key and rightsmanagement

Ensure the quality of services as perceived by theuser

Within this frame Immersive Virtual Telepres-ence (IVT) and wireless technologies will play afundamental role in helping the AmI vision to copewith the need for natural user interfaces and forubiquitous communication The former will enablethe citizen to interact with the AmI and to controlit in a natural and personalized way through voiceand gestures The latter will provide the underly-ing network and will also enable electronic devicesto communicate with each other and with the user

However the AmI requirements are not just tech-nological ISTAG identified a series of necessarycharacteristics that will permit the eventual soci-etal acceptance of AmI10 AmI should achieve thefollowing

Facilitate human contact Be orientated towards community and cultural

enhancement Help to build knowledge and skills for work

better quality of work citizenship and consumerchoice

Inspire trust and confidence Be consistent with long-term sustainability both

at personal societal and environmental levels Be controllable by ordinary peoplemdashie the

ldquooff-switchrdquo should be within reach (these tech-nologies could very easily acquire an aspect ofldquothem controlling usrdquo)

Moreover the various AmI markets will requirespecific contents to be successful Particularly thereis a need for content-oriented tools and services to

support multi-cultural content generation its engi-neering and management

AMI IN MANAGED CARE

ldquoManaged carerdquo indicates a health care systemthat uses organizational and management controlsto offer patients appropriate care in cost-effectivetreatment settings Today the managed care envi-ronment is beginning to focus its attention on newtechnologies especially in the areas of organizationand clinical data management However the mostrecent research findings underline the possibilitythat distributed communication media could be-come a significant enabler of consumer health ini-tiatives In fact in comparison with traditionalcommunication technologies AmI offers greaterinteractivity and better tailoring of information toindividual needs In other words AmI can be con-sidered a process and not a technology includingdifferent complementary areas health care infor-mation provision administrative and clinical datacollection therapy and assessment provision Inparticular new and emerging technologies willprovide personalized intelligent assistive technol-ogy that can promote recovery and sustain inde-pendence and quality of life This vision is wellpictured by the ldquoGRIDrdquo concept14 a coordinatedresource sharing and problem solving in dynamicmulti-institutional virtual organizations supportedby technologies and data management services thatguarantee secure remote access to computing anddata resources and the co-allocation of multipleresources

In order to transform this vision in reality belowwe tried to outline a real health care scenario in-cluding all the innovations described before Sce-narios must be designed to encompass societaleconomic as well as technology developments andform a logical framework in which use cases canbe fitted The European Commission and researchorganizations such as the WWRF encourage sce-nario-based approaches for pushing the research inthe right way Experts have to analyze the scenariosdrawing consequences and future research topicsThe main output of these modeling efforts will con-sist in the ldquopieces of technologyrdquo needed to providethe functionalities envisaged within the referencescenarios

Mario a 40-year-old obese subject with Type 2 dia-betes was directed by his general practitioner tostart a self-management education program Beforebeginning the program Mario is asked to provide

298 RIVA

for information that enables the clinician to targetthe educational contents for his age lifestyle riskfactors and medical history When Mario goes tothe hospital to register for the class and for the visitthe unique ID code of his Personal Area Network isrecorded into the Information System and trackedin the Local Area Network of the hospital More-over a micro-payment system will automaticallytransfer the visit fee into the e-purse of the hospital

When a week later Mario comes back to the hos-pital his Personal Area Network is immediatelyrecognized In a couple of seconds a young nurseappears on the UMTS phone and describes the di-agnostic tests and the location of all the differentprofessionals In the meantime each professionalcan track the position of both Mario and any otherpatient on his office monitor In case of delays orproblems the visit schedule is modified to reducethe waiting time In this way all testing is done inone morning in one place Through the use of GRIDtechnologies the collected data are stored and com-pared with millions of images and files of relevantmedical information held on distributed computerAll the analyses are normal

In the afternoon Mario can choose lifestyle con-sultations customized to meet his health needs Thehospital endocrinologist clinical psychologist ex-ercise physiologist and registered dietitian giveMario specific indications that are recorded on thePDAs of the professionals Should Mario come backlater to the office of the specialist his Personal AreaNetwork is tracked by the Local Area Network andthrough the GRID system all the information aboutany previous visit and any assessment result will beimmediately available on the specialistrsquos monitor

After the visits the primary examining physicianexplains to Mario his test results and provides apersonal health action plan Through the UMTSphone a detailed written report and individualizeddirections are provided to Mario at weekly inter-vals In this way Mario can follow the plan inde-pendently from his physical location

A couple of days after Mario starts his programThe plenary takes place in a room looking muchlike a hotel foyer with comfortable furniture pleas-antly arranged As Mario enters the room and findshimself a place to work he hears a voice askingldquoHello Mario here is the program of the coures areyou readyrdquo The electronic tutoring system goesbriefly through its understanding of Mariorsquos avail-ability and preferences for the dayrsquos work Mario isan active and advanced student so the electronictutoring system says it might be useful if Mariospends some time today trying to pin down theproblem using enhanced interactive simulation andprojection facilities It then asks whether Mariowould give a brief presentation to the group Fi-nally Mario agrees on the work program for theday During the day individuals and subgroups lo-cate in appropriate spaces in the ambient location

to pursue appropriate learning experiences at apace that suits them The electronic tutoring systemnegotiates its degree of participation in these expe-riences with the aid of the mentor During the daythe mentor and electronic tutoring system conversefrequently establishing where the mentor mightmost usefully spend his time and sometimes alter-ing the schedule They will also deal with requestsfor referencesprofiles of individuals Time spent inthe ambient location ends by negotiating a home-work assignment with all individuals but onlyafter they have been informed about what the am-bient expects to happen for the rest of the day andmaking appointments for next day or next time

CONCLUSION

The proposed scenario was constructed to pro-vide something to think about with respect tolonger-term developments in Information andCommunication Technologies (ICTs) for health careMore specifically we wanted to explore the futuretechnologies that are implied by the vision of AmIIn fact the scenario exercise indicates that the visionof AmI is a strong starting point for giving directionto research over the coming 5 years Major opportu-nities to create an integrated AmI landscape can bebuilt upon emerging technological strengths inareas such as mobile communications portable de-vices systems integration embedded computingand intelligent systems design

However transforming the scenario in reality isnot an easy task the more that a technology is com-plex and costly the less the user is prone to acceptit This happens despite possibly large potential ad-vantages which are generally not reachable by theaverage user not interested in spending time andenergies in acquiring the underlying technologyfundamentals Therefore the successful systems ofthe future will adhere to the paradigm of ldquodisap-pearing technologiesrdquo valid for both communica-tions and computing and will provide improvedease-of use at the expense of an increased (but in-visible to the user) complexity of the underlyingsystems and networks necessary to transport andprocess the information in the different multimediaforms and usage contexts As both the physicianand the patient have to be put at the ldquocenter of theuniverse of technologiesrdquo clearly the elaboration ofa purely technical vision of the future of health careis not only insufficient but even dangerous Ratherany viable technical solutions must be put into amuch wider perspective

In this sense clinicians and health care providersthat want to exploit AmI potential need a significant

AMBIENT INTELLIGENCE IN HEALTH CARE 299

attention to project management ergonomicshuman factors and organizational changes in thestructure of the relevant health service

ACKNOWLEDGMENTS

The present work was supported by the Commis-sion of the European Communities (CEC) specifi-cally by the IST programme through the VEPSYUPDATED (IST-2000-25323) research project (wwwcybertherapyinfo)

REFERENCES

1 Riva G amp Galimberti C (eds) (2001) Towards Cyber-Psychology mind cognition and society in the internetage Amsterdam IOS Press Online wwwemergingcommunicationcomvolume2html

2 Riva G amp Galimberti C (1998) Computer-medi-ated communication identity and social interactionin an electronic environment Genetic Social and Gen-eral Psychology Monographs 124434ndash464

3 Riva G amp Davide F (eds) (2001) Communicationsthrough virtual technologies identity community andtechnology in the communication age Amsterdam IOSPress Online wwwemergingcommunicationcomvolume1html

4 Davide F Loreti P Lunghi M et al (2002)Communications through virtual technologies InGregori E Anastasi G Basagni S (eds) Advancedlectures on networking Berlin Springer-Verlag pp124ndash154

5 Riva G Davide F amp IJsselsteijn WA (eds) (2003)Being There concepts effects and measurements of userpresence in synthetic environments Amsterdam IOS

Press Online wwwemergingcommunicationcomvolume5html

6 Hertzberg J (2002) E-health round 2 ManagementCare Interface 1550ndash51

7 Meaney B (2002) Gartner lists top 10 e-health issuesfor 2002 Internet Healthcare Strategy 411

8 White L amp Terner C (2001) E-health phase twothe imperative to integrate process automation withcommunication automation for large clinical refer-ence laboratories Journal of Healthcare InformationManagement 15295ndash305

9 Fifer SK amp Thomas N (2002) A second and morepromising round of e-health enterprises ManagementCare Interface 1552ndash56

10 Ducatel K Bogdanowicz M Scapolo F et al(2000) Scenarios for ambient intelligence in 2010 (ISTAG2001 Final Report) Seville IPTS

11 Rosenblum L (2000) Virtual and Augmented Re-ality 2020 IEEE Computer Graphics and Applications2038ndash39

12 Christopoulos C (2001) Mobile augmented reality(MAR) and virtual reality Stockholm Wireless WorldResearch Forum

13 ISTAG (2002) Report of Working Group 60 of the ISTAdvisory Group concerning strategic orientations andpriorities for IST in FP6 Bruxelles ISTAG

14 Richards WG (2002) Virtual screening using gridcomputing the screensaver project Natural ReviewDrug Discovery 1551ndash555

Address reprint requests toGiuseppe Riva PhD

Universitagrave Cattolica del Sacro CuoreLargo Gemelli 1

20123 Milan Italy

E-mail auxopsylabauxologicoit

300 RIVA

Model the environment and sensors available toperceive it to take care of the world model Thisdeals with the list of authorized users availabledevices active devices state of the system andso on

Model the user behavior to keep track of all therelevant information concerning a user Also itautomatically builds the user preferences fromits past interactions and eventually abstracts theuser profile to more general community profiles

Interact with the user by taking into account theuser preferences Natural interaction with theuser replaces the keyboard and windows inter-face with a more natural interface like speechtouch or gestures

Control security aspects to ensure the privacyand security of the transferred personal dataand deal with authorization key and rightsmanagement

Ensure the quality of services as perceived by theuser

Within this frame Immersive Virtual Telepres-ence (IVT) and wireless technologies will play afundamental role in helping the AmI vision to copewith the need for natural user interfaces and forubiquitous communication The former will enablethe citizen to interact with the AmI and to controlit in a natural and personalized way through voiceand gestures The latter will provide the underly-ing network and will also enable electronic devicesto communicate with each other and with the user

However the AmI requirements are not just tech-nological ISTAG identified a series of necessarycharacteristics that will permit the eventual soci-etal acceptance of AmI10 AmI should achieve thefollowing

Facilitate human contact Be orientated towards community and cultural

enhancement Help to build knowledge and skills for work

better quality of work citizenship and consumerchoice

Inspire trust and confidence Be consistent with long-term sustainability both

at personal societal and environmental levels Be controllable by ordinary peoplemdashie the

ldquooff-switchrdquo should be within reach (these tech-nologies could very easily acquire an aspect ofldquothem controlling usrdquo)

Moreover the various AmI markets will requirespecific contents to be successful Particularly thereis a need for content-oriented tools and services to

support multi-cultural content generation its engi-neering and management

AMI IN MANAGED CARE

ldquoManaged carerdquo indicates a health care systemthat uses organizational and management controlsto offer patients appropriate care in cost-effectivetreatment settings Today the managed care envi-ronment is beginning to focus its attention on newtechnologies especially in the areas of organizationand clinical data management However the mostrecent research findings underline the possibilitythat distributed communication media could be-come a significant enabler of consumer health ini-tiatives In fact in comparison with traditionalcommunication technologies AmI offers greaterinteractivity and better tailoring of information toindividual needs In other words AmI can be con-sidered a process and not a technology includingdifferent complementary areas health care infor-mation provision administrative and clinical datacollection therapy and assessment provision Inparticular new and emerging technologies willprovide personalized intelligent assistive technol-ogy that can promote recovery and sustain inde-pendence and quality of life This vision is wellpictured by the ldquoGRIDrdquo concept14 a coordinatedresource sharing and problem solving in dynamicmulti-institutional virtual organizations supportedby technologies and data management services thatguarantee secure remote access to computing anddata resources and the co-allocation of multipleresources

In order to transform this vision in reality belowwe tried to outline a real health care scenario in-cluding all the innovations described before Sce-narios must be designed to encompass societaleconomic as well as technology developments andform a logical framework in which use cases canbe fitted The European Commission and researchorganizations such as the WWRF encourage sce-nario-based approaches for pushing the research inthe right way Experts have to analyze the scenariosdrawing consequences and future research topicsThe main output of these modeling efforts will con-sist in the ldquopieces of technologyrdquo needed to providethe functionalities envisaged within the referencescenarios

Mario a 40-year-old obese subject with Type 2 dia-betes was directed by his general practitioner tostart a self-management education program Beforebeginning the program Mario is asked to provide

298 RIVA

for information that enables the clinician to targetthe educational contents for his age lifestyle riskfactors and medical history When Mario goes tothe hospital to register for the class and for the visitthe unique ID code of his Personal Area Network isrecorded into the Information System and trackedin the Local Area Network of the hospital More-over a micro-payment system will automaticallytransfer the visit fee into the e-purse of the hospital

When a week later Mario comes back to the hos-pital his Personal Area Network is immediatelyrecognized In a couple of seconds a young nurseappears on the UMTS phone and describes the di-agnostic tests and the location of all the differentprofessionals In the meantime each professionalcan track the position of both Mario and any otherpatient on his office monitor In case of delays orproblems the visit schedule is modified to reducethe waiting time In this way all testing is done inone morning in one place Through the use of GRIDtechnologies the collected data are stored and com-pared with millions of images and files of relevantmedical information held on distributed computerAll the analyses are normal

In the afternoon Mario can choose lifestyle con-sultations customized to meet his health needs Thehospital endocrinologist clinical psychologist ex-ercise physiologist and registered dietitian giveMario specific indications that are recorded on thePDAs of the professionals Should Mario come backlater to the office of the specialist his Personal AreaNetwork is tracked by the Local Area Network andthrough the GRID system all the information aboutany previous visit and any assessment result will beimmediately available on the specialistrsquos monitor

After the visits the primary examining physicianexplains to Mario his test results and provides apersonal health action plan Through the UMTSphone a detailed written report and individualizeddirections are provided to Mario at weekly inter-vals In this way Mario can follow the plan inde-pendently from his physical location

A couple of days after Mario starts his programThe plenary takes place in a room looking muchlike a hotel foyer with comfortable furniture pleas-antly arranged As Mario enters the room and findshimself a place to work he hears a voice askingldquoHello Mario here is the program of the coures areyou readyrdquo The electronic tutoring system goesbriefly through its understanding of Mariorsquos avail-ability and preferences for the dayrsquos work Mario isan active and advanced student so the electronictutoring system says it might be useful if Mariospends some time today trying to pin down theproblem using enhanced interactive simulation andprojection facilities It then asks whether Mariowould give a brief presentation to the group Fi-nally Mario agrees on the work program for theday During the day individuals and subgroups lo-cate in appropriate spaces in the ambient location

to pursue appropriate learning experiences at apace that suits them The electronic tutoring systemnegotiates its degree of participation in these expe-riences with the aid of the mentor During the daythe mentor and electronic tutoring system conversefrequently establishing where the mentor mightmost usefully spend his time and sometimes alter-ing the schedule They will also deal with requestsfor referencesprofiles of individuals Time spent inthe ambient location ends by negotiating a home-work assignment with all individuals but onlyafter they have been informed about what the am-bient expects to happen for the rest of the day andmaking appointments for next day or next time

CONCLUSION

The proposed scenario was constructed to pro-vide something to think about with respect tolonger-term developments in Information andCommunication Technologies (ICTs) for health careMore specifically we wanted to explore the futuretechnologies that are implied by the vision of AmIIn fact the scenario exercise indicates that the visionof AmI is a strong starting point for giving directionto research over the coming 5 years Major opportu-nities to create an integrated AmI landscape can bebuilt upon emerging technological strengths inareas such as mobile communications portable de-vices systems integration embedded computingand intelligent systems design

However transforming the scenario in reality isnot an easy task the more that a technology is com-plex and costly the less the user is prone to acceptit This happens despite possibly large potential ad-vantages which are generally not reachable by theaverage user not interested in spending time andenergies in acquiring the underlying technologyfundamentals Therefore the successful systems ofthe future will adhere to the paradigm of ldquodisap-pearing technologiesrdquo valid for both communica-tions and computing and will provide improvedease-of use at the expense of an increased (but in-visible to the user) complexity of the underlyingsystems and networks necessary to transport andprocess the information in the different multimediaforms and usage contexts As both the physicianand the patient have to be put at the ldquocenter of theuniverse of technologiesrdquo clearly the elaboration ofa purely technical vision of the future of health careis not only insufficient but even dangerous Ratherany viable technical solutions must be put into amuch wider perspective

In this sense clinicians and health care providersthat want to exploit AmI potential need a significant

AMBIENT INTELLIGENCE IN HEALTH CARE 299

attention to project management ergonomicshuman factors and organizational changes in thestructure of the relevant health service

ACKNOWLEDGMENTS

The present work was supported by the Commis-sion of the European Communities (CEC) specifi-cally by the IST programme through the VEPSYUPDATED (IST-2000-25323) research project (wwwcybertherapyinfo)

REFERENCES

1 Riva G amp Galimberti C (eds) (2001) Towards Cyber-Psychology mind cognition and society in the internetage Amsterdam IOS Press Online wwwemergingcommunicationcomvolume2html

2 Riva G amp Galimberti C (1998) Computer-medi-ated communication identity and social interactionin an electronic environment Genetic Social and Gen-eral Psychology Monographs 124434ndash464

3 Riva G amp Davide F (eds) (2001) Communicationsthrough virtual technologies identity community andtechnology in the communication age Amsterdam IOSPress Online wwwemergingcommunicationcomvolume1html

4 Davide F Loreti P Lunghi M et al (2002)Communications through virtual technologies InGregori E Anastasi G Basagni S (eds) Advancedlectures on networking Berlin Springer-Verlag pp124ndash154

5 Riva G Davide F amp IJsselsteijn WA (eds) (2003)Being There concepts effects and measurements of userpresence in synthetic environments Amsterdam IOS

Press Online wwwemergingcommunicationcomvolume5html

6 Hertzberg J (2002) E-health round 2 ManagementCare Interface 1550ndash51

7 Meaney B (2002) Gartner lists top 10 e-health issuesfor 2002 Internet Healthcare Strategy 411

8 White L amp Terner C (2001) E-health phase twothe imperative to integrate process automation withcommunication automation for large clinical refer-ence laboratories Journal of Healthcare InformationManagement 15295ndash305

9 Fifer SK amp Thomas N (2002) A second and morepromising round of e-health enterprises ManagementCare Interface 1552ndash56

10 Ducatel K Bogdanowicz M Scapolo F et al(2000) Scenarios for ambient intelligence in 2010 (ISTAG2001 Final Report) Seville IPTS

11 Rosenblum L (2000) Virtual and Augmented Re-ality 2020 IEEE Computer Graphics and Applications2038ndash39

12 Christopoulos C (2001) Mobile augmented reality(MAR) and virtual reality Stockholm Wireless WorldResearch Forum

13 ISTAG (2002) Report of Working Group 60 of the ISTAdvisory Group concerning strategic orientations andpriorities for IST in FP6 Bruxelles ISTAG

14 Richards WG (2002) Virtual screening using gridcomputing the screensaver project Natural ReviewDrug Discovery 1551ndash555

Address reprint requests toGiuseppe Riva PhD

Universitagrave Cattolica del Sacro CuoreLargo Gemelli 1

20123 Milan Italy

E-mail auxopsylabauxologicoit

300 RIVA

for information that enables the clinician to targetthe educational contents for his age lifestyle riskfactors and medical history When Mario goes tothe hospital to register for the class and for the visitthe unique ID code of his Personal Area Network isrecorded into the Information System and trackedin the Local Area Network of the hospital More-over a micro-payment system will automaticallytransfer the visit fee into the e-purse of the hospital

When a week later Mario comes back to the hos-pital his Personal Area Network is immediatelyrecognized In a couple of seconds a young nurseappears on the UMTS phone and describes the di-agnostic tests and the location of all the differentprofessionals In the meantime each professionalcan track the position of both Mario and any otherpatient on his office monitor In case of delays orproblems the visit schedule is modified to reducethe waiting time In this way all testing is done inone morning in one place Through the use of GRIDtechnologies the collected data are stored and com-pared with millions of images and files of relevantmedical information held on distributed computerAll the analyses are normal

In the afternoon Mario can choose lifestyle con-sultations customized to meet his health needs Thehospital endocrinologist clinical psychologist ex-ercise physiologist and registered dietitian giveMario specific indications that are recorded on thePDAs of the professionals Should Mario come backlater to the office of the specialist his Personal AreaNetwork is tracked by the Local Area Network andthrough the GRID system all the information aboutany previous visit and any assessment result will beimmediately available on the specialistrsquos monitor

After the visits the primary examining physicianexplains to Mario his test results and provides apersonal health action plan Through the UMTSphone a detailed written report and individualizeddirections are provided to Mario at weekly inter-vals In this way Mario can follow the plan inde-pendently from his physical location

A couple of days after Mario starts his programThe plenary takes place in a room looking muchlike a hotel foyer with comfortable furniture pleas-antly arranged As Mario enters the room and findshimself a place to work he hears a voice askingldquoHello Mario here is the program of the coures areyou readyrdquo The electronic tutoring system goesbriefly through its understanding of Mariorsquos avail-ability and preferences for the dayrsquos work Mario isan active and advanced student so the electronictutoring system says it might be useful if Mariospends some time today trying to pin down theproblem using enhanced interactive simulation andprojection facilities It then asks whether Mariowould give a brief presentation to the group Fi-nally Mario agrees on the work program for theday During the day individuals and subgroups lo-cate in appropriate spaces in the ambient location

to pursue appropriate learning experiences at apace that suits them The electronic tutoring systemnegotiates its degree of participation in these expe-riences with the aid of the mentor During the daythe mentor and electronic tutoring system conversefrequently establishing where the mentor mightmost usefully spend his time and sometimes alter-ing the schedule They will also deal with requestsfor referencesprofiles of individuals Time spent inthe ambient location ends by negotiating a home-work assignment with all individuals but onlyafter they have been informed about what the am-bient expects to happen for the rest of the day andmaking appointments for next day or next time

CONCLUSION

The proposed scenario was constructed to pro-vide something to think about with respect tolonger-term developments in Information andCommunication Technologies (ICTs) for health careMore specifically we wanted to explore the futuretechnologies that are implied by the vision of AmIIn fact the scenario exercise indicates that the visionof AmI is a strong starting point for giving directionto research over the coming 5 years Major opportu-nities to create an integrated AmI landscape can bebuilt upon emerging technological strengths inareas such as mobile communications portable de-vices systems integration embedded computingand intelligent systems design

However transforming the scenario in reality isnot an easy task the more that a technology is com-plex and costly the less the user is prone to acceptit This happens despite possibly large potential ad-vantages which are generally not reachable by theaverage user not interested in spending time andenergies in acquiring the underlying technologyfundamentals Therefore the successful systems ofthe future will adhere to the paradigm of ldquodisap-pearing technologiesrdquo valid for both communica-tions and computing and will provide improvedease-of use at the expense of an increased (but in-visible to the user) complexity of the underlyingsystems and networks necessary to transport andprocess the information in the different multimediaforms and usage contexts As both the physicianand the patient have to be put at the ldquocenter of theuniverse of technologiesrdquo clearly the elaboration ofa purely technical vision of the future of health careis not only insufficient but even dangerous Ratherany viable technical solutions must be put into amuch wider perspective

In this sense clinicians and health care providersthat want to exploit AmI potential need a significant

AMBIENT INTELLIGENCE IN HEALTH CARE 299

attention to project management ergonomicshuman factors and organizational changes in thestructure of the relevant health service

ACKNOWLEDGMENTS

The present work was supported by the Commis-sion of the European Communities (CEC) specifi-cally by the IST programme through the VEPSYUPDATED (IST-2000-25323) research project (wwwcybertherapyinfo)

REFERENCES

1 Riva G amp Galimberti C (eds) (2001) Towards Cyber-Psychology mind cognition and society in the internetage Amsterdam IOS Press Online wwwemergingcommunicationcomvolume2html

2 Riva G amp Galimberti C (1998) Computer-medi-ated communication identity and social interactionin an electronic environment Genetic Social and Gen-eral Psychology Monographs 124434ndash464

3 Riva G amp Davide F (eds) (2001) Communicationsthrough virtual technologies identity community andtechnology in the communication age Amsterdam IOSPress Online wwwemergingcommunicationcomvolume1html

4 Davide F Loreti P Lunghi M et al (2002)Communications through virtual technologies InGregori E Anastasi G Basagni S (eds) Advancedlectures on networking Berlin Springer-Verlag pp124ndash154

5 Riva G Davide F amp IJsselsteijn WA (eds) (2003)Being There concepts effects and measurements of userpresence in synthetic environments Amsterdam IOS

Press Online wwwemergingcommunicationcomvolume5html

6 Hertzberg J (2002) E-health round 2 ManagementCare Interface 1550ndash51

7 Meaney B (2002) Gartner lists top 10 e-health issuesfor 2002 Internet Healthcare Strategy 411

8 White L amp Terner C (2001) E-health phase twothe imperative to integrate process automation withcommunication automation for large clinical refer-ence laboratories Journal of Healthcare InformationManagement 15295ndash305

9 Fifer SK amp Thomas N (2002) A second and morepromising round of e-health enterprises ManagementCare Interface 1552ndash56

10 Ducatel K Bogdanowicz M Scapolo F et al(2000) Scenarios for ambient intelligence in 2010 (ISTAG2001 Final Report) Seville IPTS

11 Rosenblum L (2000) Virtual and Augmented Re-ality 2020 IEEE Computer Graphics and Applications2038ndash39

12 Christopoulos C (2001) Mobile augmented reality(MAR) and virtual reality Stockholm Wireless WorldResearch Forum

13 ISTAG (2002) Report of Working Group 60 of the ISTAdvisory Group concerning strategic orientations andpriorities for IST in FP6 Bruxelles ISTAG

14 Richards WG (2002) Virtual screening using gridcomputing the screensaver project Natural ReviewDrug Discovery 1551ndash555

Address reprint requests toGiuseppe Riva PhD

Universitagrave Cattolica del Sacro CuoreLargo Gemelli 1

20123 Milan Italy

E-mail auxopsylabauxologicoit

300 RIVA

attention to project management ergonomicshuman factors and organizational changes in thestructure of the relevant health service

ACKNOWLEDGMENTS

The present work was supported by the Commis-sion of the European Communities (CEC) specifi-cally by the IST programme through the VEPSYUPDATED (IST-2000-25323) research project (wwwcybertherapyinfo)

REFERENCES

1 Riva G amp Galimberti C (eds) (2001) Towards Cyber-Psychology mind cognition and society in the internetage Amsterdam IOS Press Online wwwemergingcommunicationcomvolume2html

2 Riva G amp Galimberti C (1998) Computer-medi-ated communication identity and social interactionin an electronic environment Genetic Social and Gen-eral Psychology Monographs 124434ndash464

3 Riva G amp Davide F (eds) (2001) Communicationsthrough virtual technologies identity community andtechnology in the communication age Amsterdam IOSPress Online wwwemergingcommunicationcomvolume1html

4 Davide F Loreti P Lunghi M et al (2002)Communications through virtual technologies InGregori E Anastasi G Basagni S (eds) Advancedlectures on networking Berlin Springer-Verlag pp124ndash154

5 Riva G Davide F amp IJsselsteijn WA (eds) (2003)Being There concepts effects and measurements of userpresence in synthetic environments Amsterdam IOS

Press Online wwwemergingcommunicationcomvolume5html

6 Hertzberg J (2002) E-health round 2 ManagementCare Interface 1550ndash51

7 Meaney B (2002) Gartner lists top 10 e-health issuesfor 2002 Internet Healthcare Strategy 411

8 White L amp Terner C (2001) E-health phase twothe imperative to integrate process automation withcommunication automation for large clinical refer-ence laboratories Journal of Healthcare InformationManagement 15295ndash305

9 Fifer SK amp Thomas N (2002) A second and morepromising round of e-health enterprises ManagementCare Interface 1552ndash56

10 Ducatel K Bogdanowicz M Scapolo F et al(2000) Scenarios for ambient intelligence in 2010 (ISTAG2001 Final Report) Seville IPTS

11 Rosenblum L (2000) Virtual and Augmented Re-ality 2020 IEEE Computer Graphics and Applications2038ndash39

12 Christopoulos C (2001) Mobile augmented reality(MAR) and virtual reality Stockholm Wireless WorldResearch Forum

13 ISTAG (2002) Report of Working Group 60 of the ISTAdvisory Group concerning strategic orientations andpriorities for IST in FP6 Bruxelles ISTAG

14 Richards WG (2002) Virtual screening using gridcomputing the screensaver project Natural ReviewDrug Discovery 1551ndash555

Address reprint requests toGiuseppe Riva PhD

Universitagrave Cattolica del Sacro CuoreLargo Gemelli 1

20123 Milan Italy

E-mail auxopsylabauxologicoit

300 RIVA