=Paper=
{{Paper
|id=Vol-2142/paper10
|storemode=property
|title=Smart augmented reality mHealth for medication adherence
|pdfUrl=https://ceur-ws.org/Vol-2142/paper10.pdf
|volume=Vol-2142
|authors=Martin Ingeson,Madeleine Blusi,Juan Carlos Nieves
|dblpUrl=https://dblp.org/rec/conf/ijcai/IngesonBN18
}}
==Smart augmented reality mHealth for medication adherence==
https://ceur-ws.org/Vol-2142/paper10.pdf
Smart Augmented Reality mHealth for Medication
Adherence
Martin Ingeson1 , Madeleine Blusi2 , Juan Carlos Nieves1?
1
Department of Computing Science
Umeå University
SE-901 87, Umeå, Sweden
martiningeson@gmail.com, jcnieves@cs.umu.se
2
Department of Community Medicine and Rehabilitation
Umeå University
SE-901 87, Umeå, Sweden
madeleine.blusi@umu.se
Abstract. The aim of this paper is to introduce a smart mHealth application
based on the augmented reality (AR)-paradigm that can support patients with
common problems, related to management of their medication. This smart mHealth
application is designed and implemented as a medication coach intelligent agent,
called Medication Coach Intelligent Agent (MCIA). The MCIA will have to man-
age different types of information such as the medication plan (medication regime)
of the patients, medication restrictions, as well as the patient’s preferences and
sensor input data from an AR-headset. Considering all this information, the MCIA
leads with holistic decisions in order to offer personalized and unobtrusive inter-
ventions, in an autonomous way, to the patients. From a long term perspective,
the MCIA should also evaluate its performance over time and adapt in order to im-
prove its interventions with the patients. To show the feasibility of our approach,
a proof-of-concept prototype was implemented and evaluated. The results show
a high potential for using the MCIA in real settings.
1 Introduction
Medication adherence is a global problem [9], which can be defined as the “extent to
which a patient acts in accordance with the prescribed interval, and dose of a dosing
regimen” [10]. Lack of medication adherence leads to patients not achieving sufficient
health outcomes [18], and about 25-50% of the patients do not follow their prescriptions
correctly [16]. Non-adherence has been estimated to a cost of 100-289 billion dollars a
year for the U.S healthcare system [22].
Several attempts have been made in order to address this problem such as differ-
ent mHealth-applications3 and different types of robots. Even though some interesting
robots are on its way such as Pillo 4 , robots have by nature, the limitation of being more
or less fixed in its location.
?
Contact author.
3
Practice of medicine and public health using mobile devices, apps, smart devices and smart-
phones
4
https://www.pillohealth.com
Some of the critiques towards current mHealth- applications is that they lack several
basic adherence attributes [13], as well as persuasive techniques to engage people in the
digital management of their disease [12].
Non-adherence can be either intentional or unintentional [8]. Unintentional non-
adherence could, at least in theory, easily be addressed by sending reminders to patients.
This may work very well for mHealth-applications, but it is more difficult when using
robots since the user may not be close enough to the robot at all times. Intentional
non-adherence is more challenging since sending a reminder can be seen as a useless
attempt since, it will most likely not change the mental state of the patient. There is a
conflict of interest between the system/agent and the patient in this situation. Persuasive
techniques may play an important role when dealing with intentional non-adherence,
but as mentioned many mHealth-applications lack this feature. AR5 -headsets open up
for a seamless interaction and brings a new approach for dealing with the problems of
non-adherence.
Against this background, this paper introduces a novel solution to lead with the med-
ication adherence problem based on the AR-paradigm and intelligent coaching systems.
In particular, we introduce the so-called Medication Coach Intelligent Agent (MCIA).
The MCIA has proactive and reactive behavior in order to support the medical manage-
ment of patients. Moreover, the MCIA has autonomous reasoning capabilities that allow
the MCIA to lead with long-term goals in the settings of medication plans. As part of
the results of this paper, an architecture of the MCIA is introduced. This architecture
aims for a technologically scalable solution based on an AR-headset and multi-agent
systems. We also present a usability evaluation of a proof-of-concept prototype of the
MCIA.
The rest of the paper is organized as follows. In Section 2, different issues regarding
medication management are discussed. In Section 3, a theoretical framework regarding
the MCIA is presented. In Section 4, an implementation of the MCIA in the settings of
the Microsoft HoloLens is presented. In Section 5, an evaluation of our proof-of-concept
prototype is described. In Section 6, a short review of the related work is presented. In
the last section, conclusions and future work are outlined.
2 Medication Scenario
The research in this project was developed as nurses from home healthcare brought at-
tention to several patients having problems maintaining medication adherence through
self management. Self management includes strategies and activities a person performs
to live well with illness and it can be performed by the individual or in collabora-
tion with a significant other [4, 7, 23]. Patients who are unable to perform health- and
medication related activities as self management, for example handling and taking pre-
scribed pills and following a medication plan, can get professional help in their homes,
so called home healthcare [4]. A common reason for patients over age 70 to enroll
in home healthcare is they are no longer able to handle their medication through self
management and need professional help.
5
Augmented reality
2.1 Patient Groups
From a medication management perspective, patients who use medicine regularly can
be categorized into three conceptual groups. Group 1 is independent and do not rely
on help from others for managing their medication. Group 2 is partly independent,
receives help from relatives or friends, but do not get professional help. Group 3 is in
need of professional help.
The target group for the research in this project are patients from groups 2 and 3.
The purpose is to investigate if AR-technology (using an AR-headset) may be used as a
tool to increase their ability to improve and maintain medicine-related self management,
thereby contributing to them staying independent for a longer time, delaying need for
home healthcare and facilitate medication adherence.
2.2 Rules for Interchangeable Medicines
Many patients have several different medicines, as a strategy to simplify handling pills
they use pill dispensers, where the medicine is distributed on a weekly basis. A common
problem for the target group, and a reason why many patients need help managing their
medication, is the continuous variation regarding their medicines, names of medicines
and the visual appearance of pills and packages. This leads to patients and their non-
professional helpers being confused when handling medication and preparing pill dis-
pensers, which in turn leads to needing a nurse to come to their homes on a regular
basis, preparing the dispenser for them.
What actually causes the variation is that the pharmacies can deliver different brands
for the same type of medicine. The names and boxes varies with the brand and this
makes the patients insecure and afraid of preparing their dispensers. The underlying
reason for the frequent exchange of medicine brands are the rules for interchangeable
medicines which are applied in most European countries. According to the rules, if a
patient gets prescription for a particular medicine, the pharmacy always has to offer the
brand with the lowest price if the medicines are interchangeable6 .
One of the main aims of the MCIA is to make patients and their helpers confident
enough, using an AR-headset, to prepare their dispensers and therefore remove or delay
the need of home healthcare (nurse). Another priority of the MCIA, in order to consider
a long term experience, will be to help the patients to follow their medication plans
through self management.
2.3 Prescription and On Demand Medicines
For this project a characterization of medicines has been made since there are dif-
ferences in how different types of medicines should be managed by the MCIA. All
medicines comes with prescription from a doctor. Prescriptions include adherence in-
formation about how the medicine should be taken regarding dose and time schedule.
Adherence information is personalized for each patient, printed on adhesive labels at
the pharmacy and attached to each package of medicine.
6
https://www.apoteket.se/kundservice/receptlakemedel-sa-fungerar-det/
Medicines to be taken on a Regular Basis: The prescription label on these medicines
state dose and the specific times each dose of the medicine should be taken. The goal
of the MCIA is to make sure that the patient takes these medicines at the times they are
specified.
Medicines to be taken On Demand: This type of medicines are medicines that
the patient can take when he or she feels the need. Examples of common on demand
medicines are pills to decrease pain or anxiety. The information on the prescription label
states strength per dose, minimum time interval between doses and maximum amount
of doses allowed in 24 hours. The goal of the MCIA will be to make sure that the user
does not exceed the maximum dosage per day and occasion.
3 Theoretical Framework
The aim of this section is to formally introduce both data sources and a multi-criteria
decision making approach for supporting the decision making processes of the MCIA.
3.1 Data Modeling
Let us start introducing the basic definition of a time point. A time point is a time stamp
hDate, time_clocki. T denotes all the possible time points. Now let us introduce the
basic definition of a medicine. A particularly interesting attribute of a medicine is its
Anatomical Therapeutic Chemical (ATC)-code. The ATC-classification is an interna-
tionally accepted classification system, based on active ingredients and their therapeu-
tic, pharmacological and chemical properties7 . By AT C_codes, we denote a finite set
of ATC-codes. Hence, a medicine is defined as follows:
Definition 1. Medicine
A medicine m is a tuple of the form h, ς, p, δ, αi, such that m ∈ AT C_codes × R ×
[0, 1]× I × Active_ingridients, where ς ∈ R denotes a substance concentration in
milligrams, p ∈ [0, 1] denotes a priority degree, δ ∈ I denotes a time interval such that
I = T × T . M denotes the set of all possible medicines.
Medicines will be managed in terms of events. An event is something that hap-
pens and which should be acknowledged by the MCIA. For example, if a reminder is
presented to a patient whereupon the patient takes the medicines, the MCIA should
notice that event and not present any more reminders regarding the same medicines
for the same occasion. Events could also be things like eating food, drinking milk or
other things that might have an impact, or have an effect, on the users’ medication.
This project however, only considers events regarding taking of an oral medicine, and
is defined as follows:
Definition 2. Event
An event e is a pair hm, ti, such that e ∈ M × T . E denotes the set of all possible
events.
7
http://www.hpra.ie/homepage/medicines/medicines-information/
atc-codes
Constraints regarding medications can appear in three different ways. Firstly, it can
be a medicine incompatibility, i.e. some medicines should not be taken at the same time
as others, since it may have an impact on the effect of one or both of the medicines
[5]. Secondly, there are time constraints. For example, if a patient takes an on demand
medicine (such as regular painkillers), then a certain amount of time has to elapse until
he or she can take it again. Thirdly, there can be a maximum dosage, or amount, per
day. Due to lack of space, the formal definition of these constraints are not presented in
this paper. The formal definition of these constrains can be found in [14]. We assume
that the set of all possible constraints are denoted by Constraints.
A medication plan is the general plan which the MCIA wants the patient to follow.
It is the foundation of the goals of the MCIA, and it is adherence to the medication
plan that will be the primary source of feedback on how well the MCIA performs.
The medication plan consists of all medicines that are prescribed, and also a set of
constraints which should be considered while taking these medicines.
Definition 3. Medication plan
A medication plan M P is of the form M P = h(m1 , m2 , . . . , mn ), µi such that mi ∈
M(1 ≤ i ≤ n), µ = {C1 , C2 , . . . , Cn }, Ci ∈ Constraints(1 ≤ i ≤ n).
Medication adherence is the measure of how well patients follow their medication
plan. This is important information for the MCIA, since it can be seen as the result of
its actions and decisions. Medication adherence can be divided into two parts, overall
adherence (how well the patient is following the medication plan), and the individual
adherence for a specific medicine. It is not easy to measure adherence since there are
many factors which it depends on, e.g. skipping one medicine one time might be fine,
while skipping another is not. Elementary factors of estimating the adherence are the
priority of each medicine, which indicates how important it is to take the medicine, and
the history of the intakes (compliance to the plan). The two definitions of adherence are
presented below. An adherence function will be used to calculate adherence.
Definition 4. Medication adherence for individual medicines
Let βm be the medication adherence of a medicine m such that βm = f1 (γm , p) where
f1 is an adherence function for individual medicines, γm is the history for medicine m
and p be its priority.
Definition 5. Medication adherence in general Pn
Let π be the over all medication adherence π = f2 ( 1 βmi ) where, f2 is an overall
adherence function, and βmi is the individual adherence for medicine mi (1 ≤ i ≤ n).
Let us point out that the adherence functions f1 (w.r.t. Definition 4) and f2 (w.r.t
Definition 5) are basically distance functions between the current state of adherence and
the intended medication plan. Hence, these functions can be implemented in different
ways. In our proof-of-concept prototype, f1 was implemented as a model checking
function, based on weak-constraints, following Answer Set Programming (ASP) [6],
regarding the constraints of each medication in the medication plan.
3.2 Decision Making Modeling
In order to make decisions considering all of the relevant information such as the med-
ication plan and the so called information variables, a multi-criteria decision making-
approach has been chosen and more specifically, the weighted sum method (WSM) [15].
Information variables are used by the WSM for calculating weighted sums; an informa-
tion variable is a pair of the form hn, vi, where n is a propositional atom that describes
what the variable represents (such as a preference or a context factor) and v ∈ [0, 1],
e.g. hpref ersAudioOutput, 0.4i, hnoisy, 0.8i.
Information variables are compensatory. Having a global rank where a good cri-
terion can compensate for a bad criterion is usually referred to as the full aggregation
approach [15]. This is highly desirable since the MCIA will deal with conflicting infor-
mation and priorities.
Information availability. One of the drawbacks with multi-criterion decision mak-
ing in general, is that a lot of information has to be specified. In this case however, the
information should always be available in real time through sensors and internal values.
All desires (also called goals), which the MCIA has committed to achieving, are
called intentions and for each intention there is a finite set of actions {a1 , a2 , . . . , an }.
Actions are basically different ways of achieving an intention. Actions can also be seen
as the MCIA’s means of interacting with the environment. The distinction between in-
tentions and actions is a way of handling high level reasoning (using intentions), while
still being able to adapt and be sensitive to the current situation (by using an appropriate
action). An intention is defined as follows:
Definition 6. Intention
An intention x is a pair hID, αi, where ID ∈ N, α be the intention to be performed.
Example 1. Let xr be the intention to send a reminder to the user. Then there is a set
of actions {a1 , a2 , a3 } related the intention xr , where a1 = use audio output, a2 =
use visual output and a3 = use audio and visual output.
Before presenting the definition of decision making, a couple of related definitions
are presented. Utiliy weights can be seen as the priority of the information variable
regarding a given decision, and is defined in the following way.
Definition 7. Utility weights
Let wxd be the weight for information variable x regarding the decision d, then wxd ∈
{L, M, H} (low, medium or high importance).
An exact numeric value of the utility weight for the different priorities, is not defined
and it may have to depend on the type of decision. However, a value between 0 and 1
will always be used for each of the different levels of importance.
The utility function U (a), uses information variables with utility weights to calcu-
late the utility of an alternative a and is defined in the following way.
Definition 8. Utility function
Let a bePan action, and σ1 , σ2 , . . . , σn be the positive information variables, then
n
U (a) = 0 xi wi where, xi is the value of the information variable σi (1 ≤ i ≤ n), wi
be the weight of the information variable σi .
Only positive information variables are used in the calculation. Positive, simply
means that if the information variable has a high value, it should increase the utility
for the given alternative. This is chosen for simplicity of the calculation, but it puts
some requirements on what information variables there must be in order for the utility
function to be fair. Competing alternatives should always depend on similar information
variables, which means that they should have the same importance and have a similar
purpose. This problem could be addressed by setting a weight which corresponds to
the exact value of the importance of the variable, but it is hard to exactly define the
importance of an information variable for a given decision. Instead, utility weights are
merely a rough estimation of how important an information variable is.
Information which is not defined explicitly as a value (such as information in the
medication plan), but may still be important when calculating the utility of the alter-
native, will be converted into an information variable using a separate function. This
function varies depending on the type of information, but the result will be a number
between 0 and 1 and will therefore be treated as a regular information variable.
The decision of choosing the best action is taken in real time by using the following
definition.
Definition 9. Decision making
Let D be a decision and a1 , a2 , . . . , an be competing actions, then
D = max(U (a1 ), U (a2 ), .., U (an )) such that U (ai ) is a utility function which calcu-
lates the utility of ai (1 ≤ i ≤ n).
A plan is simply a list of intentions which, if nothing changes, will be executed by
the MCIA.
Definition 10. Plan
Let δ be a plan δ = (ν, θ), ν = [x1 , x2 , . . . , xn ] where each xi (1 ≤ i ≤ n) be
an intention, θ = [l1 , l2 , . . . , ln ] be a list of dependencies such that li = (π, β), π ∈
{ID|(ID, α) appears_in ν}, β ⊆ {ID|(ID, α) appears_in ν}8 and π ∈ / β.
4 Implementation
In this section, a proof-of-concept prototype of the MCIA is described. In this proof-of-
concept prototype, the MCIA has been embodied as a smart augmented reality (AR)-
mHealth application in the settings of a Microsoft HoloLens. This AR-mHealth appli-
cation was designed as a long-term experience application (LTEA) [14]. The internal
reasoning process of the MCIA follows the beliefs-desires-intentions (BDI)-model [24].
The BDI approach was chosen to handle a practical reasoning algorithm. Unity and Vi-
sual Studio were used to implement the prototype, and Vuforia was used as a plug-in
to Unity in order to recognize medicine boxes. The general architecture of the sys-
tem is depicted by Figure 1. The architecture consists of three major components, the
MCIA, external agents and databases. The external agents and the databases provides
the MCIA with the information it needs in order to supply the services to the user. The
external agents, which are also BDI-agents, were introduced in our previous work [20]
8
appears_in is the classical membership operator in lists.
Fig. 1. Architecture
The reasoning loop of the MCIA can be seen in Figure 2. A plan of intentions (later
referred to as plan) will be constructed using the current state, referred to as internal
state (Figure 1, 2), and the long-term goals. This plan will be created on a daily ba-
sis and planning will take place over a specific time period. By practical reasons, it
is assumed that this planning process will take place during night time. This means
that when the user wakes up, the plan for the day has already been made and only re-
planning using the event-driven approach is necessary. The reason why it is referred to
as an event-driven process is that events can be seen as triggers that changes the internal
mental state of the MCIA. Therefore, in the case of an event, the MCIA should check
for interactions with the plan and re-plan accordingly.
Proactive behavior emerges by actions executed in order to achieve the intentions
of the MCIA, such as sending reminders to the patient. Reminders are also context-
aware regarding time, but in our proof of concept, also by simulated information from
the environment. Reactive behavior emerges by using input to directly trigger some be-
havior, e.g. using voice commands and information regarding the user’s vision (using
the AR-headset), it is possible to display information regarding medicine boxes. Au-
tonmous behavior emerges by reasoning about the intentions of the day. The purpose
Fig. 2. Reasoning loop
of intentions are to improve medication adherence of the user, and by evaluating the
behavior of the user, the reasoning can be adapted.
5 Evaluation
In order to show the feasibility of our approach, a usability evaluation of the proof-of-
concept prototype of the MCIA was done. We aimed to answer the following questions:
– Is there a difference, related to age, regarding if people are willing to use an AR-
headset for medication management?
– Is there a difference, related to experience of using smart technology, regarding if
people are willing to use an AR-headset for medication management?
The functionality involved displaying information about medicine boxes regarding
two features namely, helping the user to use a medicine at this moment and to help the
user to prepare a dispenser. The evaluation involved 15 participants who were selected
by using the following criteria: a.- Different levels of management of medication on a
regular basis; b.- Wide range of ages (medication management in applies to people in all
ages, not just elderly); c.- Different experiences using smart technology in general. The
setting was a quiet and home-like environment. The participants were able to use voice,
vision and gestures to interact with the system and were presented with both visual and
audible output. Table 1 summarizes the visual information presented to the participants.
After the test they were asked to fill in a form. Responses were on a five-point Likert-
type scale graded from 1 (strongly disagree) to 5 (strongly agree). The lower bound to
agree was made at 4 (4 or 5 = agree).
Table 1. Visual information about medicines presented to test participants
The evaluation showed that of all participants 20% perceived the technology hard
to use and 13% thought that they would need a lot of training before using this technol-
ogy in real life. There were a couple of vast differences regarding participants over and
under 70 (4 and 11 respectively), and also between experienced smart technology users
and those less experienced (8 and 7 respectively). Of the participants over 70, 50% were
willing to use the technology in the future but none thought other people would appreci-
ate the technology. For the participants under 70, the corresponding numbers were 91%
and 100%. For participants over 70, 0% considered themselves as experienced smart
technology users, while 73% of the people under 70 considered themselves as experi-
enced. Of all experienced participants 100% were willing to use this technology in the
future and 88% thought that most other people would appreciate the technology.
6 Related work
The possibilities of using smart-glasses (AR) within a system to assist doctors and other
healthcare-personnel in emergency situations was explored in [11]. Smart-glasses was
connected to different types of medical equipment and was used to display important
information for the person wearing them. The smart-glasses could also be used to record
video/audio and to take snapshots of the process.
Mitrasinovic et al. concluded that smart-glasses have evident utility to healthcare
professionals [19]. A major advantage mentioned by Mitrasinovic et al. is that the
glasses are hands-free which liberates the users from giving manual input.
A concept to send context-aware reminders to users in order to increase medication
adherence was presented in [17]. They argued that sending reminders should depend on
other factors than time, since there are a lot of scenarios where time-based reminders
can fail. Results showed that the concept proved to be better compared to time-based
reminders, which motivates the need of being context-aware.
An article about using a humanoid robot to support elderly peoples’ everyday life
[21], supplied similar functionality that we wish to do. Their prototype showed that
there is potential in using a humanoid robot, and by using a robot (NAO in this case) it
is possible to handle additional problem domains such as emergency situations.
General tools to increase medication adherence for patients are smart dispensers
(e.g. [3]), robots (e.g. [2]) and applications to mobile devices (e.g. [1]). General func-
tionality of these devices is to remind the patient to take the medicine and to help them
with taking the right medicines. Our vision is to combine all of these common features
and to add a more intelligent behavior.
7 Conclusions and Future Work
Medication adherence is a healthcare issue that affects both youth and elderly patients
around the world. Until now, there is no a general solution that can support the dynamic
demands that each individual requires for keeping his or her self-medication manage-
ment optimal. In this regard, we argue that our approach based on intelligent coaching
systems and AR-headsets shows a solid and scalable solution for leading with the com-
plex processes of tailored services on medication management. Results from our evalu-
ation showed that participants felt comfortable using an AR-headset during medication
management procedures, such as taking pills and putting pills into pill dispensers. The
evaluation indicates that the MCIA embodied in an AR-headset can be a useful tool in
helping patients to maintain self management and medication adherence. From a soci-
etal perspective, maintained self management is likely to delay or possibly prevent, the
need for professional assistance by nurses. As most western countries suffer from lack
of nurses and other health care professionals the effects of the MCIA would potentially
have a high impact on sustainability of public health resources. In our future work, we
aim for a complete implementation of the MCIA and a long term usability evaluation of
the MCIA.
Acknowledgements: This research has been supported by Nordic Telemedic Center
(EU Interreg Botnia Atlantica), SFO-V Strategic Research Area Health Care Science
and CEDAR (Centre for Demographic and Aging Research).
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