UbiMMS: an ubiquitous medication monitoring system based on remote device management methods.
Abstract: Medication adherence is one of the most important factors in treating chronic diseases. However, current medication dispensers, which are devices that deliver medication to chronic disease patients according to predetermined schedules, are not equipped with internal remote management functions. Here, we propose a ubiquitous medication monitoring system (UbiMMS) that provides remote functions for medication status transmission, configuration management, software management, and real-time error management. We provide an overview and performance evaluation of the UbiMMS, and show that the proposed system is adequate for remotely monitoring and managing a medication dispenser in real time.

Keywords (MeSH): Health Communication; Personal Health Services; Information Management; Drug Therapy Management.

Supplementary keyword: Health Information Management.
Subject: Chronic diseases (Care and treatment)
Patient monitoring equipment (Technology application)
Patient monitoring equipment (Usage)
Authors: Pak, JuGeon
Park, KeeHyun
Pub Date: 02/01/2012
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Feb, 2012 Source Volume: 41 Source Issue: 1
Topic: Computer Subject: Technology application
Geographic: Geographic Scope: South Korea Geographic Code: 9SOUT South Korea
Accession Number: 286971368
Full Text: Introduction

The number of patients with chronic diseases such as hypertension, diabetes, and hyperlipidemia has steadily increased in recent years, largely due to the ageing of many populations and changes in lifestyle, such as eating habits and physical inactivity (World Health Organization [WHO] 2010). Medication adherence, which refers to the extent to which a patient follows the doctor's instructions about the timing, dosage, and frequency of prescribed medicines (WHO 2003), is one of the most important factors in treating chronic diseases (Ownby 2006; Pan American Health Organization 2003; Dunbar-Jacob & Mortimer-Stephens 2001). Medication dispensers, which are personal health devices (PHDs) that deliver medication to the patient according to predetermined schedules, are considered very efficient for improving medication adherence (Frick et al. 2001; Laster, Martin & Fleming 1996). However, given that the users of such medication dispensers are typically senior citizens and patients with chronic diseases, medication dispensers currently in use have the following problems: (a) most existing medication dispensers require users to configure a medication schedule manually; (b) numerous medication dispensers cannot communicate with external devices, and therefore, the capacity for continuous monitoring is limited; and (c) existing medication dispensers are not equipped with remote device management functions. Consequently, users must manage their medication dispenser by themselves.

For these reasons, an efficient remote device management method for medication dispensers is essential.

To overcome the problems associated with the personal use of medication dispensers, we propose the Ubiquitous Medication Monitoring System (UbiMMS), based on remote device management methods. The functions and benefits of UbiMMS are as follows:

* prevention of mis-dosing by proper dispensation of medications according to a medication schedule

* prevention of under-dosing by alerting the user with an alarm at the time that medications need to be taken

* periodic transmission of a patient's medical status to a monitoring server

* remote management of medication schedule

* remote management of medication dispenser

* support for two types of message-encoding method: XML (W3C 2008) and WBXML (W3C 1999)

* guaranteed compatibility with the de facto international standard for mobile device management, Open Mobile Alliance (OMA) Device Management (DM) (Open Mobile Alliance [OMA] n.d.).

The aim of this paper is to provide an overview and performance evaluation of the UbiMMS for managing medication dispersers remotely.

Overview of UbiMMS

Figure 1 shows a schematic illustration of the UbiMMS, which is comprised of medication dispensers and a monitoring server. Once medication schedules and system settings are configured manually by users or automatically via the remote monitoring server, the configured information is stored in memory. When the real-time clock reaches the medication time, the alarm notifies the user by a buzzer that it is time to take medications. If the user presses the dispense button at that time, the predetermined medications are dispensed. The medication dispensers transmit the patient's medication and device status and device configurations. The medication status is transmitted periodically, whereas the device configurations are transmitted whenever the monitoring server sends a request. Information on event occurrences such as a shortage of medication, medication jam, memory overload, software error, or non-adherence is transmitted immediately.

[FIGURE 1 OMITTED]

The monitoring server sends the received status data and configurations to medical staff and system administrators via a medication monitor and a system monitor, respectively. In addition, it generates management operations to manage configurations, software, and medication dispenser errors if necessary.

The processes related to the management operations (i.e. generation, transmission, analysis, and application) are performed by the DM agents installed in the medication dispensers and the monitoring server. The DM agent consists of a Session Manager, Authentication Manager, Protocol Manager, DM Function Manager, and Tree Manager. If the DM agent was to run constantly, it would be very inefficient in terms of power consumption and resource use. Therefore, we designed and implemented the DM agent so that it remains in sleep mode until a specific event occurs. If an event occurs, the DM Daemon runs the DM agent to establish a management session with the monitoring server. Details of the implementation can be found elsewhere (Jugeon & Keehyun n.d.).

The medication dispenser and monitoring server in the UbiMMS exchange management messages. These messages contain medication status, system settings, and management commands. As these exchanges can be a burden for networks, efficient message encoding methods are required. The UbiMMS provides XML and WBXML encoding methods.

Medication dispenser management method

In this paper, we have defined the manageable data of the medication dispenser as management objects (MOs) and arranged them into a tree structure called a DM tree. Figure 2 depicts the DM tree for the medication dispenser.

[FIGURE 2 OMITTED]

The monitoring server manages the medication dispenser through management operations that contain several commands such as ADD, DELETE, REPLACE, and GET. That is, the monitoring server modifies specific MOs using management commands. We have designed the following management operations: medication status transmission, configuration management, software management, and error reporting. For these operations, the medication dispenser and monitoring server exchange several messages during a management session.

Medication status transmission

The medication status is stored in the node ./Medication/Med_Status/Tray. The medication dispenser transmits the medication status with the REPLACE command when the server requests it or the timer reaches the transmission time. The monitoring server stores the received medication status in its datastore. Once this process has been completed, the stored medication status is provided to the medical staff through the medication monitor.

Configuration management

The monitoring server sends management commands to add, delete, or replace the target configurations. If the monitoring server sends a new medication schedule and transmission interval using REPLACE commands, the medication dispenser modifies the existing schedule and interval to the received values, and thereafter operates according to the updated schedule and interval.

Software management

When a new version of software is released, the monitoring server starts updating the software of the medication dispenser. First, it sends the URL for updating the software along with a REPLACE command to the medication dispenser. The medication dispenser then connects to the URL and downloads the new software automatically. After the completion of downloading, the Monitoring Server sends an EXEC command to the medication dispenser to install the downloaded software. The medication dispenser installs the software automatically and returns the result of the update.

Error management

If an error occurs in the medication dispenser, a dynamic node ./Medication/Error is generated with a specific error code. This node transmits the error code to the monitoring server by using a REPLACE command. The monitoring server analyses the error code, and performs a proper error recovery process: notification of the patient and his/her guardians in the case of a medication shortage or medication jam, deletion of unnecessary data taking up space, and reinstallation of software in the case of a software error.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

Evaluation of UbiMMS

The UbiMMS is a client-server system; for this reason, its response time is an important consideration. Hence, we evaluated the response time for sending and receiving a message in the UbiMMS.

Response time

We first evaluated the response time of the medication dispenser during configuration management operations. The response times were measured repeatedly as we increased the number of management commands. The result of this evaluation is shown in Figure 3.

Based on this figure, the response time for ADD commands increased by 7.4% on average when the number of management commands increased by 10. The response times for DELETE, REPLACE, and GET commands increased by 2.6, 4.8, and 5.3% respectively. Approximately 15 s were required to process 100 management commands. In other words, it took about 15 s to update 100 system settings in the UbiMMS. Secondly, we measured the response times for other management operations including software management, medication status transmission, and error management. The result is shown in Figure 4.

[FIGURE 5 OMITTED]

The response time for software management operation was examined by measuring the time required for the medication dispenser to download and install the firmware (3.62 MB). This required around 17 s. The time required for medication status transmission and error reporting was 6 s on average.

Remote management operation

To demonstrate the proper operation of the UbiMMS, we present an example of how to manage a medication schedule using the proposed method, as shown in Figure 5.

In the example in Figure 5(a), the medication dispenser is scheduled to dispense four types of medication at 08:30, 13:30, 18:30, and 22:30. The monitoring server generates a new medication schedule, which is shown in Figure 5(b). The medication dispenser then changes its current schedule to the new one received from the monitoring server, as shown in Figure 5(c). We can then verify the success or failure of the management operation. In Figure 5(d), the value of the status field is shown as 'completed'. This indicates that the management operation was a success. Thereafter the medication dispenser operates according to the updated schedule.

Discussion

Medication dispensers are helpful for older people and people with chronic diseases because they can improve medication adherence (Ownby 2006; Pan American Health Organization 2003; Dunbar-Jacob & Mortimer-Stephens 2001). However, this is true only if medication schedules are properly configured and the medication dispensers operate normally; otherwise, they can cause serious harm to health. Therefore, it is important to properly manage medication dispensers.

In this paper, we have presented the UbiMMS, a medication monitoring system based on remote management methods (specifically OMA DM). Based on the results of the evaluation, this system manages the medication dispenser efficiently. The overall response time did not substantially increase with an increase in the number of management commands, and the average response times during the management operations were appropriate. Therefore, we suggest that the UbiMMS is a suitable system for remote real-time monitoring and management of a medication dispenser. In practice, this system is about to be used in two demonstration projects in Daegu, South Korea, because of its demonstrated convenience and reliability. We suggest that remote management methods could usefully be applied in other healthcare devices to make them more convenient and reliable.

Conclusion

In this paper, we proposed the UbiMMS as a useful device to overcome the problems of existing medication dispensers, such as their inconvenience and low reliability. The UbiMMS is comprised of a medication dispenser and a monitoring server, and uses remote management methods. It has the distinguishing feature of remotely executing the following functions: medication status transmission, configuration management, medication schedule management, software management, and error management. Moreover, because the UbiMMS is compatible with OMA DM, a multitude of OMA DM servers can be utilized as monitoring servers for the system. The UbiMMS is appropriate for monitoring and managing medication dispensers because it generates low-bandwidth messages and achieves fast response times. For future work, we plan to survey the practical effects of the UbiMMS in the ongoing demonstration projects.

Acknowledgments

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education, Science, and Technology (No. 2011-0207).

References

Dunbar-Jacob, J. and Mortimer-Stephens, M.K. (2001). Treatment adherence in chronic disease. Journal of Clinical Epidemiology 54(12): 49-52.

Frick, P.A., Lavreys, L., Mandaliya, K. and Kreiss, J.K. (2001). Impact of an alarm device on medication compliance in woman in Mombassa, Kenya. International Journal of STD and AIDS 12(5): 329-333.

Jugeon, P and Keehyun, P (n.d.). Construction of a management system for medication dispensers. Unpublished manuscript (submitted for review).

Laster, S.F., Martin, J.L. and Fleming, J.B. (1996). The effect of a medication alarm device on patient compliance with topical pilocarpine. Journal of the American Optometric Association 67(11): 654-658.

Open Mobile Alliance (OMA) (n.d.). OMA Device Management Protocol. OMA DM Specification. Available at: http://www. openmobilealliance.org.

Ownby, R.L. (2006). Medication adherence and cognition. Medical, personal and economic factors influence level of adherence in older adults. Geriatrics 61(2): 30-35.

Pan American Health Organization (2003). Poor adherence to long-term treatment of chronic diseases is a worldwide problem. Revista Panamericana Salud Publica 14(3): 218-221.

World Health Organization (2003). Adherence to long term therapies: evidence for action, WHO. Available at: www.who.int/chp/ knowledge/publications/adherence_report/en/

World Health Organization (2010). Global status report on NCDs. WHO. Available at: http://www.who.int/topics/chronic_ diseases/en/

W3C (2008). Extensible Markup Language(XML) ver. 1.0. W3C Recommendation. Available at: http://www.w3.org/TR/xml

W3C (1999). WAP Binary XML Content Format. W3C NOTE. Available at: http://www.w3.org/TR/wbxml

JuGeon Pak BSC, MSC(CompEngr)

Doctoral Candidate

Department of Computer Engineering

Keimyung University

SOUTH KOREA

email: corea@kmu.ac.kr

Corresponding author

KeeHyun Park BSC, MSC, PhD

Professor

Department of Computer Engineering

Keimyung University

1000, Sindang-dong

Dalseo-gu, Daegu 704-701

SOUTH KOREA

Fax: +82 53 580 6969

email: khp@kmu.ac.kr
Figure 4: Response times of medication dispenser for
different management operations

                  Management Operations

Software Mgmt           17404
Status Mgmt              6018.6
Error Mgmt               6017.6

Note: Table made from bar graph.
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