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Towards a location based or context aware system in a hospital setting?

- technical issues- issues relating to use in the organisaton

Lill Kristiansen, Prof. Dr. Scient

Inst. for Telematikk, NTNUlillk@item.ntnu.no

www.item.ntnu.no/~lillk

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Content

Background / some of my previous work IP-telephony, calendar/location intergration with

telephony,..(1999-2006) H.323. annex K, SIP, SIMPLE,

The group-communication system implemented in pats (H2003) Mainly technical focus

The study of the patient signal and presence button as in use today ethnographic study (EiT 2004),

A qualitative study of nurses’ attitude toward location

TOS education (IS, CSCW, CMC, ...)

Rel. work, further work, cooperation, labs,..

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From tech. to tech. in use

I come from the technology side Building new technology and evaluationg the systems

from a technology perspective

Ex. of work H.323 annex K, integrating http into IP-telephony setup, Using location and status into call setup and messages

Forthun’s work to be presented in some more detail

None of these systems have been tested on real users

Now interested in the whole issue of user, organization and technology

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Some previous tech. work of mine / my students

IP-telephony at Ericsson AS, Norway

Including integration of IP-tel. and url’s as described in H.323, ver. 4 annex K A generic mechanism for sending a url during call setup

phase, typically back to A during ringing phase (pre-connect)

’opening up’ the telephony network for presence and more

Also involved in architecture and standardization for mobility, OSA Open Service access for Ericsson

Later SIP, SIP-Jain, SIP session mobility based on location/context (with P-O Osland Telenor)

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Without opening up the telephony network ComPage (Teepo, UiO, 1999)

2) Click-to-call

Web-browser

3)

Callsetup H.323

1)

E.g.Net-

meeting

-

IP-based tel. netw.

Web-server withe.g. preferences / presence

PSTN-GW

webIP-netw

PSTN netw.

Call layer(Telcoproperties)

Service layerweb-based

Advantage: Simple

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Opening up the telco networkusing H.323 Annex K and OSA

P-SCSFP-SCSF Visited B

S-CSCFS-CSCF

Home A

1

2

7

1517

P-CSCFP-CSCFVisited A

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AB

GGSNGGSNSGSNSGSN

Radio Access NetworkRadio Access Network

GGSNGGSNSGSNSGSN

Radio Access NetworkRadio Access Network

S-CSCFS-CSCF

Home B

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I-CSCFI-CSCF

HSSHSS

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14

6

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I-CSCFI-CSCF

HSSHSS

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B’s presence service GUI via e.g. Outlook

9B)

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H.323 annex K (http service control) Ex. with Call Waiting (H.450) plus interactions

Terminal C Terminal B

Setup

End-user C

GET url (I’ll wait)

Connect

Web-server

Http 200 OK (data)

Terminal Browser

Alerting (url) callWaiting.invoke

Load(url)

Notify B, its urgent

Http 200 OK (data)

Display

GET url

I’m busy now, but you may:

1. Wait - it’s urgent, 2. Leave a message

May be endpoint centric (at Bs endpoint) or network centric B’s VASP

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’Interactive screening’ using SIP (2005)

From Østhus and Kristiansen (2005) (ServiceFrame and OSA was not used)

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Medical Department

Stroke Unit

G1 G2 G3 G4 G1 G2 G3 G4 G1 G2 G3 G4

Heart Unit Kidney Unit

The following slides are from student Marte Forthun’s presentation at Telenor 2004

Forthuns work was mainly technical. Example of opening up the session establishment pluging in a new concept such as ’group’ into ServiceFrame

FICTITIOUS DEPARTMENT

Group communication for healthcare workers designed in ServiceFrame

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SCENARIO 1 FROM TRONDHEIM UNIVERSITY HOSPITAL– HELP WITH PATIENT

Interface on handheld terminal

Lise

Per

Location: Room 331Presence: MeetingGroupSession: 0

Primary group - G1

Help Patient

Stroke Unit

Ole

Location: Room 338Presence: Busy with patientGroupSession: 0

Kari

Location: Room 337Presence: FreeGroupSession: 0

Primary group – G1

Location: Room 333Presence: Busy with patientGroupSession: 1

Lise

Location: Room 333Presence: Busy with patientGroupSession: 1

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SCENARIO 2 FROM TRONDHEIM UNIVERSITY HOSPITAL– EMERGENCY

Location: Room 333Presence: EmergencyGroupSession: 1

Emergency team

The patient’s doctor

Per

Primary group - G1

Emergency

Stroke Unit

Primary group - G1

Stroke Unit

EMERGENCY IN ROOM 333

Interface on the terminals

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CONTEXT-AWARE INFORMATION

”Context is any information that can be used to characterize the situation of an entity. An enitiy is a person, place or object that is considered relevant to the interaction between the user and an application, including the user and applications themselves”

(Dey, June 1999)

USE OF CONTEXT-AWARE INFORMATION IN THE HOSPITAL

•Location: Indoor positioning – sensors

•Calendar: User’s calendar, group calendar etc.

•Sessions: Call sessions, instant message session, real-time sessions,..

•Role: Trained nurse, doctor,...

•Presence Types: ”Free”, ”Busy with patient”, ”Meeting”, ”Lunch”, ”Emergency”, ”Offline”

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Forthuns work

Her work was not tested on users because of several factors:

1. Pats did not support J2ME in 2003, i.e. user interface was not on handheld (but faked on a PC)1. hard to simulate a real scenario in this case

2. Pats did not support accurate indoor location at that time We had Radionor Cordis radio eye, but that is mostly suited for

places like Nidarosdomen, glassgården etc. (high ceilings) location from several sources was prepared for though

3. Today we have Radionor office indoor location integratedin pats i.e. in items corridor and Svanæs has Radionor1. Svanæs’ usability lab is not linked to pats though...

Also Forthuns work focus on session establishment, adding location info, ’group hunt’ etc She does not address establishing a voice stream She assumes ServiceFrame everywhere, no use of standards

such as e.g. SIP on endpoint or in network

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Knappen ’The button’ study (2004)

Left: button for the nurse (on door frame in the room)

3 levels: ’help’, ’nurse need help, ’hearth arrest’

Middle: No nurse id , just indicationg ’presence’

Right: Signalling a patient calling for help (ringeknapp) with room idOR signalling that a nurse is called (kalt opp)OR several in round robin fashion

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Location based system in a hospital setting; an exploratory study

A qualitative study H06 Lill and two PhD studens (ifi, UiO)

RQ1 Automatic vs. manual sharing of information: Does it matter to the nurses if the location and status is shared

automatically or manually? For instance, are they more comfortable pushing a button when they enter a room to signal their presence, or is it OK for them to be tracked continuously as they move around? Are there places or situations where these issues are looked upon differently?

RQ2 Awareness of potential use and misuse of information: To what degree do the nurses realize the potential for use of

information when they are sharing location and status with others? Do they think differently about this depending on who they are sharing with? Does it matter if they share with fellow nurses, doctors, or management?

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Methods

Semi-structured interviews with 3 nurses suited as methods since we were not trained in

observations, interviews ’easier’

Recruited via friends/ connection 2 recruited via friendship and interviewed on their spare

time (also friends of each other) 1 recruited via connections already established at a major

Univ. hospital. ’gatekeeper’ Interview done during work hours

Content analysis

(Later 2 more interviews in another country, not yet analysed)

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Underreseached area

Little previous literature relating to our RQs Previous work such as ’mobility work’ by Bardram and Bossen

tries to separate the spatial dimension (from time) Did not work for us, our health domain experts were clearly relating to

both space and time at most occasions Bentley 1992 are discussing manual procedures in air traffic

control relating to safety, but not manual ’registration’ per se ihospital and Mexico studies all seems to assume that location

tracking is a good thing

Most previous work has focused on doctors (ihospital, Scholl et al) and on leading nurses (Mexico) Little focus on ’the average nurse’

and even less on patients!

We found a need to read A. Strauss (soc. of med. work) and his SOP (standard op. procedures) SOP deals with both time and space)

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Findings (1/3)

Nurses are positive to management seeing how much they actually work

As well as to use such a system as partial evidence in case of a lawsuit after a death incident

The health experts (nurses) were talking about manual work such as refilling of clean sheets and linen and food serving, and this led us to the concept invisible work. Star and Strauss: disembedding background work

an attempt by a group of nurses at the University of Iowa to categorize and make visible all the work that nurses do.

A location system may visualize (parts of) invisible work without ‘understanding’ the work (i.e. without a need to have a category for the work)

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Findings (2/3)

All our findings must be understood in the context of a ’nurse identity’ (Palen and Dourish (2003) ’ Identity boundary ‘) E.g. nurses concern with patients is a part of their professional self-image

Our three health experts had opposite views on ‘surveillance’ issues The 2 friends of same age showed opposite attitudes

A manual procedure for registering location our idea: to give them ‘more control’ and to introduce a system close to

the existing system (Knappen, 2004) maybe they are more interested in what the location info is used for than to avoid

registration as such error prone (forget to register in hectic work)

but with an ICT system a re-registration may cancel the forgotten deregistration (unlike today’s manual system without id)

ICT offers new possibilities, but hard for the nurses to imagine all our thoughts In most cases they wanted to see identity (role was not enough)

todays system show no identity

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Findings (3/3)

Nurses are quite aware of how such a system may be fooled and show wrong (mediation of reality) “You may have someone wear the badge for you” “You may have helped in at a hearth arrest on your way back from

lunch” (not having had a long lunch break) “A location system may register that ‘someone was there’, but it

tells nothing about the quality of the care”

The latter comment is important: Such a system may result in behavior adapted towards what is

measured (location) and may result in ‘fake care’ (presence, not care)

Will a location/presence system help or destroy enforcing / visualizing existing ‘rhythms’ or destroy all rhythms via ‘always accessible everywhere on every

device’?

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Further work

Mutual learning (Kyng, 95) Did the nurses understand our ideas presented orally? How to present the system ideas and design to them,

including techn. solutions and limitations? How to involve them in the design? Presenting UML diagrams to health care domain experts?

Building prototypes Using Service Frame? pats infrastructure (OSA-parts),

others?

User testing In ’real life’? (maybe for home care? at hospital???) In ’big lab’ (empty place at St.Olavs in a new building?) Approbation work, side effects,...

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TOS Telecommunication, Organization and Society

siv.ing education in coop with sociology

I have oriented students lately towards CSCW work but with a particular focus on mobility, real time aspects,

session initiation Including session negotiation /rerouting based on location,

calendar info, netw. cap. and human decisions

i.e. a telecom focus (as opposed to IT-focus)

We could do more cooperation with iss (I believe) SOS1010 has proved useful (CMC) Discussion on new courses relating to work ongoing

Also HCI courses from idi may be of relevance

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(Org. and soc.) vs. technology

IS approachs tech. system often built by someone else may conclude with some general ’implications for design’ though

CSCW / HCI approach which may focus on studying users, building prototypes and real user testing well suitable for our student’s mainly techn. skills may use well known technology

focus on the user behavior and/or org. impact or focus on e.g. gathering of user requirements (PD)

may use newer technology e.g. use of pats lab either focus on technology and techn. tools (NEW!) or focus on user requirements and interactions between user (domain

expert) and designer (technical experts i.e. using ’mutual learning’ from Kyng (PD)

User and organization behavior

Many CSCW studies assume/use skilled ICT office workers or comp. sci. students as the users: different for nurses!

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• Often used in organizational studies (with ICT aspects)• Often critizised for being ’consultancy, not research’• RCA: Between the ’consultant/researcher’ and ’client ’ (=boss?)• Diagnoses may be via ethnographic studies, contextual design,..)• The intervention may be:

• new ICT system or new orginization/process• (little focus on building the ICT, rather on deploying /’impl.’)

(Canonical) Action Research AR/CAR

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Life or lab for the testing? (1/2)

AR assumes a real organization ’real life’ and doing the changes ’for real’

Also without AR one may think of studying a prototype ’in real life’ e.g out in the city using TT and/or GSM infrastructure and pats APIs In real distributed office environments Whitaker has tested some propotypes such as

’hubbub’, and Active Badges, Harper, 1993

Pats is a lab for building applications (’workshop’/ ’verksted’) pats enables the use of the applications in ’live network’ (GSM) via APIs

suited for testing ’for real’ in the city (mostly outdoor if location is used)

Some applications can be tested ’for real ’in the city for home care workers and other filed workers Suitable for pats-build applicATIONS using location, SMS, voice telephony

etc via GSM network

But problems with accurate indoor location services in such a place as a bed ward

Other problems with testing in a real hospital as well Issues of patient safety if only new prototype is in use Issues of ’not real’ if both old system and new prototype needs to be used

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Life or lab? (2/2)

In ’faked reality’ (’big lab’) Dag Svanæs’ usability lab as example

build a fake bed ward (with a short corridor) Role plays with mock technology Test real prototypes in this ’faked reality’

In ’small lab’ Controlled but ‘artificial’ tests ’Negotiator’ by Whitaker tested in such a controlled

environment ’simulating the office desks’ in a test lab) Negotiator: Negotiate at a desk a new time for the call,

assume it is never suitable to take the call immediately May be OK for same office environments, but less so for

health workers walking, interrupting, caring, and handling heart arrests

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References

Scholl, J., Hasvold, P., Henriksen,E. and Ellingsen, G.,"Managing communication availability and interruptions: A Study of Mobile Communication in an Oncology Department" Accepted at pervasive07

Ellingsen, G. and Monteiro, E., A patchwork planet. Integration and cooperation in hospitals, CSCW the journal, 12(1): 71 – 95, 2003.

http://www.idi.ntnu.no/~ericm/patchwork.pdf Focus on ‘IT’-systems, such as X-ray, EPR. Less focus on ‘person-to.person-

communication’ My student Alex is working on this

ihospital.dk (head was Bardram, head is now Kyng, Bardram is with ITU now) many publications but they are not looking into details of telephony session establishment, here item/pats

can contribute

Bentley, R., et al . 1992. Ethnographically-informed systems design for air traffic control. In Proc. CSCW '92. ACM Press, pp 123-12

http://doi.acm.org/10.1145/143457.143470 On manual work / on ethnographic methods relating to ‘implications for design’ i.e.

‘today’ vs ‘tomorrow’

Massimi, M., Ganoe, C., Carroll, J.M. 2007  Scavenger Hunt: An Empirical Method for Mobile Collaborative Problem-Solving, Pervasive Computing, Vol. 6(1), pp 81-87

http://ieeexplore.ieee.org/xpls/abs_all.jsp?isnumber=4101128&arnumber=4101146&count=17&index=13 About usability (HCI) testing ‘in lab’ and ‘in real’ Not about general use of system in an organizational setting

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References

Woodruff, A. and Aoki, P. M. 2004. Push-to-Talk Social Talk. CSCW the journal 13, 5-6 (Dec. 2004), 409-441.

http://dx.doi.org/10.1007/s10606-004-5060-x Teenage users in private setting Interesting effects of ’instant listen’ with ’delayed answers’ Interesting comments on the ’limitations’ with semi duplex, turned out to be a nice to

have feature

Jones, Q., Grandhi S.A. Terveen L and Whittaker, S.2004, ,People-to-People-to-Geographical-Places: The P3 Framework for Location-Based Community Systems, Computer Supported Cooperative Work (CSCW), Volume 13, Numbers 3-4 pp249-282

http://www.springerlink.com/content/q465ph125r5681r5/ A conceptual framework, mainly focus on social tasks, dating/lunching etc

Wiberg, M. and Whittaker, S. 2005. Managing availability: Supporting lightweight negotiations to handle interruptions. ACM Trans. Comput.-Hum. Interact. 12, 4 (Dec. 2005), 356-387.

http://doi.acm.org/10.1145/1121112.1121114 A study of how ‘talking sessions’ are established in offices today (univ. researchers in

HCI as users) A propotype of ‘Negotiator’ for negotiating to call or be called up after x min. or

deferring the call for x minutes User evaluation of Negotiator in an (artificial) lab setting

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References

PUSH-2-TALK IN VOIP DECENTRALIZED by Florian Maurer, presented at BB4All, IST project, supervised by KTH (using SIP/minisip) http://www.bb2all.org/papers/Maurer%20Push-2-Talk.pdf

Østhus. Osland, Kristiansen (2005) ENME: An ENriched MEdia application utilizing context for session mobility; technical and human issues. Proc. UISW (workshop of EUC2005), LNCSE series 2005;Vol. 3823 pp.316-326 http://www.springerlink.com/openurl.asp?genre=article&is

sn=0302-9743&volume=3823&spage=316

Østhus, Egil Conradi; Kristiansen, L.,(2005) A presence based multimedia call screening service. In: Short papers companion proceedings to LNCS 3744: Springer-Verlag . ISBN 2-553-01401-5. pp. 21-25

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Some relevant products / standards

Bubble talk (Digi, Malaysia, Telenor Pakistan ..) BubbleTalk TM is a "click, talk and send" Short Voice Messaging

Service. It's a "talk and listen" messaging alternative to the "type and read" service provided by SMS. (proprietary solution)

http://www.digi.com.my/data_services/messaging/datamsg_bt_faq.do

Push-to-talk over Cellular (PoC) semi-duplex (’talk or listen’ / walkie-talkie-like)

Over WLAN/GPRS/... Over TETRA incl. *group communication* Ericsson, Motorola, Siemens, Nokia, “Push-to-talk over Cellular (Poc)

specification” (from Aug. 2003, i.e. old version)) input to etsi http://www.ericsson.com/multiservicenetworks/distr/PoC_specifications.ZIP