SMAI - Mobile System for Elderly Monitoring - IEEE Xplore

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SMAI – Mobile System for Elderly Monitoring. Matheus Costa Stutzel1, Michel Fillipo1, Alexandre. Sztajnberg1,2,3. 1Bacharelado em Ciência da Computação / ...
SMAI – Mobile System for Elderly Monitoring Matheus Costa Stutzel1, Michel Fillipo1, Alexandre Sztajnberg1,2,3 1

Bacharelado em Ciência da Computação / IME 2 CComp/IME and 3PEL/FEN Postgraduate Programs UERJ, Rio de Janeiro, RJ - Brazil

André Brittes, Luciana Branco da Motta Núcleo de Atenção ao Idoso (NAI) Universidade Aberta de Terceira Idade (UnATI) UERJ, Rio de Janeiro, RJ - Brazil [email protected], [email protected]

[email protected], [email protected], [email protected] Abstract— The SMAI uses Android mobile applications as the infrastructure to monitor elderly patients with chronic degenerative disease that present functional loss. The objectives are: (i) making the caregiver communication with the health team more agile; (ii) reducing caregiver’s stress; (iii) providing the health team information about the patient's condition more often in an organized manner, facilitating decision-making. Applications are developed under the guidance of the health team and assessed in a quasi-randomized clinical trial with 30 + 30 patients accompanied by NAI/UERJ. Keywords—elderly monitoring; caregiver support; mobile application; Android

I. INTRODUCTION Population aging is a worldwide phenomenon, which has been happening in an accelerated pace in Brazil. According to projections from the World Bank, the elderly population in Brazil will triplicate over the next four decades, from less than 20 million in 2010 to about 65 million by 2050. This phenomenon is followed by a change in the pattern of morbidity and mortality, determined by greater prevalence of chronic diseases among the elderly [1]. According to Alzheimer's Disease International, published in the World Alzheimer Report 2015, it is estimated that the number of elderly living with dementia, needing continuous care, worldwide, will also nearly double every 20 years [2]. It is estimated that if there is improvement in the health condition, the proportion of elderly dependents will remain stable, which would represent a total of approximately 3.2 in 2020, 4.2 in 2030 and 5.6 million in 2040. On the other hand, if there is no improvement, this figure would reach 4.4, 6.7 and 10.1 million respectively [1]. For a health care system originally structured to deal with acute illnesses observed in the young population, it is necessary to adequate for the specificities of incurable chronic diseases, which can cause functional disability, requiring long-term and expensive care [3]. Chronic diseases have the potential to cause disabilities, adding losses in autonomy and independence for daily living and increasing the need for long-term care provided by family, friends and community [4], [3]. In Brazil, as in many other countries, the family is the main form of social support

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available for care. Legislation and public policy claim, and the society itself believes, that the elderly should be cared by their family [5]. Within the family, the presence of dependent elderly involves emotional, physical and financial burden [6]. Thus, it is important to develop actions to enable the health team to support caregivers, relieving the stress of caring. In the Rio de Janeiro State University (UERJ), the NAI Care Center for the Elderly (Núcleo de Atenção ao Idoso) at the Open University of the Third Age (UnATI) provides a continuous monitoring service for elderly patients with various stages of neurocognitive disorder (dementia). A multidisciplinary team composed of geriatricians, psychiatrists, physical therapists, nurses, social workers, nutritionists, psychologists and speech therapists follows and monitors 250 patients and their caregivers. The service is free. Periodic medical ambulatorial consultations are scheduled for each patient, accompanied by their caregivers. In addition, a telephone check is also performed periodically. Established protocols and procedures are followed, and recommendations are emphasized with the caregivers in emergency situations. The service is offered taking into account the characteristics of the group of patients monitored and their caregivers: (i) the caregiver is usually a family member and is constantly stressed, (ii) the family has, on average, low-income and most reside in peripheral neighborhoods and (iii) bus and train are used to get to NAI (public transport system in Rio de Janeiro does not have the best reputations). So each on-site appointment or meeting imposes some sacrifice to the caregiver and patient. Information technology has been considered an important support to facilitate communication and monitoring. Progress on hardware and telecommunication areas paved the way for telemedicine applications [7]. eHealth applications, where mobile wireless devices allow remote monitoring and diagnosis, can be integrated to the dependent elderly care network, complementing the traditional in-site care. This paper presents the Mobile System for Elderly Monitoring (SMAI, Sistema Móvel de Assistência ao Idoso). The system is developed by a team consisting of researchers from the LCC - Computer Science Laboratory and NAI professionals at UERJ. The SMAI aims to (i) make the communication between caregiver and the health team faster; (ii) reduce the caregiver’s stress; (ii) facilitate the care and elderly support in their daily living activities; (iii) provide the

health team information about the patient's condition more often and in an organized manner, facilitating decision-making. Moreover, the impact of using the system to improve the quality of life for patients and caregivers, the complications and adherence to treatments is also assessed. The system is designed for the context of the group of patients and caregivers monitored by the NAI, considering the characteristics and constraints of this group, the current adopted health practices and the team experience in the care of this group.

[16] studies the impact of a monitoring system for patients with diabetes, and demonstrate that the use of mobile technology can be effective in the treatment and decision making, reducing the effects of hyperglycemia and improving patient support. [17] highlights the use of telemonitoring technologies and services for independent seniors living with chronic diseases. However, they note that the created solutions must meet specific health needs in order to have significant impact on improving the quality of life of this population.

From a technical point of view the system was designed to be as simple as possible for caregivers and patients. Therefore, smart environments with sensors or wearable devices were not considered. The deployment and operation of such a complex system would not be feasible for the target audience. Even the cost of communication was taken into account. The system is structured by applications for smartphone (caregivers) and tablets (NAI team) devices, and a web application for the management of the system itself.

Currently, there is a variety of health applications used to monitor blood pressure, glycemia, exercise and nutritional support. Among these applications, it is important to highlight those for the monitoring of patients with cancer or chronic diseases that require attention from the health team. After installation, many of them end up being discarded by the users due to content gaps or problems in use, related to system instability. According to [18], most of these applications are developed with no previous requirements elicitation and no clinical effectiveness is assessed afterwards.

An initial assessment was carried out with a small set of caregivers to verify positive and negative aspects in using a first prototype. The smartphones were assigned with minimal training and the system was used for two weeks. The evaluation was based on the amount and frequency of information sent and, then, through an interview with caregivers. The return, in general was very positive. Some issues were raised by caregivers, leading to some improvements in the prototype for the next assessment cycle, presented in this article.

SMAI is developed by a team that includes health professionals who establish application requirements before development, comprising the information to be collected, alarms and notifications, and the presentation interface.

II. RELATED WORK

III. PREPARATION The proposed system takes advantage of the lessons learned from previous projects ([19] and [20]), considering specific aspects of the target group: dependent elderly patients and caregivers or family members who have varying degrees of difficulty with technology. In previous designs it was considered a system deployed in the patient’s residence, consisting of a computer, sensors, and a data acquisition system with some complexity. Although technically consistent, the hardware kit had a high cost and would operate only in the patient's home. It was assumed that the patient would have Internet connection [21]. In practice, a very small number of patients who agreed to make use of the system had the necessary conditions.

Many recent studies show the benefits on the use of telemedicine in the control of chronic diseases for patients and for healthcare systems [8], [9], [13], [11]. Some of them are centered in notifications and reminders to patients, in order to improve treatment adherence [12], [13].

SMAI is proposed with a focus on simple applications, for use in a smartphone equipment that is already part of the daily activities of patients or caregivers. The understanding is that the use of a mobile device does not introduce significant changes in their routines.

[14] evaluates various technologies for e-Health in “Digital Health Information for the Consumer: Evidence and Policy Implications”. Different technology aspects are assessed, including the impact for the patient, for medical and health services already established. One of the recurring problems detected is the interruption of the use of the system for several reasons: lack of incentives, lack of interest, and no perception of benefits, among others.

Internet access has become ubiquitous and more affordable. Devices that allow Internet access also have become cheaper. Still, due to the low acquisitive power of most patients and caregivers monitored, for the evaluation of the system, a smartphone with Internet access for data transmission and receiving alerts is provided for each patient.

The remaining text is structured as follows. Section II presents related work. Section III presents the context of the project and the preliminary study to help the system definition. Section IV presents an overview of the system and Section V addresses the developed prototype, discussing some implementation details. In Section VI there is a discussion about the evaluation carried out. Section VII brings the last considerations.

The review presented in [15] classifies smartphone applications presented in 2894 articles. Most applications are related to diagnosis of diseases or medical calculators. Only 15 of the surveyed applications are related to monitoring patients with chronic diseases. 15 of these few applications try to make playful and attractive use of the application.

With the aim of making the use of the system more attractive, behind the technical aspects of the applications (Section IV) the system introduces playful aspects, in the same line of serious games as discussed in [22]. The experience of the health team indicates that social and fun activities included in the routine of a patient or their caregivers increases the interest and adherence to treatment.

Before beginning the development of the SMAI, a preliminary survey on the use of computing and mobile resources was carried out by applying a questionnaire, developed by the LCC team, to the group monitored by the NAI. 42 patients or their caregivers responded to the questions. Of the total respondents: • 76.60% had computers at home and 93.62% had mobile. 72.34% know sending SMS (text message); • 80.85% know, or someone close knows, how to use e-mail and/or social networks like Facebook; • 72.34% have Internet access at home, and of these 73% think the access is good; • 86% of respondents access the Internet several times a week, and 40% access every day. The results constituted important information to drive the approach to design the SMAI. The use of cell phones and Internet access are already part of the everyday life of most patients, family members or caregivers. Of these, 25.53% used the Android system [23], while 59.57% does not use Android and 14.89% didn’t know. Based on this information the Android system was adopted as a platform. IV. MOBILE SYSTEM FOR ELDERLY MONITORING SMAI, Mobile System for Elderly Monitoring, consists of three applications: the SMAI Caregiver, the SMAI Doctor and the SMAI Web. All interaction is mediated by an application cloud server. Users have access to the system via smartphone or tablet devices, in their houses or on the move, outside home. Fig. 1 shows how the SMAI elements are structured. SMAI Caregiver

SMAI Doctor

Family Internet Health professional

Caregiver

Application Server Patient

• API • DataBase

SMAI Web • Reports • Quality monitoring

Fig. 1. SMAI structure

The SMAI Caregiver runs in smartphones devices, allowing the caregiver sending and receiving information to/from the NAI health team about the patient's condition, physiological measurements, behavioral data and notifications such as: • reminders about medication and scheduled appointments; • information containing measured blood pressure and glycemia; • a daily report with information about the patient’s behavior, eating routine, evacuation and urination; • a simple weekly report about the caregiver her/himself; • sending short messages to the health team and receiving messages with care guidelines;

• patient's location using a combination of GPS and networkbased location systems • sending an alarm, called NAI Alarm, to the health team. There is a SMAI Patient version, which has fewer options, aiming to receive patient’s information on general condition, maintaining a "virtual" connection with the NAI team. Health professionals have access to the system in a tablet, where the SMAI Doctor allows monitoring and interacting with the group of patients. Among the features are: • a dash-board displaying the group status; • viewing details and history data of each patient, including current and latter-day location, allowing checking their mobility; • sending consultation and scheduling reminders medicaments administration, texting messages individual or group of patients;

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• viewing current and past messages and alarms; • viewing patients’ and caregivers’ reports. All information is sent to the application server in the cloud, which provides a set of services through an API. Also from this server, the messages, notification and alarm metainformation are pulled. This service has availability and security requirements for eHealth applications. Health professionals, patients and caregivers are registered in the server’s database allowing authentication and access control. All stored data in this server is encrypted ensuring privacy. The SMAI Web application copies the data from the cloud server database for backup purposes and later evaluation of the system. This module is accessed via web and also allows visualization of application and quality data, such as received and transmitted bytes, application usage statistics, and error reporting. It is mostly used by the development team. A. Privacy and Security Interaction of each actor is preceded by the identification and authentication with the cloud server. Each device contains a digital private key, generated in the first connection to the service database, which is encrypted using AES CBC and stored in the local memory. This guarantees the authenticity and confidentiality of information without requiring the user to present the ID in each connection. It is assumed that maintaining the device safe and the responsible use of the application is not an issue. The access of each health professional to the patient’s data is controlled by permission and authorization sharing mechanisms within the application server. Appointments, medication reminders and notifications for a patient or group of patients are stamped with the ID of the attending health professional. Each caregiver receives a pre-configured smartphone with the SMAI Caregiver application and a customized ID preassociated. Thus, no action is required from the caregiver for identification purposes.

For the NAI professionals each tablet is also delivered preconfigured with the SMAI Doctor application and their respective credential pre-set, thus enabling access to the system without the need to send the ID each time. This is only necessary when adding a new patient to the group, given that explicit data custody sharing credential is required. B. Fault Tolerance Data are transmitted and received over the Internet. In the absence of a connection, for example, the failure of the GPRS ("no signal") the SMAI still provides visualization of history information and new data input. Also, every data generated by the user is immediately saved in the device's internal memory, so there is no loss if anything goes wrong. Only after this process, sending data to the cloud server is initiated. The caregiver can still, for instance, fill up the Daily Report and “send it to NAI”. Once the application receives confirmation of dispatch, the local copy is discarded. In case of error, the process is restarted after a certain time, which varies with the error. V. IMPLEMENTATION The SMAI mobile applications were developed for the Android 4.0 system. Functionalities, information panels and notifications have been designed in accordance to the guidance and requirements of the health team of the NAI, and implemented following the practices and design patterns recommended by Google [23].

Some modules make use of Android services, such as the Location (which uses GPS) – to record the patient’s location, Notification - to remind the caregiver of medication administration, appointments or to send a report. Notifications in SMAI use a specially adapted engine. By the time the user needs to be notified, the system performs three actions: (i) the standard Android notification is triggered; (ii) a "floating" notification is enabled - an icon that blinks "overlapping" the application on the foreground - becoming an urgent warning to the caregiver perform some task in the system and (iii) also locally saves an encrypted record, containing information about the notification. This record allows the SMAI managing notifications. For example, if the notification demands confirmation, this notification is only cleared when this confirmation happens. In other cases, for example, the Daily Report, which generates a notification every day, if the caregiver does not report a day, the system avoids "accumulating" reports. Thus, a due notification is replaced by the current, avoiding overloading the caregiver with two reports in the same day. We note that this was one of the specific requirements of the NAI team. All transmitted data is XML structured according to the specification of the cloud server API. The transmission procedure included in the API encrypts the data being sent. So, privacy is handled all the way. As mentioned before, input data is saved in the local memory and only discarded after reception confirmation. Fig. 3 shows a normal flow.

A. SMAI Caregiver Fig. 2 shows the main elements of the SMAI Caregiver application, which are discussed along with some of the adopted solutions. Network usage App Update

Cloud Application Server

SMAI Web

GPS

SMAI Caregiver XML HealthVaultInitializationHandler

Fig. 3. Normal interaction flow

FragmentActivity

Location View.OnTouchListener

MainActivity

SuperActivity

Notification

Local File System

Activities / Options Reports / Messaging

Alarm Android Services

Configuration



Fig. 2. SMAI Caregiver

The application has a main menu with modules to input information to be sent to (or received from) the cloud service. Each module inherits a set of *Activity classes, which transmit/receive the data in encrypted XML format. A configuration module allows the user to customize font sizes, background colors and change some features, e.g., the GPS.

Two more features are integrated: (i) an updating mechanism, and (ii) a module for monitoring transmission and reception counters, enabling checking the "health" of each device and managing credits for data access with the mobile provider. These services are not health information, but proved to be useful during the evaluation. In these specific cases data are sent to a Linux server at the LCC lab, not to the cloud application server. This same server runs the SMAI Web. When loaded, the application starts all background activities, for example, sending the patient's location and checking for updates. A main menu displays all the information options the caregiver can send (Fig. 4a). Figs. 4b,c,d show examples of input data for Pain, Blood Pressure and Temperature. Some modules are context-aware, triggering complementary data input. For example, if the temperature exceeds 37.8ºC possible related problems are checked (Fig 4e).

(a)

(b)

(c)

(a)

(b)

(c)

(d)

(e)

(f)

(d)

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Fig. 4. Main menu and input information modules

Fig. 5. Reports, Notifications and Reminders

Every day, the caregiver is prompted to fill out a Daily Report (Fig. 5a). A notification is generated at 8:00PM as a reminder (Fig 5f). She can fill the items according to the perceived importance or on medical advice. For example, in Fig. 5b we have the General Information panel, where the caregiver registers the sleep quality, if there has been - or not behavioral disorders and hydration of the patient.

(Fig. 6). Moreover, it uses the same Android services and, also, the Google Maps API to display the location of patients on a map. The application logic, however, is more complex.

This is another feature specifically designed for the group of patients monitored and is consistent with the practices that should be adopted by the caregiver. There is already a routine so that the patient's day to day information is registered on a paper form, and handled to the health professional staff, when possible, helping them to follow the patient’s outcomes and complications. Using the SMAI Caregiver application can make this a faster routine and provide on-time information, since the reports are (almost) immediately available. The caregiver, himself is prompted to answer few questions once a week (Fig. 5c). This allows monitoring her stress level. Also Fig. 5d,e,f present some examples of notifications/confirmations, as well as a first approach to gamify the system. If the caregiver is assiduous sending the information she is rewarded with "congratulations messages" more often. The first evaluation (Section VI.A) showed that, even simple, the solution has a very positive effect. B. SMAI Doctor The structure of the application used by the health professional is similar to the caregiver’s, and, it also uses the *Activity classes as a basis to interact with the cloud server

The SMAI Doctor contains in the base a list of the monitored patients, and an automatic update mechanism to download from the cloud server the latest information sent by the caregivers. The list is persisted in a local database, and displayed in the initial Dash Board panel (Fig.7). The need for storage in the local database was dimensioned for up to 60 patients, with a daily use of the system for two years. The tablet resources were also dimensioned in that way. Local DataBase App Update

Cloud Application Server

SMAI Web

Google Maps API

SMAI Doctor XML HealthVaultInitializationHandler

FragmentActivity View.OnTouchListener

MainActivity

SuperActivity

Notification Local File System Local DataBase

Fig. 6. SMAI Doctor

Dash Board / Report / Reminder / Messaging

Configuration

Alarm Android Services



Fig. 9. Patient/caregiver history Location; Daily Reports

Fig. 7. Dash Board, patient details

Patients with a triggered alarm are displayed with a red border in the Dash Board (Fig. 7a). When a patient is selected, a menu, similar to that in the SMAI Caregiver is opened (Fig. 7b), with additional options such as the chart of the transmitted physiological measurements (Fig. 8). The professional can then browse the information.

The patient’s Location history and filled Daily Reports are also available to the health team (Fig. 9) allowing an organized browsing of the information. Some options in the SMAI Doctor allow listing the items sent by the patient in the form of reports, or adding elements that can be notified to the patient. This is the case of medication reminders. The professional can see the record of the medications that had their notification confirmed by a caregiver, or can add/delete a reminder (Fig. 10).

Fig. 10. Medication reminder input

In certain types of physiological information, such as blood pressure, for example, thresholds can be individually configured for a patient (Fig. 11). So, if a received measurement is outside the threshold limits, the SMAI Doctor generates a notification, warning the professional. This feature is especially useful in the SMAI context because the basal parameters for elderly patients are generally different from that for younger adults.

Fig. 8. Pain history and details

Fig. 11. Threshold and limits configuration

VI. EVALUATION A. Pilot Study In early 2015, the SMAI system was submitted to a first assessment. A group of caregivers was selected and each one received a Motorola Moto G smartphone with a prepaid chip with enough credits for two months. The SMAI Caregiver version was pre-installed on each device. A meeting was held for the delivery of the equipment and a simple hands-on training was offered by the LCC computing team, explaining the use of the main functions for each caregiver. This training lasted on average 40 min. The objective of the evaluation was to understand how the caregiver would perceive the new tool, ease of use, intuitiveness and willingness to continue using the system. Each caregiver should use the system for 15 days in the best way, with no commitment to provide real data. Finally, another meeting where the equipment would be returned and an informal interview would be carried out with each caregiver. During the 15 days of evaluation, the use of the system was monitored through the SMAI Doctor. Also, the data transmitted and received counters by GPRS and the WiFi network (if enabled) and what was the specific consumption of the SMAI application was monitored through the SMAI Web. The meeting for returning the equipment was scheduled by the system itself. From this first assessment, we highlight that: • there has been data transmission from all caregivers, every day, with a varying rate; • data transmission footprint for the SMAI Caregiver is acceptable. Average of 700 kB per day; • as a drawback, Android triggers updates and other mechanisms that use data access. This represented 90% of the consumption recorded in the two-week evaluation. The returning interview with the caregivers was also informal. They were asked who was the experience using the system. The answers were audio-recorded. After filtering the audio, we learned that: • all of them were able to use the system. They would use it in a long-term, if possible; • one caregiver tried to provide detailed information on the patient's activities, assigning an unexpected use to Physical Activity module additionally registering “domestic activities”. This was considered in the next version; • some caregivers had difficulties using some features or didn’t understand the application flow. Overall, an improvement in the communication pattern was observed between the health care team, caregivers, family and patient, evidenced by the exchanged text messages. In addition, there was improvement on the clinical management through the correct use of medications, driven by the reminders, and therapeutic dosage adjustment in insulin-dependent patients from the information sent by the caregiver about the glycemic measurement. However, it was found the need for continuous training on the use of the system.

B. Clinical Trial After the Pilot Study and technical improvements on SMAI applications, a new evaluation was planned as a quasirandomized clinical trial. The study sample consists of 60 patients and caregivers, assisted and monitored by the Neurocognitive Disorders Clinic at the NAI/UnATI/UERJ. The assignment of 30 smartphones to the caregivers was randomized. 30 caregivers were included in the control group. A new protocol has been proposed to adapt the established routines, given the new possibilities of interaction. One of the points discussed, for example, is the activation of the NAI Alarm (see Fig.4a). It must be accompanied by a text message explaining the alarm reason (Fig. 4f) and the caregiver must be aware that the NAI cannot make emergency interventions and does not provide emergency care services. The same point was discussed in the context of the health professionals: how and how timely the alarms will (or have to) be responded and how often monitoring should be done (shifts, for instance). It was also been considered, still at this point, possible technological problems (lack of connectivity, for example). As the clinical trial is currently being run, the information on the impact on SMAI system effectiveness and usability will still be evaluated. As part of the trial, data will be also collected by questionnaires in the various stages of the evaluation to gather information from the control group and to facilitate dimensioning quality parameters of the system: • how the quality of life of the family and caregivers was affected, with and without the use of the proposed monitoring system; • response of the patients themselves using the system, perceived indirectly or through statistical correlation of collected data; • adherence of the caregivers to use the proposed system, correlated with other aspects evaluated; and • health staff perception regarding the monitoring work. VII. CONCLUSION The focus of the SMAI approach is simplicity. The main goal is helping caregivers in their activity, not representing just a new assignment or concern, among many others that are already part of their day. The first evaluations tell us that the design options adopted are good. Most input doesn’t require the caregiver to use the virtual keyboard, but this would not be a problem, as we verified on our preliminary survey. The use of interactive interface and pickers limit data input to the correct ranges. The current version embeds an experimental feature, allowing blood pressure input, via Bluetooth, from Continua Allianceenabled devices, with no human intervention. Nevertheless, the cost of such devices is still prohibitive for our standards. The system relies on the caregiver’s responsibility to have the correct information input. We believe that the development of the application customized, from the beginning, considering the context of the patient group and driven by the medical team expertise will achieve the stated objectives.

One of the lessons learned up to this point, observed informally during in-person meetings with the SMAI users, is the effect of strengthening the caregiver-doctor relationship. For example, the SMAI simple messaging system allows the NAI team sending small guidelines texts. Thus, in addition to the notifications and reminders, the caregiver can receive from the NAI team, personalized messages. The daily monitoring of the information sent by caregivers allows small interventions in the form of messages or even through phone calls in a shorter time span when compared to standard procedures. Caregiver's perception is that the support is more effective, what increases the adhesion to the use of the system. The effectiveness of the system can be as rewarding as scoring points in a game. The beneficial effect of being part of a care network, even virtual, supporting the caregiver with answers to their questions is also found in social networking environments as in [24]. We will improve the scoring and reward system (something like the 'stars' in the early school years), without imposing a situation of stress or competition, but allowing the health professionals and the patient himself measure how the system is being used. This can be currently evaluated through the SMAI Web, but just by the health team, and without the playful side. For example, if all the routines and actions requested in the treatment plan were duly registered, or if all alerts have been acknowledged within 30 minutes, the caregiver earn points or virtual medals and will be entitled to change the background color application. SMAI applications have been used almost one year, in their several versions, and are currently being evaluated. The software is registered in the Brazilian INPI (reg. BR 51 2015 000668 1) and an international patent is pending.

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ACKNOWLEDGMENT We thank our colleagues from NAI/UnATI/UERJ on the use and evaluation of the SMAI. This work is supported by FAPERJ and CNPq funding agencies (contract numbers E26/110.243/2014 and 449861/2014-7, respectively).

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