CYBERPSYCHOLOGY & BEHAVIOR

Volume 6, Number 3, 2003

© Mary Ann Liebert, Inc.

Ambient Intelligence in Health Care

GIUSEPPE RIVA, Ph.D.

ABSTRACT

Ambient Intelligence (AmI) is a new paradigm in information technology, in which people

are empowered through a digital environment that is aware of their presence and context,
and is sensitive, adaptive, and responsive to their needs, habits, gestures and emotions. The
most 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 interfaces
into the real environment, so that the user can interact with other individuals and with the
environment itself in the most natural and intuitive way. How does the emergence of the AmI
paradigm influence the future of health care? Using a scenario-based approach, this paper
outlines 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 AmI
potential need a significant attention to technology, ergonomics, project management, human
factors and organizational changes in the structure of the relevant health service.

INTRODUCTION • Increase of richness and completeness of com-

munications, through the development of multi-

H UMAN–COMPUTER INTERACTION has come a long

way since the early days when computer users,
working in the DOS environment, copied files on a
media technologies, towards “Immersive Virtual
Telepresence” (IVT), including an increased at-
tention to the aspects of human perception and
disk by typing instructions like “DIR/p” or “COPY of person-machine interaction
myfile.exe a:/.” In fact, during the past 15 years,
technology’s focus has gradually been shifting away The possible result of these converging trends is
from the computer as such, to the user.1,2 Clear signs Ambient Intelligence (AmI; Fig. 1). AmI is a new
of this transformation were the development of the paradigm in information technology, in which peo-
modern graphical user interface, and the emergence ple are empowered through a digital environment
of totally new interactive communication environ- that is aware of their presence and context, and is
ments, such as Computer Mediated Communication sensitive, adaptive, and responsive to their needs,
(CMC) and Computer Supported Collaborative habits, gestures and emotions, is the next logical
Work (CSCW).3 However, a series of new technology step of this process.4,5
advancement, are providing the background for a In fact, as underlined by the AMBIENCE Project,
new change. According to different analysts IT world AmI can be defined as the merger of two important
is now in the middle of two concurrent trends4: visions and trends—“ubiquitous computing” and
“social user interfaces”:
• Pervasive diffusion of intelligence in the space
around us, through the development of wireless It builds on advanced networking technologies,
network technologies—WiFi and Bluetooth—ad- which allow robust, ad-hoc networks to be formed
vanced mobile communication—2.5 G and 3G by a broad range of mobile devices and other
networks—and intelligent sensors objects (ubiquitous- or pervasive computing). By

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

295
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FIG. 1. Converging technologies in the Ambient Intelligence paradigm.

(Adapted from Davide et al.4)

adding adaptive user-system interaction methods, cars and cities—through AmI will collectively de-
based on new insights in the way people like to in- velop a pervasive network of intelligent devices
teract with computing devices (social user inter- that will cooperatively gather, process and trans-
faces), digital environments can be created which port information.10 As noted by the ISTAG group10:
improve the quality of life of people by acting on
their behalf. These context aware systems combine Such an environment is sensitive to the presence of
ubiquitous information, communication, and enter- living creatures (persons, groups of persons and
tainment with enhanced personalization, natural maybe even animals) in it, and supports their activ-
interaction and intelligence. ities. It “remembers and anticipates” in its behavior.
—www.itea-office.org/projects/facts sheets/ The humans and physical entities—or their cyber
ambience fact sheet.htm representatives—together with services share this
new space, which encompasses the physical and
How does the emergence of the AmI paradigm virtual world.”
influence our vision of health care? This paper will
try to answer to this question. Specifically, using a AmI can be seen as the integration of functions at
scenario-based approach the paper will outline a the local level across the various environments. On
possible role of AmI in health care. one side this enables knowledge, content organiza-
tion and processing. On the other side, it also en-
ables the direct natural and intuitive interaction of
THE EMERGENCE OF AMI SPACE the user with applications and services spanning
collections of environments, including the cyber-
To date, some e-health applications have im- space level. In this sense, the AmI paradigm can
proved the quality of health care, and later they be seen as the direct extension of today’s concept
will lead to substantial cost savings.6,7 For instance, of ubiquitous computing: the integration of micro-
physicians can review radiological films and pa- processors into everyday objects. However, AmI
thology slides in remote sites, or assist and perform will also be more than this: a pervasive and unob-
surgery via remote robotics. trusive intelligence in the surrounding environ-
However, most of these applications are used for ment supporting the activities and interactions of
discrete clinical activities, such as scripting, lab-test- the users.4
ing, patient monitoring, and condition-specific di- The most ambitious expression of AmI is Intelli-
agnostics and treatment.8 As recently noted by Fifer gent Mixed Reality (IMR). Using IMR, it is possible
and Thomas,9 “the new question about E-medicine to seamlessly integrate computer interfaces into the
practice may be not ‘when will it happen?’ but real environment, so that the user can interact with
when will the fragmented E-health systems be con- other individuals and with the environment itself
nected?.” in the most natural and intuitive way.
A possible solution to this question comes from Within IMR, a key role will be played by Mobile
AmI. According to the vision of AmI provided by Mixed Reality (MMR): the enhancement of infor-
the Information Society Technologies Advisory mation of a mobile user about a real scene through
Group (ISTAG) to the European Commission, all the embedding of any objects (e.g., 3D, images,
the environment around us—homes and offices, videos, text, computer graphics, sound) within his
AMBIENT INTELLIGENCE IN HEALTH CARE 297

or her sensorial information.11 In this scenario, the • Augmented reality or virtual reality combined with
embedded information is based on factors like lo- conversational multimedia (or “virtual immersive
cation and direction of view, user situation/context cooperative environments”): Conversational multi-
aware (e.g., day of the time, holidays of business re- media can be also added to a VR or an aug-
lated), user preferences (i.e., preference in terms of mented reality scenario, where a user can see the
content and interests), terminal capabilities, and avatar of another user coming into the scene and
network capabilities. a 3D video conference is carried on. If we use
Moreover, following the AmI paradigm, any em- VR, given the position and orientation informa-
bedded object is context aware and based on fac- tion of the first user in the world, the second user
tors like location, direction of view, user situation, can put the first one (or his or her avatar) in a 3D
user preferences, terminal capabilities, and net- synthetic world.
work capabilities.
The possibilities offered by MMR are huge. By In the future, the terminal will be able to sense the
integrating within a common interface a wireless presence of a user and calculate his/her current sit-
network connection, wearable computer and head- uation. Throughout the environment, bio sensing
mounted display, MMR virtually enhances users’ will be used to enhance person-to-person and per-
experience by providing information for any object son-to-device communications. Biometrics technol-
surrounding them. They can manipulate and exam- ogy will be used to enhance security by combining
ine real objects and simultaneously receive addi- static (facial recognition) and dynamic information
tional information about them or the task at hand. (voice and lip movement, uncontrolled user ges-
Moreover, using augmented or mixed reality tures), as well as user’s habits, which the network
technologies, the information is presented three-di- will be able to acquire and maintain.
mensionally and is integrated into the real world. Further developing these points, ISTAG intro-
Recently, Christopoulos12 identified the following duced the concept of AmI Space. The Ami Space is
applications of MMR: composed of networked (using a changing collec-
tion of heterogeneous network) embedded systems
• Smart signs added to the real world: Smart signs hosting services that are dynamically configured
overlaid on user real world may provide infor- distributed components (Fig. 2). The AmI Space
mation assistance and advertisement based on can be seen as the integration of functions at the
user preferences. local level across the various environments and en-
• Information assistant (or “virtual guide”): The virtual ables the direct natural and intuitive dialogue of
guide knows where the user is, his or her heading, the user with applications and services spanning
as well as the properties of the surrounding envi- collections of environments—as well as at the cy-
ronment; interaction can be through voice or ges- berspace level—allowing knowledge and content
tures, and the virtual guide can be an animated organization and processing.13
guide and provides assistance in different scenar- In particular, the Ami Space should offer capabil-
ios based on location and context information. ities to accomplish the following:

FIG. 2. The AmI space. (Adapted from ISTAG.13)

298 RIVA

• Model the environment and sensors available to support multi-cultural content generation, its engi-
perceive it, to take care of the world model. This neering and management.
deals with the list of authorized users, available
devices, active devices, state of the system, and
so on.
AMI IN MANAGED CARE
• Model the user behavior to keep track of all the
relevant information concerning a user. Also, it
“Managed care” indicates a health care system
automatically builds the user preferences from
that uses organizational and management controls
its past interactions and eventually, abstracts the
to offer patients appropriate care in cost-effective
user profile to more general community profiles.
treatment settings. Today, the managed care envi-
• Interact with the user by taking into account the
ronment is beginning to focus its attention on new
user preferences. Natural interaction with the
technologies especially in the areas of organization
user replaces the keyboard and windows inter-
and clinical data management. However, the most
face with a more natural interface like speech,
recent research findings underline the possibility
touch or gestures.
that distributed communication media could be-
• Control security aspects to ensure the privacy
come a significant enabler of consumer health ini-
and security of the transferred personal data
tiatives. In fact, in comparison with traditional
and deal with authorization, key and rights
communication technologies, AmI offers greater
management.
interactivity and better tailoring of information to
• Ensure the quality of services as perceived by the
individual needs. In other words, AmI can be con-
user.
sidered a process and not a technology, including
different complementary areas: health care infor-
Within this frame, Immersive Virtual Telepres-
mation provision, administrative and clinical data
ence (IVT) and wireless technologies will play a
collection, therapy and assessment provision. In
fundamental role in helping the AmI vision to cope
particular, new and emerging technologies will
with the need for natural user interfaces and for
provide personalized, intelligent, assistive technol-
ubiquitous communication. The former will enable
ogy that can promote recovery and sustain inde-
the citizen to interact with the AmI and to control
pendence and quality of life. This vision is well
it in a natural and personalized way through voice
pictured by the “GRID” concept14: a coordinated
and gestures. The latter will provide the underly-
resource sharing and problem solving in dynamic,
ing network and will also enable electronic devices
multi-institutional virtual organizations supported
to communicate with each other and with the user.
by technologies and data management services that
However, the AmI requirements are not just tech-
guarantee secure remote access to computing and
nological. ISTAG identified a series of necessary
data resources and the co-allocation of multiple
characteristics that will permit the eventual soci-
resources.
etal acceptance of AmI.10 AmI should achieve the
In order to transform this vision in reality, below
following:
we tried to outline a real health care scenario in-
cluding all the innovations described before. Sce-
• Facilitate human contact
narios must be designed to encompass societal,
• Be orientated towards community and cultural
economic as well as technology developments and
enhancement
form a logical framework in which use cases can
• Help to build knowledge and skills for work,
be fitted. The European Commission and research
better quality of work, citizenship and consumer
organizations, such as the WWRF, encourage sce-
choice
nario-based approaches for pushing the research in
• Inspire trust and confidence
the right way. Experts have to analyze the scenarios
• Be consistent with long-term sustainability both
drawing consequences, and future research topics.
at personal, societal and environmental levels
The main output of these modeling efforts will con-
• Be controllable by ordinary people—i.e., the
sist in the “pieces of technology” needed to provide
“off-switch” should be within reach (these tech-
the functionalities envisaged within the reference
nologies could very easily acquire an aspect of
scenarios:
“them controlling us”)
Mario, a 40-year-old obese subject with Type 2 dia-
Moreover, the various AmI markets will require betes, was directed by his general practitioner to
specific contents to be successful. Particularly there start a self-management education program. Before
is a need for content-oriented tools and services to beginning the program, Mario is asked to provide
AMBIENT INTELLIGENCE IN HEALTH CARE 299

for information that enables the clinician to target to pursue appropriate learning experiences at a
the educational contents for his age, lifestyle, risk pace that suits them. The electronic tutoring system
factors and medical history. When Mario goes to negotiates its degree of participation in these expe-
the hospital to register for the class and for the visit, riences with the aid of the mentor. During the day,
the unique ID code of his Personal Area Network is the mentor and electronic tutoring system converse
recorded into the Information System and tracked frequently, establishing where the mentor might
in the Local Area Network of the hospital. More- most usefully spend his time, and sometimes alter-
over, a micro-payment system will automatically ing the schedule. They will also deal with requests
transfer the visit fee into the e-purse of the hospital. for references/profiles of individuals. Time spent in
When a week later Mario comes back to the hos- the ambient location ends by negotiating a home-
pital, his Personal Area Network is immediately work assignment with all individuals, but only
recognized. In a couple of seconds, a young nurse after they have been informed about what the am-
appears on the UMTS phone and describes the di- bient expects to happen for the rest of the day and
agnostic tests and the location of all the different making appointments for next day or next time.
professionals. In the meantime, each professional
can track the position of both Mario and any other
patient on his office monitor. In case of delays or
CONCLUSION
problems, the visit schedule is modified to reduce
the waiting time. In this way, all testing is done in
one morning in one place. Through the use of GRID The proposed scenario was constructed to pro-
technologies, the collected data are stored and com- vide something to think about with respect to
pared with millions of images and files of relevant longer-term developments in Information and
medical information held on distributed computer. Communication Technologies (ICTs) for health care.
All the analyses are normal. More specifically we wanted to explore the future
In the afternoon, Mario can choose lifestyle con- technologies that are implied by the vision of AmI.
sultations customized to meet his health needs. The In fact, the scenario exercise indicates that the vision
hospital endocrinologist, clinical psychologist, ex- of AmI is a strong starting point for giving direction
ercise physiologist and registered dietitian give to research over the coming 5 years. Major opportu-
Mario specific indications that are recorded on the
nities to create an integrated AmI landscape can be
PDAs of the professionals. Should Mario come back
built upon emerging technological strengths in
later to the office of the specialist, his Personal Area
Network is tracked by the Local Area Network, and areas such as mobile communications, portable de-
through the GRID system, all the information about vices, systems integration, embedded computing
any previous visit and any assessment result will be and intelligent systems design.
immediately available on the specialist’s monitor. However, transforming the scenario in reality is
After the visits, the primary examining physician not an easy task: the more that a technology is com-
explains to Mario his test results and provides a plex and costly, the less the user is prone to accept
personal health action plan. Through the UMTS it. This happens despite possibly large potential ad-
phone, a detailed written report and individualized vantages, which are generally not reachable by the
directions are provided to Mario at weekly inter- average user not interested in spending time and
vals. In this way, Mario can follow the plan inde-
energies in acquiring the underlying technology
pendently from his physical location.
fundamentals. Therefore, the successful systems of
A couple of days after, Mario starts his program.
The plenary takes place in a room looking much the future will adhere to the paradigm of “disap-
like a hotel foyer with comfortable furniture pleas- pearing technologies,” valid for both communica-
antly arranged. As Mario enters the room and finds tions and computing, and will provide improved
himself a place to work, he hears a voice asking ease-of use at the expense of an increased (but in-
“Hello Mario, here is the program of the coures: are visible to the user) complexity of the underlying
you ready?” The electronic tutoring system goes systems and networks necessary to transport and
briefly through its understanding of Mario’s avail- process the information in the different multimedia
ability and preferences for the day’s work. Mario is forms and usage contexts. As both the physician
an active and advanced student, so the electronic and the patient have to be put at the “center of the
tutoring system says it might be useful if Mario
universe of technologies,” clearly the elaboration of
spends some time today trying to pin down the
a purely technical vision of the future of health care
problem using enhanced interactive simulation and
projection facilities. It then asks whether Mario is not only insufficient but even dangerous. Rather,
would give a brief presentation to the group. Fi- any viable technical solutions must be put into a
nally, Mario agrees on the work program for the much wider perspective.
day. During the day, individuals and subgroups lo- In this sense, clinicians and health care providers
cate in appropriate spaces in the ambient location that want to exploit AmI potential need a significant
300 RIVA

attention to project management, ergonomics, Press. Online: www.emergingcommunication.com/

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7. Meaney, B. (2002). Gartner lists top 10 e-health issues
for 2002. Internet Healthcare Strategy 4:11.
ACKNOWLEDGMENTS 8. White, L., & Terner, C. (2001). E-health, phase two:
the imperative to integrate process automation with
The present work was supported by the Commis- communication automation for large clinical refer-
sion of the European Communities (CEC), specifi- ence laboratories. Journal of Healthcare Information
cally by the IST programme through the VEPSY Management 15:295–305.
UPDATED (IST-2000-25323) research project (www. 9. Fifer, S.K., & Thomas, N. (2002). A second and more
cybertherapy.info). promising round of e-health enterprises. Management
Care Interface 15:52–56.
10. Ducatel, K., Bogdanowicz, M., Scapolo, F., et al.
(2000). Scenarios for ambient intelligence in 2010 (ISTAG
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