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MEDICAL AND CARE COMPUNETICS 3
Studies in Health Technology and
Informatics
This book series was started in 1990 to promote research conducted under the auspices of the EC
programmes’ Advanced Informatics in Medicine (AIM) and Biomedical and Health Research
(BHR) bioengineering branch. A driving aspect of international health informatics is that
telecommunication technology, rehabilitative technology, intelligent home technology and many
other components are moving together and form one integrated world of information and
communication media. The complete series has been accepted in Medline. Volumes from 2005
onwards are available online.
Series Editors:
Dr. J.P. Christensen, Prof. G. de Moor, Prof. A. Famili, Prof. A. Hasman, Prof. L. Hunter,
Dr. I. Iakovidis, Dr. Z. Kolitsi, Mr. O. Le Dour, Dr. A. Lymberis, Prof. P.F. Niederer,
Prof. A. Pedotti, Prof. O. Rienhoff, Prof. F.H. Roger France, Dr. N. Rossing,
Prof. N. Saranummi, Dr. E.R. Siegel, Dr. P. Wilson, Prof. E.J.S. Hovenga,
Prof. M.A. Musen and Prof. J. Mantas
Volume 121
Recently published in this series
Vol. 120. V. Hernández, I. Blanquer, T. Solomonides, V. Breton and Y. Legré (Eds.),
Challenges and Opportunities of HealthGrids – Proceedings of Healthgrid 2006
Vol. 119. J.D. Westwood, R.S. Haluck, H.M. Hoffman, G.T. Mogel, R. Phillips, R.A. Robb and
K.G. Vosburgh (Eds.), Medicine Meets Virtual Reality 14 – Accelerating Change in
Healthcare: Next Medical Toolkit
Vol. 118. R.G. Bushko (Ed.), Future of Intelligent and Extelligent Health Environment
Vol. 117. C.D. Nugent, P.J. McCullagh, E.T. McAdams and A. Lymberis (Eds.), Personalised
Health Management Systems – The Integration of Innovative Sensing, Textile,
Information and Communication Technologies
Vol. 116. R. Engelbrecht, A. Geissbuhler, C. Lovis and G. Mihalas (Eds.), Connecting Medical
Informatics and Bio-Informatics – Proceedings of MIE2005
Vol. 115. N. Saranummi, D. Piggott, D.G. Katehakis, M. Tsiknakis and K. Bernstein (Eds.),
Regional Health Economies and ICT Services

Vol. 114. L. Bos, S. Laxminarayan and A. Marsh (Eds.), Medical and Care Compunetics 2
Vol. 113. J.S. Suri, C. Yuan, D.L. Wilson and S. Laxminarayan (Eds.), Plaque Imaging: Pixel to
Molecular Level
Vol. 112. T. Solomonides, R. McClatchey, V. Breton, Y. Legré and S. Nørager (Eds.), From
Grid to Healthgrid
Vol. 111. J.D. Westwood, R.S. Haluck, H.M. Hoffman, G.T. Mogel, R. Phillips, R.A. Robb and
K.G. Vosburgh (Eds.), Medicine Meets Virtual Reality 13
ISSN 0926-9630
Medical and Care Compunetics 3
Edited by
Lodewijk Bos
President ICMCC
Laura Roa
Escuela Superior de Ingeniería, University of Seville, Spain
Kanagasingam Yogesan
Centre of Excellence in e-Medicine Lions Eye Institute, Australia
Brian O’Connell
Department of Computer Science, Central Connecticut State University, USA
Andy Marsh
VMW Solutions, UK
and
Bernd Blobel
eHealth Competence Center, University of Regensburg Medical Center,
Germany
Amsterdam • Berlin • Oxford • Tokyo • Washington, DC
© 2006 The authors.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, without prior written permission from the publisher.
ISBN 1-58603-620-3
Library of Congress Control Number: 2006925767

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v




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Medical and Care Compunetics 3 vii
L. Bos et al. (Eds.)
IOS Press, 2006
© 2006 The authors. All rights reserved.
Preface
This book accompanies the third annual ICMCC Event. In the 12 months since our

previous conference we established the goals of the ICMCC Foundation.
To become the leading source for citizen/patient-related information using the lat-
est medical and care compunetics is the first of these goals. ICMCC has been one of the
first organizations recognizing the possible thread to patient safety of the information
available on the internet.
ICMCC also recognizes the problems of professionals to find information on the
latest developments in medical and care compunetics in a structured way.
These two aspects form the basis for becoming the leading Knowledge Centre on
medicine and care.
To realize this goal our third annual event covers aspects concerning:
• Information supply to patient and professional
• Electronic health records, its standards, its social implications
• New developments in medical & care compunetics.
Our third goal is to serve as the central meeting place for exchanging information
on all aspects related to medical and care compunetics and for all those concerned. We
are therefore pleased to be a platform once again for a number of European Commis-
sion (IST) funded projects.
And we are proud to be the platform for the EFMI (European Federation for Medi-
cal Informatics) Working Groups “Electronic Health Records”, “Security, Safety and
Ethics” and “Cards” and we would like to thank Dr. Bernd Blobel and Dr. Peter
Pharow for their work to organise this session.
On September 29, 2005 our co-founder Prof. Swamy Laxminarayan passed away.
We will be forever in his debt for his believe in our organisation and goals and his re-
lentless support. To honour the memory of one of the greatest minds in biomedicine
and biotechnology of the twentieth century ICMCC will this year initiate an annual
Swamy Laxminarayan lecture.
On behalf of the ICMCC Foundation board we wish to thank the IFMBE and the
WABT-ICET-UNESCO for accepting us as members and for their support for this con-
ference. We are equally grateful for the endorsement by the IEEE-SSIT.
Finally we would like to thank all the authors who have contributed to making the

third ICMCC Event into an interesting and challenging conference.
Lodewijk Bos
Laura Roa
Brian O’Connell
Kanagasingam Yogesan
Andy Marsh
Bernd Blobel
viii
Board Lists
Council Board
Drs Lodewijk Bos, president, The Netherlands
Robert von Hinke Kessler (vice-president, treasurer, secretary general),
The Netherlands
Denis Carroll, (vice-president), Westminster University, UK
Dr Andy Marsh (vice-president), VMWSolutions, UK
Prof. Brian O’Connell (vice-president), Central Connecticut State University, USA
Prof. Kanagasingam Yogesan (vice-president), Centre of Excellence in e-Medicine,
Australia
Organizing Committee
Event chair
Drs Lodewijk Bos, president of ICMCC, The Netherlands
Scientific chair
Prof. Laura Roa, Biomedical Engineering Program, University of Sevilla, Spain
Chair Electronic health records, its standards, its social implications
Prof. Brian O’Connell, Central Connecticut State University, USA
Co-chair: Bryan Manning, UK
Chair Developments in Medical & Care Compunetics
Prof. Kanagasingam Yogesan, Director, Centre of Excellence in e-Medicine, Australia
Scientific Advisory Board
Prof. Dr Emile Aarts, Philips, Technical University Eindhoven, The Netherlands

Dr Hamideh Afsarmanesh, Universiteit van Amsterdam, The Netherlands
Prof. Metin Akay, Dartmouth University, USA
Prof. Andreas S. Anayiotos, University of Alabama at Birmingham, USA
Prof. Hamid R. Arabnia, PhD, The University of Georgia, USA
Dr. Rajeev Bali Coventry University, UK
Drs Iddo Bante, Centre for Telematics and Information Technology (CTIT)/
Technology Circle Twente (TKT), The Netherlands
PD Dr Bernd Blobel, Institute of Biometry and Medical Informatics, Universität
Magdeburg, Germany
Dr Charles Boucher, University Medical Center Utrecht, The Netherlands
Prof. Peter Brett, Aston University, Birmingham, UK
Dr Jimmy Chan Tak-shing, Alice Ho Miu Ling Nethersole Hospital, Hong Kong,
China
ix
Juan Carlos Chia, Proventis, UK
Dr Thierry Chaussalet, University of Westminster, London, UK
Dr Malcolm Clarke, Brunel University, UK
Dr Ir Adrie Dumay, TNO, The Netherlands
Ad Emmen, Genias Benelux, The Netherlands
Prof. Ken Foster, University of Pennsylvania, USA
Dr Walter Greenleaf, Greenleaf Med. Group, USA
Prof. Dr. Dr. h.c. Helmut Hutten, University of Technology Graz, Austria
Bob Ireland, Kowa Research Europe, UK
Prof. Robert Istepanian, Kingston University, UK
Prof. Dr Chris Johnson, SCI, University of Utah, USA
Prof. Ida Jovanovic, Children’s Hospital of Belgrade, Serbia and Montenegro
Prof. Zoran Jovanovic, University of Belgrade, Serbia and Montenegro
Donald W. Kemper, Healthwise, USA
Makoto Kikuchi, National Defense Medical College, Japan
Prof. Dr Luis G. Kun, National Defense University, USA

Prof. Dr Michael Lightner, University of Colorado Boulder, President IEEE, USA
Prof. DrSc. Ratko Magjarevic, University of Zagreb, Croatia
Prof. Dr Joachim Nagel, University of Stuttgart, President IFMBE, Germany
Prof. Raouf Naguib, Coventry University, UK; University of Carleton, Canada
Ron Oberleitner, TalkAutism, e-MERGE Medical Marketing, USA
Prof. Marimuthu Palaniswami, University of Melbourne Parkville, Australia
Prof. Dr Neill Piland, Idaho State University, USA
Michael L. Popovich MS SE, STC, Tucson, USA
Prof. Dr Ir Hans Reiber, Leiden University Medical Center, The Netherlands
Dr George Roussos, SCSIS, Univ. of London, UK
Sandip K. Roy, PhD, Novartis Pharmaceuticals, USA
Prof. Dr-Ing. Giorgos Sakas, Fraunhofer IGD, Germany
Clyde Saldanha, JITH, UK
Prof. Dr Niilo Saranummi, VTT Information Technologies, Past-President EAMBES,
Finland
Prof. Corey Schou, Idaho State University, USA
Anna Siromoney PhD, Womens Christian College, India
Prof. Dr Peter Sloot, Universiteit van Amsterdam, The Netherlands
Prof. Dr Jasjit Suri, Senior Director, R & D., Fischer Imaging Corporation, Denver,
USA
Basel Solaiman, INSERM-ENST, France
Prof. Mihai Tarata, University of Medicine and Pharmacy of Craiova, Romania
Dr. Joseph Tritto, World Academy of Biomedical Technologies, UNESCO, France
Prof. Dr Bertie Zwetsloot-Schonk, Leiden University Medical Center, The Netherlands
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xi
Contents
Preface vii
Lodewijk Bos, Laura Roa, Brian O’Connell, Kanagasingam Yogesan,
Andy Marsh and Bernd Blobel

Board Lists viii
PARKSERVICE: Home Support and Walking Aid for People with
Parkinson’s Disease 1
U. Delprato, R. Greenlaw and M. Cristaldi
Assistive Technology – Behaviourally Assisted 7
S. Benton and B. Manning
Empowering the Impaired Through the Appropriate Use of Information
Technology and Internet 15
Ishita Sanyal
Telemedicine Odyssey Customised Telemedicine Solution for Rural and
Remote Areas in India 22
Jagjit Singh Bhatia and Sagri Sharma
A Deployable Framework for Mobile Telemedicine Applications 36
N.A. Ikhu-Omoregbe, C.K. Ayo and S.A. Ehikioya
Applications of ePerSpace Service Management Platform in Health Care 42
Kambiz Madani and Mahi Lohi
Context-Aware Workflow Management of Mobile Health Applications 47
Alfons Salden and Remco Poortinga
Health Inequalities and Emerging Themes in Compunetics 62
M. Chris Gibbons
Integrated Multimedia Medical Data Agent in E-Health 70
P. di Giacomo, Fabrizio L. Ricci and Leonardo Bocchi
Developing Health Surveillance Networks: An Adaptive Approach 74
Suzanne Tamang, Danny Kopec, Tony McCofie and Karen Levy
Using UMLS to Map from a Library to a Clinical Classification: Improving
the Functionality of a Digital Library 86
Judas Robinson, Simon de Lusignan, Patty Kostkova and Bruce Madge
Methodological Issues for the Information Model of a Knowledge-Based
Telehealthcare System for Nephrology (Nefrotel) 96
Manuel Prado, Laura M. Roa and Javier Reina-Tosina

xii
HEARTFAID: A Knowledge Based Platform of Services for Supporting
Medical-Clinical Management of Heart Failure Within Elderly Population 108
Domenico Conforti, Domenico Costanzo, Francesco Perticone,
Gianfranco Parati, Kalina Kawecka-Jaszcz, Andrew Marsh,
Christos Biniaris, Manolis Stratakis, Riccardo Fontanelli,
Davide Guerri, Ovidio Salvettis, Manolis Tsiknakis, Franco Chiarugi,
Dragan Gamberger and Mariaconsuelo Valentini
The State of the Art in the Reduction of Medical Errors 126
Danny Kopec, Suzanne Tamang, Karen Levy, Ronald Eckhardt
and Gene Shagas
e-Care Integration: To Meet the Demographic Challenge 138
Bryan R.M. Manning and Mary McKeon Stosuy
Applied Medical & Care Compunetics to Public Health Disease Surveillance
and Management: Leveraging External Data Sources – A Key to Public Health
Preparedness 151
Michael L. Popovich and Todd Watkins
Patient Record Access – The Time Has Come 162
Brian Fisher, Richard Fitton, Charline Poirier and David Stables
New Trends in the Virtualization of Hospitals – Tools for Global e-Health 168
Georgi Graschew, Theo A. Roelofs, Stefan Rakowsky, Peter M. Schlag,
Paul Heinzlreiter, Dieter Kranzlmüller and Jens Volkert
Monitoring the Integration of Hospital Information Systems: How It May
Ensure and Improve the Quality of Data 176
Ricardo Cruz-Correia, Pedro Vieira-Marques, Ana Ferreira,
Ernesto Oliveira-Palhares, Pedro Costa and Altamiro Costa-Pereira
MedIEQ – Quality Labelling of Medical Web Content Using Multilingual
Information Extraction 183
Miquel Angel Mayer, Vangelis Karkaletsis, Kostas Stamatakis,
Angela Leis, Dagmar Villarroel, Christian Thomeczek, Martin Labský,

Fernando López-Ostenero and Timo Honkela
Improving Uptake of a Breast Screening Programme: A Knowledge
Management Approach for Opportunistic Intervention 191
Vikraman Baskaran, Rajeev K. Bali, Hisbel Arochena, Raouf N.G. Naguib,
Margot Wheaton and Matthew Wallis
EHR Standards – A Comparative Study 198
Bernd Blobel and Peter Pharow
Developing a Strategic Framework for Healthcare Standards 207
Bryan R.M. Manning
Lowering the Barrier to a Decentralized NHIN Using the Open Healthcare
Framework 214
Eishay Smith and James H. Kaufman
xiii
Knowledge Management and Electronic Care Records: Incorporating Social,
Legal and Ethical Issues 221
James Bassinder, Rajeev K. Bali and Raouf Naguib
Integrated Electronic Health Records Management System 228
P. di Giacomo, Fabrizio L. Ricci and Leonardo Bocchi
Standards for Medical Device Communication: X73 PoC-MDC 242
Miguel Galarraga, Luis Serrano, Ignacio Martínez and Paula de Toledo
A Standard Ontology for the Semantic Integration of Components in
Healthcare Organizations 257
I. Román, L.M. Roa, G. Madinabeitia and L.J. Reina
A Novel Management Database in Obstetrics and Gynaecology to Introduce
the Electronic Healthcare Record and Improve the Clinical Audit Process 266
Khaled El Hayes, Conor Harrity and Tahani Abu Zeineh
EFMI Session
SNOMED-CT: The Advanced Terminology and Coding System for eHealth 279
Kevin Donnelly
EHR in the Perspective of Security, Integrity and Ethics 291

Ragnar Nordberg
Personal Health – The Future Care Paradigm 299
Thomas Norgall, Bernd Blobel and Peter Pharow
Formal Policies for Flexible EHR Security 307
Bernd Blobel and Peter Pharow
Citizen Empowerment Using Healthcare and Welfare Cards 317
Paul Cheshire
BioHealth – The Need for Security and Identity Management Standards
in eHealth 327
Claudia Hildebrand, Peter Pharow, Rolf Engelbrecht, Bernd Blobel,
Mario Savastano and Asbjorn Hovsto
Formal Design of Electronic Public Health Records 337
Diego M. Lopez and Bernd Blobel
Specific Interoperability Problems of Security Infrastructure Services 349
Peter Pharow and Bernd Blobel
Sharable EHR Systems in Finland 364
Kari Harno and Pekka Ruotsalainen
xiv
Invited Paper
Information Therapy: The Strategic Role of Prescribed Information in
Disease Self-Management 373
Molly Mettler and Donald W. Kemper
Author Index 385
PARKSERVICE: Home Support and
Walking Aid for People with Parkinson’s
Disease
U. Delprato
a,1
, R. Greenlaw
b

, M. Cristaldi
c
a
PARKAID Srl, Italy
b
Oxford Computer Consultants Ltd, UK
c
IES Srl, Via del Babuino 99, Italy
Abstract. PARKSERVICE is a telemedical application currently being validated
in the EU. The objectives are to provide a combination of home clinical and social
support for people with Parkinson’s disease with a revolutionary walking aid that
uses “visual cues” to enable improved mobility. Early results are presented and the
outlook of home telemedicine and visual cueing for people with PD is discussed.
Keywords. Telemedicine, Parkinson’s disease, visual cueing
Introduction
PARKSERVICE is a new telemedical application combining home-based support for
people with Parkinson’s disease (PD) and a PD-specific walking aid which uses a
strategy known as visual cueing. PD is estimated to affect 100-180 per 100,000 of the
population (with most surveys favoring the higher estimate) and has an annual
incidence of 4-20 per 100,000[1],[2]. Taking a population of approximately 450M
citizens this implies 450,000-900,000 people with PD (PWP) in the EU.
PD is a progressive, incurable neurological disease resulting in depletion of the
neurotransmitter dopamine in the brain. Currently all therapy is symptomatic and
primarily based on pharmacological enhancement of dopamine levels via the drug
levadopa.
The three cardinal signs of PD are bradykinesia (decrease in movement), resting
tremor (shaking, usually of the extremities of the limbs) and rigidity (muscular stiffness,
cramps). As the disease progresses PWP typically suffer from gait abnormalities,
falling and periods of complete immobility (akinesia or “freezing”). Additionally there
are complications associated with long-term use of levadopa, including daily

fluctuations between “on” periods of good symptom control (normal mobility) with
“off” periods of poor symptom control (poor mobility) and even dyskinetic periods of
exaggerated poorly controlled mobility. Transitions between these phases are primarily

1
Corresponding Author: Uberto Delprato, ParkAid srl, Via del Babuino 99, 00131
Roma, Italy;
Medical and Care Compunetics 3
L. Bos et al. (Eds.)
IOS Press, 2006
© 2006 The authors. All rights reserved.
1
associated with the concentration of levadopa in the blood, but can be triggered
precipitately by tiredness or stress. Episodes of “freezing” can occur in either “on” or
“off” phases, although on-phase freezing is rare and difficult to treat[3]. Freezing is
associated with falling and heightened levels of anxiety. Falls are common in PD: two
thirds of people with PD fall each year with most eventually becoming fallers [4].
It is well known that some subjects who experience freezing can suddenly and
dramatically “break out” of their frozen posture in the presence of particular cues, the
nature of which vary with the individual. For example, some PWP who are unable to
walk normally can dance to music, walk over obstacles, stripes or up stairs or when
emotionally stimulated. (PD literature includes episodes of paralyzed PWP running out
of burning buildings) [5]. Enhanced mobility under these conditions is known as
paradoxical kinesis. (This is described in more detail below.)
Good management of PD requires clinical specialists both for accurate diagnosis and
regular follow up. Periodic adjustments of drug regime are normal. Management is
complicated because of the difficulty PWP experience getting to clinics, and in
fluctuating PD, because the PWP may present few disabling symptoms during an
appointment. Additionally there is a European shortage of neurologists [6].
PD is an expensive disease. In the UK the total annual direct cost of care including

NHS (National Health Service), social services and private expenditure per patient have
been estimated at ~€9,000 (£5,993, 2003) per patient per year [7]. With a total UK
population of 60M this implies a total direct cost of PD in the UK of ~€1,000M (2003).
The same study estimated total annual direct costs of €6,300 for patients living at
home, €23,260 for patients whose time was divided between home and an institution
and €29,300 for patients in full-time institutional care.
Thus, every year someone with PD can stay at home, rather than take up part-time
institutional care, saves (UK, 2003) €14,000/year.
The relevant aspects of PD can therefore be summarized as follows: PWP suffer
varying and complex symptoms associated both with the disease itself and with the
long-term use of levadopa, the primary pharmacological therapy. The effects of PD are
particularly profound on mobility (with associated loss of confidence and social
exclusion). Some PWP display a startling recovery of mobility in the presence of
“cues” such as stripes on the floor. The management of PD is complex and expensive,
both in per-patient terms and in total (since PD is a widespread disease). PWP may
experience difficulties finding suitable neurologists, traveling to clinics, and describing
symptoms whilst there.
In many ways, therefore, PWP present an excellent group for telemedicine: the
disease is widespread, affects mobility, there is a shortage of neurologists and treatment
is expensive. The presence of paradoxical kinesis also presents intriguing possibilities
for enhancing mobility (which are described below).
1. Parkservice
PARKSERVICE is an application of telemedicine targeted specifically at PWP. The
service consists of three parts: PARKLINE, a TV-based communication system for the
PWP at home, PARKCLINIC, a complementary system for clinicians and INDIGO, a
mobility aid for PWP mediated through PARKLINE.
U. Delprato et al. / PARKSERVICE: Home Support and Walking Aid2
Firstly, through PARKLINE, a PWP is connected through the Internet to their
clinician and to other PWP. The primarily medium of interaction is exchange of off-
line video which can take place via broadband or dial-up connection. PWP can make

short videos of themselves using a web-cam controlled by television remote control
(via a multimedia PC). The objective is to provide a simple user experience with push-
button interface. After taking a video the user can review it, reject it or distribute it to a
list of other PARKSERVICE users including their own clinicians.
PARKLINE also supports other ways of data exchange: particularly a symptom diary
(which is useful for understanding a patient with fluctuating PD) and text messaging
(which obviously requires a keyboard).
Secondly, since PARKLINE requires special hardware to enable user access
PARKCLINIC has been provided for secure clinical access through web browsers.
With PARKCLINIC a clinician can view videos uploaded by PWP at home, send text
messages to them or upload videos of their own.
Thirdly, INDIGO is a new mobility aid which uses video delivered through a pair of
glasses to trigger paradoxical kinesis in suitable PWP.
Therefore, using PARKSERVICE a PWP at home can video their evolving
symptoms of PD and their response to different drug regimes. They can experiment
with visual cueing, exchanging video records with their clinicians and other PWP. For
those PWP who exhibit paradoxical kinesis a secondary component of
PARKSERVICE, INDIGO, can be used to enhance mobility throughout and beyond
the home.
2. Telemedicine and PD
As long ago as 1993 a pilot study of telemedicine for patients with Parkinson's
disease demonstrated the possibility of dependable and valid remote-assessment of
these patients. Patients also viewed this technology as enabling access to better health
care [8]. This result was confirmed in 2002 in a study which included the adjustment of
PD medication via videophone [9]. However, few research initiatives have made an
impact on the market. This is unfortunate because PWP represent a particularly
appropriate population for telemedicine for the following reasons:
x The disease is widespread
x Clinical treatment is expensive
x There is a shortage of neurologists

x Travel is difficult
x Assessment by video has been validated
x Some PWP react strongly to appropriate video stimulation (paradoxical
kinesis).
Therefore the opportunity exists to make a cost-effective case for telemedicine
beneficial to people with PD.
U. Delprato et al. / PARKSERVICE: Home Support and Walking Aid 3
3. INDIGO and Paradoxical Kinesis
An important component of PARKSERVICE is a mobility aid called INDIGO.
INDIGO consists of a pair of glasses with integrated visual display and wearable
electronics which feed visual cues to the wearer, triggering paradoxical kinesis in
suitable PWP.
Many people with PD have difficulty initiating and sustaining walking in conditions
which would normally present no problems (such as an unobstructed corridor). The
degree of these mobility difficulties can vary with the subject, the time of day and the
stage of disease but are always accompanied by severe loss in quality of life. Typically
when people with PD can only move very slowly or completely freeze (phases called
“bradykinesia” and “akinesia” respectively) they feel vulnerable and isolated.
Accompanying symptoms include an expressionless “masked” face, a weak voice and
bent posture. Social interaction becomes extremely difficult and each year many deaths
and injuries occur as people with PD attempt to move whilst in this state.
Paradoxically, when visual “obstructions” are placed in their way, a small proportion
of people with PD undergo a dramatic release from these symptoms and can suddenly
stand up straight, speak strongly and walk normally: an effect called paradoxical
kinesis. These “obstructions” can be as simple as pieces of paper set down on the floor
and are usually referred to as visual “cues”.
The physiological mechanisms of paradoxical kinesis are not understood and until
recently there was little opportunity to analyse it or exploit it. However, technology has
now evolved to the point where a user, wearing adapted glasses, can see visual cues,
such as virtual “pieces of paper” wherever they looked whilst continuing to negotiate

the real world, interacting normally with other people. This allows certain people with
PD to walk, to talk and to socialise where before they were effectively paralysed.
Figure 1. INDIGO in use with darkened glasses.
U. Delprato et al. / PARKSERVICE: Home Support and Walking Aid4
Visual cues do not trigger paradoxical kinesis in all PWP but the number of suitable
PWP and the nature of the visual cueing that is most effective is not known. It is
believed that PWP in the intermediate stages (II-IV on the Hoehn-Yahr scale of I-V)
respond. In earlier work we estimated 15% of this population would benefit from visual
cueing but this was not statistically significant. [10]
It is therefore expected that PWP will need to experiment with different visual
cueing, by downloading selections of video on to their home television. If they find
they respond positively the PARKSERVICE consortium will provide an appropriately
configured INDIGO.
To date, the most popular choice for visual cues has been simply black and white
stripes scrolling upwards. [ibid]
4. Market Validation
Validation trials of PARKSERVICE will take place in summer 2006 involving
several associations of PWP and clinical investigators. Additionally independent
clinical trials of INDIGO will take place led by the Institute of Neurology, Lodon. The
major areas of investigation are listed below:
Drug management by video: the clinical assessment of PWP by video. This has been
investigated before – if these results can be confirmed this would be of enormous
importance to the market validation of telemedicine for PWP.
Social inclusion of PWP: do PWP report a greater feeling of connectedness to their
clinicians and other PWP given the ability to make and exchange messages from home,
principally by video.
Walking aids based on visual cueing: INDIGO, and devices using cueing, have
become increasing available in the last few years. However, none has become a mature
product. This may be due to a lack of clinical validation of this new device which
should be addressed by clinical trials.

In addition to these issues, to be addressed this summer, a market analysis has been
performed. Recalling that PARKSERVICE is aimed at users who have Parkinson’s
disease with targeted symptoms living at home who have or could get Internet access
and taking prevalence figures of 100-200 per 100,000 of the general population,
adjusting for disease stage, Internet availability, and possible co-morbid conditions
such as dementia, we estimate 180,000 to 360,000 potential PARKSERVICE users in
EU-25. Interestingly, 60% of the PD telemedicine market lives in UK, France,
Germany and Italy.
We also examined the trends in the PD market for telemedicine. The patient
population will steadily grow, due to the combined effect of the growth in the general
population in Europe and of the longer life expectancy of ageing people and PWP in
particular, but these demographic effects will be dwarfed over the next few years by the
effect of Internet penetration into European households. Considering an unchanged
prevalence of PD, we estimate an increase of the population of PWP by 6,000 between
2006 and 2008.
U. Delprato et al. / PARKSERVICE: Home Support and Walking Aid 5
Acknowledgments
The PARKSERVICE market validation project receives support from the
European Commission’s e-Ten initiative in Information, Society and Media.
References
[1] Dodel RC, Eggert KM, Singer MS, Eichhorn TE, Pogarell O, Oertel WH. “The costs of drug treatment
in Parkinson's disease”. Movement Disorders 1998, 13,249-54
[2] D Twelves et al. “Systematic review of incidence studies in Parkinson's Disease.” Movement Disorders
2003 18:19-31
[3] Kompoliti K, Goetz C, Leurgans S et al., “On freezing in Parkinson’s disease: resistance to visual cue
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U. Delprato et al. / PARKSERVICE: Home Support and Walking Aid6
Assistive Technology – Behaviourally
Assisted
12
Business Psychology Centre, Department of Psychology, University of Westminster
Centre for Business Information, Organisation, and Process Management, Westminster
Business School, University of Westminster
Abstract. In considering the recurrent problems involved in technology led
initiatives within the public sector, this paper seeks to identify change
management requirements needed to help avoid these latent pitfalls in the
widespread introduction of Assistive Technology.
It develops a change process approach based on current clinical psychology
techniques used in assessing sources and level of resistance to behavioural change
and applies them to managing effective benefits realisation.
Keywords. Change management, Assistive Technology, Radar plots, Behavioural
Adaptation and Business Psychology
Introduction: Organisational Capacity to Create New Behaviour
Sadly the ageing process tends to be accompanied by an ever widening set of ailments
and impairments that, without appropriate care support, increasingly limits the quality
of life and the maintenance of an independent lifestyle. Its effects are not solely
confined to physical health, but extend across the spectrum of psychosocial and socio-
economic areas as well. Moreover as these multivariate problems are frequently
interlinked, dealing with them individually within organisationally assigned boundaries

almost guarantees poor results and wasted effort. Logically what is needed is a “joined-
up” multi-disciplinary, multi-agency approach, which provides effective co-ordination
support to frontline staff.
The issue this raises is the cross-professional need to understand the benefits that
change can bring and that will accrue not only to their patients, but also to the quality
of care they deliver. The core of this lies in gaining a better understanding of the
interaction and interdependencies between their separate professional processes and its
impact on their roles and relationships, shown below in Figure 1.

1

2

S. Benton and B. Manning
Medical and Care Compunetics 3
L. Bos et al. (Eds.)
IOS Press, 2006
© 2006 The authors. All rights reserved.
7
8xL 2xK
6xP 3xQ
3xX 3xX
Interdependencies
[a.1] [a.2]
[a.3] [a.4]
Profession A
Profession B
Profession C
2xK
Figure 1 Integrated Care Process Interaction

To augment this process a full deconstruction of the core roles would inform a
parallel production of tactical and strategic behavioural programmes able to consolidate
best practice, under changing terms, whilst stretching towards changing and new
performance targets in a sustainable manner. This could be viewed in terms of an
iterative examination and weighting of roles, skills and competence, the primary basis
of which is a coherency of competence that connects personal and individual
competence to team competence (to maximise tactical delivery) and to organisational
processes and professional culture to maximise strategic competence. The Bpsy©
model offers a framework for the development of behavioural change programmes
based upon an integration of; personal, team and organisational competence, an outline
will follow.
1. The Situation: A Challenge for Joined-up Coherency
The potential complexity of a single case, even at a high level, is demonstrated in the
“radar plot” shown below in Figure 1, in which each of the sixteen main “dimensions”
of need is scaled outward from zero at the centre to a maximum of ten on the periphery.
The results of a typical initial assessment are combined as an area plot to provide a
graphic demonstration of the problem space. The risk of fragmented diagnostic and
support actions is ever present given the range of information points taken to profile the
medical and personal needs of this patient.
This approach helps to emphasise the degree to which current levels of care and
human resource are unlikely to increase in step with the predicted escalation in care
need.
S. Benton and B. Manning / Assistive Technology – Behaviourally Assisted8
Figure 2 Radar Plot of Core Process Needs
This representation helps to highlight three significant problem areas that lie
beyond the red level- 6 “danger” band. Whilst the overall health of the patient has not
yet entered the “at risk“ zone there are concerns over the level of nutrition, which could
be associated with financial problems. However mental health issues that have also
contributed probably drive this to worrying levels of social disassociation and possible
neglect.

Besides providing a readily understandable picture of the overall situation
presented it also indicates the likely inter-disciplinary, inter-agency complexities
involved and the level of case co-ordination needed to improve the position. In order to
achieve the coherency aimed for, a similar behavioural radar plot would be developed
against which the four fundamental quadrants shown above could be mapped in terms
of underlying behavioural sets. Resolving these issues in practice will hinge on
appropriate knowledge of each of the relevant care pathway options, the linking
interdependencies between them, and the necessary resources required to delivery
quality care. However up to now little or no progress has been made towards achieving
this necessary degree of integration. The most likely catalyst to set this underway is the
rising spectre of a massive surge in the number of over 65s that is set to double to
around 40% of the population of many nations over the next few decades. This is set to
be compounded by substantial reductions in the number of available carers as the
effects of the lowering in national birthrates begin to hit home.
S. Benton and B. Manning / Assistive Technology – Behaviourally Assisted 9
Figure 3 Implications of Change
2. Change: Coherence between Technology and Behaviour
The immediate effect of a diminishing pool of care professionals on service delivery is
bound to focus on finding ways of “working smarter” to meet increasing demand
whilst maintaining quality of care. This will inevitable involve seeking ways to
optimise multi-disciplinary, multi-agency working through radical process
improvement, re-design, and resource substitution. Essentially, within the capacity for
integration will be the need for role clarity assigned within each of these processes and
the re design of skill and behavioural competence to promote integrated use of existing
and evolving technology and existing and evolving competence. In this instance
competence is taken to represent those work specific skills necessary to the effective
delivery of work targets. This will necessarily require re modeling of organizational
practices, professional skill sets and resource planning. Under such conditions new
technology may serve to amplify personal and professional disabling behaviour as the
adaptation to changing work roles and processes re shape organizational performance

and deliverables’ criteria (Bridges, 2003).
An illustration of the response to such demands is shown in the s plot in Figure 4.
This illustrates the nature of behavioural adjustment to change (in the strictest terms it
shows the recovery to loss, (Kubler-Ross, 1991)) in this instance we are concerned to
effect organisational change, but all change is personal. The original coping stage,
shown on the peak of the right hand quadrant, would represent the current situation, the
existing relationship with technology, skill sets and strategic objectives. The opposite
peak is the perceived new opportunity for a change in strategic objective and direction
as identified by the organisational executive. One observation is that the line of sight is
significantly different to those whose responsibilities and roles require the adjustment
to change objectives via a purchase on the behavioural here and now. The curve
illustrates the disablers associated with personal and organisational change. The lower
S. Benton and B. Manning / Assistive Technology – Behaviourally Assisted10
left quadrant highlights some of the behavioural resistance accompanying this change
and the lower right quadrant highlights facilitative behaviours, to be acquired.
Change:
The Transition Curve
S
e
l
f
C
o
n
f
i
d
e
n
c

e
Se
l
f
E
s
t
e
e
m
P
e
r
c
e
i
v
e
d
E
f
f
e
c
t
i
v
e
n
e

s
s
Anger & Anxiety
Hidden
Past
R
e
s
i
s
t
a
n
c
e
&
S
a
b
o
t
a
g
e
Denial
Open
Commitment
New Ways of Working
Future
Adapting,

Exploring New Ideas
OVER TIME
Frustration & Confusion
Low
Disruption of thinking,
feeling
and behaving!
Testing
Acceptance
Resistance
Bargaining
Coping
Shock
Current
State
Future
State
Coping
Adapted from Gary Austin, circleindigo (2004)
Figure 4 The Transitional Curve: Pathway to Behavioural Adaptation
The relationship between the personal and organisational disablers will be written
in the assumptions and expectations embedded within the personal and interpersonal
culture, described by Hofstede (1997) as the ‘behavioural software’, that either
enhances or reduces individuals’; teams and organizations’ capacity to adapt and utilize
new technology and work practices. Frequently, the schism between these two
elements is exacerbated by technological change. The future state may show up clearly
on the executive radar screen, as opportunities that cannot be missed, however unless
the technological and behavioural change programmes are fully integrated and capable
of mutual re design the time spent on the downwards slope in Figure 4 will lead to
convoluted patterns of denial and resistance with commensurate waste of time and

temporary (probably short term funded) resourcing.
3. Sustainability: The Need for Assistive Behaviour
In order to achieve a change in behaviour rather than a shift reaction to changing
procedural and technological imperatives (which invariably fail to meet new criteria
over time) behavioural change programmes should aim to maximize the coherence
S. Benton and B. Manning / Assistive Technology – Behaviourally Assisted 11