Feature Article
INTERVIEW WITH DR. ANTHONY GLASCOCK
AND DR. DAVID KUTZIK, DREXEL UNIVERSITY
Where there's smoke...
The "Smart Home" concept comes home at last-with a few
changes
In the last few years,
there has been quite a buzz in the long-term care industry
about the "Smart Home" concept-a new wave of technologies
that aims to monitor elders in their homes electronically
and with minimal interference to encourage aging in place.
While conference audiences and magazine readers have
embraced the idea, they are generally left wondering when
exactly this futuristic technology would actually be ready
to enter people's homes. For the most part, that question
has gone unanswered.
Enter Dr. Anthony
Glascock, a gerontologist and professor of anthropology at
Drexel University, and Dr. David Kutzik, an associate
professor of sociology at Drexel and a gerontologist with
a background in technology. The pair are co-inventors of
the technology used in New York-based Living
Independently's QuietCare system. They hold the patents on
the technology in both the United States and Canada, with
patents pending in the European Union and elsewhere. The
system strips the Smart Home idea of bells and whistles,
using small wireless sensors placed throughout the home to
monitor activities of daily living (ADLs). It reports
these findings to the QuietCare-Status center for analysis
24/7, and immediately contacts a designated caregiver if
anything seems amiss. The system is simple, affordable,
and unobtrusive, but perhaps most significantly, it is
available today, the first of its kind to actually hit the
market.
Glascock and Kutzik talked
with Nursing Homes/Long Term Care Management Assistant
Editor Todd Hutlock about aging in place, their system and
how it differs from the Smart Home concept, and other
related topics.
How did the project begin?
Glascock: My area of
research for the last 10 to 15 years has been home
healthcare and home delivery of care. Dave and I have been
working on this project for ten and a half years. Back in
the late 1980s, I had been doing a lot of research on
multi site, multicultural projects supported by the
National Institute on Aging, in Africa, China, the United
States, and Ireland. I lived in a small community in
western Ireland for about 18 months, and as part of my
research, I asked people there a series of questions, one
of which was "Have you ever cared for or helped an older
person?" Usually I got answers like, "Yes, we drive my
mother to the hospital in Galway" or "We take my older
aunt to Mass on Sunday." A man named Sean said, "Yes, I
get up every morning and I look across the valley at
Paddy's house to see if smoke is coming out of the
chimney." I had no idea what that meant. He said, "If I
see smoke coming out of his chimney by half-seven in the
morning, I know that he's up, he's started his fire, he's
got his tea going, he's up and around, and everything's
okay. If I don't see smoke by half-seven, I walk over
there because there might be something wrong."
Fast-forward another two
or three years, and my mother was experiencing some health
problems and needed to change her medication regimen. At
that time, she was extremely hard of hearing-now she's
deaf-and I didn't want to make that phone call to ensure
shewas taking her medication for some fairly typical
reasons- because it was in the morning, I was on my way to
work, I was rushed, etc. Plus, that awkward role
reversal-I have over time assumed the parental role, but
it is still very difficult for children to become the
parent. All I wanted to do was just see if she had taken
her medication somehow. So I asked Dave if it would be
possible for us to check via computer if my mother had
taken her medication, following the idea of the smoke
coming out of the chimney. Dave said no, that's too
difficult. A day later, he came back and said yes, it can
be done, let's do it. His father was very ill at that
time, my mother was having health problems, and so we
developed the system primarily to help our own parents and
ourselves, to provide more security for them, and more
peace of mind for us. Our philosophy, though, goes right
back to the smoke out the chimney-to develop a system that
is non intrusive, passive, and doesn't ask people to
change their behavior, and yet provides a record of what
they are doing so changes can be seen and you can
intervene before they become a crisis.
How did Living Independently get
involved in the project?
Kutzik: They sought us
out, but our contact there, George Boyajian [see sidebar],
is someone whom we met years before when we were looking
around to see how to commercialize. He contacted me, and
then the main people behind Living Independently came and
met Anthony and myself and our business representative in
Philadelphia and the rest is history.
Glascock: We're not
business people. We decided a long time ago that we are
what we call "true believers in the system." We really
just think it will help people. We did not take out second
mortgages on our houses, and we did not build these
systems in a garage and sell them out of the back of our
truck.
Kutzik: Though we did
build them in a garage!
Glascock: True, we did do
that in the research stage. But we decided a long time ago
that the only way we could only have this system brought
to market in the United States was through a company like
Living Independently. We explored different options, and
this seemed to be the best one.
So you got into building the
system to help your own situations, and then somewhere
along the way, it occurred to you that it could help
others, as well?
Glascock: Yes, exactly.
Kutzik: Also, I got into
gerontology through work in the planning department of the
local area agency on aging. I was involved in the design
and redesign of long-term care case management systems,
and I've done a lot of work in medication adherence. So
our research interests came into this from the beginning,
and as a research tool, this system is incredible. No one
has ever known what people are actually doing other than
asking someone-who also might potentially have a memory
problem-"Have you remembered to remember to take your
medication today?" or, "Have you done x, y, or z?"
Retrospective interviewing essentially. Now, for the first
time, in an unobtrusive way, we know what people are
doing, and sometimes more importantly what they are not
doing, 24/7, automatically.
Glascock: Let me give you
an example. A few years ago, I had an infection of the
prostate. As you know, males are pretty sensitive about
this, so I went to my urologist. The doctor said to me,
"Has your behavior changed? Are you getting up more at
night to go to the toilet?" Now, I do a lot of cycling and
I put incredible amounts of fluid in my body and I
normally get up several times a night. I had no idea of
the change. In fact, I had no idea how many times a night
I usually got up before the infection. So, even if you are
not cognitively impaired-and some elders are-even if it's
an important thing, you just might not know. The doctor
asked me if this behavior had changed, and I said, "I
don't know." So I asked my wife, "Do I get up more? How
many times do I get up on average?" Well, this system
tells you that sort of thing- you don't have to remember.
David put it in my house and actually monitored me when we
were on a trip once, for which I have great gratitude, but
at least I was able to tell the doctor the next time what
my average was.
Kutzik: To make it clear,
I did not perform any sort of prostate exam on him.
Glascock: [laughs] Well,
the point is that the activities of daily living, the
things that we do 10,000 times in our life without
thinking about them, are the hardest things to remember,
even if you aren't cognitively impaired. We went to a
whole series of professionals-physicians, geriatric
nurses, geriatric social workers, case managers, discharge
planners, etc.-and asked them what we should monitor. The
top ten items were very consistent. We developed a system
that was software- driven, where you can add and subtract
and monitor different things, could monitor different
types of people-children, the elderly, etc.-and any
caregiver can assess the information exactly and then take
steps. The key is to deliver the appropriate care by the
appropriate person at the appropriate time. When things
are not looking good or have changed, the longer you wait,
the more chances that it can turn into a crisis and the
more chances that the person will end up in some sort of a
facility rather than in his or her own home. We want to
keep people living independently as long as possible with
the highest level of security and peace of mind.
Can you fill me in a little bit on
the history of the research for this project?
Kutzik: Our first
installation, after prototyping the system in a lab, was
in a large medical center's ADL suite in a rehab wing,
where people were brought in to spend time overnight
independently and to carry out the ADLs. We had our
monitoring system set up, and we monitored everything in
the world there with motion detectors and appliance
monitors, and validated it with TV cameras that recorded
what they were doing. So we had cases such as asking a
person, "Did you use your reacher to grab that item
instead of getting on top of a chair?" and she replied
that of course she used the reacher-but we would know from
the TV cameras that she didn't. We learned a great deal
from things like this, in addition to cross-validating the
fundamental measurement concept. The main thing was that
we didn't really have to monitor so many things to really
get a good picture of the ADLs, as long as we targeted
what we're monitoring, and those objects that are
invariably interacted with or used or passed by in the
environment when you carry out these tasks. From there, we
basically took this larger system, put it in a suitcase,
took it on the road, and did a series of different tests
in the homes of folks living alone. Through those trials,
we basically showed that a few motion detectors and a
couple of reed switches can tell you an amazing amount of
detail about the people's ADLs. From there, we basically
went Web. We saw this as a Web-based system and a
Web-based business, essentially.
Glascock: Remember, this
was academic research. We built these on Dave's kitchen
table. We installed them, checked them, and developed the
algorithms. We're social scientists so we believe in trend
analysis, but we're also minimalists-the fewer things you
need to monitor, the cleaner the data and the easier they
are to interpret. We narrowed this down to as little
equipment as possible, but behind that is a very
sophisticated computer software package that actually
continuously analyzes the data, looks for trends, and
looks for variations from the trends. That's the
intellectual property. Many of the other people who are
working with this sort of technology and in similar areas
started with the technology and tried to develop a dual
use for it, be it submarine technology or security systems
or whatever. We started with a need and then tried to use
only existing technology that was readily available, the
idea being to keep it cost-effective. We're the anti-Smart
Home people.
How do you see what you're doing
as different from what the Smart Home researchers are
doing?
Glascock:You might call it
"impaired Smart Home." We deliberately dumbed-down
SmartHomes. There's nothing wrong with the Smart Home
philosophy, it's just very expensive. It asks people to do
a lot of things. For example, we were at a meeting and we
saw a Dutch Smart Home project that tried to do a lot of
very sophisticated things, but as people grow older, they
become less willing and able to deal with change. So they
put all of this very nice, sophisticated stuff in, and
they had to take it all out. People just did not want it.
I think much of the Smart Home technology is built by
young people and is aimed at relatively well-off younger
people who want to do interesting, technologically
sophisticated things in the home.
Kutzik: It's also built by
engineers. We worked with a large company early on and
there was a real divergence of opinion. Basically, they
had the view that if you monitor everything and have a
gigantic artificial intelligence system to figure out what
is going on, then you basically have a Smart Home that can
assist or even conduct care giving. The fact is that ADLs
do not afford task analysis structures and databases the
way factories that produce paper do since people are not
working on automated assembly lines in their homes. So we
have a theoretical difference as well as a gerontologic
difference. Personally, I do not want to be in a nursing
home like the one in Japan where a teddy bear with wires
in its back asks you how you are feeling today and times
how long your response takes and makes measurements based
on that sort of information. I don't want to be messed
with in my house like that, and older people are sensitive
about those things. It gets into the areas of dignity, as
well as environmental press-you must not do everything for
People ethat they are still capable of doing. The house
and the environment should not intervene all the time, or
the people will become dependent, and that is not good.
That's the main difference between us and many of the
Smart Home people.
How important was keeping the cost
of the system low in the design stages?
Glascock: We want this to
be so cost-effective that it becomes widely used. We
believe that the people who need it the most are people
who have the least ability to pay for sophisticated
systems. If you have lots of money, you can buy support;
you can have an all-day nurse or the like. The people who
can't afford that, who need to have a relatively
inexpensive system that allows them to remain in their own
homes and to feel secure-those people need it.
Kutzik: The other thing
is, unlike any other system that you might want to compare
it to, it does not require a high-speed Internet
connection or a fancy digital cable or DSL or what have
you. It basically uses the existing phone line, dialing in
to an 800-number. It is intended to be as simple as
possible, and it can be done very cost-effectively, and
that's not even factoring in the cost savings of keeping
someone out of a facility such as a nursing home or
hospital longer.
Glascock: Our thinking was
if you can keep a person out of the hospital for one
night, the savings will pay for the system for a whole
year. Dave and I had early discussions about how much it
was going to cost to build these systems. When we first
came up with this idea, we couldn't do half of the things
we wanted to do-the technology just wasn't there. But we
were able to look down the road a bit and we thought that
by the time we get all of this together, the technology
will be there to allow us to do it, and that is what
happened. When we first started doing this, we weren't
working on the Web, we were doing it with phone lines and
microwaves. We've come a long way. But underlying all of
this is the story about Sean watching to see if smoke is
coming out of the old man's chimney. That's the most
simple, cost-effective, and noninvasive medium you can
find. We wanted something that was like smoke, basically,
and it turned out to be the Internet. We have this
presentation that we make to our fellow researchers called
"From Smoke to E-mail" which basically explains how the
Internet actually comes as close as you can to being
smoke, sort of the electronic smoke metaphor. I mean, we
milked this metaphor to the point where we're not even
embarrassed by it anymore. We're academics so we don't
really have monetary rewards, so when people tell us it's
a great story, we just tell it over and over and over
again.
Do you feel like you were thinking
ahead of the curve with all of this back when you started?
It must have all seemed very high-tech and futuristic a
decade ago.
Glascock: People always
say to us now, "Wow, what a brilliant idea. You were ahead
of the curve." Well, it's not always best to be first,
because no one gets it. You have to figure it all out and
explain it to companies and then they invariably tell you,
"Well, that's not a bad idea. Give us a call when you get
it a little further developed. Are other people doing
this?" As if it's not a good idea unless there are
competitors.
Kutzik: Well, they'll say
you are brilliant and that it's a good idea, they just
won't give you any money.
Glascock: Right-you'll
hear that it's a brilliant idea, but they will question
whether it is a good business idea. We are at the stage
now where we will be able to prove it's a great business
idea.
What's next for the two of you,
and how do you see this type of technology growing in the
future?
Glascock: The next stage
is what we call the basic homecare platform. What we do is
essentially behavioral monitoring because we monitor ADLs.
We think there is going to be a platform that is going to
unite the behavioral monitoring with the nascent
telemedicine, security, and environmental technologythat
is coming out now, and we happen to think that our
platform is the logical one to make that step. We are
already talking to people who want to add blood pressure
and diabetes monitoring to this platform. We've taken a
different approach because we didn't have endless
resources. We developed a platform that is extremely
simple and extremely cost-effective. Cost drives the
market in America. If we have a simple platform that you
can attach other things to, and it keeps that cost
extremely low, why wouldn't we be that platform for the
future? We are in discussions to add more simple
technologies-simple things like a scale or temperature.
Kutzik: Or knowing that
the stove was left on, or if the person has left the
apartment with the door open or unlocked.
Glascock: It's not our
area, but we've developed a platform that can accommodate
these things. Something like a thermometer costs very
little to add, but it gives people an added sense of
security. And how cost- effective is that compared to
sending case -workers out knocking on doors during heat
waves?
Kutzik: It's 10,000 times
more efficient.
Glascock: And that had
better make it into the article! [laughs]
SIDEBAR
Bringing New
Technology Home
Marketing and selling a
product that the world has never seen before can be a
challenge for any company. In the case of the QuietCare
system-the first such monitoring system of its kind- that
challenge is being taken up by the New York-based company
Living Independently.
The QuietCare system uses
infrared sensors and a sophisticated computer program to
analyze ADLs of the elderly. Wireless sensors are placed
in five areas of the home-such as the bedroom, bathroom,
and kitchen-to monitor specific ADLs. The system "learns"
a person's specific behavior patterns using proprietary
algorithms. The sensors continuously track motion and
transmit the data to a base station (about the size of a
paperback book); the base station then sends the data over
the existing telephone line to the company's secure server
for analysis. The data are then updated at least 12 times
daily. This information is posted on a private Web page,
accessible to the designated caregiver. According to how
the data match a person's normal measurements, the
indicators given to the caregiver can be "green,"
"yellow," or "red." "Red" alerts are sent directly to the
caregiver via telephone, cell phone text message, e-mail,
pager message, or fax.
George Boyajian, PhD,
executive vice-president-Strategy, Research and
Development of Living Independently, sums up the appeal of
the QuietCare system with a simple metaphor that most
every consumer can grasp: "If you look at the traditional
personal emergency response systems-alarm bracelets,
necklaces, and watches, etc.-they are like the airbag in a
car. The system goes off after the 'crash,' or the medical
crisis occurs, if it goes off at all, and many times the
elders are not wearing them or won't use them anyway. Our
system is the brakes and the steering wheel that help you
avoid accidents before they occur."
According to Boyajian, the
entire project came about rather quickly: "In 2002, I
joined forces with my business partner John Lakian, and we
were interestedin starting biotech businesses. I told John
that I knew of Dave Kutzik and Anthony Glascock's work and
that I thought it would be very good to pursue. In late
2002, we licensed the patents from Dave and Anthony (they
own the patents, and we have the exclusive commercial
license to them, which is generally the way these deals
are done). We went from an idea that they had and built an
entire software/hardware system and platform and tested it
over about 12 to 14 months, and then fielded it and
started selling it-an absurdly quick turnaround."
Since its arrival in the marketplace in early 2004, the
QuietCare system has sold well,Boyajian reports.
To what does Boyajian
attribute the early success of the QuietCare system? "Part
of the success is knowing people who can get things done,
and so part of it is just experience," Boyajian explains.
"Another thing is keeping the system as simple as
possible.
The problem with most new
technologies and new products, especially those based on
the Internet, is that they overbuild and don't listen to
the experts in the field. Large technology companies are
overbuilding these spectacularly engineered,
measure-everything- in-the-house systems, but when you
talk to geriatricians, they don't want or need all of that
information. What they need are the ADL reports that
indicate changes in functional health. Many companies
haven't focused on these key indicators of health."
Another key to success has
been the system's relatively low cost, a pleasant surprise
to those who picture new technology as being prohibitively
expensive. "Give Dave and Anthony credit for that- and
mainly Dave-in that they worked mainly with off-the-shelf
hardware," says Boyajian. "We aren't dependent on anyone's
hardware, per se: We can use anyone's motion detectors,
for instance. What really makes our system work and makes
it cost- effective is that the communications device is
unique. We found a company that had produced this type of
product for another purpose, and then we had them redesign
it for us and they now build it custom for us. We can get
all of the hardware for under $150, which again is unheard
of in this business.
"Most technology companies
say, 'We've got a hammer. Let's go look for nails.'
They'll use their 'hammer' to bang in anything, and these
big companies doing Smart Home research have all of these
motes and mites and these tiny little sensors, and that is
their hammer," Boyajian continues. "We need to get away
from that. The problem here is that caregivers are
stressed because they don't have enough information to
make the proper decision. We figured out what needed to be
monitored and made a simple system to do that-in other
words we built the simplest and least expensive hammer to
do the job. We took our time and with Dave and Anthony's
help built an efficient system. As Ben Franklin said, 'If
I had more time, I would have written a shorter letter.'
"Most of our sales to date
have been institutional sales," says Boyajian. "We're
working with healthcare systems, government agencies, and
not-for-profit agencies who are putting this into their
facilities and their patients' or clients' homes and using
it to serve their constituents better."
