Adaptação à distância de próteses auditivas acústicas: a teleaudiologia aplicada na melhoria da condução das Políticas Públicas no Brasil

INTRODUÇÃO: O governo brasileiro atualmente credencia cerca de 140 centros especializados para adaptações de aparelhos de amplificação sonora individual via SUS. Adaptações à distância através da internet podem permitir maior eficiência na prestação deste serviço e com maiores chances de aceitação por parte do paciente do SUS. OBJETIVOS: Descrever o caso de adaptação à distância realizado entre duas cidades, com revisão da literatura. MÉTODO: Equipamentos de informática e de tecnologia da informação, programador universal, aparelhos de amplificação sonora individual. ESTUDO DE CASO: Uma fonoaudióloga lotada num centro especializado introduziu a um centro remoto (distância de 200 km) um novo aparelho de amplificação sonora individual e seu programa de adaptação. O centro remoto assistiu a adaptação de dois pacientes em sua clínica, realizando voluntariamente a adaptação do terceiro paciente. Todo o procedimento foi realizado através da internet, contando com recursos de áudio e vídeo em todos os procedimentos. RESULTADOS: Três pacientes foram adaptados à distância. Três fonoaudiólogas receberam treinamento à distância de como adaptar aparelhos auditivos. CONCLUSÃO: Foi possível adaptar AASI à distância, além de prover treinamento e habilitar um centro remoto na adaptação de um novo aparelho de amplificação sonora individual e de seu programa de adaptação. Tal procedimento pode ser útil ao governo na condução de políticas públicas da saúde auditiva.

Telessaúde: avaliação da eficácia da teleconsulta na programação e adaptação de aparelho de amplificação sonora individual

OBJETIVO: Avaliar a eficácia da teleconsulta para a programação, verificação e adaptação do aparelho de amplificação sonora individual (AASI). MÉTODOS: Cinquenta participantes com deficiência auditiva (idades entre 39 e 88 anos), com média dos limiares audiométricos entre 30 e 68,75 dBNA, foram alocados em dois grupos (randomização estratificada), controle (n=25) e experimental (n=25), submetidos respectivamente à consulta face a face e teleconsulta síncrona com video interativo e controle remoto de aplicativos. Foram realizadas a programação e verificação do AASI (medidas com microfone sonda) e orientação dos participantes quanto ao uso e cuidados com o dispositivo. O tempo para os procedimentos foi cronometrado. Após as consultas um avaliador, cego quanto aos grupos, aplicou o teste de percepção da fala Hearing in Noise Test (HINT) Brasil. Aproximadamente um mês após as consultas, foi verificado o tempo diário de uso do AASI e administrado o questionário International Outcome Inventory for Hearing Aids (IOI-HA). RESULTADOS: Maior tempo para a programação e verificação e menor tempo para orientação foi observado para o grupo experimental. Não houve diferença entre grupos no tempo total do atendimento. A equiparação das medidas com microfone sonda aos respectivos targets de amplificação foi similar para os dois grupos. Não houve diferença entre os grupos quanto aos resultados do HINT-Brasil (silêncio e ruído), o tempo médio de uso diário do AASI e resultados do IOI-HA. CONCLUSÃO: A teleconsulta é um procedimento eficaz para a programação, verificação do AASI e orientação de usuários quando serviços face a face não estiverem disponíveis.

Body ares networks for human motor assessment

Healthcare, Human Computer Interfaces (HCI), Security and Biometry are the most promising application scenario directly involved in the Body Area Networks (BANs) evolution. Both wearable devices and sensors directly integrated in garments envision a word in which each of us is supervised by an invisible assistant monitoring our health and daily-life activities. New opportunities are enabled because improvements in sensors miniaturization and transmission efficiency of the wireless protocols, that achieved the integration of high computational power aboard independent, energy-autonomous, small form factor devices. Application’s purposes are various: (I) data collection to achieve off-line knowledge discovery; (II) user notification of his/her activities or in case a danger occurs; (III) biofeedback rehabilitation; (IV) remote alarm activation in case the subject need assistance; (V) introduction of a more natural interaction with the surrounding computerized environment; (VI) users identification by physiological or behavioral characteristics. Telemedicine and mHealth [1] are two of the leading concepts directly related to healthcare. The capability to borne unobtrusiveness objects supports users’ autonomy. A new sense of freedom is shown to the user, not only supported by a psychological help but a real safety improvement. Furthermore, medical community aims the introduction of new devices to innovate patient treatments. In particular, the extension of the ambulatory analysis in the real life scenario by proving continuous acquisition. The wide diffusion of emerging wellness portable equipment extended the usability of wearable devices also for fitness and training by monitoring user performance on the working task. The learning of the right execution techniques related to work, sport, music can be supported by an electronic trainer furnishing the adequate aid. HCIs made real the concept of Ubiquitous, Pervasive Computing and Calm Technology introduced in the 1988 by Marc Weiser and John Seeley Brown. They promotes the creation of pervasive environments, enhancing the human experience. Context aware, adaptive and proactive environments serve and help people by becoming sensitive and reactive to their presence, since electronics is ubiquitous and deployed everywhere. In this thesis we pay attention to the integration of all the aspects involved in a BAN development. Starting from the choice of sensors we design the node, configure the radio network, implement real-time data analysis and provide a feedback to the user. We present algorithms to be implemented in wearable assistant for posture and gait analysis and to provide assistance on different walking conditions, preventing falls. Our aim, expressed by the idea to contribute at the development of a non proprietary solutions, driven us to integrate commercial and standard solutions in our devices. We use sensors available on the market and avoided to design specialized sensors in ASIC technologies. We employ standard radio protocol and open source projects when it was achieved. The specific contributions of the PhD research activities are presented and discussed in the following. • We have designed and build several wireless sensor node providing both sensing and actuator capability making the focus on the flexibility, small form factor and low power consumption. The key idea was to develop a simple and general purpose architecture for rapid analysis, prototyping and deployment of BAN solutions. Two different sensing units are integrated: kinematic (3D accelerometer and 3D gyroscopes) and kinetic (foot-floor contact pressure forces). Two kind of feedbacks were implemented: audio and vibrotactile. • Since the system built is a suitable platform for testing and measuring the features and the constraints of a sensor network (radio communication, network protocols, power consumption and autonomy), we made a comparison between Bluetooth and ZigBee performance in terms of throughput and energy efficiency. Test in the field evaluate the usability in the fall detection scenario. • To prove the flexibility of the architecture designed, we have implemented a wearable system for human posture rehabilitation. The application was developed in conjunction with biomedical engineers who provided the audio-algorithms to furnish a biofeedback to the user about his/her stability. • We explored off-line gait analysis of collected data, developing an algorithm to detect foot inclination in the sagittal plane, during walk. • In collaboration with the Wearable Lab – ETH, Zurich, we developed an algorithm to monitor the user during several walking condition where the user carry a load. The remainder of the thesis is organized as follows. Chapter I gives an overview about Body Area Networks (BANs), illustrating the relevant features of this technology and the key challenges still open. It concludes with a short list of the real solutions and prototypes proposed by academic research and manufacturers. The domain of the posture and gait analysis, the methodologies, and the technologies used to provide real-time feedback on detected events, are illustrated in Chapter II. The Chapter III and IV, respectively, shown BANs developed with the purpose to detect fall and monitor the gait taking advantage by two inertial measurement unit and baropodometric insoles. Chapter V reports an audio-biofeedback system to improve balance on the information provided by the use centre of mass. A walking assistant based on the KNN classifier to detect walking alteration on load carriage, is described in Chapter VI.

Das OtCM-System zur elektronischen Compliance-Messung : Qualitätsuntersuchung der OtCM-Blister und e-Dispenser ; Validierung und Nutzenevaluation im Vergleich mit MEMS

Im Rahmen der vorliegenden Arbeit wurden Eignung und Nutzen des „Objective therapy Compliance Measurement“ (OtCMTM)-Systems, einer innovativen Weiterentwicklung im Bereich der elektronischen Compliance-Messung, untersucht. Unter experimentellen Bedingungen wurden Funktionalität und Verlässlichkeit der elektronischen OtCMTM-Blisterpackungen überprüft, um deren Eignung für den klinischen Einsatz zu zeigen. Funktionalität (≥90% lesbare Blister), Richtigkeit (≤2% Fehler) und Robustheit waren bei den OtCMTM-Blistern der Version 3 gegeben, nachdem die Fehler der Versionen 1 und 2 in Zusammenarbeit mit dem Hersteller TCG identifiziert und eliminiert worden waren. Der als Alternative zu den elektronischen Blistern für die Verpackung von klinischen Prüfmustern entwickelte OtCMTM e-Dispenser wurde bezüglich Funktionalität und Anwenderfreundlichkeit in einer Pilotstudie untersucht. Dabei wurde ein Optimierungsbedarf festgestellt. In einer klinischen Studie wurde das OtCMTM-System mit dem als „Goldstandard“ geltenden MEMS® verglichen. Vergleichskriterien waren Datenqualität, Akzeptanz und Anwenderfreundlichkeit, Zeitaufwand bei der Bereitstellung der Medikation und Datenauswertung, sowie Validität. Insgesamt 40 Patienten, die mit Rekawan® retard 600mg behandelt wurden, nahmen an der offenen, randomisierten, prospektiven Studie teil. Das OtCMTM-System zeigte sich bezüglich Validität, Akzeptanz und Anwenderfreundlichkeit mit MEMS® vergleichbar. Eine erwartete Zeitersparnis wurde mit dem OtCMTM-System gegenüber MEMS® nicht erreicht. Vorteile des OtCMTM-Systems sind eine höhere Datenqualität und die Möglichkeit zum Einsatz in der Telemedizin.

Optimisation of chemical lysis protocol for point-of-care leukocyte differentiation

The full blood cell (FBC) count is the most common indicator of diseases. At present hematology analyzers are used for the blood cell characterization, but, recently, there has been interest in using techniques that take advantage of microscale devices and intrinsic properties of cells for increased automation and decreased cost. Microfluidic technologies offer solutions to handling and processing small volumes of blood (2-50 uL taken by finger prick) for point-of-care(PoC) applications. Several PoC blood analyzers are in use and may have applications in the fields of telemedicine, out patient monitoring and medical care in resource limited settings. They have the advantage to be easy to move and much cheaper than traditional analyzers, which require bulky instruments and consume large amount of reagents. The development of miniaturized point-of-care diagnostic tests may be enabled by chip-based technologies for cell separation and sorting. Many current diagnostic tests depend on fractionated blood components: plasma, red blood cells (RBCs), white blood cells (WBCs), and platelets. Specifically, white blood cell differentiation and counting provide valuable information for diagnostic purposes. For example, a low number of WBCs, called leukopenia, may be an indicator of bone marrow deficiency or failure, collagen- vascular diseases, disease of the liver or spleen. The leukocytosis, a high number of WBCs, may be due to anemia, infectious diseases, leukemia or tissue damage. In the laboratory of hybrid biodevices, at the University of Southampton,it was developed a functioning micro impedance cytometer technology for WBC differentiation and counting. It is capable to classify cells and particles on the base of their dielectric properties, in addition to their size, without the need of labeling, in a flow format similar to that of a traditional flow cytometer. It was demonstrated that the micro impedance cytometer system can detect and differentiate monocytes, neutrophils and lymphocytes, which are the three major human leukocyte populations. The simplicity and portability of the microfluidic impedance chip offer a range of potential applications in cell analysis including point-of-care diagnostic systems. The microfluidic device has been integrated into a sample preparation cartridge that semi-automatically performs erythrocyte lysis before leukocyte analysis. Generally erythrocytes are manually lysed according to a specific chemical lysis protocol, but this process has been automated in the cartridge. In this research work the chemical lysis protocol, defined in the patent US 5155044 A, was optimized in order to improve white blood cell differentiation and count performed by the integrated cartridge.

A feasibility study for the provision of electronic healthcare tools and services in areas of Greece, Cyprus and Italy

Background Through this paper, we present the initial steps for the creation of an integrated platform for the provision of a series of eHealth tools and services to both citizens and travelers in isolated areas of thesoutheast Mediterranean, and on board ships travelling across it. The platform was created through an INTERREG IIIB ARCHIMED project called INTERMED. Methods The support of primary healthcare, home care and the continuous education of physicians are the three major issues that the proposed platform is trying to facilitate. The proposed system is based on state-of-the-art telemedicine systems and is able to provide the following healthcare services: i) Telecollaboration and teleconsultation services between remotely located healthcare providers, ii) telemedicine services in emergencies, iii) home telecare services for "at risk" citizens such as the elderly and patients with chronic diseases, and iv) eLearning services for the continuous training through seminars of both healthcare personnel (physicians, nurses etc) and persons supporting "at risk" citizens. These systems support data transmission over simple phone lines, internet connections, integrated services digital network/digital subscriber lines, satellite links, mobile networks (GPRS/3G), and wireless local area networks. The data corresponds, among others, to voice, vital biosignals, still medical images, video, and data used by eLearning applications. The proposed platform comprises several systems, each supporting different services. These were integrated using a common data storage and exchange scheme in order to achieve system interoperability in terms of software, language and national characteristics. Results The platform has been installed and evaluated in different rural and urban sites in Greece, Cyprus and Italy. The evaluation was mainly related to technical issues and user satisfaction. The selected sites are, among others, rural health centers, ambulances, homes of "at-risk" citizens, and a ferry. Conclusions The results proved the functionality and utilization of the platform in various rural places in Greece, Cyprus and Italy. However, further actions are needed to enable the local healthcare systems and the different population groups to be familiarized with, and use in their everyday lives, mature technological solutions for the provision of healthcare services.

Do we need new personalized emergency telehealth solutions? A survey of 100 emergency department patients and a first report of the swiss limmex emergency wristwatch: an original study

Development of new personal mobile and wireless devices for healthcare has become essential due to our aging population characterized by constant rise in chronic diseases that consequently require a complex treatment and close monitoring. Personal telehealth devices allow patients to adequately receive their appropriate treatment, followup with their doctors, and report any emergency without the need of the presence of any caregivers with them thus increasing their quality of life in a cost-effective fashion. This paper includes a brief overview of personal telehealth systems, a survey of 100 consecutive ED patients aged >65 years, and introduces "Limmex" a new GSM based technology packaged in a wristwatch. Limmex can by a push of a button initiate multiple emergency call and establish mobile communication between the patient and a preselected person, institution, or a search and rescue service. To the best of our knowledge, Limmex is the first of its kind worldwide.

A Mobile Feedback System for Integrated E-health Platforms to improve Self-Care and Compliance of Diabetes Mellitus Patients

Exploiting the full potential of telemedical systems means using platform based solutions: data are recovered from biomedical sensors, hospital information systems, care-givers, as well as patients themselves, and are processed and redistributed in an either centralized or, more probably, decentralized way. The integration of all these different devices, and interfaces, as well as the automated analysis and representation of all the pieces of information are current key challenges in telemedicine. Mobile phone technology has just begun to offer great opportunities of using this diverse information for guiding, warning, and educating patients, thus increasing their autonomy and adherence to their prescriptions. However, most of these existing mobile solutions are not based on platform systems and therefore represent limited, isolated applications. This article depicts how telemedical systems, based on integrated health data platforms, can maximize prescription adherence in chronic patients through mobile feedback. The application described here has been developed in an EU-funded R&D project called METABO, dedicated to patients with type 1 or type 2 Diabetes Mellitus

Requisitos en la infraestructura de red para servicios de comunicación entre paciente y centro sanitario

El presente Proyecto Fin de Carrera consiste en un estudio de los accesos a red que utilizan los servicios a los que están adscritos los usuarios de servicios de teleasistencia, planteando al final del mismo un modelo de previsión de caídas que permita que ese acceso a red no sea un problema para la prestación del servicio. Para poder llegar a los objetivos anteriormente descritos, iniciaremos este documento presentando qué se entiende actualmente como servicios de telemedicina y teleasistencia. Prestaremos atención a los actores que intervienen, usos y beneficios que tienen tanto para los pacientes como para las administraciones públicas. Una vez sepamos en qué consisten, centraremos la atención en las redes de acceso que se utilizan para prestar los servicios de telemedicina, con sus ventajas y desventajas. Puesto que no todos los servicios tienen los mismos requisitos generales de fiabilidad o velocidad de transmisión, veremos cómo se puede garantizar las necesidades de cada tipo de servicio por parte del proveedor de red. El siguiente paso para llegar a establecer el modelo de previsión de caídas será conocer las necesidades técnicas y de los actores para prestar un servicio de teleasistencia en el hogar de un paciente. Esto incluirá estudiar qué equipos se necesitan, cómo gestionarlos y cómo marcar el tráfico para que el operador de red sepa cómo tratarlo según el servicio de teleasistencia que se está utilizando, llevando a generar un modelo de supervisión de enlaces de teleasistencia. Llegados a este punto estaremos ya preparados para establecer un modelo de previsión de caídas de la conexión, describiendo la lógica que se necesite para ello, y poniéndolo en práctica con dos ejemplo concretos: un servicio de telemonitorización domiciliaria y otro servicio de telemonitorización ambulatoria. Para finalizar, realizaremos una recapitulación sobre lo estudiado en este documento y realizaremos una serie de recomendaciones. ABSTRACT. This Thesis is a study of the access network to be used with services assigned to patients that are users of telecare services. In the last chapter we will describe a fall forecasting model that allows the access network to not be an issue for the service. For achieving the objectives described above, this paper will begin with the presentation of what is now understood as telemedicine and telecare services. We pay attention to the actors involved, uses and benefits that they have both for patients and for public administrations. Once we know what telecare means and what requisites they have, we will focus on access networks which are used to provide telemedicine services, with their advantages and disadvantages. Since not all services have the same general requirements of reliability and transmission speed, we will try to see how you can ensure the needs of each type of service from the network provider's point of view. The next step is to establish that the forecasting model of falls will meet the technical needs and actors to provide telecare service in the home of a patient. This will include a study of what equipment is needed, how to manage and how to mark traffic for the network operator knowing how to treat it according to the telecare service being used, and this will lead us to the creation of a model of telecare link monitoring. At this point we are already prepared to establish a forecasting model of connection drops, describing the logic that is needed for this, and putting it into practice with two concrete examples: telemonitoring service and an ambulatory telemonitoring service. Finally, we will have a recap on what has been studied in this paper and will make a series of recommendations.

BioMet®Phon: A system to monitor phonation quality in the clinics

BioMet®Phon is a software application developed for the characterization of voice in voice quality evaluation. Initially it was conceived as plain research code to estimate the glottal source from voice and obtain the biomechanical parameters of the vocal folds from the spectral density of the estimate. This code grew to what is now the Glottex®Engine package (G®E). Further demands from users in laryngology and speech therapy fields instantiated the development of a specific Graphic User Interface (GUI’s) to encapsulate user interaction with the G®E. This gave place to BioMet®Phon, an application which extracts the glottal source from voice and offers a complete parameterization of this signal, including distortion, cepstral, spectral, biomechanical, time domain, contact and tremor parameters. The semantic capabilities of biomechanical parameters are discussed. Study cases from its application to the field of laryngology and speech therapy are given and discussed. Validation results in voice pathology detection are also presented. Applications to laryngology, speech therapy, and monitoring neurological deterioration in the elder are proposed.

Monitorización y optimización de terapias de tele-neurorrehabilitación cognitiva

El Daño Cerebral Adquirido (DCA) se define como una lesión cerebral que ocurre después del nacimiento y que no guarda relación con defectos congénitos o enfermedades degenerativas. En el cerebro, se llevan a cabo las funciones mentales superiores como la atención, la memoria, las funciones ejecutivas y el lenguaje, consideradas pre-requisitos básicos de la inteligencia. Sea cual sea su causa, todo daño cerebral puede afectar a una o varias de estas funciones, de ahí la gravedad del problema. A pesar de los avances en nuevas técnicas de intervención precoz y el desarrollo de los cuidados intensivos, las afectaciones cerebrales aún no tienen tratamiento ni quirúrgico ni farmacológico que permita una restitución de las funciones perdidas. Los tratamientos de neurorrehabilitación cognitiva y funcional pretenden, por tanto, la minimización o compensación de las alteraciones ocasionadas por una lesión en el sistema nervioso. En concreto, la rehabilitación cognitiva se define como el proceso en el que personas que han sufrido un daño cerebral trabajan de manera conjunta con profesionales de la salud para remediar o aliviar los déficits cognitivos surgidos como consecuencia de un episodio neurológico. Esto se consigue gracias a la naturaleza plástica del sistema nervioso, donde el cerebro es capaz de reconfigurar sus conexiones neuronales, tanto creando nuevas como modificando las ya existentes. Durante los últimos años hemos visto una transformación de la sociedad, en lo que se ha denominado "sociedad de la información", cuyo pilar básico son las Tecnologías de la Información y las Comunicaciones (TIC). La aplicación de estas tecnologías en medicina ha revolucionado la manera en que se proveen los servicios sanitarios. Así, donde tecnología y medicina se mezclan, la telerrehabilitación se define como la rehabilitación a distancia, ayudando a extender los servicios de rehabilitación más allá de los centros hospitalarios, rompiendo las barreras geográficas, mejorando la eficiencia de los procesos y monitorizando en todo momento el estado y evolución del paciente. En este contexto, el objetivo general de la presente tesis es mejorar la rehabilitación neuropsicológica de pacientes que sufren alteraciones cognitivas, mediante el diseño, desarrollo y validación de un sistema de telemedicina que incorpora las TIC para avanzar hacia un nuevo paradigma personalizado, ubicuo y ecológico. Para conseguirlo, se han definido los siguientes objetivos específicos: • Analizar y modelar un sistema de telerrehabilitación, mediante la definición de objetivos y requisitos de usuario para diseñar las diferentes funcionalidades necesarias. • Definir una arquitectura de telerrehabilitación escalable para la prestación de diferentes servicios que agrupe las funcionalidades necesarias en módulos. • Diseñar y desarrollar la plataforma de telerrehabilitación, incluida la interfaz de usuario, creando diferentes roles de usuario con sus propias funcionalidades. • Desarrollar de un módulo de análisis de datos para extraer conocimiento basado en los resultados históricos de las sesiones de rehabilitación almacenadas en el sistema. • Evaluación de los resultados obtenidos por los pacientes después del programa de rehabilitación, obteniendo conclusiones sobre los beneficios del servicio implementado. • Evaluación técnica de la plataforma de telerrehabilitación, así como su usabilidad y la relación coste/beneficio. • Integración de un dispositivo de eye-tracking que permita la monitorización de la atención visual mientras los pacientes ejecutan tareas de neurorrehabilitación. •Diseño y desarrollo de un entorno de monitorización que permita obtener patrones de atención visual. Como resumen de los resultados obtenidos, se ha desarrollado y validado técnicamente la plataforma de telerrehabilitación cognitiva, demostrando la mejora en la eficiencia de los procesos, sin que esto resulte en una reducción de la eficacia del tratamiento. Además, se ha llevado a cabo una evaluación de la usabilidad del sistema, con muy buenos resultados. Respecto al módulo de análisis de datos, se ha diseñado y desarrollado un algoritmo que configura y planifica sesiones de rehabilitación para los pacientes, de manera automática, teniendo en cuenta las características específicas de cada paciente. Este algoritmo se ha denominado Intelligent Therapy Assistant (ITA). Los resultados obtenidos por el asistente muestran una mejora tanto en la eficiencia como en la eficacia de los procesos, comparado los resultados obtenidos con los de la planificación manual llevada a cabo por los terapeutas. Por último, se ha integrado con éxito el dispositivo de eye-tracking en la plataforma de telerrehabilitación, llevando a cabo una prueba con pacientes y sujetos control que ha demostrado la viabilidad técnica de la solución, así como la existencia de diferencias en los patrones de atención visual en pacientes con daño cerebral. ABSTRACT Acquired Brain Injury (ABI) is defined as brain damage that suddenly and unexpectedly appears in people’s life, being the main cause of disability in developed countries. The brain is responsible of the higher cognitive functions such as attention, memory, executive functions or language, which are considered basic requirements of the intelligence. Whatever its cause is, every ABI may affects one or several functions, highlighting the severity of the problem. New techniques of early intervention and the development of intensive ABI care have noticeably improved the survival rate. However, despite these advances, brain injuries still have no surgical or pharmacological treatment to re-establish lost functions. Cognitive rehabilitation is defined as a process whereby people with brain injury work together with health service professionals and others to remediate or alleviate cognitive deficits arising from a neurological insult. This is achieved by taking advantage of the plastic nature of the nervous system, where the brain can reconfigure its connections, both creating new ones, and modifying the previously existing. Neuro-rehabilitation aims to optimize the plastic nature by inducing a reorganization of the neural network, based on specific experiences. Personalized interventions from individual impairment profile will be necessary to optimize the remaining resources by potentiating adaptive responses and inhibiting maladaptive changes. In the last years, some applications and software programs have been developed to train or stimulate cognitive functions of different neuropsychological disorders, such as ABI, Alzheimer, psychiatric disorders, attention deficit or hyperactivity disorder (ADHD). The application of technologies into medicine has changed the paradigm. Telemedicine allows improving the quality of clinical services, providing better access to them and helping to break geographical barriers. Moreover, one of the main advantages of telemedicine is the possibility to extend the therapeutic processes beyond the hospital (e.g. patient's home). As a consequence, a reduction of unnecessary costs and a better costs/benefits ratio are achieved, making possible a more efficient use of the available resources In this context, the main objective of this work is to improve neuro-rehabilitation of patients suffering cognitive deficits, by designing, developing and validating a telemedicine system that incorporates ICTs to change this paradigm, making it more personalized, ubiquitous and ecologic. The following specific objectives have been defined: • To analyse and model a tele-rehabilitation system, defining objectives and user requirements to design the different needed functionalities. • To define a scalable tele-rehabilitation architecture to offer different services grouping functionalities into modules. • To design and develop the tele-rehabilitation platform, including the graphic user interface, creating different user roles and permissions. • To develop a data analysis module to extract knowledge based on the historic results from the rehabilitation sessions stored in the system. • To evaluate the obtained results by patients after the rehabilitation program, arising conclusions about the benefits of the implemented service. • To technically evaluate the tele-rehabilitation platform, and its usability and the costs/benefit ratio. • To integrate an eye-tracking device allowing the monitoring of the visual attention while patients execute rehabilitation tasks. •To design and develop a monitoring environment that allows to obtain visual attention patterns. Summarizing the obtained results, the cognitive tele-rehabilitation platform has been developed and evaluated technically, demonstrating the improvements on the efficiency without worsening the efficacy of the process. Besides, a usability evaluation has been carried out, with very good results. Regarding the data analysis module, an algorithm has been designed and developed to automatically select and configure rehabilitation sessions, taking into account the specific characteristics of each patient. This algorithm is called Intelligent Therapy Assistant (ITA). The obtained results show an improvement both in the efficiency and the efficacy of the process, comparing the results obtained by patients when they receive treatments scheduled manually by therapists. Finally, an eye-tracking device has been integrated in the tele-rehabilitation platform, carrying out a study with patients and control subjects demonstrating the technical viability of the developed monitoring environment. First results also show that there are differences between the visual attention patterns between ABI patients and control subjects.

Propuesta de un sistema para detección precoz de trastornos del lenguaje en niños de 0 a 6 años

Las Tecnologías de la Información y las Comunicaciones han propiciado avances en el contexto de la salud tanto en la gestión efectiva de información socio‐sanitaria de forma electrónica, como en la provisión de servicios de e‐salud y telemedicina. Los antecedentes de investigación publicados en esta área corroboran este hecho presentando las mejoras experimentadas en la atención de la población y en la provisión de servicios sanitarios. La atención temprana, cuyos principios científicos se fundamentan en los campos de la pediatría, neurología, psicología, psiquiatría, pedagogía, fisiatría y lingüística, entre otros, tiene como finalidad ofrecer a los niños con déficit o con riesgo de padecerlos un conjunto de acciones optimizadoras y compensadoras, que faciliten su adecuada maduración en todos los ámbitos y que les permita alcanzar el máximo nivel de desarrollo personal y de integración social. La detección de posibles alteraciones en el desarrollo infantil es un aspecto clave de la atención temprana en la medida en que puede posibilitar la puesta en marcha de diversos mecanismos de actuación disponibles en las entidades implicadas, valiosos para la calidad de vida de la persona. Cuanto antes se realice la detección, existen mayores garantías de prevenir patologías añadidas, lograr mejoras funcionales y posibilitar un ajuste más adaptativo entre el niño y su entorno. El objetivo de la investigación presentada en esta tesis doctoral es analizar, diseñar, verificar y validar un sistema de información abierto, basado en conocimiento, que facilite efectivamente a los profesionales que trabajan con la población infantil entre 0 y 6 años la detección precoz de posibles trastornos del lenguaje. Desde el punto de vista metodológico, la Ingeniería del Conocimiento ofrece un marco conceptual sólido que permite desarrollar y validar Sistemas de Ayuda a la Toma de Decisiones distribuidos y escalables, capaces de ayudar al pediatra de Atención Primaria y al educador infantil en la detección precoz de posibles trastornos del lenguaje en niños. La evaluación del sistema se ha realizado de forma incremental mediante el diseño y validación de pruebas de campo experimentales consistentes en la evaluación de niños en dos escenarios distintos: la escuela infantil y el centro de atención temprana. Los experimentos realizados en poblaciones distintas con alrededor de 344 niños durante 2 años, han permitido contrastar la buena adecuación del sistema propuesto a las necesidades de detección de los profesionales que trabajan con niños entre 0 y 6 años. La tesis resultante ha permitido caracterizar el uso del sistema en entornos reales, conocer la aceptación entre los usuarios y su impacto en la provisión de un servicio de atención temprana como el descrito para el correcto seguimiento del desarrollo del lenguaje en los niños, además de proponer un nuevo modelo de atención y evaluación cooperativa que permita incrementar el conocimiento experimental existente al respecto. ABSTRACT The Information and Communication Technology have led to advances in the context of health both in the effective management of socio‐health information electronically, and in the provision of e‐health and telemedicine. The history of research published in this area confirm this fact by presenting the improvements in the care of the population and the provision of health services. Early attention, whose scientific principles are based on the fields of pediatrics, neurology, psychology, psychiatry, pedagogy, physical medicine and linguistics, among others, aims to provide children with deficits or risk of suffering a set of enhancer actions, which facilitate adequate maturation in all areas and allow them to achieve the highest level of personal development and social integration. The detection of possible changes in child development is a key aspect of early intervention to the extent that it can enable the implementation of different mechanisms of action available to the entities involved, valuable to the quality of life of the person. The earlier the detection is made, there are more guarantees added to prevent diseases, achieving functional improvements and enable a more adaptive fit between the child and his environment. The aim of the research presented is to analyze, design, verify and validate an open information system, based on knowledge, which effectively provide professionals working with the child population between 0 and 6 years, in processes of early detection of language disorders. From the methodological point of view, Knowledge Engineering provides a solid conceptual framework to develop and validate a distributed and scalable decision support systems aim to assist pediatricians and language therapists at early identification and referral of language disorder in childhood. The system evaluation was performed incrementally with the design and validation of consistent experimental field tests in the assessment of children in two different scenarios: the nursery and early intervention center. Experiments in different populations with about 344 children over 2 years, allowed to testing the adequacy of the proposed good detection needs of professionals working with children between 0 and 6 years old system. The resulting thesis has allowed to formalizing the system at real environments and to identifying the acceptance by users as well as its impact on the provision of an early intervention service, such as the one described for the proper monitoring of language development in children. In addition, it proposes a new model of care and cooperative evaluation that lets to increase the existing experimental knowledge about it.

Patient-oriented computerized clinical guidelines for mobile decision support in gestational diabetes

The risks associated with gestational diabetes (GD) can be reduced with an active treatment able to improve glycemic control. Advances in mobile health can provide new patient-centric models for GD to create personalized health care services, increase patient independence and improve patients’ self-management capabilities, and potentially improve their treatment compliance. In these models, decision-support functions play an essential role. The telemedicine system MobiGuide provides personalized medical decision support for GD patients that is based on computerized clinical guidelines and adapted to a mobile environment. The patient’s access to the system is supported by a smartphone-based application that enhances the efficiency and ease of use of the system. We formalized the GD guideline into a computer-interpretable guideline (CIG). We identified several workflows that provide decision-support functionalities to patients and 4 types of personalized advice to be delivered through a mobile application at home, which is a preliminary step to providing decision-support tools in a telemedicine system: (1) therapy, to help patients to comply with medical prescriptions; (2) monitoring, to help patients to comply with monitoring instructions; (3) clinical assessment, to inform patients about their health conditions; and (4) upcoming events, to deal with patients’ personal context or special events. The whole process to specify patient-oriented decision support functionalities ensures that it is based on the knowledge contained in the GD clinical guideline and thus follows evidence-based recommendations but at the same time is patient-oriented, which could enhance clinical outcomes and patients’ acceptance of the whole system.

Service for the pseudonymization of electronic healthcare records based on ISO/EN 13606 for the secondary use of information

The availability of electronic health data favors scientific advance through the creation of repositories for secondary use. Data anonymization is a mandatory step to comply with current legislation. A service for the pseudonymization of electronic healthcare record (EHR) extracts aimed at facilitating the exchange of clinical information for secondary use in compliance with legislation on data protection is presented. According to ISO/TS 25237, pseudonymization is a particular type of anonymization. This tool performs the anonymizations by maintaining three quasi-identifiers (gender, date of birth and place of residence) with a degree of specification selected by the user. The developed system is based on the ISO/EN 13606 norm using its characteristics specifically favorable for anonymization. The service is made up of two independent modules: the demographic server and the pseudonymizing module. The demographic server supports the permanent storage of the demographic entities and the management of the identifiers. The pseudonymizing module anonymizes the ISO/EN 13606 extracts. The pseudonymizing process consists of four phases: the storage of the demographic information included in the extract, the substitution of the identifiers, the elimination of the demographic information of the extract and the elimination of key data in free-text fields. The described pseudonymizing system was used in three Telemedicine research projects with satisfactory results. A problem was detected with the type of data in a demographic data field and a proposal for modification was prepared for the group in charge of the drawing up and revision of the ISO/EN 13606 norm.

Capacity Building through education, research and collaboration: AFRICA BUILD, an eHealth Case Study

AFRICA BUILD (AB) is a Coordination Action project under the 7th European Framework Programme having the aim of improving the capacities for health research and education in Africa through Information and Communication Technologies (ICT). This project, started in 2012, has promoted health research, education and evidence-based practice in Africa through the creation of centers of excellence, by using ICT,?know-how?, eLearning and knowledge sharing, through Web-enabled virtual communities.