uCare is an advanced system designed for monitoring patients with heart disease during home-based cardiac rehabilitation. Ensuring the safety of patients and their compliance with the rehabilitation program is the primary goal of uCare. Modern information and communication technologies (ICTs) are revolutionizing the way people interact with each other, and the barriers between virtual and real life are being overcome. These technologies allow the almost unlimited transmission of information and have led to the development of tools for the management of patients at a distance, with a positive impact on patient quality of life and health care costs.
In the United States, heart disease accounts for one death every 37 seconds. In Italy about 45% of 500,000 annual deaths are caused by a cardiovascular event. The causes of heart diseases vary widely. Changes in lifestyle and the frenetic rhythms of modern life, combined with bad eating habits, have led to a giddying increase in the problem over the last few years. The treatment of heart failure takes up a large part of scientific research in the field of cardiology. Despite this, it is possible to identify and eliminate the cause only in a small percentage of cases. In the other situations, the therapeutic objective is to reduce the severity of the symptoms, increase the functional autonomy of the patient, slow down disease progression and prevent complications, thus increasing survival and improving the quality of life.
Especially after an intervention, patients with heart disease may have a negative perception of their health and develop depression. Post-surgery depression is an important issue in cardiac rehabilitation. Returning to good health requires variable amounts of time but is almost invariably a demanding process. For this reason, rehabilitating patients are offered psychological support for the management of depression, anxiety, and other emotional problems. Angioplasty, bypass and other operations following heart attacks are carried out increasingly often, on 35 year old patients, young people who should not have these problems. But these are increasingly frequent as they do not look after their own health.
“Cardiac rehabilitation is the combination of interventions required to ensure the best physical, psychological, and social conditions so that patients with chronic heart disease or following an acute cardiovascular event (heart attack) can maintain or return to an active life.”* This definition highlights the two categories of individuals requiring cardiac rehabilitation, namely patients with post-acute heart disease and patients with chronic heart disease. It also points out the main objective of cardiac rehabilitation: to re-establish and maintain a health status as close as possible to “good health”, by preventing disease progression, reducing the risk of cardiovascular events, and promoting the recovery process.
Physical activity can be performed at home or in rehabilitation centres under the supervision of a health care professional. Self-managed cardiac rehabilitation, also called home-based cardiac rehabilitation has a number of advantages from a practical point of view. In home-based cardiac rehabilitation, patients follow a program of physical training according to the indications received at the discharge from hospital. The information regarding the response to physical exercise obtained either automatically or by heart rate self-measurement, or by the transmission of the ECG via cardio-telephone devices, is sent to the rehabilitation centre. This method has proven effective and safe, leading to a substantial decrease in costs and involvement of medical personnel. However, due to the lack of a direct relationship with health care professionals, some of the objectives of rehabilitation are not met. Indeed, patient education, diet counselling, and psychosocial support, are all essential for bringing about effective and persistent life style changes, are not implemented. As a consequence, home- based cardiac rehabilitation is reserved to selected patients and particularly to those who are unable to attend a centre-based supervised program.
The Home Setting
Patients undergoing home-based cardiac rehabilitation will use at home medical devices that are typical of the hospital setting. The possibility for patients to remain in a familiar environment has several benefits. For example, among older patients a frequent reason of missed follow-up visits is the difficulty of leaving home. The home setting is familiar and reassuring, it brings patients back to their every-day routine, and reminds them that life goes on after the intervention and that it can be even better than before. Probably for all these reasons, however, medical devices at home have a negative impact on patients as they remind them of the hospital and betray the patient’s illness to those unaware of it. In addition, some patients decide to give up self-monitoring and thus rehabilitation once at home, as they perceive the discharge from the hospital as a demonstration of their complete recovery, which makes further care unnecessary. Therefore, the home setting has both advantages and disadvantages: it affects positively patient psychological condition and it has a positive impact on health care costs by reducing the expenses for medical resources; on the other hand, however, patients are no longer fully controlled by a health care professional.
The Objectives of the uCare System
Despite continuous progress and considerable research efforts in the field of cardiovascular medicine, not all patients with a cardiac illness have access to cardiology centres, for various reasons including geographical distances and disabilities that complicate long-distance travel. While in big cities, patients can have face- to-face contacts with healthcare professionals at all disease stages, people living in remote areas may be excluded from this type of service. After cardiovascular interventions, visits to the physician are essential. However, mostly due to geographical distances, many patients do not attend their follow-up visits, with potentially negative consequences for their health and for the outcomes of cardiac rehabilitation. Advances in medicine may become useless if patients are prevented from taking advantage from them by the distance from the centres providing the latest therapies. With regard to the diet during cardiac rehabilitation, patients are informed about which food to prefer and which food to avoid, and receive comprehensive diet counselling at the discharge from hospital.
A systematic review published in 2010 in the British Medical Journal analysed the data from 12 clinical trials comparing home-based and centre-based cardiac rehabilitation and found no differences in terms of patient outcomes between the two strategies. Home-based rehabilitation was however associated with a better patient compliance with the rehabilitation program. Thisfinding is particularly interesting because the poor attendance of rehabilitation programs taking place in hospitals or gyms is one of the major problems in cardiac rehabilitation. Among the reasons leading to poor participation to centre-based rehabilitation, the authors pointed out problems with accessing the centre and parking, a dislike of groups, and work or family commitments.
The main objectives of the uCare system are therefore to monitor patients undergoing cardiac rehabilitation at home with regard to the different components of the rehabilitation process – exercise, diet, medications, fluid volume control, psychological condition, social life – with a reduced use of medical resources and thus a favourable impact on costs.
Usually the patient with heart disease is unaccustomed to the use of technology and especially averse to instruments that remind him of being sick. The product is therefore intended to blend into the home environment as much as possible and not to impose itself as an object that is a constant reminder of the disease to the user, and to those who see it. Since the system is intended primarily to educate the patient towards empowerment, inspiration has been taken from the mirror, that is the emblematic object of taking care of themselves in every day life. The shape of uCare is similar to a classic mirror with clean and essential lines. As long as you do not turn it on, the display is in stand-by mode, allowing it to reflect the user on it’s surface. The mirror is the most important object for the care of the user and has a very strong symbolic value, as it is a familiar piece of furniture, but also a way to interact with ourselves and, in part, to remind us who we are. It is through it that we can observe ourselves and image through the eyes of the others. The silhouette carved on the back allows you to hang the device, hold it with more ease and for air to circulates in the cooling system, entering and exiting from a concealed grid on the back. The edge of the frame is slightly tilted making the pro le thinner and appear aesthetically lighter.
The main concept behind the development of the uCare system was the need to establish a constant communication bridge between patients with heart disease and undergoing cardiac rehabilitation and health care professionals, based on ICTs. Modern communication has considerably improved so that mobile technologies and the Internet allow now simultaneous communication between people that comes very close to real face-to- face interactions.
The uCare system is composed by a central unit – a mirror – with which users can interact to control the peripheral devices that monitor various clinical parameters. By taking advantage of the Wi-Fi technology, the system can also be used to communicate with other uCare users and with authorized health care professionals who have access to the patient clinical data stored in the system. All data are stored and sent automatically to the central unit.
There are two main general concepts on which this system is based. Firstly, patients should be made aware of the fact that the hard process of cardiac rehabilitation is essential for their own well-being; the system aims at teaching patients how to take care of themselves by exercising and by following an healthy and balanced diet, by encouraging their autonomy without making them feel left to their own devices. Secondly, uCare has been designed and developed by taking into account the mean age of patients with heart disease.
Great care has been taken to make the uCare device as user friendly as possible. The use of instruments for the measurement of vital parameters, including the sphygmomanometer, the body fat monitor, and optionally the pedometer, is explained to patients at hospital discharge. Once at home, patients can use these instruments as indicated in their program, in the same way as patients undergoing conventional home-based cardiac rehabilitation. The difference between conventional home-based rehabilitation and home-based rehabilitation with uCare lies in the mode and extent of information communication.
The interactive display contains all the information necessary for an optimal rehabilitation process and provides support to patients by creating a bridge between patients and the involved medical staff. In this way, most visits to health care professionals during rehabilitation are no longer necessary and patients can very conveniently contact the physician and other health care professionals by means of a video call, if they need to ask a question. Thanks to the memory system of uCare it is possible to perform at home the exercises of physical reconditioning. In this way patients no longer have to travel to rehabilitation centres or gyms.
The uCare device is equipped with a medication dispenser in the upper part of the device. The dispenser is composed of 14 compartments, for delivering the medications required for a 1-week therapy with twice daily drug administration (an internal wheel rotates on itself twice daily and delivers the tablets needed). One of the problems associated with therapies based on the assumption of tablets is the uncertainty about having taken them or not. uCare is also designed to overcome this problem, as the absence of tablets in the compartment means that they have already been taken. Furthermore, thanks to the particular tetradecagon shape of its internal component, it is possible to remove the dispenser from its housing for loading it once weekly, or simply for taking it along when leaving home.
Prerequisites for use
The patient must be instructed regarding the use of the system during the last days of his hospital stay, and for the first three days after discharge, a nurse should go to a patient’s home to check that he can use it properly and his ability to manage the instrument on his own by filling in the right form (similar to that for simple forms for transitional home care).
The availability of the doctor (who needs to be willing to give advice and check patient data remotely), of the dietician (who needs to commit to updating the patient’s diet by internet) and the physiotherapist (who needs to be able to see the parameters during effort reconditioning to determine the patient’s progress) is of great importance and in order to make the system sustainable, medical personnel needs to find time to dedicate to telemedicine during the work day when they are available to patients to check on their parameters, and in the case of the physiotherapist, to check that the prescribed exercises are being done (which is verified by the parameters data themselves).
By considering the environmental requisites right from the first phases of development (including cost, performance, legal, cultural and aesthetic aspects) we can act preventively on environmental impact related issues instead of finding solutions to damage caused after the product has been made. In this way we can obtain financial and environmental advantages. This is why we need to be clear about the concept of lifecycle of a product when we design and evaluate it. During its lifecycle the product is considered with relation to the flow of materials, energy and emissions due to the activities that accompany it during its lifespan. This is composed principally of five processes: pre-production, production, distribution, use and disposal. By correctly designing the product, the designer can act on each one of these phases to optimise resources and reduce environmental impact. As far as uCare is concerned, the materials and internal components are not good examples of eco-sustainability but, by carefully choosing how they are made and assembled, and taking strategic advantage of the temporary use of the product, we can reduce its cost and environmental damage.
“Useful life” is also an important concept to bear in mind during the design phase. Useful life measures how long a product and its materials can last maintaining its performance at a standard predetermined level. By satisfying several demands, something that is possible during the temporary use of uCare, the object to be used for a longer period, avoiding having to discard it after it is used just once, and making more intense use possible.
Another strong point of this system is clearly the standardization of the components: production costs are reduced and when the product is discarded, several parts can be recycled without having to undergo major transformations. By conceiving and designing products that are easy to take apart, maintenance, repair, updating and re-production become easier; making it easier to separate materials simplifies recycling for some and separation for others (when there are harmful materials). This is why uCare uses permanent joints which can be opened easily and reversibly and removable joints (screws and rivets), using glue only in case of extreme necessity.