Precise RTLS in Healthcare May Inform Future Best Clinical Practices
At the April Intelligent Health Association conference at the Roosevelt University in Chicago, the U. S. Department of Veterans Affairs SmartHome Project took center stage. Team members covered the process by which SmartHome technologies are matched with veterans with disabilities, and the wide variety of smart home technologies that have resulted from this project.
Dr. William Kearns, one of the James A. Haley VA Hospital SmartHome grant’s original authors and faculty in the Department of Rehabilitation and Mental Health Counseling in the College of Behavioral and Community Sciences at the University of South Florida, addressed unanticipated research findings obtained from pervasive Real Time Location Services (RTLS) operating continuously in the SmartHome. His findings have the potential to affect best clinical practices for treating persons with traumatic brain injury and other cognitive impairments.
RTLS data automatically identifies and tracks the location of people in real time with no special effort aside from wearing a small tracking tag. The VA SmartHome RTLS tracks the tag and its wearer throughout the building and the vicinity. All veterans residing in the VA SmartHome receive treatment for traumatic brain injury and may have significant cognitive impairments. Dr. Kearns’ findings reveal that the effects of cognitive impairment are seen in one’s walking patterns much in the same way police field sobriety tests reveal short-term cognitive impairment in the walking patterns of intoxicated persons.
Dr. Kearns employs fractal mathematics, specifically “Fractal Dimension” (aka “Fractal D”), a method used by animal ecologists studying spatial orientation behavior in naturalistic settings, and adapted it to quantify straightness of natural walking paths in persons. Fractal D ranges from 1.0 (perfectly straight paths) to 2.0 (completely chaotic paths) and normative data has been collected on intact and injured persons, as well as on persons with dementia. Of the 22 VA SmartHome veterans the team tracked for four months, 10 veterans showed declines in Fractal D and 12 did not. Those patients who showed declining Fractal D had significantly better clinical outcomes.
“One of the difficulties in determining recovery from traumatic brain injury is that there are no reliable biomarkers… none; if you’ve seen one TBI, you’ve seen one TBI.” said Dr. Kearns. “Fractal D reflects the summation of many different influences affecting locomotion. It is relatively easy to get the raw data from an accurate tracking system, and then measure changes with the state of recovery, which may be predictive of other aspects of functional recovery.”
In a subsequent study, Dr. Kearns and the SmartHome team collected Fractal D from Global Positioning System (GPS) loggers at patient admission & linked it with those patients’ prompting compliance data gathered over the next six months of their recovery. They found that high Fractal D at admission predicted poorer compliance with automated prompts intended to facilitate functional recovery. The results suggest that not all TBI victims will do well with automated prompting (e.g., APPS) on devices, such as smart phones, intended to remind them to take medication, and that those with the best prognosis for benefiting from APPS in the future may be predicted from their early walking patterns.
Dr. Kearns explains, “It’s almost a given that when a person with TBI is released from rehabilitation they are given smart phones to help them remain independent. The naïve assumption is that they can use the technology and it will help everyone. Our results indicate that not everyone will benefit, and that those who will benefit may be predicted in advance using Fractal D.”
The U. S. Department of Defense estimates that between 2000 and 2014 over 320,000 veterans have sustained traumatic brain injury. While the majority of these injuries are classified as mild, 17.5% range from moderate to penetrating, with lifelong consequences. The Centers for Disease Control and Prevention (SCD) estimate that 1.7 million Americans sustain a TBI annually, and in 2010, healthcare costs totaled $76.3 billion. The Brain Injury Association of America reports the average costs of rehabilitation are excessive; hospital-based acute rehabilitation is approximately $8,000 per day, post-acute residential care ranges from $850 to $2,500 per day, and day treatment programs, excluding room and board, range from $600 to $1,000 for four hours of therapy.
Dr. Kearns’ findings have important practice and policy implications. Individuals with high Fractal D are less likely to benefit from the use of automated prompting upon release. Declines in Fractal D may benchmark an inpatient’s progress, and provide an indicator of the point in treatment when they could be discharged, allowing more efficient use of precious clinical resources.
As Dr. Kearns concludes, “Tracking technologies have provided us with unprecedented opportunities to gain insights into the process of rehabilitation. Fractal D might become a reasonable biometric to help track TBI recovery and to encourage new guidelines and protocols for treating individuals who do not respond to standard care interventions.”
For more information about Dr. Kearns, see his website or contact him at firstname.lastname@example.org.
ARTICLES OF INTEREST: Kearns, W. D., Scott, S., Fozard, J., Dillahunt-Aspillaga, C., & Jasiewicz, J. (2015, forthcoming). Decreased movement path tortuosity is associated with improved functional status in TBI patients. Journal of Head Trauma Rehabilitation.
Kearns, W. D., Fozard, J., Ray, R., Jasiewicz, J., Craighead, J., & Pagano, C. (2015, forthcoming). Movement path tortuosity predicts compliance with therapeutic behavioral prompts in TBI patients. Journal of Head Trauma Rehabilitation.