The 'Smart Technology' future is now: interview with Eric Dishman, Intel Corporation.

Intel Corporation is known to most around the country as one of the world's leading technology manufacturers, primarily in the computer marketplace. But if Intel's Eric Dishman has his way, the company will soon be known for much more than that.

Intel's Proactive Health Research program, led by Dishman, has jumped head-first into the aging services technologies market, first by teaming up with the American Association of Homes and Services for the Aging to form the Center for Aging Services Technologies (CAST), and more recently by partnering with the Alzheimer's Association on the Everyday Technologies for Alzheimer Care (ETAC) project. Through these associations, and on its own, Intel figures to be at the forefront of the next wave of technologies to hit the long-term care market.

Nursing Homes/Long Term Care Management Assistant Editor Todd Hutlock spoke with Dishman about these and other topics.

Hutlock: How did Intel develop the Proactive Health Research program, and what was your personal role in its development?

Dishman: Intel has the largest social science group in the technology industry, and I'm one of those social scientists. We study people--not just the aging--in their everyday lives: at work, at home, at play, in all kinds of contexts in many countries throughout the world. We try to wake up not only Intel executives and engineers, but other companies we work with to other opportunity spaces they might not be thinking about.

In 1999 and 2000, just as broadband, cable modems, and the like were starting to come to the first homes in the United States, we did a study about the future of digital entertainment. We were showing concept prototypes and observing people in their own homes. We found that in almost any home with people over the age of 45 or so, many of the people weren't so interested in digital entertainment. They did, however, tell us things like, "My mom lives in Toledo, Ohio, and we live in Portland, Oregon. We need some way to look in on her and see how she's doing, because she insists on staying in her own home. We're really worried about her; no one lives close to her." We heard that kind of story often enough that I finally suggested to Intel that we brew up a project to look specifically at this aging-in-place challenge.

We looked at the demographics worldwide at that point, and we were particularly surprised that Japan and Western Europe are in an even worse aging crisis than the United States. The input from consumers combined with the demographic numbers, and my own passion--I did some caregiving for my grandmother with Alzheimer's, and I do a lot of patient advocacy work with elders with cancer--pulled it all together for me.

Hutlock: How does the Proactive Health Research program work?

Dishman: We start with the three Cs: cognitive decline, cancer, and cardiovascular disease. We chose the three Cs because of the predominance of people in their sixties, seventies, and eighties having those conditions. Most people with cancer (77%), for example, are diagnosed at age 55 and older. If you combine the costs of treating those three Cs just in the United States, it's more than $500 billion annually. If we can make an impact in those areas, it's going to make a significant economic difference, as well as benefiting the individuals.

Within each of the three Cs, there are three phases: explore, conceptualize, and test. The exploratory phase is where the social scientists are doing almost anthropologic field work--studying elders, caregivers, and the elders' adult children, including baby boomers. We're trying to anticipate what the baby boomers are going to be like as they move into their retirement years. It's not that we're ignoring today's elders, but we think there are different opportunities for this next wave of elders, because they have all these technologies--e.g., the Web, e-mail, cell phones, and instant messaging--that are a normal part of their everyday lives. Some members of that population are even big video game players. This exploratory phase represents our effort to help our engineers and the technology researchers we work with at universities understand what it's like to live the lives of these people. We obviously look for patterns and trends, as well.

In the second phase, conceptualizing, which is where we are now with the cognitive decline research, there are many prototypes. At this phase, we've taken everything we observed in the exploratory phase and we've now built prototypes from paper and foam core, as well as some functional prototype systems. We have started getting feedback about all these different ideas.

In the third phase we'll use the findings from the first two phases to narrow these ideas down and actually test systems in people's homes. We're already starting to build those systems and test them in little bits and pieces in some of our assisted living partners' facilities. The vast majority of the trials probably won't take place until February or March of next year, because it takes a while to build these functional prototypes.

We really believe in evidence-based technology research. We're modeling what we do after the way in which drug-delivery systems are developed. We don't want people purchasing these technologies, or the federal government reimbursing for them, unless they show some sort of benefit, such as reduced depression, decreased cost, increased patient satisfaction scores, or something.

Hutlock: Can you provide some examples of some of these projects?

Dishman: In our cognitive decline studies, involving 50 households in four cities over the last few months, we were looking at how you use both existing and future communications technologies to provide social support. The social isolation problem and the caregiver burden were, not surprisingly, two huge issues we saw. We saw that if you weren't socially enriched and you didn't have a network of people around to help you--either as an individual with cognitive decline or as a caregiver--that's where problems began.

For example, say you've got an elder living in a facility, and he's got four adult children and maybe 12 grandchildren scattered around the country. None of those children actually has any sense of how often the rest of them have spoken to Dad. To meet their need, we developed a simple communication system using telephone conferencing technologies that already exist. An adult child gets a phone call from the system, telling him that none of the children has called Dad within the previous two weeks. The system basically connects a social network of people, and it has some sort of intelligent routing that lets you all know that none of you has contacted Mom or Dad recently. This is trivial to do technologically on a prototype level, but it might end up having as much impact as certain kinds of medical care, if it helps to reduce depression and encourages social networking.

Going back to the digital entertainment study, something people were excited about was a prototype of a system that lets people watch TV together with a kind of shared audio chat, even with someone a thousand miles away. We categorize that as digital entertainment, but when people saw it they said, "That's what I need as a way to check to make sure Mom or Dad is okay." We did a quick experiment with what we call the "presence lamp." We put a simple off-the-shelf motion sensor on a lamp. It could let an adult child know that Mom, who is 85 and living alone in another home or city, has gotten home safely and is sitting in her favorite room in her favorite chair. The system would turn on a lamp in the home of the person the elder chose to share that information with--and vice versa, because we found that the elders weren't really willing to do this unless it was a two-way street. They wanted to know when the person they cared about was home, as well.

When we first tested this, there was a lot of anxiety; both sides were nervous. The adult children were worried that Mom and Dad would call a thousand times a day if they knew when their children were home, but that didn't happen. Most people felt some sense of presence and started to get a sense of what the other people's routines were. In other words, if it's Tuesday night and you know that Mom is usually home that night, and usually the lamp is on but suddenly it is off, you can make a quick call to check on her. It's a simple technology that may have a profound impact on "okayness checking."

Hutlock: Are there any prototype systems in the works for someone with more advanced cognitive decline, such as late-stage Alzheimer's?

Dishman: We've developed a safety monitoring system for people with advanced Alzheimer's that we've built in some detail. We saw many situations in which the people with Alzheimer's disease or some other dementia had advanced so far that they would sit most of the day, or even most of the week, in a particular chair. The caregivers would put them in bed, then bring them out and sit them in that chair for most of the day. The caregivers' fear was that these people with dementia would get up and fall, because once every three days or so, they might stand up for some unknown reason: They're looking for something, or they get hungry, or something cues their memory. That fear of patients' falling meant that caregivers had to stay in the room 24 hours a day, which is obviously impractical.

In this case, we took a simple pressure sensor and placed it into the chair or couch where the Alzheimer's patient was spending most of his or her time. We also placed what are known as stereo cameras, which send data to show whether the person is at standing level, sitting level, or lying-down level. If he's at lying-down level, that means he might have fallen. If the person stands up, the system finds the caregiver, wherever he or she is in the house, and plays a message on the nearest electronic device, be it the alarm clock or the television or whatever, alerting him or her that the Alzheimer's patient is up. Or, if the system thinks (based on the cameras) that the patient has fallen, then the system will send a more urgent message. We've also got it set up so you can let a neighbor know. We also can send the information about the patient to a cell phone or a PDA. Think of this as something that could be integrated with your home security system.

Hutlock: In a case like this, you would have to set up an entire system to implement it, as opposed to something you might bring home and simply plug into the wall.

Dishman: That's right. We believe that in the future there will be radios and computer chips in every consumer electronic device that comes out. We know many of these devices that people will have in their homes will be able to communicate with one another. So sending out a medication reminder on someone's television or clock radio is not far-fetched at all.

Hutlock: Does that roll into the concept of the "Smart Home" that we've all been hearing about?

Dishman: Well, we don't like the term "Smart Home," because most of the Smart Homes that exist aren't that smart; but the spirit of the Smart Home is right. It means getting data into the system about people's everyday lives in the context of what they're doing, so that you can get the benefit of computing and the like without having to educate people extensively on the technology.

Many elder households we've been studying have been healthy aging households. If you look at the oldest old, the ratio of women to men is 2 to 1. Many of these older women and widows, living alone either in an independent living facility or in their own homes, are not getting enough exercise anymore. Quite often they might have exercised with their late spouse, and now they've stopped. In this case we have simple sensors, like pedometers and other devices, to let elders know how many steps a day they've taken. Taking it a bit further, you can motivate the elder to exercise by using the Internet to convey this information to her fitness buddy, someone she partners with for mutual encouragement. Basically the system lets the other person know through a variety of ways--a graph on a digital photo frame, or a light turning on--that the other person is ready to go for a walk, and that she has only taken 2,000 steps today instead of the 10,000 that is her goal. We try to find opportune moments between these two households to suggest that they go exercise because neither one of them has reached her goal for that day or week.

Hutlock: It's a bit like the instant messaging concept, isn't it?

Dishman: Exactly. It's taking that notion of instant messaging and saying, "Let's get some sensor data in there about how many steps they've taken."

Another prototype we developed is a wind chime with a motor. The chime starts to move to let the person know that his fitness buddy is home and hasn't reached his exercise goals today, and that this might be a good time to call him. So the output of our system can be anything from a graph or a chart on a computer, to something more abstract like a lamp or a wind chime.

Hutlock: Whatever the person is comfortable with?

Dishman: Yes. We've used the term "personal computer" for decades, but really, they haven't been all that "personal"--they've been a box sitting on your desk. But if you look at the recent explosion of wireless laptops and PDAs and the capability of having computing information show up on a television and vice versa, suddenly things can become quite personal. You can adapt the interface to whatever you want. This has been important to today's elders that we've seen. Many of them, especially those with Alzheimer's, are losing much of what they've learned recently, and that includes the computer. So it's devices like a television or a phone where we'll have the opportunities to send messages.

Hutlock: What would you say are the core building blocks for what you're trying to accomplish with this process?

Dishman: The core building block for much of what we're doing is what we call wireless sensor networks. Different households will have different needs, but nobody will want to run cable around their homes to a bunch of sensors, so we will need secure wireless to send data back to a host PC for processing. We're focusing on how to build that infrastructure so we don't have to tear up everyone's walls. If you think about it, there already are sensor networks in many homes. Home security systems are typically sensor networks, although they are usually wired. You want the system to be able to age in place as the person ages in place, so you might not need pressure sensors or cameras tracking fall safety in the earlier stages of decline. But clearly people with Alzheimer's will eventually cross that threshold, so the system needs to be easily adapted and modular.

Hutlock: How does all of this fit in with the CAST initiative?

Dishman: Much of what we're trying to do with some of these Smart Home technologies is set up living laboratories in the continuum of care and find opportunities for an assisted living facility and researchers to build an application together and test it. We've got great technology sitting in our labs, or IBM's labs, or Microsoft's labs--how do we facilitate a national conversation to take some of these technologies and apply them to our aging crisis? That's really what the CAST initiative is about: to apply these Smart Home technologies, many of which have been around for years, to the unique problems of aging and aging in place.

CAST has had more success than we could imagine, in terms of interest from providers around the country. It really is a unique collaborative conversation, and there is a lot of excitement and energy. Hopefully, a year from now we will be talking about at least half a dozen, if not several dozen, seed projects that have gotten off the ground because of CAST.

Hutlock: When will some of this technology actually find its way into homes?

Dishman: It's hard to say, because it depends on the application. The way I look at it is that some of it is already showing up, at least in assisted living facilities. For instance, one of the assisted living facilities we work with, Elite Care in Oregon, has elders wearing badges that give location data. This provides value to both the elders and to the facility. And the elders can go to the system and see where other people are hanging out, so they can either join them or avoid them, if they wish. We're building research on top of that same system to attempt to develop a sociability index for people. We can start to take all of these little bits of data and develop an index that says how social a resident has been on a scale of one to ten. We can develop a trend line over time, so that if there's a sudden drop-off in a resident's socializing, someone can be alerted to find out why.

Unfortunately, we also found in our studies at Elite Care that often when we were counting two people as being in the same room together talking, they were actually on the sofa having a nap for three hours. We need to tweak the system so it can sense whether a conversation is taking place. It wouldn't be a Big Brother type of thing, recording everything said; it would simply monitor whether people were talking--a simple yes or no. Part of that system is here today, but to get the whole system working the way I described will likely take another four or five years. If you look out to the end of the decade, when the first baby boomers start to officially reach retirement age, I think you will see a lot more systems in place.

Hutlock: What can you tell me about the recently established program between Intel and the Alzheimer's Association?

Dishman: The program established by Intel and the Alzheimer's Association is the first of its kind in the world that we know of, and it's the first time the Alzheimer's Association has funded technology research around computing solutions for the home. Through the ETAC consortium, participants will fund research grants for exploring new uses of technology to help people with Alzheimer's disease today and in the future. We hope that ETAC will also serve as a research catalyst for universities, technology companies, industry labs, government agencies, and voluntary health organizations.

Hutlock: Do you think some elderly consumers will be resistant to these technology solutions?

Dishman: Well, the short answer to that question is yes, there will definitely be people who resist it--as well they should. There are some real privacy issues here, and people should only use what benefits them. I work for a technology company, but I am the last person in the world who wants people to adopt technology for technology's sake. Technology companies know that you will lose your customer's faith and trust if you aren't delivering something with genuine value. The elders we have shown these concepts to have been surprisingly interested and eager to sign up, because they are the ones facing the fear of declining abilities. They are saying to us that they want to decide for themselves what is too invasive or what is not invasive enough.

Hutlock: What is the ultimate goal of Intel's research?

Dishman: It is to catalyze as much research around aging-in-place technologies as possible, so that we can empower elders with more choice and options about where they live and help them stay independent and intellectually, socially, and emotionally engaged in the world. It's not just about meds compliance or functionality. It's about social and intellectual engagement and purpose, and trying to figure how to use technologies to support these higher-order things.

For further information on Intel's Proactive Health Research program, visit www.intel. com/research/prohealth; for further information on CAST, visit http://agingtech.org; and for further information on the Atzheimer's Association, visit www.alz.org. To comment on this article, please send an e-mail to hutlock1003@ nursinghomesmagazine.com.