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

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, NTNU lillk@item.ntnu.no www.item.ntnu.no/~lillk

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,..

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

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)

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

B’s presence service GUI via e.g. Outlook 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 Opening up the telco networkusing H.323 Annex K and OSA

Setup Alerting (url) callWaiting.invoke Load(url) GET url Display Http 200 OK (data) GET url (I’ll wait) Http 200 OK (data) Connect H.323 annex K (http service control) Ex. with Call Waiting (H.450) plus interactions Terminal Browser End-user C Terminal C Terminal B Web-server I’m busy now, but you may: 1. Wait - it’s urgent, 2. Leave a message Notify B, its urgent Maybe endpoint centric (at Bs endpoint) or network centric B’s VASP

’Interactive screening’ using SIP (2005) From Østhus and Kristiansen (2005) (ServiceFrame and OSA was not used)

Group communication for healthcare workers designed in ServiceFrame 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 Medical Department Stroke Unit Heart Unit Kidney Unit G1 G2 G3 G4 G1 G2 G3 G4 G1 G2 G3 G4

Primary group – G1 Lise Per Lise Location: Room 331 Presence: Meeting GroupSession: 0 Location: Room 333 Presence: Busy with patient GroupSession: 1 Stroke Unit Primary group - G1 Ole Kari Help Patient Location: Room 338 Presence: Busy with patient GroupSession: 0 Location: Room 337 Presence: Free GroupSession: 0 Interface on handheld terminal SCENARIO 1 FROM TRONDHEIM UNIVERSITY HOSPITAL – HELP WITH PATIENT Location: Room 333 Presence: Busy with patient GroupSession: 1

SCENARIO 2 FROM TRONDHEIM UNIVERSITY HOSPITAL – EMERGENCY Per Location: Room 333 Presence: Emergency GroupSession: 1 Primary group - G1 Primary group - G1 Stroke Unit Stroke Unit Emergency EMERGENCY IN ROOM 333 Interface on the terminals The patient’s doctor Emergency team

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”

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, glassgården etc. (high ceilings) • location from several sources was prepared for though • Today we have Radionor office indoor location integratedin 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 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

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 id OR signalling that a nurse is called (kalt opp) OR several in round robin fashion

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?

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)

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)

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)

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

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’?

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,...

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

(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!

(Canonical) Action Research AR/CAR • 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.’)

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

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

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

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

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&issn=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

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

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