Bruno Niman, Alejandro Rodríguez-Ascaso, Steve Brown, Torbjørn Sund
Telecare can be defined as the use of ICT to support the delivery of care directly to people outside of conventional care centers, such as hospitals or residential homes. A telecare system can be as simple as providing a person with the means to alert a remote care provider of their need for assistance. More advanced systems might automatically detect the need for assistance by monitoring activity or lack of it, using ambient or body-worn sensors.
Evidence suggests that telecare can reduce care costs ; nevertheless it has yet to become a serious alternative to hospital or residential care. The telecare installations which do succeed tend to be on a relatively small scale, and led by committed individuals with a thorough understanding of the end user (i.e. carers and their clients) needs, resulting in a system tailored to the intended user group. We believe that in order for telecare to become a successful mainstream service all stakeholders within the telecare delivery chain must pay similar strong attention to the user needs and the user experience.
An ETSI (European Telecommunications Standards Institute) STF (Specialist Task Force) has produced an EG (ETSI guide)  designed to help telecare stakeholders develop and deliver telecare systems which provide a positive end user experience. What follows is a brief description of the methodology used in developing the EG together with some examples and discussion.
Our approach to telecare services builds on the framework described in the ETSI Technical Report (TR) 102 415 , whereby personal monitoring, security management, electronic assistive technologies and information services are used to support personal health and well-being. Several approaches were considered for structuring the guidelines:
Human Factors Approach. This required the guideline clauses of the EG to be divided into five main sections, with each section addressing a major human factors topic:
- Interaction with telecare equipment
- Operational issues
- Service-related issues
The advantage of this approach was that human factors issues would be given a high visibility, which is important given the fact that the guide is aimed at addressing human-factors issues related to the user experience of telecare services. However, this approach would have made it difficult for individual stakeholders to have identified which of the guidelines were most relevant to them.
Service Lifecycle Approach. The service lifecycle approach require the EG to be divided into four main guideline sections, with each section addressing a specific part of the telecare service lifecycle:
- Service deployment
The advantage here was that specific stakeholder groups would be able to easily locate those guidelines most relevant to them. However, it was also likely that guidelines would be repeated frequently, negatively impacting practical use.
Hybrid Approach. The hybrid approach required the guidelines to be divided into the four sections listed within the lifecycle approach above. Each section would contain subsections focusing on the human factors issues described above. Stakeholders could easily locate the guidelines most relevant to them, whilst the human-factors issues would still receive a high profile. Alternatively, the human-factors issues could be promoted to become the higher-level sections with the lifecycle stages as subsections. The final choice for the structure of the EG was based on the hybrid approach with the human factors at the top level. Each human factor section firstly contains a set of generic guidelines which are applicable through the whole lifecycle of telecare. Then guidelines specific to lifecycle stages are provided.
Throughout the development of the EG the review process has played an important part in ensuring the quality and relevance of the guidelines. The ETSI HF (human factors) Committee has been responsible for reviewing the development of the guidelines since the beginning of 2006. Another important part of the review process has been to present draft guidelines at several international conferences and workshops and electronic communication means, in order to get early feedback from stakeholders within the telecare domain.
This section of the paper provides an overview of the real, effective outcomes of our work. It would not be practical to present all of the guidelines from the EG here and so, a summary of them is provided below. They have been pulled out from the generic guidelines sub-section of each human-factors element. Furthermore, human factors have been grouped within three main corresponding themes: trust, user interaction and service aspects.
An end user's trust in a system comes from his/her belief that issues relating to the security of the information used within that system have been dealt with appropriately, and that the system can deliver what is expected of it. The trust theme encompasses the following human factors elements:
Privacy and confidentiality:
- Stakeholders should respect a client's right to give, withhold or withdraw consent for others to access or disclose sensitive information about themselves.
- Whether conducting trials or providing real services, stakeholders should provide a clear explanation to the client of the procedures they will implement to protect the clients' privacy.
- Stakeholders should develop and implement an information retention policy which describes how long, and under what conditions, client information may be kept.
- Telecare systems should support the health, well-being and independent living of the client.
- Telecare systems should respect the client's decisions, dignity, integrity and preferences.
- Appropriately qualified individuals should assess whether the proposed client is capable of consenting to take part in telecare research, or to have a telecare system installed as part of a running service.
- Legal experts should be consulted to identify the relevant legal and technical requirements for the country in which the telecare system will be deployed.
- Contracts should be setup between the various stakeholders involved in the telecare service. The contracts should clearly state the contractual undertakings, including responsibilities and liabilities, of the various stakeholders involved.
Availability and reliability:
- Telecare systems should be designed and operated such that the availability and reliability of the service is appropriate to the needs of the end user.
- Telecare systems should be designed and operated such that data and information within the system are maintained unchanged during transfer, storage and retrieval.
- Telecare systems should be designed to be fail-safe.
- Telecare systems should be designed and operated so as to minimize the probability of the user making errors, as well as to minimize the adverse effects of any user error.
The communication between the user and the telecare system will have a direct influence on the user experience of the service. Interfaces and interaction procedures should be designed with the needs and preferences of end users in mind. The user interaction theme comprises the following human-factors elements:
Usability and accessibility:
- Telecare system's output should be perceivable and understandable to users. Telecare equipment should be operable with efficiency by users. Assistive technologies should be usable in conjunction with telecare equipment.
- Alarms should be effectively notified to users. Furthermore, it should be very easy for users to notify alarm situations.
- Consistency among user interfaces should be promoted in related telecare equipment and services.
- Users in the possession of the necessary abilities should always be in control of their telecare system, and also have the feeling of being in control.
Localization, customization and personalization:
- Consider the target languages and cultures when producing the source text, as well as illustrations.
- Customization and personalization should be supported.
- Telecare services should always offer user education through the entire service lifecycle.
- User education material should be offered in a multimodal, localized and accessible way.
- Legal and safety considerations should be addressed.
The service aspects theme is mainly concerned with the internal workings of the system developers and service providers, who have a direct influence upon the user experience. The service aspects theme comprises the following human factors elements:
- Stakeholders should be aware of how the introduction of a telecare system may affect and change the work practices of professionals or the organizational structures.
- Stakeholders should take steps to minimize any negative affects of such changes.
Servicing and maintenance:
- Installation, setup, configuration and maintenance should be addressed by service providers through manual, automatic, remote or presence procedures, which should remain as transparent as possible for clients, demanding minimal interaction from them.
Interoperability and roaming:
- Telecare services should offer roaming capabilities. Users should be educated to access service when roaming.
- Telecare products should promote interoperability among equipment elements. Users should be educated to easily operate interoperable pieces of equipment.
Development process and testing:
- User-centered development methods should be applied throughout all phases of the development process of telecare services, supported by pilot studies, functional, usability and robustness tests and evaluations.
Within the EG, there are more than 300 individual guidelines, and clearly a linear, unstructured enumeration was undesirable. We have therefore classified the guidelines according to the human factors and telecare equipment life cycle. We have thereby obtained a structure which facilitates browsing and searching the document, corresponding to the stakeholders' needs for a reference manual where it is easy to locate the relevant guidelines. As an example, the safety guideline "Design alarms so that if / when they are manually silenced, they are reactivated after some time and as long as the problem persists" is classified as relevant for research and development, and can therefore be ignored during the installation phase, whereas "The risks to a client of discontinuing a previously established telecare service should be carefully analyzed, and the client (or the client's proxy) should give an informed consent" is placed under service provisioning, since it has little relevance during R&D. Nevertheless, nothing prevents a stakeholder mainly involved in the latter lifecycle of telecare (e.g. a service provider or a public administration authority) to be informed on R&D good practices. This information could be of use for public procurement processes.
During our work with the guidelines, we found that the human factors aspects could be further grouped along three different themes: trust, user interaction and service aspects. This grouping is not explicitly followed in the guidelines document itself, but has been very helpful during the elaboration of the guidelines, and for the structuring of the document.
A difficulty that arose throughout the work with the guidelines was to strike the right balance between generality and specificity. If too general, a guideline becomes a platitude; if too specific its application domain will be too narrow. We have tried to be general enough to cover most of current technologies without unnecessary repetition. However, we have on purpose not covered "self care" (e.g. weight control, stopping smoking, step counters, calorific consumption estimators, etc.). It is expected that this new field will expand faster than traditional telecare. When the field of self care becomes more mature, it will probably be useful to either extend or complement the current ETSI document with guidelines covering self care equipment.
The use of ICT within social health care has not kept pace with the rapid deployment of digital communications infrastructure, devices and services which has taken place since the early 1990s. This lag may in part be a result of new technology being introduced without due consideration of human factors during its design and deployment. It is hoped that the ETSI guidelines reported on and briefly summarized in this article may inspire stakeholders to design, implement and provide telecare systems that take due account of human factors, thereby making their systems more acceptable to the end users.
The preliminary final version of the ETSI Guide (currently undergoing the ETSI Membership Approval voting) is publicly available at http://portal.etsi.org/stfs/STF_HomePages/STF299/STF299.asp.
The final version, once published in January 2008, will be freely available at www.etsi.org.
eHealth and Telecare stakeholders are invited to use this ETSI Guide as part of their operational processes, to the largest possible extent.
Bruno von Niman
About the authors
Bruno von Niman is the leader of the ETSI expert team (Specialist Task Force 299) referred to in the article. He is the founder and lead expert of vonniman consulting, the ICT user experience company, having spent the most exciting 10 years of mobile ICT development with Ericsson in Sweden as a catalyst and advocate of user experience in R&D, product development and standardization, also coordinating group activities. Bruno is vice chairman of the European Telecommunication Standards Institute's Human Factors Committee and leader of several projects sponsored by the European Commission. He represents European consumer interests in the World Wide Web Consortium (W3C), is the chairman of the Human Factors in Telecommunications Symposia (www.hft.org), and chaired the special area Mobile Communications at CHI2004 and the Industry track at Mobile HCI 2005.
Alejandro Rodríguez-Ascaso is an ETSI Specialist Task Force 299 Expert. He holds a Ph.D. in telecommunication engineering. Since 2006, he is a researcher at the National Distance Learning University of Spain (UNED). He is also involved in research and teaching activities related with the application of design for all criteria in IT, as well as in the IT mediated support to independent living. Furthermore, he is member of the Scientific Committee of the International Conference on Domotics, Robotics and Telecare for All (DRT4ALL), and member of the ICT Advisory Board of Fundacion ONCE. He is collaborating with standardisation bodies in the field of Human Factors and IT, such as ETSI and AENOR.
Steve Brown ia an ETSI Specialist Task Force 299 Expert. Since joining British Telecom's Research Department in 1985, Steve has worked on several projects related to home networking technologies and applications. In 2002 he took a leading role within a UK Department for Trade and Industry (DTI) funded initiative aimed at developing a third generation telecare system. This cutting-edge research program involved many UK partners including several universities and the Liverpool city council. Steve is currently involved in another DTI funded project aimed at developing a telecare system consisting of both body-worn and ambient sensors. Project partners include: BT, Philips, Imperial College and several other academic and business partners.
Torbjørn Sund is an ETSI Specialist Task Force 299 Expert. Torbjørn has a diploma in biomedical physics and a Ph.D. in image processing applied to medical X-rays. He has worked with mathematical modeling, computer simulation and experimental verification of physiological phenomena, sub-sea cartography, and telemedicine and teleradiology. He is now employed by Telenor Research, where he is toying with delivery of multimedia over wireless to mobile phones. Torbjørn has served as project evaluator and expert reviewer for several EU-funded research programs.
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