Mobile Healthcare: Ready for Monitoring of Children at Home?

Transcription

1 Mobile Healthcare: Ready for Monitoring of Children at Home? M.P. Jochemsen ABSTRACT This paper presents the result of a study about the improvement points that has to be made to make the mobile health technology ready for monitoring of children at home. Attention has been paid to the results and theories of other researchers and to the results found in interviews with (parents of) patients. Mobile health technology is almost ready for monitoring of children; some more attention must be given to the material and design of the intelligent device. Keywords Childcare, mobile health technology, monitoring of patients. 1. INTRODUCTION Monitoring patients while they are outside the hospital. The principle is simple: for example sensors on the body keep an eye on the vitals of the patient and alarm when something goes wrong. Data is sent through a smart phone over a mobile network to the server and from there on to a person who can help the patient. [Fre06] This means that patients can recover in their own environment, that they do not have to go to the hospital every day and that healthcare is more personalized. With access to home monitoring devices (computers and communication networks), patients can become more active in their own health care. [BI99] It is a fact that through the psychological effect of being in a familiar environment, long-term patients in homecare have a better chance of recovery than long-term patients in a hospital have. [JBKV01] 1.1 An example of mobile healthcare To clarify the idea of mobile healthcare, an example of a patient after hospitalization for cardiac infarction is used: Although the patient should be guaranteed a good quality of life, he still needs to be in constant contact with an expert physician so that his cardiac activity (e.g. the heart rate and peripheral blood pressure), body temperature and breathing frequency can be continuously monitored. However, the health condition of the patient can only partially be evaluated through his vital signal and must be mediated and integrated by other signals and information coming both from personal characteristics (risk factors, degree of disease, age, sex, family history, psychological features, etc.) and from the environmental context (e.g. whether in bed or mobile, by him or in company, at work or at home, the season and the temperature, etc.). The monitoring system should be able to Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission. 6th Twente Student Conference on IT, Enschede, 2nd February, 2007 Copyright 2007, University of Twente, Faculty of Electrical Engineering, Mathematics and Computer Science provide a feedback to the patient as well as notifying his status to somebody else, such as a relative, the family doctor, or the hospital, depending on the degree of alert detected, and possibly adapting the level of service (i.e. the intensity of the monitoring activity). [ACCM05] The above scenario shows us that the mobile healthcare technology is complex; it needs a lot of comprehension, experience and time to realize a good working technology. For example, the technology requires sensors located near the patient, the integration of different medical devices and information about the patients medical history. [ACCM05] Figure 1 shows a graphic illustration for the used scenario. Figure 1. Healthcare monitoring of a patient, source [ACCM05] redraw by M.P. Jochemsen (2006) As you can see in Figure 1, the medical network exists of layers, with in the middle the Body Area Sensor network. This network is hosted by the patient and takes care of comparison of data collected by the sensors and medical history data of the patient. The home network is an environmental sensor network and this layer interacts with the hospital network to exchange data and alerts. [ACCM05] More about the mobile health technology will be explained later. 1.2 Motivation Monitoring at a distance is already possible, but there are cases were it does not work well enough. Freeband Awareness, a project from a national research program from the Netherlands, gives for example attention to epileptic attacks. The problem the project is dealing with is that they know that just before an epileptic attack the patient s heart beats faster, but that can also indicate stress or a movement. The question here is how do you know when a person needs help? [Fre06] This research paper is not going to look for the problems with epileptic patients, but for another problem case, namely children who need mobile healthcare. Looking at the mobile health technology there is much information available about the combination mobile healthcare and patients. Knowing that the

2 technology is working in some cases already, this is a logical continuation. The growth in the field of quality assessment has been concentrated primarily in the area of adult health. [HSVM98] There is hardly any scientific literature available about the wishes and needs of children with a chronic disease and the use of mobile healthcare. Generally, when innovation takes place and technologies are improving, people first look at the functional performance of the process and to standards, in this case the mobile health technology for standard patients and their needs. [TBP01] Because children account for only 15 percent of direct expenditures on healthcare, they appear to warrant less attention from the marketplace than chronically ill adults do. [LM92] Although efforts to measure and improve quality for children can benefit from many of the methodological advances that have been developed in studying the quality of adult healthcare, adult measures cannot always simply improving quality of children's healthcare be used for children. [HSVM98] Therefore, we are going to look at issues concerning improvement of the quality of life for children with a chronic illness using mobile healthcare. In this research, the patients are sick children, who have been treated in the hospital and will be monitored with the mobile health technology at home afterwards. The process to make the child healthy again has started, but is not yet finished. Through the latest innovations in mobile healthcare, it is in some cases possible to monitor adult patients outside the hospital, but what about children and their need? In principle, children with a chronic disease have the same basic needs as healthy children. [TG03] You can imagine that they want to play outside and that they want to have friends to play with. Besides these emotional needs, there are practical and technical needs. For example, information about the location of the patient will be received by an intelligent device; how can we take care that the children do not forget or lose their smart phone or PDA? To get an answer to this question, we are going to look at the emotional, practical and technical needs of children in mobile healthcare. 1.3 Research questions The readiness of the mobile healthcare technology for monitoring of children healthcare at home is the mean theme in this paper. The main question that will be answered is as follows: What has to be improved to make the mobile health technology ready for monitoring of children healthcare at home? In order to successfully give an answer to this question, first some attention will be given to general information about the mobile health technology. Secondly, this paper will have a look on the needs of children. Subsequently, the possibilities in the mobile healthcare will be compared to the needs of children. Finally, an answer will be given to the main question of this paper. The sub questions are: Why should mobile healthcare be used (instead of treating patients in a medical organization)? What are the needs of children in mobile healthcare? How answers to these questions are received is described in the following paragraph. 2. METHOD OF RESEARCH In this paper, attention is given to the results and theories of other researchers by studying their outcomes and to the results found through communication with (parents of) children with a chronic disease. 2.1 Literature study There is a lot of literature available about the technical aspects of mobile healthcare. For information about the technology is searched in scientific articles and papers on the Internet. Many articles were found by searching on the scientific search engine of Google: In contrast to the amount of information available about the technical aspects, there was hardly anything to find about mobile healthcare for children. Therefore, there has been contact with children with a chronic disease for who the mobile health technology has changed their life or could change it in the future. 2.2 Communication with children and/or their parents When looking at the needs of children with a chronic disease, it is important to look at the needs from the view of the child. Therefore, contact has been made with children with a chronic disease and their parents. To contact children with a chronic disease, internet forums have been searched. Different kinds of diseases are considered to make the results found, through communication with these children, broader. There has been contact with patients through forums on several websites. [Ast][Cro][Diab][Diag][Epi][Vok] Websites for asthma, cancer and diabetic patients are a few of them. In Table 1 you can see how many children and parents had been contact with for the different diseases. Table 1. Number of children and/or their parents having contact with to get answers for this research Disease \ Who Children Parents Asthma Cancer Crohn disease Diabetics Epileptics Children & Parents To contact the children and their parents, requests for contact has been placed on the forums. In response, some children have send an , most of the time containing their story. For getting more information about the needs of children in mobile healthcare, an was send to these children (and/or their parents) with questions about the children and their chronic disease, about how they are dealing with it now and how they hope their life can change in the future. For example, there were questions about everyday things like hobbies, friends and playing outside. For the younger children parents reacted and gave answers about how they think their children would deal with mobile healthcare. 2.3 Results study The main research question is answered by studying the results found in de literature study and the communication with the children. Improvement points for making the technology ready for monitoring of children healthcare at home are found through comparison of the possibilities of mobile healthcare with the

3 needs of children. These points are summarized and together give an answer to the main question. 3. MOBILE HEALTHCARE To get a good view about mobile healthcare, this chapter will give basic insights in why the mobile health technology is important for better healthcare; a description will be given about how things went in the hospital before the mobile technology and why innovation has take place. After the reasons for mobile healthcare, the requirements for the technology will be discussed and the current state of the technology will be given. 3.1 Reasons for mobile healthcare How things went in the hospital before the mobile health technology? It is a simple process starting with a person who gets ill. When this person has the flu he probably will not seeing a doctor, but if it is more serious he probably will. This doctor can decide on basis of the symptoms to give medicines and send the person home or to send this person to a hospital. In the hospital, the doctors can do some more tests about which disease the patient is dealing with and they can give him the right treatment. It is possible that only medicines will be given to the patient, but also a surgery and after-treatment is possible. Not every sick person who is sent to a hospital can go home the same day; for some diseases patients have to stay in de hospital for more than one day, sometimes even for more than one month! For other diseases, it is possible that patients have to return to the hospital a few days a week or month for treatment of their illness, even if they do not feel sick. There is one reason why patients have to come back to the hospital so often: doctors can periodically see the conditions of the patients and through that, they are able to provide better advice, suggest better treatment and they will notice eventually problems of the disease and treatment earlier. Figure 2 gives a graphic view of the given process. The process for treating sick persons seems working good, why should we change this process? Why is it so important that the mobile healthcare technology will be improved and usable in the future? To answer these questions it is important to look at the people and organizations that have profits through this new technology. Therefore, the main points for improving the mobile health technology for patients, health givers and health payers will be discussed here Patients The main issue for sick persons is to get healthy again, if they are dealing with a chronic disease they want a life as normal as possible. The following reasons concern patients [Mob]: Increased freedom and improved quality-of-life. Through the mobile healthcare technology, patients do not have to be or stay in the hospital every day and accordingly have a greater chance to have a normal life. They can recover in their own environment, which increases the chance of recovery. They can also built up a social life and participate in more activities. The mobile health technology helps the patient to increase his or her freedom and improves the quality of life for the patient. Flexible, individual and effective treatment and therapy. The mobile health technology is flexible and can fit for a lot of different treatments and therapies. The treatment is the same as in the hospital except that the patient now has family and friends around him. With the mobile health technology, it is possible to make the treatment and therapy individual, which will increase the effectiveness of the therapy Healthcare givers: hospital and doctors The main objective of the hospital and her doctors is treating as much as possible persons in such a way that they get better or give these persons a treatment so that their life is as normal as possible. The following reasons concern the hospital and her doctors [Mob]: Better management and monitoring of patients therapy. Through the mobile healthcare technology, there will be a better management and monitoring of the therapy of the patient. With continuous monitoring, the treating doctor will have more and up-to-date information on the patients condition and will be able to provide better advice and to suggest better treatment. [KJBH] Data collected from every individual person will be saved and can be used when necessary. When the sensors on the body of the patients register something odd, these data can be compared to earlier data and if necessary, a doctor will be alarmed. Doctors can use intelligent-based systems for getting data to timely detect and manage health risks. They can early diagnose illness or injury and recommend treatment that would prevent further deterioration. And this all in a reasonably short time! [Par03] Besides this, every health specialist has the possibility to look into information collected about the patient. Figure 2. Process for treating patients before the mobile health technology, draw by M.P. Jochemsen (2006) Prevention as well as fast and professional handling of emergencies. The mobile health technology makes it possible for patients to recover outside the hospital; if something goes wrong, signals can be send to persons who can help the patient. The nearest caregiver or ambulance can be found using mobile telephony. This person can be sent to the place of emergency; there will be given help to the patient as quick as possible. In the old

4 situation, there were no signals send to persons who could help the patient; someone had to call a doctor or ambulance not knowing what was wrong precisely. How the technology works exactly will be explained later. Less urgent problems can be solved by giving the patient different medication or by giving the treating doctor information about what happened. [Put05] High service differentiation with low investment in technology and time. High-quality care consists of several components: the person has the opportunity to obtain needed care, the care is appropriate and skillfully provided, the care is delivered in a human manner consistent with patient preferences and the best possible outcomes are achieved. [McG97] Through the development of the mobile health technology, it is possible to treat patients in more than one way. The treating doctor can apply what is best for the patient and if he is confident that the patient is doing well he can choose for the option of monitoring the patient s recovery at home. Through the technology of monitoring of patients at a distance, doctor s time will not unnecessary be used but only in emergencies when the doctor is really needed. Besides this it also means more time and beds to treat other patients and because of that a decrease of the number of patients on the waiting list for treatment in a hospital Healthcare payers: insurance companies The following reasons concern health insurance companies [Mob]: Reduction in disease and care costs. Through mobile healthcare, reduction in disease and care cost can be reached. In the old situation, patients who are not at immediate risk but who need monitoring have to stay in a hospital for long periods so that regular measurements methods can be used. This results in high costs for the hospitals and social insurances. A patient recovering in his own house is much less expensive than recovering in a hospital, even if a doctor is coming to see the patient every day. At home, family can take care of the patient instead of expensive hospital employees and patients can use their own bed in most cases. Better management of resources. Through the possibility of monitoring of patients outside the hospital, management of resources for disease prevention takes place even as remote assistance of patients. Patients have to go to the hospital only in problem situations; the cost of in-patient care will be decreased. Significant pharmacoeconomic improvements. Medications must be functional and cost-effective despite the working, effectiveness and safety property. Through a good working mobile health technology, patients get the right medicines from the doctor. Through well functional medicines, cost reduction has take place and with that pharmacoeconomic improvements. 3.2 Requirements for the mobile health technology To reach a working mobile healthcare system, it is necessary that it is clear what the requirements for such a system are. What must the system be capable of and how does it work? The different requirements will be named and explained in this paragraph. There have to be light and portable sensors located on the body of the patients that can collect health information about the patient. Sensors on the body of the patient should be able to collect information about blood pressure and pulse rate, blood glucose and cholesterol, and there should even be sensors for electrocardiograms and brain activity. Besides sensors, there are actuators, which will help the body to control. These sensors are giving feedback to it-self to regulate the body. Insulin or morphine pumps, pace maker controllers and even electrical muscle stimulation are examples of actuators. [KJBH] Because of the fact that the patient has to keep the sensors on the body all the time, these sensors should be light and portable. The sensors must be integrated into the everyday life of the patients. Therefore, they should either fit by their look to the individual s preferences, or they should disappear, for example in clothes or jewelry. Another issue is the battery and life of the sensors and measurement devices; a user should not need to worry about constantly changing or recharging batteries for the multitude of sensors and devices at home. [KPG03] It should be possible to send information over a wireless network between the sensors and the server. To give a patient a life as normal as possible despite continues monitoring, the patient should have a complete freedom of movement. This can be reached through communication by wireless technologies. The wireless technology makes it possible to send information over a mobile network and to locate where the patient is in case of emergency. Is should be possible (through wireless technology) to locate where the patient is and to find the nearest doctor/ambulance in case of emergency. The wireless technology should make it possible to locate a patient. If an emergency happens, help must be given to the patient as quickly as possible. Therefore, it is not only necessary to locate a patient, but also to know were people who can give help to the patient are, like doctors and ambulances. For these persons it must be possible to access the medical server to get information about the health history of the patient, for example by using a PDA. Data collected by the sensors must be analyzed and saved on a medical server, for the treating doctors it must be possible to access these data. Data collected by the sensors and sent over the mobile network should be saved in a database from where it is possible for the doctors of the patient to access it, for example using a PDA. To reduce the amount of information transmitted over the network, data should be processed locally with the support of information from the patient s history accessible from the hospital network. Only in critical situations data should be forwarded and analyzed by the hospital network. [ACCM05] For privacy issues it is important that data send over the network and saved in a database is not reachable and usable for outsiders. Data about the health of the patient should be accessible for doctors, but not for outsiders. This information is private and the privacy of the patients must be guaranteed. The same concerns the sending of information over the network, outsiders may not have access to the data and there must be no opportunity for an outsider to get access. Finally, it is important to let all the available healthcare devices and sources integrate with each other. To get the technology work, it is necessary that the different medical devices integrate with each other and with environmental data acquired by sensors located near the patient.

5 Patient data available from the electronic medical records stored by the hospital, hospital administrative information about admission/discharge of patients, and the management of financial data and health care resources are also important for integrating. It should be possible to access and integrate all available health care resources offering a continuous, widespread, cooperative health care system and tools for personalized patient monitoring. [ACCM05] 3.3 Mobile healthcare now and in the future Mobile healthcare is already possible for some diseases, for example, diabetic patients already use insulin pumps. The technology is not working in every situation and for every chronic disease yet. How the technology is working precisely (or for some diseases: must work in the future) is shown in figure 3. Figure 3. Network for monitoring of a patient, draw by M.P. Jochemsen (2006) In figure 3, the network for monitoring of a patient is given. Here the patient has sensors on his or her body for the registration of different values. The patient wears a personal server, like a PDA, with him all the time. This personal server can receive, through wireless communication, the data collected through the sensors and can store this information. The personal server can forward these data to the medical server using WLAN, GPRS, UMTS or Bluetooth and the use of mobile devices in the environment. The variety of mobile devices includes personal digital assistants (PDAs), laptops, notebooks, GPS, smartphones, etc. Treating doctors and caregivers have access to these data on the medical server. Besides sending data over a wireless network from the patient s personal server to the medical server, it is possible to send data in the other direction. This is for getting medical history data about the patient, which can be compared by the personal server with new up-to-date data collected from the sensors on the body. It is possible that not every medical employee will understand the goals and objectives of implementing the mobile health technology. Hospitals and other medical organizations have to educate their staff about the goals and advantages of implementing the technology. Insufficient comprehension will lower individual s intent to use the new technology and finally result in unsuccessful innovations adoption. [WWL05] In the future, the mobile health technology must be usable for monitoring and treatment of more diseases. For future innovations can be thought of applications for disease management. These applications must be able to effectively help chronic ill people take better care of themselves; they must manage medical conditions over time, improve outcomes, give lower costs and support monitoring. These applications should increase the quality of life for the patient more and should give the doctor more time for spending on other patients. 4. CHRONIC DISEASES AND NEEDS OF CHILDREN Now it is clear what mobile healthcare exactly is and how far the technology is right now, the needs of children are to be discussed. Before getting to these needs, first a definition of chronic diseases will be given. After this, the basic needs of children and the needs for children with a chronic disease, who could use the mobile healthcare technology in the future to get a better quality of life will be discussed. 4.1 Chronic disease A chronic disease is a long-lasting or recurrent impairment, which can be progressive and life threatening or can be come along with a relative normal life, despite the decrease of body and mental functioning. [Why92] Normally a disease is called chronic if the handicap is there for six months or longer and the patient still lives. [RBG99] Chronic diseases vary in seriousness, duration, cause, form, progressively, prognosis, functional constraints, visibility, pain, treatment form and rules to live with it. [ES01] The chronic diseases you see the most are: asthma (about 9.5% of the children), migraine, skin diseases, epileptics, diabetes mellitus and diseases from heart, liver and gut. Some diseases you have your whole life and it is not possible to recover from them, for example cystic fibrosis and diabetes mellitus. From other diseases, it is possible for the children to recover, here you can think of leukemia for example. [TG03] Children with a chronically disease do not feel sick all the time. They can have long periods within they are almost free of complaints. These quiet periods can vary with bad periods. In these bad periods, the children may need intensive medical healthcare. The consequences of illness or a handicap can change the normal development of a child in a negative way. So is it possible that the children deal with restriction of physiological and sensorial disabilities. [TG03] 4.2 Needs of patients Maslow, an American psychologist, said that every human being has a strong feeling or desire that has to be fulfilled to make that person feel good. These basic needs are universal. [Mas87] In principle, children with a chronic disease have the same basic needs as healthy children. For the achievement of these needs is a cooperating environment an important condition. [TG03] It is important that children despite their disabilities can fulfill their basic needs. [TG03] In the first place, these children want to live their life as normal as possible. They do not want to be different from the rest and they want the same treatment. [CB02] This means they want, just like healthy children, to go to school, to play a sport, to have a job, live on their own, have friends, go out and do more things healthy children can do. Schlösser and Colland have done a research for the quality of life of children in different stages of their life. They found that for baby s it is important that they can sleep and eat well. For a child in the age 2 till 4 it is important to move a lot, they want to play outside with other children. Children that go to school want to participate with activities at school and in the neighbourhood. Teenagers want to have contact with people of their own age and they experience positive future possibilities as a mean issue of the quality of life. [SC01]

6 It is important for children to socialize with other children of their age, they have to develop their social skills and find appreciation. [RGG94] For many children with a chronic disease it is difficult to keep a lot of friends, because they spend a lot of their time in the hospital or at home in their bed. Distraction, fun and playing is really important for these children, because it is a fact that through entertainment and pleasure recovery time will be decreased. [Kin92] For getting more information about how children with a chronic disease think about mobile health and about how it can change their lives, there has been contact with some children and their parents. In these contacts, attention has been paid to the things the mobile healthcare technology has to fulfill to give the children a better quality of life. For example, there has been talked about the fact that children want to play, both inside and outside the house. When children play outside, they may want to play hide-and-seek and it is possible that they hide in the weirdest places, and it could be somewhere where is no access to the network. You can say to a child where he can play or not, but the friends of these children may play everywhere and it is for a child difficult that he may not. About the unpleasantness for a child of wearing the sensors on the body and the device near the body all the time, one of the parents said the following: My son is two years old and he has diabetes. For a year now, he has an insulin pump. For Children of that age it is not a problem to wear something at the body. He never takes it off and he never sees the pump as unpleasant. This mother is not the only one who said that children would not see sensors or an intelligent device as unpleasant. In fact, even the children self say that they know that they have to care these things with them all the time to survive. They know that the technology give them the opportunity to have a normal life outside the hospital, despite the wearing of these things. Because the children see the meaning of mobile healthcare, they will not take the sensors and the devices away. The same apply for the chance of losing the intelligent device. According to the children this chance is nothing, because they would take care that they do not lose it. Another interesting point what came up in the contact with the children was the chance that a child falls and hurts himself and as a result, the intelligent device gets broken. Also on this point, the children were sure that they would be careful and they would take care that the intelligent device does not fall or gets broken. Not one of the parents and almost none of the children mentioned something about the presentation of the sensors and the intelligent device, but one of the children said: For me it should be important that I will not be reminded to the hospital anymore, the sensors and the intelligent device or the actuator have to look nice and must be child friendly. I think about nice colors and sweet little figures on it. Or maybe the device can be a teddy bear or something. Children have also hobbies that might be increase their quality of life. For many hobbies, they say that they can simply fulfill them in a more peaceful way. A few of the children (around 10%) mentioned that they want be able to swim with the sensors on their body. Generally, the children with a chronic disease know the mobile health technology can increase their quality of life. 5. DISCUSSION AND CONCLUSION Now we know a lot about the mobile health technology and about the needs of children who have a chronic disease, the results found before can be interpret and an answer to the sub questions and the main research question can be given. Why should mobile healthcare be used? Mobile healthcare technology makes it possible for children to recover and to be monitored outside the hospital. This new technology can improve the quality of life for many children. For the organizations (most of the time hospitals) that give care and treat the child, the technology means a better management and monitoring of the therapy and a faster handling of emergencies. Besides this it also means more time for doctors and free beds in the medical organizations to treat other patients and because of that a decrease of the number of patients on the waiting list for treatment in a hospital. What are the needs of children in mobile healthcare? The most important things been said about the needs of children, is that the children want to have a life as normal as possible and that it is important for them to socialize with other children of their age. Using mobile health technology the satisfying of these two issues can be increased. The children and their parents said that the biggest problem they see is the chance that children want to play outside and could reach an area where no connection is to the network. They see no problem wearing the sensors on the body and the intelligent device near the body. The change of losing the device or get the device broken is according to the children nothing. A few of the children mentioned that for them it would be important that the sensors and the device or the actuator has a friendly design and is made of a nice material. Children want be able to play a sport, but they know it is not always possible because of their illness. What has to be improved to make the mobile health technology ready for monitoring of children healthcare at home? Reachability of the network is not only important for the use of mobile healthcare through children, but also for adult patients. The network is a technical issue and it is a requirement that it works perfect before using the concept of mobile healthcare. The children say they do not fall and that they would take care the intelligent device would not get broken. Because of the fact that you can not regulate if you will fall or you will not and of the fact that little children fall more often than adults, it is necessary to take care that the intelligent device is made of such a material that it will not brake when something happened. One of the children mentioned that she would like it when the device is something like a teddy bear. It can be an option, if the device is inside the teddy bear; in this way, the intelligent device will not get broken so easy. The last issue that came up is the design of the sensors and the intelligent device and the actuator. Probably it is not a problem to develop and produce some colorful and child friendly designs, to remind the children less to the hospital and the fact that they are ill. Besides this, there is the option of putting sensors in clothes or jewelry. There are differences between healthcare for adults and for children. For both of them mobile healthcare is already working for some diseases but not for every chronic disease and in every situation. Therefore, the technology must be further improved and specialized for these diseases. Besides this, the mobile health technology is almost ready for monitoring of children;

7 some more attention should be given to the material and design of the intelligent device. ACKNOWLEDGMENTS We would like to thank our track supervisors, W. Bandsma and R. Middel, for guidance during making this paper. We would also like to thank the children and their parents for their time and valuable answers and J.H. Hegeman, L.M. Perloy and other reviewers for their comments on reviews of this paper. REFERENCES [ACCM05] Amato, G., Chessa, S., Conforti, F., Macerata, A., Marchesi, C., Health Care Monitoring of Mobile Patients. ERCIM News, 60, Jan [Ast] [BI99] Balas, E.A., Iakovidis, I. Distance technologies for patient monitoring. British Medical Journal, Nov [CB02] Claessens, M., Boer, J. de, Kinderen en jongeren met een chronische ziekte en hun ouders. Een onderzoek naar de knelpunten die kinderen/jongeren met een chronische ziekte en hun ouders ervaren in zorgverlening en maatschappelijke participatie. CG- Raad, Utrecht, May [Cro] [Diab] [Diag] [Epi] [ES01] Elich, M.,Sinnema, G., Chronische ziekte en lichamelijke handicap. In Handboek Kinderen & Adolescenten, BSL, Houten, Aug [Fre06] Freeband Awareness. De juiste zorg op de juiste plek. Freenovation, Apr [HSVM98] Halfon, N., Schuster, M., Wendy Valentine, W., McGlynn, E., Improving the Quality of Healthcare for Children: Implementing the Results of the AHSR Research Agenda Conference. HSR: Health Services Research, 33-4, Oct [JBKV01] Jones, V., Bults, R., Konstantas, D., Vierhout, P.A.M Healthcare PANs: Personal Area Networks for trauma care and home care. In Proceedings Fourth International Symposium on Wireless Personal Multimedia Communications, , [Kin92] Kind en ziekenhuis, Themanummer Kwaliteit, 15-2, Jun [KJBH] Konstantas, D., Jones, V., Bults, B., Herzog, R., MobiHealth innovative 2.5 / 3G mobile services and applications for healthcare. [KPG03] Korhonen, I., Parkka, J., Gils, van, M., Health Monitoring in the Home of the Future - Infrastructure and Usage Models for Wearable Sensors That Measure Health Data in the Daily Environments of the Users. In IEEE Engineering in Medicine and biology magazine, May/Jun [LM92] Lewit, E. M., Monheit, A. C., Expenditures on Health Care for Children and Pregnant Women. The Future of Children, 2-2, , [Mas87] Maslow, A.H. Motivation and personality, Harper & Row, New York, [McG97] McGlynn, E. A., Six Challenges in Measuring the Quality of Health Care. Health Affairs, 16-3, 7-21, [Mob] Mobihealth: Herzog, R., Konstantas, D., Jones, V., Bults, R., Innovative GPRS/UMTS mobile services for applications in healthcare. [Par03] R. Paradiso, R., Wearable Health Care System for Vital Signs Monitoring. In Proceedings of the 4th Annual IEEE Conference on Information Technology Applications, [Put05] Putter, T., In de ban van zorg op afstand. Knowhow, 02-05, Telematica Instituut Telin, Feb [RGG94] Rispen, J., Goudema, P.P., Groenendaal, J.J.M., Preventie van psychosociale problemen bij kinderen en jeugdigen., Bohn Stafleu Van Lochum, Houten/Zaventem, [RBG99] Ruwaard, D., Berg Jeths, A. van den, Gijsen, R., Demografie van chronisch zieke in Nederland. Chronisch-ziekenbeleid in de jaren negentig, [SC01] Schlosser, M., Colland, V., State of the Art, Kwaliteitvan-leven onderzoek bij kinderen met astma. Pulmonair, 8-2, 7-11, Jun [TBP01] Tidd, J., Bessant, K., Pavitt, K., Key Issues in Innovation Management. Management Innovation. Integrating Technological, Market and Organisational Change, 3-63, [TG03] Tielen, L.M., Ginkgo Zorgprojecten. ICT en kinderen met chronische ziekten, VSB Fonds, Utrecht, Jan [Vok] [Why92] Whyte, D.A., A family Nursing Approach to the care of a Child with a Chronic Illness. Journal of Advanced Nursing, 17-3, , 1992 [WWL05] Wu, J., Wang, S., Lin, L., What Drives Mobile Health Care? An Empirical Evaluation of Technology Acceptance. In Proceedings of the 38th Hawaii International Conference on System Sciences, 2005.