遠距居家照護系統之現況與發展 徐業良 元智大學主任秘書 機械系教授 老人福祉科技研究中心主任 元智大學主任秘書 機械系教授 老人福祉科技研究中心主任 2007/12/18 臺北市立聯合醫院陽明院區演講

徐業良個人簡介 Education Experience National Taiwan University, Mechanical Engineering, B.S., 1981/09-1985/06. Stanford University, of Mechanical Engineering, M.S., 1987/09-1988/06. Stanford University, Mechanical Engineering, Ph.D., 1989/07-1992/06. Experience Professor, Department of Mechanical Engineering, Yuan Ze University, 2001/02-present. Secretary General, Yuan Ze University, 2005/08-present. Chairman, Department of Mechanical Engineering, Yuan Ze University, 1999/08-2005/07. Director, Office of Physical Education, Yuan Ze University, 2002/08-present. Director, Gerontechnology Research Center, Yuan Ze University, 2000/08-present. Columnist, Car Magazine, 1995/06-present. Dean, Office of Information Services, Yuan Ze University, 1997/08-1999/07.

Aging Society Population aged 65 and above, projection in 2020 by WHO

Gerontechnology The increasing needs for elderly care cannot be solved by increasing the number of care-givers. “How can technology be best used to support the needs of aging society?” Gerontechnology includes the research and development of techniques and technological products, based on the knowledge of aging processes, for the benefit of a preferred living and working environment and adapted medical care for the elderly. [Graafmans and Bouma, 1993] Although technology can greatly aid older adults, it must first be designed to accommodate their needs. There is a great need for both basic and applied research to address the usability of devices of the aged.

Gerontechnology Research Center (GRC) in the aim of improving the quality of life of older adults. Older adults Industrial companies Service Institutions to develop technologies, products, academic research, and educational programs in the field of Gerontechnology, Academic research Product development Advanced technologies Education Government resources GRC Academic resources Academic programs Facilities and infrastructure Human resources the Gerontechnology Research Center further integrates external resources, Yuan Ze University On the basis of the support from Yuan Ze University,

Gerontechnology Research Center, Yuan Ze University Started preparation in 2000/10. Officially established in 2003/01. Medical Treatment Health Care Support of Daily Living Tele-homecare, Home telehealth Main Focus of GRC

Telemedicine, Telehealth, e-Health Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care. It is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Telehealth is often used to encompass a broader definition of remote healthcare that does not always involve clinical services [ATA]. e-Health is a term used particularly in the UK and Europe for healthcare practice which is supported by electronic processes and communication.

Tele-homecare, Home telehealth “Tele-homecare” + “Telehomecare”  54,300 hits in Google; “Home telehealth”  48,200 hits in Google; Definition: Tele-homecare can be defined as the use of information and communication technologies to enable effective delivery and management of health services at a patient’s residence. [Office of Health and Information Highway, Canada, 1998] Users: Tele-homecare differs from telemedicine in the sense that people who transmit and receive medical information are not medical doctors but the patients themselves and their families, nurses, care-givers, home-helpers and medical technical experts, etc. [Masatsugu, 2002] Goal: Home telehealth allows the patient the dignity of remaining in their own home for as long as possible and by providing care that is equal to or superior than approaches that rely solely on health providers coming into the home for scheduled visits. [ATA]

Philips Lifeline Service (http://www.lifelinesys.com/) Lifeline is the first and most established Personal Emergency Response System (PERS). It was developed in 1974 by Lifeline System, Inc., which was recently acquired by Philips (2006/01). Story of a lifeline call.  On average, Lifeline costs a little more than a dollar a day, depending upon where you live. No long-term service contracts or need to purchase equipment. Over 500,000 subscribers continuously monitored.

Lifeline Service in Taiwan 金立盟安全科技股份有限公司結合台灣地區社福團體、衛生，醫療等單位建立生命守護連線服務，由金立盟公司自行開發的隨身發訊器及家用對講發報機，主要服務對象為年滿65歲以上患有猝發性疾病及失能的獨居長者，提供意外事件及緊急醫療事件處理、定期居家訪視、健康問題諮詢與心理衛生支持等服務，每月收費1500元（多為政府全額補助），依照一定比例分配至金立盟公司、衛生醫療單位與社福團體。 生命連線基金會引進Lifeline Systems的緊急照護服務系統，透過生命連線Call Center的服務，結合當地社會福利團體與衛生醫療單位，與金立盟生命守護連線的服務型態相同。 2006年底各縣市列冊需關懷之獨居老人人數共49,728人，其中安裝緊急救援連線有4,622人【行政院主計處】。

Tunstall’s Lifeline 4000+ (http://www.tunstall.co.uk/) 50 years in telecare and telehealth (started in UK, 1957), over 2.5 million users

Tunstall: Activities of Daily Living Monitoring Activities of Daily Living (ADL) Monitoring: To provide an unobtrusive method of capturing a person’s behaviour patterns so if a deviation from the norm occurs, it can be identified, the cause investigated and preventative action taken.

Tunstall Taiwan台灣康舒妥公司(http://www.tunstall.com.tw/) Lifeline 400 + Trigger + 12 months monitoring free: £299 Monthly Service Charge: £12 安裝費1500元，保證金3000元 月費：1300元∕1500元（含攝影機）

Health Hero Network (http://www.healthhero.com/) Health Buddy® System Health Buddy® Appliance : USD 99 Monthly Service Charge: USD 49.99 Health Hero Network has received 57 U.S. patents.

Health Buddy® Appliance Interactive interface for diabetic patients Health Hero Network’s health management programs cover over 30 health conditions.

MediCompass (http://www.medicompass.com/) Connecting Patients, Care Professionals, and Health Plans PHR: Personal Health Record “Our site is an online resource that allows you to store and track all of your health related data in a completely secure and private environment. Monitoring this information keeps you informed of your progress. You are also able to share information online with your healthcare team” Monthly Subscription Plan: $4.95; Annual Subscription Plan: 39.95 Metriklink, one time cost: $79.95;（2003年產業科技創新研討會，工研院易芝玲博士）

台灣富士通(Fujitsu Taiwan, http://www.fujitsu.com/tw/) 日本的「保健福利部(The Ministry of Health and Welfare, MHW)」將遠距醫療照護定位為輔助性的醫療服務，於1997年12月宣布遠距醫療之行為不會抵觸醫療法規 日本於2000年將視訊醫療諮詢服務納入健康保險給付項目。 富士通遠距醫療照護系統目前於日本已有數十個導入案例。 系統引進台灣價格

亞太健康遠距科技股份有限公司 遠距居家健康照護＄4999專案 II. 服務內容 ＊ 每週專業照護人員到府照護服務 ＊ 資深護理師提供遠距健康諮詢 ＊ 每月提供健康報告書 ＊ 每年一次的血液分析及檢測 ＊ 特約醫院的掛號、轉診及領藥服務 ＊ 健康資料保存全球使用 ＊ 提供最新的健康保健資訊 II. 收費標準 加入會員入會費＄2000及第一個月服務費＄4999於申請加入時繳交，採現金或信用卡刷卡付款。於每月第一週到府照護服務時同時收取，採現金付款，收費同時開立收據。

真茂科技遠距照護服務(http://www.netown.net.tw) 在家庭中或社區內使用「真茂寶貝機」或「真茂珍愛」每日固定量測血壓值、血糖值、脈搏、體重、BMI、血氧量、尖峰吐氣流速值等，所得生理量測值上傳至系統，您可在網路上看到生理量測值的即時及歷史資料，在平時固定至醫療院所回診時，醫師可以讀取這些資料，以做精確的健康評估。另外，當系統接收到居民所量測的生理資訊超過正常值範圍時，會立即對量測者本身、親友及家庭醫師，以簡訊及e-mail發出異常狀況提醒，讓三方能即時察覺到量測者的身體異常狀況，並做出回應處理。 寶貝機設備費用25,000元，量測設備需另購，若需要「優客ㄦ」系統所提供的資料處理與警急事件服務，則需支付每月基本服務費999元。 (2007/05)

亞東醫院安心卡，振興醫院遠距心臟照護服務 病人感到心痛時，便可將卡片放置在心臟前，錄下20秒心音後再用電話或手機傳回醫院的接收器，醫師立刻就能看到清晰的心電圖，依此心電圖進行判讀，能在第一時間偵測病情處理病況，同時還能建立專屬病歷資料庫，隨時掌握病患的病情變化。 其醫療團隊服務費用每月2,500元，安心卡設備費用可單買安心卡35,000元，或租用每週1,500元。「安心卡」使用人次約200人，傳送至「安心照護中心」約10~20通/天，冬天較頻繁約20~30通/天。 振興醫院遠距心臟照護服務，護心卡 月租7000元，周租2000元。

Card Guard (http://http://www.cardguard.com/) Card Guard Wireless in Motion  The PMP4 wireless medical monitors communicate with a PDA or cellular phone, thus allowing acquisition and transmission of data from the patient to the PMP4 webbased medical center. Physicians and patients alike can access this web center using a PC based browser.

中華電信氣喘手機 將氣喘照護的WHO標準範例建置於系統平台，系統平台依據患者輸入之健康資料判斷、分析，再藉由手機的定位系統提醒患者週遭空氣、氣溫等變化，提供每日氣喘狀況報告、定期電話關懷、每月氣喘評估報告與長庚氣喘專線掛號服務。 付費方式為月付299元（免收設定費及日後簡訊提醒費用）。台灣胸腔協會提供低收入戶氣喘病患，免繳一年的氣喘照護服務月租費（3,588元）及專案購機優惠。目前約有三千多人加入此項服務。 手機氣喘服務平台 長庚醫院 中華電信 氣喘手機 氣喘患者 上傳健康資料 每月評估報告 環境變化 吹氣 患者氣喘狀況

中興保全Mini Bond (http://www.minibond.tw) 採用AGPS衛星定位設備，提供位置查詢、定時回報、遠端守護、緊急求救、簡易通話、派遣服務。  MiniBond設備費用單機18,000元（或綁約兩年6,999元)，每月基本服務費699元，派遣服務兩小時內3,000元，超過兩小時每小時加1,000元（中華電信通話費另計）

典型的遠距居家照護系統架構 量測的生理訊號超過正常範圍時，系統會立即對家人或照護者以簡訊或e-mail發出提醒 醫師看診時可以讀取長期的健康監測資料，做更精確的評估 家人或照護者隨時可在網路上看到這些資料，瞭解高齡者的健康狀態 經由電話線或網際網路上傳到服務機構的中央伺服器 高齡者在家中每日固定量測血壓、血糖、體重等生理訊號

遠距居家健康照護服務分類及主導產業(I) Personal Emergency Response System (PERS): Lifeline, Tunstall’s telecare, Card Guard, Mini Bond. Long term wellness monitoring: Tunstall’s ADL monitoring, Health Buddy System, MediCompass, Fujitsu, 亞太、真茂。 主導產業： 醫療院所：如亞東醫院、振興醫院 電信公司：如中華電信 保全公司：如中興保全 “Home Health Care Provider”：Lifeline service, Tunstall, Health Hero Network, MediComapss, Card Guard, Fujitsu, 亞太、真茂。

遠距居家健康照護服務分類及主導產業(II) 從不同產業出發進入遠距居家照護產業，經營的主題也不同 如醫療院所多以疾病照護為主題 電信公司則強調通信平台（特別是手機）的應用 保全公司結合通報中心、保全員之架構 “Home Health Care Provider”：常由醫療器材廠商或資訊、電子產品廠商轉型。單純由居家健康照護服務機構或醫療器材廠商推動的遠距居家健康照護系統，除了個人健康照護記錄(PHR)的經營模式，強調自我健康管理的概念之外，大多還是結合醫療機構、照護單位、政府機構、社會福利機構等，希望提供更為完整的照護服務。 Brand and Trust

Evaluation of Home Telehealth Systems: User Acceptance Individual needs and perceived benefits A study by Teasdale and Roush [2001] used Lifeline to see if users felt more secure with the technology. All users reported a greater sense of security during their PERS use. Cost: device cost and monthly fee, health insurance and government subsidy User friendliness: installation and operation Data security and issues on privacy, control, choice, and dignity Whether people want their entire house wired and monitored, What activities are monitored and how, Where the information gathered goes and who sees it or has access to it, Whether the consumer has the choice to turn it off when privacy is desired, What happens to it in relation to decisions about whether a person can stay in the home or not.

Evaluation of Home Telehealth Systems: Clinical Outcome Through proactive monitoring, self-care education, medication management and behavior modification to improve clinical outcome. System reliability and accuracy of the measurements at home. Who will receive and review the data, human or computer algorithm? Who will take action? Will the users change their health management attitudes and behaviors? In 2002, a VA analysis of those participating in its home health-monitoring program, similar to Health Buddy, showed a 63 percent drop in hospital admissions, a 40 percent drop in emergency room visits, a 60 percent decline in bed days of care, a 64 percent drop in nursing home admissions, and an 88 percent reduction in nursing home bed days of care. Patient satisfaction rates exceeded 90 percent.

Evaluation of Home Telehealth Systems: Economic Analysis 2006 “Innovative Approach to the Delivery of Healthcare” ABBY Award Winner: Health Hero Network, honored for its “Health Buddy” telehealth interface between patients at home and their providers. Health Buddy is currently in use by over 12,000 patients and has proven its worth in clinical trials: reduced hospital admissions by 63%; reduced congested heart failure (CHF) hospitalizations by 72%; reduced CHF inpatient bed days from 8.6 to 1.7; increased medication compliance from 34% to 94%; reduced CHF costs/patient/year from $25.0K to $11.8K.

遠距居家照護已經是完全成熟的技術，國內有許多相關研究，也已有業者推出遠距居家照護服務，然而目前仍然沒有一個商業上成功的系統 李源德院長的「COM-COM理論」：系統過度COMplex、COst過高、且使用者沒有足夠的Motivation 這些系統除了動輒上萬元的硬體費用外，使用者還必須負擔每月數百到數千元的費用訂購相關服務，花費甚至高於直接看醫生所需的費用，因此除非有強烈需求，目前為止還無法為一般使用者廣泛接受

除了技術的研發之外，必須發展一套適合於國內的遠距居家照護經營模式。 建立遠距居家照護系統必須考慮的問題： What is the “smallest possible” home tele-health system? 系統定位與規劃 系統建置與經營 服務程序 營運模式 資通訊架構 系 統 成 效 評 估 外部資源結合與標準、法令限制

The Decentralized Home Telehealth System – Information Structure Sensor 1 Cable/wireless transmitter receiver PIC Server MMC Distributed Data Server Household E-mail server/SMS Java applet server Application server Care-giver/Client user Browser E-Mail box/ Mobile phone Event alert Request/Data VB program Applet Regular report message Sensor 2 Sensor 3

Advantages of the Decentralized Home Telehealth System Structure This system is a user-centered, product-oriented system instead of a service-oriented system. The system can be easily adapted and implemented in a home environment at a very low cost. The user does not have to subscribe to service from the home healthcare provider. Health monitoring data is stored within the household. Only authorized caregivers can access the data. Privacy is more greatly protected. The route from the sensor to server is much shorter. Data transmission is easier and more reliable. Data integrity will be better preserved. The distributed structure of the system can be adapted to integrate with a centralized database and the home healthcare provider.

The Decentralized Home Telehealth System – Applications PIC Server Distributed Data Server Decentralized Home Telehealth System Sensing devices Sensor network Application software Event algorithms Telepresence Robot for Interpersonal Communication Bed actigraphy Snoring and OSAS Blood pressure, blood glucose ECG, SPO2 Weight, body temperature Temperature and humidity Home safety and security Activity of daily living Fall detection RFID system Sleep Quality Vital Signs Environmental Parameters Telepresence Interactions Mobility Parameters Patents received: 6 Patents in reviewed Taiwan: 12 Filed in USA: 3

Applications: Environment Monitoring System

Applications: Monitoring of Activities of Daily Living (ADL) 外出行為 磁簧開關 電器使用 電流感測器 廁所使用 燈光感測器 水銀開關 DDS Internet 沐浴使用 燈光感測器 磁簧開關 特定區域活動 人體紅外線 燈光感測器 臥床時間 壓力感測器

Applications: Monitoring of Activities of Daily Living (ADL) 廚房活動狀況監測

Applications: Sleep Quality Monitoring System (I) Application server Event message E-mail server/SMS Upper Limb Conductive Mat Java applet server Event alert Applet Distributed Data Server Body Conductive Mat Cable Request/Data PIC Server Browser VB program MMC Leg Conductive Mat E-Mail box/ Mobile phone Regular report Household Care-giver/Client user

Applications: Sleep Quality Monitoring System (II) Bed Actigraphy ---Physical Activity Detecting Mat A B

Applications: Sleep Quality Monitoring System (III) Normal Arousal Sensitivity 89.5%, PPV 94.8%, Specificity 84.3%

TRIC – Telepresence Robot for Interpersonal Communication Aging is associated with an increased risk for isolation. The main aim behind TRIC’s development is to allow elderly populations to remain in their home environments, while loved ones and caregivers are able to maintain a higher level of communication than via traditional methods. TRIC aims to be a low-cost, lightweight robot, which can be easily implemented in the home environment.

Telepresence robot applications in medical care (I) Dr. Robot (2003) 160cm, 100kg $150,000 120 Dr. Robots used in hospitals

Telepresence robot applications in medical care (II) Providing Education by Bringing Learning Environments to students (PEBBLE) (2004)

Evaluation of TRIC Users’ nonverbal communication elements were expressed through TRIC. Experience of interacting with the remote operator through TRIC B-2. Did you notice the facial expression of TRIC during conversation? Yes: 89% B-3. Did you notice the body movement of TRIC during conversation? Yes: 81% B-4. Did TRIC look at you when you speak (eye contact)? Yes: 86% Experience of using instant messenger to interact with another person C-2. Did you notice the facial expression of the other person during conversation? Yes: 93% C-3. Did you notice the body movement of the other person during conversation? Yes: 77% C-4. Did the other person look at you when you speak (eye contact)? Yes: 58% Experience of interacting with the remote operator through TRIC B-7. Who did you communicate with? (TRIC/operator in remote site) TRIC: 42% Experience of using instant messenger to interact with another person C-6. Where was the other person? (Your home/A remote place) Your home: 11%

Applications: 糖尿病患自我健康管理 Sensor 1 Cable/wireless transmitter receiver PIC Server MMC Distributed Data Server Household E-mail server/SMS Java applet server Application server Care-giver/Client user Browser E-Mail box/ Mobile phone Event alert Request/Data VB program Applet Regular report message Sensor 2 Sensor 3 http://grc.yzu.edu.tw/

The “Direct-to-Consumer Approach” 醫護人員 居家環境 S DDS i i i P P S 高齡者 $ 零售商 家人或照護者 i $ S Cash flow Product flow Information flow Service flow P

遠距居家照護服務提供者模式 居家環境 遠距居家照護服務提供者 高齡者 家人或照護者 i $ S Cash flow Product flow Information flow Service flow P 高齡者 居家環境 家人或照護者 DDS 遠距居家照護服務提供者

There is currently a greater need for implementation of what we already have, than for more technical research. But to promote implementation, we need evidence of what works.

Home healthcare research in Gerontechnology Research Center Yuan Ze University Thank You http://GRC.yzu.edu.tw/ http://designer.mech.yzu.edu.tw/ Yeh-Liang Hsu mehsu@saturn.yzu.edu.tw