Lill Kristiansen, Prof. Dr. Scient Inst. for Telematikk, NTNU lillk@item.ntnu.no

1. Towards a location based or context aware system in a hospital setting? - technical issues - issues relating to use in the organization Lill Kristiansen, Prof. Dr. Scient Inst. for Telematikk, NTNU lillk@item.ntnu.no www.item.ntnu.no/~lillk

2. Content • Background / some of my previous work • IP-telephony, calendar/location integration with telephony,..(1999-2006) • H.323. annex K, (later similar functionality in SIP/extensions) • OSA/Parlay for call control in particular • The group-communication system implemented in pats (H2003) intended for nurses’ communication • A qualitative study of nurses’ attitude toward location tracking in a hospital • Studies of location, presence etc. in health care organizations by my students

3. From tech. to tech. in use • I come from the technology side • Building new technology and evaluationg the systems from a technology perspective • Now interested in the whole issue of user, organization and technology • supervising master student in systems engineering • as well as master students specialicing in TOS ’Telecom. Organization and Technology’

4. 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 alerting (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)

5. PSTN-GW Without opening up the telephony network ComPage (Teepo, UiO, 1999) Web-server withe.g. preferences / presence webIP-netw Service layer web- based Web-browser 1) 2) Click-to-call IP-based tel. netw. PSTN netw. Call layer(Telcoproperties) 3) E.g.Net-meeting - Call setup H.323 Advantage: Simple

6. B’s presence service /screening rules (GUI via e.g. Outlook or MSN..) Opening up the telco network with OSA OSA/ Parlay call control Home A Home B HSS HSS 9B) 8 7 4 3 9 6 5 S-CSCF I-CSCF S-CSCF I-CSCF 14 15 16 17 2 Visited B Visited A P-SCSF P-CSCF 18 1 GGSN GGSN SGSN SGSN Radio Access Network Radio Access Network B A

7. ’Interactive screening’ using SIP (2005) From Østhus and Kristiansen (2005) (WS instead of OSA was used)

8. pats lab • I assume you have a basic knowlegde of the lab • I will briefly present the overall picture and ServiceFrame • Then a more detailed presentation of ” Group communication for healthcare workers designed in ServiceFrame” • carried out by stud. Marte Forthun, fall 2003

9. Service engineering Service deployment and execution Telenor Mobil GSM loc SMS MMS WAP push Service Platforms/ interfaces PATS lab: Available resources (2006) Rational Rose Telelogic (UML 2.0) Incomit iSea ServiceFrame Mobilus IBM Websphere Incomit parlay GW Ericsson Parlay GW Bravida Ericsson MM Streamingserver CPA Map Radio-nor WLAN pos POI Red-M Bluetooth Route

10. Parlay and UMTS Open Service Access;Migration and Convergence

11. soap http RMI, ... From methods and tools to running code Methods Methods Service engineering Tools Tools Service Creation Environments Service Creation Environments Service Services Services and Services deployment Application Application Servers (Service Servers (Service execution Terminals Execution Environments) Execution E nvironments) APIs Parlay, OSA, JAIN, ... Terminal Service Service Enablers Service Enablers platforms Access and transport network Access and transport network

12. Application server: Service architecture Service Frame concepts Edge towards the SCS Service capability Server (to OSA)

13. Application Server: platform portability Functionality using Actor model Modeling Platform lndependentModeling Platform SpecificModeling Implementation using Actor classes Implementation using Actor classes Implementation using Actor classes JavaFrame EJB ActorFrame .NET ActorFrame Implementation EJB .NET JVM

14. Group communication for healthcare workers designed in ServiceFrame The following slides are from student Marte Forthun’s presentation (slightly modified) Forthuns work was mainly technical. Example of a kind of ‘service composition’, introducing a new concept such as ’group’ into ServiceFrame FICTITIOUS DEPARTMENT Medical Department Stroke Unit Heart Unit Kidney Unit G1 G2 G3 G4 G1 G2 G3 G4 G1 G2 G3 G4

15. 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”

16. SCENARIO 1 FROM TRONDHEIM UNIVERSITY HOSPITAL – HELP WITH PATIENT Lise Location: Room 333 Presence: Busy with patient GroupSession: 1 Stroke Unit Primary group - G1 Help Patient Interface on handheld terminal or on PDA in pocket

17. Anna Ola Per Stroke Unit Stroke Unit Primary group - G1 Primary group - G1 Kari Lise Able to help in room 333? Help Patient Location: Room 333 Presence: Busy with patient GroupSession: 1 Location: Room 337 Presence: Free GroupSession: 1 Yes No (Service) Network knows the presence information of all in group and routes the message 3 2 4 1 Interface on handheld terminals

18. Per Location: Room 333 Presence: Emergency GroupSession: 1 Primary group - G1 Stroke Unit EMERGENCY IN ROOM 333 SCENARIO 2 FROM TRONDHEIM UNIVERSITY HOSPITAL – EMERGENCY (Service) Network knows the presence information of all in group Primary group - G1 Stroke Unit Emergency The patient’s doctor Interface on the terminals Emergency team

19. GROUP AGENT SYSTEM GroupManager:Groupname, address, user’s group GroupAgent:Groupname, users, access to update

20. GROUP AGENT UserSession:Real-time messaging, context-information

21. Forthuns work • Her work was not tested on users because of several factors: • Pats did not support J2ME in 2003, i.e. user interface was not on handheld (but faked on a PC) • hard to simulate a real scenario in this case • 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 (high ceilings) • location from several sources was prepared for though • Today we have Radionor office indoor location integrated in pats i.e. in items corridor and Svanæs has Radionor • Svanæs’ usability lab is not linked to pats though... • Also Forthuns work focus on session establishment, adding location info, ’group hunt’ etc • She assumes ServiceFrame everywhere, no use of standards such as e.g. SIP/GSM/3G or SIMPLE or MSN ‘standard’ • That can be added of course

22. 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 indicating ’presence’ Right: Signalling a patient calling for help (ringeknapp) with room id OR signalling that a nurse is called (kalt opp) OR several numbers in round robin fashion

23. Location based system in a hospital setting; an exploratory study • A qualitative study fall 06 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?

24. Findings (1/3) • 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 • Nurses are positive to showing location data to management in order to show how much they actually wallk/run • 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 reports 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) (see e.g. Forthuns 6 defined presence categories) • A human user can then ‘understand’/interpret the location and other context info (without a need to have a category for the work)

25. Findings (2/3) • A manual procedure for registering location • our idea: to give them ‘more control’ and to introduce a system close to the existing system • 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 • based on user id and location they felt they would be able to guess on the activity /’get a sense of what is going on’

26. 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) • Nurses are positive to use such a system as partial evidence in case of a lawsuit after a death incident • This requires a persistent system though • Other use of the system may need only ephemeral data (no storage) • Will a location/presence system help or destroy • enforcing / visualizing existing ‘rhythms’ • or destroy all rhythms via ‘always accessible everywhere on every device’ and causing more interrupts?

27. Further work • Mutual learning (Kyng, 1995) • Did the health domain esperts understand our ideas as presented orally? • New possibilities not present in today’s wellknown system was intended in our new system • How to involve health domain experts in the design? • Presenting UML diagrams to health care domain experts?? • Building prototypes e.g. via pats lab • User testing • using pats infrastructure and live network and maybe Trådløse Trondheim? • In ’real life’ (maybe for home care? at hospital???) • In ’big lab’ (empty place at St.Olavs in a new building?)

28. Other health related work • Students in TOS Telecom. Organization and Society • Studies of technologies for home care workers • Fall 2004-spring 2005 • interrupts caused by calls • Use of collegues and EPR /Gerica for info about patients • Spring 2007 • Design methods for participatory design • testing out two different methods of running work shops • Use of location, maps and cameras in home care • Studies in hospital • use of location and e-tagging of medicine • study of communication and coordination (quite close to Scholl et al) • Studies of introduction of ICT based tool Sampro for ’Individuell plan’

29. 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 • Bydgås, S et al. MOSSA Telenor report • 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 • 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

30. 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 • 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 • Teenage users in private setting • Interesting to test on field workers such as trygghetspatruljen • 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 • A propotype of ‘Negotiator’ for negotiating to call or be called up after x min. or deferring the call for x minutes (running on PC and PDA) • User evaluation of Negotiator in a lab setting using desks and not allowing any calls to take precedence over the current desk activity, • Interesting study, but some assumptions are not relevant for health care where some calls will have higher precedence than current task

31. 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, E.C., Osland, P-O, Kristiansen, L. (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&issn=0302-9743&volume=3823&spage=316 • Using SIP extensions and web services (not using OSA) • Demo build using model railroad and RFID • Østhus, E.C., 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

32. 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 • Relating to the study ”Push-to-Talk Social Talk” by Woodruff and Aoki (2004), but some different features though. • Both Bubble talk and PoC may be used for professional field workers • 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 • SIP and IMS of course • OSA of course

33. GROUP AGENT SYSTEM GroupManager:Groupname, address, user’s group GroupAgent:Groupname, users, access to update

34. GROUP AGENT UserSession:Real-time messaging, context-information

35. USER AGENT

36. USER AGENT SERVICE GroupService:Exist when user subscribe on group services

37. GROUP SERVICE GroupSession:Updating user session with context information, routing of messages Administration:Administrative privileges