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Robotics in Health and Human Services

An Overview of Health and Human Service Robotics

K.G.

Engelhardt

Senior Research Scientist, Director, Center for Human Servwe

Robotics,

Carnegie Mellon

University, Pittsburgh,

PA

15213,

U.S.A

Application of robotic technology to health and human service areas requires considerations along several dimensions. This paper will present an overview of the variables that could impact on the successful use of robotic and artificial intelli- gence technologies in health and human service domains. The challenging question: how do robotic scientists begin to re- search in a domain that is ill-defined and rapidly changing and for innovations that are not yet developed but rapidly evolv- ing? Our work has taken a process approach. First, we work interdisciplinary to identify needs by working directly with potential end-users and simultaneously to examine whether there are existing or future planned technologies that can fill/address these needs. This method also serves to illuminate clinical and technical functional and performance capabilities that will be required. It is a dynamic, iterative process called Interactive Evaluation.

Kevword~: Health

robotics,

tive evaluation.

Human

service robotics,

Interac-

K.G. Engelhardt is presently a Senior Research Scientist at Carnegie Mellon University and Director of the Center for Human Service Robotics, Carnegie Mellon University. She holds degrees with University Distinction and De- partmental Honors in Human Biology and Physiological Psychology from Stanford University. She has over one hundred publications and presenta- tions in a spectrum of fields world- wide related to robotic technologies in non-manufacturing domains. She was the first individual to testify before the United States Congress in 1984 regarding the potential for robotics in health and

human service roles. She is president of the National Service

Robot Association and

Associate editor of the

International

Journal of Technology and Aging.

She serves on Technology

Council for RI/SME and board of directors for Robex of the Instrument Society of America. She is on the board of direc- tors for the Robotics Industries Association.

North-Holland Robotics and Autonomous Systems 5 (1989) 205-226

I. Introduction

Robots

can

be

defined

as

systems

that

can

sense, think,

and

act

[32].

For

the

purpose

of

discussion in this paper,

I define Service Robotics

as robotic systems that function as smart, program- mable tools, and that can sense, think, and act to benefit or enable humans.

The best starting place for considering uses for this class of advanced technologies in health and human service domains is the identification of unmet or undermet human needs. Human appli- cations, not technology driven applications have a better probability of being appropriate systems that can be successfully diffused. Potential task sets that may be amenable to robotic intervention are derived from utilization of classical task analy- sis paradigms in concert with sociomedical re- search methodologies. Sensitivity to human dig- nity and desire for independence are critical con- siderations in conducting this type of research. As computers become smarter they will become more robotic. It will be important to explore the acceptance and use of these innovations by older persons as well as by their younger cohorts. The stereotypes of the older person as technophobic have not been demonstrated to be accurate [11]. What does seem to be a critical variable is the way in which the technology is introduced to the ma- ture user and the appropriates of the design of the system. Methodologies which incorporate a sup- portive procedure for the systematic introduction of these devices and a user-focused system design, appear to be the key to successful use and adop- tion [19]. Adult principles of learning can be ap- plied to the training of individuals in the use of advanced technologies, whether the technology is a computer or a robot [21]. It is also important to begin to understand the attitudes and the percep-

0921-8830/89/$3.50 ;O 1989, Elsevier Science Publishers B.V. (North-Holland)

  • 206 K.G. Engelhardt / Health and Human Service Robotics

tions of older users towards this class of smart devices, and to understand how microprocessor technology is presently being used by providers of care for the elderly [21].

1.1. Problem Statements:

The Need

"Need: something required or desired that is lack- ing" [50].

Need can be considered from several perspectives. Appropriate technological solutions to human need can be characterized by dearly defining areas of need and systematically specifying technologi- cal systems that offer the best answers to the

problem areas. First, individuals with temporary or permanent physical limitations have needs for replacing lost functional capabilities. These 'needs' are based on the assumptions that independence is a universal human goal and the maximum functional inde- pendence is currently not being achieved through existing measures. A person's control (both per- ceived control and functional control) of his/her personal space is an important component of hu- man dignity and quality of life. One of our re- search goals has been to identify and elaborate these areas of need and to research robotic tech- nologies which might be used to address these "shortfalls" in human performance functioning. Our basic assumption is that both the humans and the machines have "disabilities" and that an ap- propriate performance match of both the abilities of the human and the capabilities of the robot are essential for successful human-system integration. Second, need can be considered from the pro- fessional caregiver's perspective. The informal caregiver (family, friends) plays a significant role in caring for and maintaining the older person at home [5,38]. Their burden is significant [39]. Their need for assistive technology is as great as, or greater than the formal caregivers'. As numerous informal caregivers become frail themselves, and further tax occurs on existing health care delivery mechanisms [4, 47], the need for alternative meth- ods of care provision, such as assistive technology, will intensify. Formal caregivers, health care pro- fessionals, as well as informal caregivers have stated that by replacing odious, routine, demean-

ing, or boring

tasks they could be relieved of the

less desirable caregiving responsibilities, and could be freed to deliver care that humans can uniquely provide. In this way, robotic technology holds potential for augmenting their quality caregiving by reducing some of the burdensome aspects of it. Fetch and carry tasks, lifting and transferring, vital signs monitoring, feeding, bowel and bladder care are alI example tasks in which caregivers would like "a hand" from technology [15]. Third, need can be considered from the per-

spective

of

medical

administrators

who

are pre-

sently facing enormous challenges an an increas- ingly competitive health care environment. Tech- nology that can demonstrate cost savings while maintaining or improving existing quality of care can address one of the most pressing needs in today's cost conscious industry. Health care ad- ministrators will need to consider the cost/ benefit/risk relationships that exist for potential robotic devices. Multipurpose tools can provide increased cost justification and increased func- tional capabilities. This class of technology also holds the potential for answering previously un- solvable, labor intensive challenges, such as pa- tient wandering or meal preparation and delivery. Fourth, need can be considered from the macro, societal perspective. Needs exist in a larger frame- work. It is important to note that there is no monolithic health care industry. This "industry" is a mosaic of sociopolitical entities which coexist in the "non-system" of health care delivery m the United States. These entities include (but are not limited to) federal, state, and local governments. as well as religious and proprietary corporations, private non-profit organlzatmns, consumer groups,

and professional associations. Health care was a $458 billion industry in 1986 and comprised 10.9% of our Gross National Product. It amounted to $1837 per person of which approximately 40% came from public funds [46].

1.2. Problem Statements:

Cost and Definitions

Health services for the elderly account for more than three percent of the U.S. gross national prod- uct. Rice [34] estimates a $120 billion annual expenditure for personal health care for the 29 million elderly aged 65 and over. This represents a per capita expenditure of $4,200 for those aged 65 and older which is more than twice the per capita expenditure of the entire population. Institutional-

K.G. Engelhardt / Health and Human Service Robotics

207

ized care represents the major expense consuming two-thirds of the total cost - approximately $54 billion allocated to hospital care and $25 billion allocated to nursing home care. The major fund- ing source of this care is Medicare, paying almost

half of the total care costs of the elderly [34]. Medicaid, the Veterans Administration, and other government programs pay for an additional $22 billion in care. Such expenditures mandate investi- gation of new ways of providing quality, cost-ef- fective health services to present and subsequent generations of older people. The shifting age structure of our society has caused changes in the prevalence and composition of disability. The shift toward gradually decreas- ing functional abilities as a result of age and/or chronic illness is producing a new population of individuals who could benefit from assistance but who might not be classified as "disabled" by traditional classification schemes or by self-report. Few good studies exist which detail ergonom- ics, strength, neuromuscular, biomechanical, and perceptual variables of either disabled or older populations. An additional complication derives from the difficulty associated with the stigma "disabled" or "handicapped." Many individuals, especially older ones, prefer not to think of them- selves as disabled or handicapped because they have some gradual loss in functional capabilities. How many individuals, at any age, who wear glasses would call themselves "visually handi-

capped"

in a survey? - and yet, eyeglasses are an

assistive device that reduce the functional limita- tions results from impaired eyesight. Furthermore, measurement of functional disability (or capa- bility) is also not always standard and within and between measures variability often exists [39]. Accurate information about incidence and prevalence of disabilities is difficult to quantify because of problems inherently involved in col- lecting descriptive data. Since disabilities are gen- erally a result of trauma or disease, patients are classified by the etiology of their disability rather than by functional deficits or, better yet, remain- ing functional abilities. Presently, functional needs can only be approximated, particularly in aging populations. The National Center for Health Sta- tistics reports that 81% of all persons over age 65 have chronic conditions that impair their ability to function independently. Further, 46% are limited in their activities because of chronic conditions,

while 39% are limited in major activities (Ameri- can Health Planning Association, 1982) [25]. In 1980, 11.3% of the total population, or 25.5 million people, were of age 65 or older. This number will double by the year 2020, growing to approximately 17.3% of the total population. While in 1980, 10 million persons were 75 or older, 22 million will be 75 or older by the year 2020 [34]. The shift in population also suggests a smaller working age labor force and hence fewer workers to care for disabled persons. Such growth in the "older old" imply a greater burden to existing health care providers. While some of these future older people will be healthier than current seniors, many will require increased health services. Such demand may be partly met by technology working in concert with human caregivers to augment hu- man caregiving capabilities.

2. Service Robotics

2.1. Background

Engelhardt

[16]

presented

the

concept

for

Health and Human Service Robotics in expert testimony to the House Select Committee on Aging. This milestone represented the first time that policy makers had recognized that robotic technology could be utilized to address the unmet and undermet needs of our aging population. "For the first time in history we have the opportunity to begin innovative research in functional rehabilita- tion of cognitive capabilities, speech, mobility,

and manipulation. Our research investigates ways in which robotic technology can be used to in- crease the independence of elderly persons and persons with physical disabilities." (p. 14, [16]). Engelhardt introduced this concept to the profes- sional robotics societies such as the Robotics In- dustries Association, the National Personal Ro- botics Association, and Robotics International/ SME in 1984 and 1985. The origins of service robotic (Fig. 1 and artificial intelligence technologies can be traced along several pathways with varying amounts of crossover among the multiple lineages which prim- arily evolved in parallel: industrial manipulators (robotics), teleoperators, computers, office equip- ment (the use of technology in non-manufactur- ing), durable medical equipment, and consumer/

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Health and Human Service Robotics

SERVICE ROBOTICS

(L

Technologies )1 J,

Sensor

"~

MaChine'i

Vision

~,

Artificial Intelligence "~"

I

\

Industrial

Robotics

~

Computers

Durable

Medical

Equipment

and Medical Instrumentation Electronics

Consumer Electronics

Household Appliances I Personal Robots

1

L

Educatiol)al Robots

Fig. 1. Origins of service robotics.

medical electronics. The convergence of these areas and visionary research and development along with rapidly evolving miniaturized, lower cost, flexible chip technologies provided an array to tools and resources for creating a new class: service robotics.

2.2. Industrial Robotics

The earliest roots of modem automation (de- rived from previous advances in clockmaking) can be traced to mechanized toys (dolls), known as automatons, which entertained 18th century Europeans. During the 19th century, the creation of the "Jacquard Loom", Boolean Algebra, and Babbage's designs for counting machines provided the basis for the use of punch cards, the concepts of the binary system, and automatic digital calcu- lation respectively. However, the invention of electricity was required before early 20th century individuals, such as U.S. Census Bureau statisti- cian Herman Hollerith, could create electromecha- nical tabulating or calculating machines. The origins of modem teleoperators can be traced to research in nuclear telemanipulators conducted at the Argonne National Laboratory under the direc- tion of Ray Goertz. From the late 1940s to the late 1960s, master-slave manipulators primarily evolved in the U.S. and Europe in nuclear, under- sea, and space applications [48]. The application of master-slave manipulators to rehabilitation be- gan in the early 1960s with the Case Institute of Technology's computerized orthosis. In the early 1970s, the University of Heidelberg developed an

industrial manipulator and minicomputer to store points and to integrate special purpose devices (telephone, typewriter, custom mouth-stick con- trolled keyboard) primarily for vocational use. The convergence of teleoperators with industrial robots which began during the 1970s across appli- cation domains continues into the present. The boundaries have blurred. The 1920s produced a proliferation of electric tabulating and calculating machines, electric job time and cost recorders, electric sorting machines, ticketograph and pro- duction control boards, money-weight computing scales, and attendance time recorders (time clocks) by IBM and largely based on Hollerith's patents. During the late 1930s and 1940s, the first analog computer (Bush's Differential Analyzer), the first electromechanical digital computer (The IBM Au- tomatic Sequence Controlled Calculator or Mark I), and the first electronic (using vacuum tubes) computer (ENIAC) were developed The invention of the transistor in 1948 provided the miniaturiza- tion and reliability for the "solid-state devices" of the 1950s and 1960s. George C. Devol Jr. is con- sidered the originator of modern robotic tech- nology. His more than forty patents (circa 1950s) including the 1954 one for "programmed article transfer" served as the basis for the commerciali- zation of industrial robotic technology during the 1960s, most visibly by Joe Engelberger and Unim-

ation [2]. Service robot evolution can be analogized to biological evolution. Different forms will evolve to fill different niches best suited to their particular range of skills. No less than in the case of their living counterparts, robotic species differentiation and successful survival are a result of taking ad- vantage of appropriate environmental niches. The more successful ones will work in optimal settings best suited to their individual strengths and which minimize their weaknesses [15]. The range of ap- plications for robotic technology in health and human services will vary according to their use m particular environments or niches. An analogy to different kinds of vehicles for specific uses offers

an illustration of this point.

For instance, even

though a car and pick-up are both motor vehicles and function in roughly the same ways, they are generally utilized for somewhat different purposes. Further. a piece of construction equipment such as a crane or earth mover is also a vehicle, but again, the "jobs" they perform for humans are different

K.G. Engelhardt / Itealth and Human Serl#ce Robotics

209

from a family minivan or sports car. Likewise, robotic applications in health and human service

domains will have a wide spectrum of forms and functions. Preconceived ideas regarding what a

health

and human service robot IS or LOOKS

LIKE should be expunged [14]. Whatever the niche, the more interactively a robot works with a

physically limited human, the more demand will be placed on its technological capabilities. Increas- ingly complex tasks, that require direct contact with a person with disabilities, will demand ever more sophisticated sensory integration and a higher degree of machine intelligence.

2.3. Sensors

Both sensor integration and end-effector de- signs will play significant roles in successful user- acceptable designs. Versatile, high performance end-effectors with fine control capabilities, gener- alizable functions, and increased sensor aug- mented intelligence will be needed to perform jobs in close proximity with humans. Sensors in the manufacturing environment have provided the ad- ditional "critical mass" requisite for ensuring the viability of robotic handling of parts, inspection, and quality control. The identification of these sensory capabilities is only one side of the chal- lenge, Creatively and thoughtfully synthesizing of the technologies to meet health and human service requisites is the other, especially considering the approximately 2.65 × 1032 possibilities for com- bining existing sensory capabilities [13].

the design is often experimental. The "risks to health" for Class 3 devices include bodily injury if the device malfunctions. If robotic assistants are perceived as Class 3 devices, their diffusion pro- cess could be substantially affected by the FDA approval procedures. Innovative evaluative re-

search is required if realistic standards

are

to

be

met and medical necessity established. Third parties play significant roles in health care delivery. As mentioned earlier, many disabled and elderly individuals are dependent on third party payers (government, private insurance com- panies, employers, etc.) for their health care be- nefits, including assistive devices. These agencies only reimburse services or products that are de- fined as "medically necessary" as determined by physicians. Reimbursement approval, and conse- quent placement on an "approved" list, is depen- dent on devices being defined as medically neces- sary. In designing smart technologies for dissemi- nation to individual consumers (e.g. for home use), it will be important that these devices be classified as prescription worthy durable medical equipment (DME) and be prescribed by a physi- cian for an infirm patient; in this way, it may be approved for reimbursement by an authorized third party payer. Since robots have no proven track record in health and human service roles, careful consideration of human factors and multi- ple safety variables, during the systems' design phases, will be critical. Education of third party payers as well as relevant medical personnel will be critical to these efforts.

2.4. Durable Medical Equipment

Service Robotics also are derived from existing health service technology roots, especially in terms of the regulatory compatibility requirements for durable medical equipment. Medical devices are regulated by the FDA based upon the 1976 amendments to the Food and Drug Administra- tion Act. The FDA assigns devices to one of three classes with each class subject to different regu- lations. For example, "Class 3" devices are subject to "pre-market" approval because satisfactory performance of a particular device has not been demonstrated and, therefore, it is not possible to establish an adequate performance standard for the device. Additionally, data to support effective and safe use of this class of devices do not exist as

2.5.

Consumer/Medical

Electronics

The growth of the consumer electronic industry during the past twenty years also contributed to the proliferation of microprocessor based technol- ogy. Calculators, entertainment equipment, kitchen appliances, and office equipment that incorpo- rated computer technology into their devices pro- vided mechanisms for users to become familiar with the operation of "programmable" technol- ogies. Concurrently, the evolution of electronic durable medical equipment, primarily in the areas of diagnosis and therapy enabled medical person- nel to acquire familiarity with electronic technol- ogy in their work environments. The recognition that technology, in general, could improve caregiv- ing of aging individuals was accelerated by a

  • 210 K.G. Engelhardt / Health and Human Service Robotics

NATO sponsored conference focusing on technol- ogy and aging [35].

2.6. Personal Robots

Players in 1980s: The 1980s witnessed the growth of "educational robots" and toy robots for two purposes primarily: training of industrial robot users and coursework in primary, secondary, and community/technical college programs. The 1980s also spawned much interest from hobbyists. The popularity of Star Wars in the motion picture media and other positive portrayals of robotic technologies encouraged the utilization of "pro- motional robots" to entertain. The first Interna- tional Personal Robot Congress held in April, 1984, recognized the potential for robotic technol- ogy to assist in caregiving domains [15].

2. 7. Precursors to Service Robots

The most primitive forms of this new breed of assistive robotics existed in research laboratories in 1970s and 1980s. Early work was conducted by NASA's Jet Propulsion Laboratory which built a voice-controlled wheelchair with a robotic arm attached to it. The French Spartacus Robotic Aid was the first robotic aid with optical proximity detectors for grasp and object localization [48]. This category of research, in general, retained a number of shortcomings, such as size, power, and user-interfaces. Prosthesis-based devices have not been as sophisticated as industrial manipulators due to the emphasis on anatomical fidelity. The Johns Hopkins systems attempted to bridge this gap with a microprocessor augmented prosthesis which was set up in a structured work/eat en- vironment [41]. The VA/Stanford system devel- oped in 1979/80 incorporated off-the-shelf tech- nology: human-scale industrial robotic manipula- tor with six degrees of freedom, a microprocessor- based voice recognition unit, synthesized voice response unit, and high-level software on a Zilog MCZ 1/25 microprocessor. Evaluation research with this prototype system began in 1981 and demonstrated the feasibility of employing an off-the-shelf robotic manipulator in a range of applications. Research data have shown that quadriplegics (individuals who have four limbs primarily without function) would like a robotic assistant in several categories of tasks [15]. Four

important areas are: (1) vocationally related tasks such as opening file drawers, extracting files, (2) personal care tasks and activities of daily living such as cooking and feeding, grooming, and retri- eval and placement of items (fetch and carry tasks), (3) recreational tasks such as board games and painting, (4) therapeutic such as maintenance range-of-motion physical therapy and training of visual monitoring for individuals with sensory-de- prived limbs [15,17]. Over 100 users, who ranged in age from 5 to 90 years with educational back- grounds ranging from 8th grade to Ph.D./M:D., were trained using standardized training proce- dures. The training procedures were based on andragogical (adult-learning) principles and were introduced systematically with a set of increas- ingly difficult tasks. The training task sets had been chosen for "meaningfulness" as well as for their increasing control complexity: For instance, the first problem that users had to solve was using the robot under step-by-step voice commands to pick up a cup and straw and bring them to his/her mouth. Giving oneself a drink of water was the highest priority need identified by our quadrip- legic users. This need request was then translated into performance parameters for a first level task set with the prototype robotic system, Subsequent tasks required increasingly difficult control of the robotic movements, such as moving ("piloting") the robot from one spatial plane to another. Al- though not the subject of this paper, research projects with educational and personal robots to ascertain their potential application to health and human service roles for children as well as older adults were conducted on three robotic systems:

RB5X TM, Hero 2000 TM, and Ropet TM [15].

2.8. Recent Progress

In 1986, the National Service Robot Associa- tion was organized under the Robotics Industries Association sponsorship. It represented the first national organization to officially focus the inter- ests of persons in the field of Service Robotics. It evolved from the National Personal Robot Associ- ation which was formed in 1984. In June, 1986, The World Rehabilitation Fund published a monograph containing summaries: of a dozen single case implementations of rehabili- tation applications of robotic technology in the

K.G. Engelhardt /

Health and Human Service Robotics

211

laboratory and field evaluation sites [24]. The

2.10.

Innovations

and Evaluative Research:

Meth-

major flaw with these early efforts is that they

odology

represented single case implementations whose generalizability was unclear or projected to be many years away [33]. The founding of the Health & Human Services Robotics Laboratory, in January, 1986, by one of the leading international academic research in- stitutions in robotics and artificial intelligence demonstrated a milestone in the recognition of robots in service domains as the next frontier for this hybrid class of advanced technologies. Robotics International of Society of Manufac- turing Engineers and Carnegie Mellon University sponsored the first invitational roundtable, enti- tled: "Strategic Planning for Robotics in Health and Human Services." This meeting, chaired by K.G. Engelhardt and moderated by Les Ottinger (President of RI), brought together expert repre- sentatives from medicine, robotics, nursing, academia, manufacturing industries, health care delivery administration, food service industries, and robotic/vision/computer manufacturers to discuss the potential for robotics in health and human service domains. Issues that were consid- ered included: safety, product development, prod- uct liability, marketing, responsible implementa- tion, priority setting, and technology transfer. This gathering represented the first attempt to give organized, interdisciplinary guidance to this newly

Most technology development occurs in iso- lation from its intended end-users regardless of the application domain. The discrepancy between technically trained developers and disabled, elderly, or health professionals is large; therefore, the technology created has often been inap- propriate for the individuals for whom it was intended to be designed [31]. At best, end-users were only included "after the fact." Benchmark testing (evaluation) occurred in isolation because designers assumed they were the "experts" in their fields. Interactive Evaluation was created as a constructive mechanism for bridging this chasm between technical developers and various users. Interactive Evaluation provides the mechanism for providing valuable user feedback to researchers, developers, designers, and manufacturers at every stage of an innovation creation. This type of re- search and development process is energy inten- sive, requiring more "effort" on the parts of pro- fessionals unaccustomed to working together. This may be one reason why there have been few, if any, evaluative methodologies that focused on the interactive approach. The benefit of this approach in terms of a higher quality, more usable system far exceeds the cost particularly as the complexity of the system increases.

evolving field.

Interactive

Evaluation (I/E)

is

a

process for

2.9. Summary of the Introduction

From a simple, programmed robot arm that can perform repetitive tasks in a structured workspace to the more sophisticated systems that have integrated sensory and communication capa- bilities which can be programmed off-line using high-level languages and potentially coupled to CAD/CAM systems, the potential designs seem almost limitless. However, as robotic systems are designed, they will need to evolve to fill particular niches. Investigation is required regarding the op- timal designs for (a) disability type/level, (b) di- verse settings ranging from in-home care for very mildly impaired to longterm institutional care of severely disabled, and (c) the best mix of sensory and robotic capabilities to address human needs in specified domains.

delineating needs and assessing the feasibility of developing and disseminating prototype robotic systems. The interactive process was conceived to facilitate the creation of systems that incorporate recent advances in robotic technology and artifi- cial intelligence and to gather research informa- tion on human-machine integration [12,18,9]. Evaluative research conducted within this frame- work is dynamic, iterative, interdisciplinary (Fig. 2) and includes basic, baseline, and applied re- search. It is important to draw upon expertise from relevant areas. Innovative research ap- proaches, which work to blend the protocols of different fields, are required to examine human system interactions and integration [13]. The fields of psychology, medicine, human fac- tors, computer science, engineering, and design all offer paradigms to help us gain basic knowledge required to build more intelligent systems. Multi- disciplinary research protocols allow a wide variety

  • 212 K.G. Engelhardt / Health and Human Service Robotics

Fig. 2. Model of interactiveevaluation.

of allied professionals and disabled persons to be involved in the lifecycle of a potential product. Evaluative research includes potential end-users as research and development partners throughout all stages of potential product creation, from idea conceptualization through technology transfer. This methodology facilitates the definition, design, development, and dissemination of appropriate state-of-the-art technology in a potentially cost-ef- fective manner [49].

The outcome of the needs research

are task

taxonomies that can be analyzed from the various technical and clinical perspectives. Hypothetical scenarios are formulated to test assumptions and stimulate discussion of potential design tradeoffs. Human performance determines the desirable machine characteristics. If technological capabili- ties exist which meet the criteria of the desirable machine characteristics, then feasibility research can begin. If technological capabilities partially exist, the human performance provides the justifi- cation for development of new technological capa- bilities. Likewise, machine performance can help define the desirable human characteristics. To- gether these methods provide the mechanism of screening out inappropriate technologies and in- appropriate use of technologies for particular user sub-groups. Another capability derived from this methodological approach is that the division of labor between the intelligent human and the smart system can be examined and optimized. In this way both the human and the machine can perform

the task which each does best.

2.11. Applications: Service Robotics

The experimental approach used to identify potential needs which advanced robotic technolo- gies might address is entitled "Interactive Evalua- tion" [15]. This approach was utilized in a three part study that examined the application of robotic technology in longterm care. The study was the first of its kind and conducted at the Veterans Administration Nursing Home Care Unit in Menlo Park, California. The first phase of this study identified tasks that were amenable to augmenta- tion or replacement of robotic technology. The research team identified 54 subgroups of tasks (needs) that roughly divided (overlap is unavoida- ble) into the following twelve major descriptive categories:

Patient

Transport-Lift-Transfer:

The

challenge

of safely lifting and transferring individuals with partial or total paralysis, extensive weakness, or increased fragility due to age is significant. One

robotic solution could be a track-mounted robot arm that glides along the ceiling until it reaches the room to which it has been summoned. The care giver or the older person could then direct

the arm to assist in

lifting or transferring the

individual from bed to chair or wheelchair to bath, for example. This assistance could also help reduce back injuries and increase job satisfaction for health-care workers and offer increased independence for the older person. • Ambulation: This same ceiling-mounted robotic arm could offer an "elbow" to people who need exercise but are a bit shaky, or it could help by pushing a wheelchair along the arm's track cor-

ridor. Another solution could be comfortable parachute-like harnesses to safely support weakened individuals in standing positions. These "people walkers" would be programmed to move at varying speeds (under computer control) depending on the individual's pre- scribed exercise regimens. Currently, patients are rarely walked individually on a daily basis because there is not enough free staff time to assist them. Regularly prescribed exercises might affect an older person's quality of life, health, and sleeping patterns. Housekeeping: A whole range of housekeeping tasks are amenable to service robotic interven- tion. Hospital kitchen activities, laundry tasks, hallway upkeep, room readiness (including au-

K.G. Engelhardt /

Health and Human Service Robotics

213

tomatic bed making), and other ancillary services should be more efficiently accom- plished. • Physical Therapy: Our research showed that robotic technologies hold the possibility for playing a role in both patient therapy and ther- apist training [13]. In delivering therapeutic reg- imens, the human therapist has a finite amount of energy. One therapist commented that she was physically able to deliver only 5-8 repe- titions/patient for range of motion exercises for nursing home patients, but tha( the physi- cian and the patients would have "liked to have had 25" [18]. Furthermore, back injuries are a serious concern for practicing therapists and at the present time training in body mechanics is generally practiced using the assistance of other able-bodied students, so they are never exposed to particular functional disabilities in their training. Our research specified a system that can deliver a range of motion exercises for muscle maintenance for institutionalized pa- tients; and, if designed properly, the same robotic system could also be used as a teaching tool for student therapists, thus increasing its usefulness. It could be programmed to mimick certain disabilities (for instance, flaccidity in paralyzed patients, stovepipe rigidity in Parkin- son disease patients) which could assist novice therapists in learning appropriate body mecha- nics and learning the characteristics of various muscle capabilities associated with specific dis- abilities [13]. The precision and repeatability of therapist-programmed and robot-administered exercises could provide new tools for improving physical therapy service delivery. From the health care perspective, we do not know what impact these types of applications might have on the quality of health care service delivery. The increased costs associated with such a sys- tem might be justified because it can increase the therapist's productivity and serve more pa- tients. Its dual role of therapist assistant and therapist trainer are two factors which could contribute to increased productivity, improved quality of care and cost justification. The ever growing flexibility of this class of technology can allow us to think about designing systen~s that perform multiple roles/functions. • Depuddler (urine cleaning devices): Robotic Floor Cleaning devices could locate urine, clean

it,

dry

it,

deodorize

the

"accident"

area

and

move on. Such a system could be summoned on

demand in addition to performing routine cleaning tasks.

Surveillance

and

Monitoring:

This

area

is

a

chronic problem for caregivers of institutional- ized patients (particularly Alzheimers type dis- eases) who are plagued by wandering behavior and falls. Our research specified a system that could utilize space technologies such as satel- lites to track wanderers and artificial intelli- gence techniques within the environment to locate and if necessary communicate with the wanderer. Perimeter wiring and electronic door monitoring were also part of the integrated system that was proposed. Presently, research is underway in the Health and Human Services Robotics Laboratory to extend these concepts into small environments. • Physician Assistant: Expert systems for diag- nosis, therapy, and case management are al- ready being utilized in both research and clini- cal domains [44]. There are, at the present time, mechanical telemanipulating devices that are attached to x-ray machines. These paddle-like rigid L-shaped devices, which physicians manipulate with joysticks from behind protec- tive shielding, extend physicians' capability by allowing them to manipulate patients' abdo- mens while remaining safe from radiological exposure. These devices are reminiscent of the telemanipulators used in the nuclear industries where early use of robots occurred. They rely solely on the intelligence of the physician. There

are also experimental robotic tools assisting in stereotaxic surgical procedures. Feasibility was

demonstrated

1987.

at

the

Robots

11 Conference in

• Nurse Assistant (included fetch and carry tasks):

When we begin to consider the design of robots that may be used in health service environ- ments, we can draw on numerous existing in- dustrial application areas. Automated Guided Vehicle Systems (AGVS) technology is already performing materials handling tasks in industry. Similar systems are already beginning to be implemented in the interstitial spaces of new hospital buildings to transport supplies. Up- graded related technology can be utilized in an institutional health care environment to trans- port meals, drinks, and personal items to pa-

  • 214 K.G. Engelhardt /

Health and Human Service Robotics

tients. Such a mobile robotic device could also move from patient to patient and collect vital signs data and, with two-way communication, provide a link with the centralized nursing sta- tion. Autonomous navigation research is being actively pursued in university, industry, and government laboratories. Prototype vehicle sys- tems with increased degrees of autonomy have already proven feasible in semi-structured set-

tings [30]. The Health

and Human Services

Robotics Laboratory has already conducted re- search in four areas for companies interested in creating self-navigating fetch and carry robotic systems. This research encompassed four major areas with several subareas: (1) functionality, (2) safety, (3) human-machine interface, and (4) appearance/design revision recommenda- tions. Functionality contains four subsections:

(a) Task Profiles, (b) Productivity, (c) Cost, and (d) Ambulation Rates. Safety contains four sub- sections: (a) Design Features and Error Re- covery, (b) OSHA/NIOSH Regulations, (c) FDA: Medical Device Industry Regulations, and (d) Acceptable Risk [21]. • Patient Assistant: Robotic aids can also perform manipulation tasks in an older person's physical environment. Our research has shown that older people are capable of using a robotic aid, and it has identified a range of health and indepen- dence-related applications from stationary, sensory-less, bedside-mounted manipulators to problem-solving, self-navigating vehicles with robotic arms that work in coordination. A low- cost manipulator could be mounted on a bed-

side table, hospital bed, or wall track and per- form pick-and-place tasks for a bedbound per- son. A stationary system with some sensory capabilities, such as force and tactile sensors, could help with some personal grooming and feeding tasks. A mobile, guided vehicle could deliver food trays or perform simple fetch-and- carry tasks. A self-navigating robot wheelchair could transport the individual and have a robotic arm attached to perform manipulation tasks. • Vital Signs Monitoring: Intelligent ICUs already exist. Remote vital signs monitoring is under investigation. Implantable monitors and medi- cation dispensors are being researched [8].

Mental Stimulation

and Cognitive Rehabilitation:

Maintenance

of

previously learned

skills and

learning of new ones is important

at

all ages.

The use of computers and robotic technology to stimulate creativity has been termed "the foun- tain of youth" [28]. • Other: One miscellaneous group of tasks did not classify into any of the other categories. Many of these have indirect benefits across environments. One example is 'laboratory robots." Robots are currently working in re- search and diagnostic laboratories. There are over 1200 laboratory robots in use performing routine laboratory tasks from sample prepara- tion to radioimmunoassays. They continue to prove increasingly useful in tasks associated with handling of agents associated with com- municable diseases such as tuberculosis, AIDS, or other substances which are dangerous to humans. Another task in this miscellaneous group were fetch and carry tasks both directly related to patient care and not directly related to patient care. The second and third phases of the study surveyed attitudes of the administration and staff toward computers and robots, and demonstrated for the first time in history the feasibility of inpatient elderly nursing home residents using a prototype robotic system [19]. The patients ranged in age from 63 to 91 and had not been exposed to robotics before. The direction and composition of the team were important variables in the success of the project because technically trained person- nel in isolation and clinically trained personnel working alone did not identify potential robotic interventions. This potential task list might be generalized to a wide range of health and humans service settings. Candidate settings include: emer- gency/ urgent care units, hospitals, skilled nursing facilities, intermediate care facilities, domiciliary, residential, in-home and ambulatory care sites. This research demonstrated that it is feasible for older users to successfully complete standar- dized tasks, utilizing a sophisticated, voice con- trolled robot, in the same amount of time as younger users. The attitudes of older users, ex- posed to advanced robotic technology can best be summed up by a comment from our oldest robot user. He was a 91 year old man, who was in a nursing home and his global attitude was:

"whatever works". The aura of mystique sur- rounding robotics was immaterial to him. He felt that the needs were great and he didn't care what you called the answer to these needs, whether

K.G. Engelhardt /

Health and Human Ser~,ice Robotics

215

robot,

or

car,

or

telephone,

"works"

to answer

his need,

or

microwave.

If

it

then

he

will

use

it.

Such

functional

utility,

conjoined

with

ap-

propriate aesthetics will be what the next genera- tion and future generations of smart technologies will require in order to better serve humans of any

age.

3. Research: Present Efforts in CHSR

Our research presently continues in the Center for Human Service Robotics (CHSR) Laboratory at Carnegie Mellon University. This laboratory was created in 1986 to research, design, develop, evaluate, and help disseminate prototypic systems based on robotics and artificial intelligence tech- nologies in the areas of health care and human services. This laboratory is unique in its approach to exploring innovative strategies for safe and efficient interactions of humans and machine sys- tems and particularly in its emphasis on the use of advanced technologies in the service of aging and disabled individuals. Studies in basic, baseline, and applied research are conducted. Laboratory research spans a spectrum of investigations: (a) basic needs identification, human perception, and attitudinal assessments; (b) baseline examination of human-system integration parameters and safety considerations; (c) applied "smart" environments that are forgiving, therapeutic, and rehabilitative. Multiple robotic research, development, and evaluation testbeds are currently running in the CHSR Laboratory. These span a wide spectrum of industrial, personal, and service robotic technolo- gies which include an IBM 7565, Westinghouse- Unimation Puma 260, UMI RTX, and a CRS M1A, TRC mobile base. In addition to the robot controllers, the Laboratory also has IBM RT sci- entific workstations, IBM Voice Communications Application Program Interfaces, personal com- puters, and integration with "The Andrew System". The Andrew System is a joint Carnegie Mellon-IBM effort to create a comprehensive net- work, file system, mail, and document preparation capability that links all computer components within a single large organization. Presently, re- searchers have backgrounds in electrical en- gineering, computer science, mathematics, health services research, industrial design, human bi-

ology,

psychology,

nursing.

mechanical

engineering,

and

3.1. Basic Research

Needs research is required, but how does basic research occur? From the perspective of the robotic domain, basic research is requisite in fundamental needs and potential applications. In this case, it requires the combined knowledge and experience of persons with both robotic and health care back- grounds. This might be accomplished through the use of multidisciplinary teams. However, too often the technical person, with little or no experience in health care delivery, will find it difficult to imag- ine or visualize application areas in this unfamiliar field. On the other hand, the clinician's reluctance to accept robotic technology, or their unfamiliarity with or misconceptions about robots, may prevent him/her from envisioning relevant uses for a de- vice he/she can only barely start to imagine. Involving potential users, who can clearly articu- late their needs and who demand technological utility, can be the driving force behind the direc- tion of causality in discovering appropriate appli- cation areas [15]. The study which identified twelve categories of potential application areas for robotic technology in longterm care was an example of basic research in "needs".

3.1.1. Basic Research. Human Perception & Intelli- gent Informed Monitoring & Alerting

The creation of new concepts of caregiving based on recent advances in smart technologies and methodologies requires basic research into ways in which expert human caregiving can be augmented and supplemented with "technological interventions" [11]. Such basic research serves the dual purpose of increasing our understanding of the mechanisms of expert human perceptions and actions involved in caregiving as well as illuminat- ing specific areas where technology might inter- vene. Such a respite role for smart caregiving technology has been termed "respite robotics" [12] that is, robotic interventions that could relieve a minimum of two hours of caregiving

resources - it could be a useful tool in helping to

relieve caregiver burdening.

Evidence of caregiver

burdening

is becoming increasingly documented

[39].

The prevention and/or recovery from acci-

  • 216 K.G. Engelhardt /Health and Human Service Robotics

dents, such as falls, is a major factor in formal and informal caregiver burdening. The primary recom- mendation that has been made to reduce the likeli- hood of falls has been to increase caregivers' time devoted to direct observations or monitoring [43]. In fact, one of the critical workload variables for both professional and non-professional caregivers is assuring the safety of the disabled patient throughout the course of the day and night. Care- givers are expected to monitor the patient and prevent, if possible, the patient from endangering him/herself or others. Evidence suggests that the psychological burden associated with providing round-the-clock care and monitoring is a major factor in non-professional caregivers' need for re- spite care and/or permanent institutionalization of the disabled person. Furthermore, literature has also shown that nurses' job satisfaction is higher when they are relieved of routine, monotonous jobs such as monitoring. Recent advances in artifi- cial sensors and artificial intelligence can be utilized to research and develop "informed alert- ing systems" that monitor the patient for "at risk" behaviors and then informs the caregiver of the impending danger. Monitoring and alerting is a logical starting place for a respite robot function because of the critical nature of present and future anticipated needs, and because it is "a tractable problem" from the artificial intelligence perspective using state-of-the-art technology. Since our previous re- search identified surveillance or monitoring as one of the major areas where robotic and artificial intelligence technology can make a significant im- pact, a project (initiated in January, 1986) is underway that may have implications for helping to reduce accidents in institutionalized elderly [12]. Such a system can be non-invasive, non-intrusive ("essentially blind") and can become "smart" enough to monitor elderly patients for unsafe ac- tions and provide appropriate, meaningful infor- mation to caregivers. For instance, falls that occur in all health care institutions place patients at higher risk. Improving quality of care upgrading monitoring and alerting capabilities without com- promising the patient's privacy is a desirable goal. Accidents are costly - from both the point of view of human suffering AND resource expenditures. Increasing staff resources for monitoring chores/ tasks is a difficult mechanism to pursue because it is prohibitively costly. Robotic systems of this

class hold potential for extending some of the caregiver's monitoring capabilities. Such a system would provide the caregiver with extra "ears" or "eyes' and the patient with an increased measure of safety. Such improvements for higher quality care provision have implications for cost savings as more citizens age with accompanying frailties. Another potential benefit of an Intelligent Informed Alerting System is that it has the poten- tial for helping improve the quality of care and increasing the caregiver's job satisfaction by re- ducing the caregiver's monitoring burden. It also has the added advantage of being modularly designed so that extended capabilities could be added to the system in future iterations as other respite needs become better identified. The con- cept of advanced technology as intervention was presented to NIH Falls and Accident Prevention Study Group [11]. Such intervention is one tool in the spectrum of service delivery and technological interventions that could be utilized to improve the quality and productivity of caregiving.

3.1.2. Basic Research: Attitudes

Introduction of and attitudes toward advanced technologies will play a major role in how people of all ages accept and utilize robotic assistants in future service roles. Since the application of advanced and robotic technologies in the service sector is only beginning, attitudes toward related microprocessor-based innovations provide indica- tors of potential attitudes toward robots. The Technology Center (TC) at the 1986 Bi-annual Meeting of the American Association of Retired Persons provided an opportunity to begin to col- lect preliminary information. The CHSR designed, conducted, and analyzed evaluative research to investigate aging individu- als' interactions with computer-based technologies using the Interactive Evaluation methodology: At the last station of the TC, an exit questionnaire was available on two circular tables containing fourteen IBM portable laptop computers. Par- ticipants were encouraged to complete the survey before leaving the TC by AARP staff. Approxi- mately 10% of TC participants responded to the 39 survey questions which required 10-15 minutes to complete. The individuals who chose to answer the questionnaire were a self-selected group of subjects interested in the TC. The instructions appeared at the top of the screen and the question

K.G. Engelhardt /

tteallh and Human Ser~,ice Robotics

217

in the middle of the screen. Only one question appeared on the screen at a time to help reduce confusion. The keys needed to answer the survey questions were marked with color coded cues in the shape of starts to facilitate easier use for individuals not familiar/comfortable with qwerty keyboard layouts. The survey consisted of 22 di- chotomous questions, 16 Likert Style questions, and one birthyear question. The questionnaire was divided into five areas of investigation: (1) general attitudes toward computers, (2) human factors issues, (3) demographics and prior experience with selected technologies, (4) effects of their visits to the Technology Center where they could experi- ence personal computers {both desktop and porta- ble), automated gas pumps, automatic teller mach- ines, and credit card telephones in a supportive environment conductive to adult learning, (5) potential applications for personal computers. This paper will only discuss the results of the first area:

general attitudes toward computers. In an effort to focus our initial investigation we restricted our analyses to those individuals who had answered every question and who were at least 50 years age. Of the 388 respondents who met these criteria, 203 (52.3%) were females and 185 (47.7%) were males; they had an average of 63.5 years (and a standard deviation of 6.0 years). Approximately two-thirds of the respondents had incomes between $20,000 and $60,000. Average income is approximately $40,000. The mean edu- cation attained was a college degree. Over 80% had some education beyond high school (some college, vocational, technical, trade school or training in the military) or higher. Space does not permit presentation of all the data results; there- fore, highlights only are mentioned in the discus- sion. The general attitude questions afford the op- portunity to ascertain this subpopulation's percep- tion of technology. While 83.5% stated they were fascinated with and 78.1% stated they were excited about computers, 49.7% also stated they were con- fused and 61.1% stated they were ignorant. Over- all, they believed that computers have made living in our society easier and that one has to under- stand computers in order "to make it in the world today." They were very positive; however, it was a self-selected sample of people who had chosen to spend some of their conference time visiting the

TC

in

the

first

place.

They

were

a

group

who

"liked machines." The excellent attendance and participation indicate that many individuals in this population are enthusiastic and they want to learn more about computers. These data indicate that older people are not homogeneously "tech- nophobic" as some stereotypes portray.

The

subpopulation

is of particular

interest

to

Carnegie Mellon's Center for Human Service Robotics because this cohort represents more ad- vanced education levels and socioeconomic status which seems to positively correspond to the pro- ject demographics of future aging populations. The introduction of, acceptance of, and use of advanced technology is an important area of ex- ploration for both future and present generations of older persons in order to avoid what Engel- hardt terms "technology lag" [15]. Opportunities to become familiar with unfamiliar and perhaps frightening innovations will be necessary in order to integrate the older population successfully into the "computer age". While this research popula- tion may be '" the norm" among persons presently over age 50, they do reflect the demographics of the aging population in coming decades, especially as the highly educated and affluent "baby boomers" age. The data have been treated as descriptive or "trend data" because attitudes of "control groups" were not examined and because the respondents were self-selected. Another re- search variable that should be explored is that most respondents were experienced 'qwerty' key- board users who had used typewriters. The roles of labels, cues, and other markings also needs further investigation.

3.2. Baseline Research

3.2.1. Baseline Research: Robotic Command and Control from the Human Perspecti~e

Development of command and control voca- bularies for both autonomous and guided vehicles includes research on human preference and natu- ral language interfaces. The goal of this area of investigation is to optimize effectiveness and ef- ficiency of voice input/output in the operation of mobile robots. An optimal mobile robot control vocabulary will have sufficient complexity to al-

low the user to perform complicated task se- quences and yet have enough simplicity so that it

does

not

burden

the user's cognitive workload.

Symbols, markers, landmarks, and cues may play important roles in improving remote robot gui-

  • 218 K.G. Engelhardt / Health and Human Service Robotics

dance and control. Better understanding of toler- ance levels will help us learn more about human-system interactions. The types of mean- ingful utterances that people choose to control and command smart systems will contribute to our basic knowledge regarding human perception of machine movement. The necessity for command and control re- search projects has derived from past experience with a stationary voice-controlled robotic system, the first generation Veterans Administration/ Stanford University robotic aid described earlier. While developing and standardizing training pro- cedures for this newly evolved robotic system, exploratory observational data showed that as the orientation of the robot changed, confusion in- creased regarding the movement of the robotic arm based on particular commands. The labelling of the robot arm with color coded directional indicators (arrows) helped decrease this confusion. More detailed discussion of this observation is described in [21]. This experience suggest that any mobile robot, which is voice operated, might be more effectively controlled if the command vocabulary fits the

perceived movement pattern, and if visual markers, such as movement direction indicators, are placed on the robot so they are useful as cues to the human operator. Such markers need to be visible when the robot is within the visual range of the user and when it is seen on a remote monitor. The CHSR Laboratory's Robotic Vocational Workstation II project incorporates a CRS SRS- M1A robotic manipulator, mounted on a horizon- tal track, an IBM PC XT, and an Oragon Systems Voice Recognition board among other peripherals. The Robotic Vocational Workstation allows users to operate the robot in real-time and prepro- grammed motions with both voice and keyboard entry. The directional markers shown in Fig. 3 have assisted naive users in learning the robot's motion. The markers have provided feedback re- garding the name of the joint as well as the direction of motion. Color coding of the markers with the corresponding markers on the keypad enhanced the process of learning which keys cause which motions. Simulations of the robotic arm on the screen assist in teaching the corresponding voice commands. Our experience also suggests that, to develop

218 K.G. Engelhardt / Health and Human Service Robotics dance and control. Better understanding of toler-

Fig. 3. Robotic vocational workstation with directional markers.

K.G. Engelhardt /

Health and Human Ser~#ce Robotics

219

better mobile robot training materials, more atten- tion needs to be paid to the Human Factors variables such as "interactive" error avoidance strategies for commanding robots [9]. Perception of control (or one's locus of control) is expected to increase if users learn that they can easily and quickly recover from errors. The strategy of choos- ing only commands that are meaningfully familiar and comfortable to the user will be important as a robot safety (error avoidance) strategy. This type of research is critical because the gap between machine appropriate communication and meaningful human communication is wide. His- torically, the gap was initially bridged by punch cards and assembly-type language; and subse- quently by "high level" programming languages, and menus. Natural language interfaces, such as voice control, hold promise for reducing the burden of learning 'computerease' in order to access particular applications or customize off- the-shelf software for a special user need [32].

3.2.2. Baseline Research: Voice Command and Con- trol

Humans have demonstrated extensive adapta- bility when communicating with living entities

different from themselves. For example, we train animals to respond to a subset of verbal com- mands most successfully communicated in a firm tone in the imperative tense. We simplify our sentence structure and speak more slowly when communicating with children in order to increase the effectiveness of our communication with them. We listen more attentively, employ more gestures and often speak more slowly when communicating with someone who does not have the same native language as we do. We also generally alter our communication style when communicating through a telephone or other mass media such as radio, television, films, or video. Likewise, humans are likely to adapt their communication patterns to successfully interact with mobile robots. They

are also likely to tolerate a certain amount of communication error as we already do when we

interact

with

other

entities,

human

and

non-hu-

man. Six pilot subjects have navigated structured, mazelike environments from both a regular view and a remote view. Their verbal commands have been analyzed from a functional perspective. One objective has been to classify the commands in terms of the roles they play in conveying desired

K.G. Engelhardt / Health and Human Ser~#ce Robotics 219 better mobile robot training materials, more atten-

Fig. 4. Rectangular maze without markers for mobilanguage research project.

  • 220 K.G. Engelhardt / Health and Human Service Robotics

movement to an intelligent mobile entity. A sec- ondary goal has been to collect baseline data as to what specific verbal and gestural commands a wide age range of individuals utilize to direct an "intelligent" mobile entity. This pilot research is being conducted as part of the Health and Human Services Robotics Laboratory's "Mobilanguage" Project [21]. Existing mobile robot bases provide the necessary technological tools for exploring the appropriate voice commands. Several are being investigated as part of this research. Baseline studies of human-to-intelligent human, human-to-intelligent machine (robot), within structured and unstructured environments will help to formalize anecdotal and sparse evidence regarding the interaction of mobile intelligent robots with humans of varying ages and abilities.

3.2.3. Baseline Research: Safety

In the medical community, efficacy is closely linked to safety. Efficacy may be thought of as a probability of benefit from use of a medical tech- nology. The Office of Technology Assessment de- fines safety as ',a judgement of the acceptability of relative risk in a specified situation" ([31], p. xii). Stringent clinical demonstration of the ex- pected benefits in relation to the relative risks will be a requirement for "medical" service robotic systems.

Safety

is, and continues to be, the number one

issue that transcends all other questions. Safety for the human and safety for the robot (and other humans and objects in its environment) is of paramount importance in the acceptance and dif-

fusion of robots into health and human service settings. Safety is always relative. It is dependent on the desires and values of the individuals devel- oping, designing, manufacturing, purchasing, and using the technology. The priorities of the organi- zation and the society also impact on safety. One example of the significant role these values can play in safety is in determining the boundary conditions under which a system functions safely. The values and priorities of the individuals, organizations, and society that facilitated the deci- sion to launch the shuttle Challenger on that cold January morning appeared to override the stated boundaries of safety for a specific component of the shuttle. The "risk" was judged to be "accepta- ble" and the shuttle was launched without any regard having been given to the potential for

escape for the human occupants. We will now

spend great sums trying to "band-aid" a fix for accomodating human safety. Had serious human factors research been included in each step of the shuttle design, development, and launch, we might have had a different outcome. Our research makes optimization of human factors and human safety with robots our number one priority as is con- sistent with a human driven approach. The safety requirements for the spectrum of care delivery settings from medical to human service are being examined. For instance, our re- search has demonstrated that the rapid robot manipulation and motion speeds required in the manufacturing environment appear to be un-

desirable in the health and human

service do-

mains. Passive safety features, which already exist

in various forms of industrial robot systems, can be built into the electromechanical design of service robot manipulators. For example, fire re- sistance, manual/passive movement capability, elimination of sharp edges and protrusions, pad- ding, speed restrictions, low inertias of moving

parts

to limit the effects of collisions, and maxi-

mum

static forces all offer increased potential

safety for human users, the robot itself, and their

environment. Safe service robotic systems are ex- pected to contain lower level supervisory system managers which monitor critical parameters such as forces, velocities, accelerations, checkpoints, de- viance into "off-limit" areas, self turn-off and start up, diagnostic error messages, and informed feedback to the user regarding system status. Such built in system safety managers, combined with passive safety design features, form the basis for the application of the conceptualization of "inher- ent safety" for service robotics [11]. Rendering the robot more autonomous by fu- sion of capabilities such as force, tactile, and proximity sensors should enable a significant re- duction in the cognitive workload of the robot user. Study of multiple sensors and their integra- tion will also allow us to determine redundant and overlapping safety mechanisms to be implemented along with voice and manual overrides and emer- gency stops. Such fusion and redundancy further supports the concept of inherent safety, or "safety architecture", for the human-robot system. As end-effectors (robot "" hands") become more sophisticated, they will be used in more human service areas. The need for sensitive and delicate

K.G. Engelhardt /

Health and Human Seruice Robotics

221

touch, required for many tasks in a manufacturing environment, will become mandatory for robotic systems that help lift or transport a frail patient whose body or garments must be handled with a confident but gentle touch. This is, indeed, the requisite domain for applications of both "hi tech and hi touch" and these constraints can serve to push smart technology toward more utilitarian configurations.

3.2.4. Baseline Research: Human System Integra- tion Parameters"

Baseline research on human system integration is critical to appropriately match the human user capabilities to technical capabilities. The case of technologies involved in cognitive reminding, re- training, and research illustrates many of the key issues of human system integration. While the utilization of smart technologies to ameliorate the cognitive capabilities of aging individuals is only beginning to be examined, interventions that can reduce the impact of declining mental functions are a high priority because of their importance in maintaining independence and dignity and for their potential for decreasing caregiver burdening. We are researching expert systems for daily living that can be built into the smart home environ- ment. Voice input/output technologies enable meaningful communication to occur between the resident and the environment as well as others outside the environment. Currently, our research is focused on one aspect of a service robotic system: the reminding func- tion which is called "Mind Jogger." It is essen- tially a voice output messaging system that allows individualized and personalized messages to be delivered at appropriate predetermined times. They can even be recorded in the caregiver's own voice. This is important if an older person is reassured by or responds more positively to a certain person's voice (perhaps her daughter's). In this case, the voice output message will sound like her daughter's voice, not like a robot. The system can also be programmed to "nag" a slightly for- getful or somewhat stubborn person. Likewise, the system is "interactive" so that the resident can engage in conversation with the system and the caregivers who programmed the system. For ex- ample, existing personal emergency alert system capability could be expanded to include nonur- gent 'reassurance' capability. Natural language

machine

interfaces provide the tools for creating

such dialogue. Meaningful messaging communi- cation could range from medical reminders to messages of reassurances. Answers to questions related to identity, time, date, place, and activities could also be stored. These messages are not just buzzers or bells which have no informational con- tent. For instance, if the caregiver needed to be away for awhile the voice messenger could provide reassuring reminders which could be spoken at regular intervals or be output in response to pa- tient initiated queries. Examples of the content of

such messages include:

"Mother, it is 2:00, I will be back in 1 hour

at

3 : 00." "Mother,

it

is 2 : 15,

l

will

be home

in 45 minutes,

then we will eat." "Mother, it is 2:30, 1 will be with you in half an hour. It is time to take your medication which is on the kitchen counter. Please take it now." "Mother, please tell me when you've finished tak-

ing your medication. Thank you. 1 love you." Development of effective cognitive retraining and reminding will depend on the system's ability to

communicate reminders to its user in a form and

at a pace that is compatible with the

user's ability

to comprehend. Baseline research is underway to determine effective communication strategies be- tween such systems and a range of individuals with varying capabilities. The Interaction Evalua- tion methodology provides a theoretical frame- work for conducting this research because it di- rectly links human and machine performance and characteristics.

3. 3. Applied Research. Smart Homes

Technology that is designed to enhance re-

maining capabilities and to enable the individual with adapted, new, replaced and/or additional capabilities may be thought of as "enabling tech- nology" or "augmentative technology". Astro- nauts who operate manipulators (robot arms) in space for satellite maintenance are utilizing tech- nology which augments their existing human capa-

bilities:

that

is,

they are

not

limited by their own

physical

strength

or

proximity.

Likewise,

augmentative technology can be utilized by older persons to increase or expand the limits of what they can accomplish. The remote controller for a television enables the viewer to operate his/her

  • 222 K. G. Engelhardt /

Health and Human Service Robotics

television without physically touching it. The au- tomobile with wheels which can "run" faster than human legs extends the humans mobility capabil- ity whether abled or disabled. The caregiver who must help care for a disabled, but noninstitu- tionalized, person, as well as the carereceiver could benefit greatly from enabling technology that would augment caregiving goals and carereceiving needs. An integrated system of such enabling technol- ogies might well be a "Smart Home" [13, 12]. Working toward the use of this class of technology for enhancing a person's living space is a relatively new concept, but well-suited to the needs of older individuals and their quest for least restrictive environments and self-sufficiency. The goal of ex- panding the "centers of control" [27] for persons with disabilities is one for which smart technology can be harnessed. Smart Homes have the potential for decreasing what Lawton describes as "environ- mental press" and increasing the stimulation and communication and monitoring potential for homebound individuals. A Smart Home can pro- vide a CARING, FORGIVING environment that engenders a therapeutic, rehabilitative, and en-

abling life space by: optimizing the use of residual abilities (including retraining), compensating for lost capabilities, as well as enhancing, augmenting, or extending typical human capabilities. Telecom- munication evolution epitomizes this concept of capability extension. From the next room "Wat- son, come here, I need you" - to the hand crank - to the rotary dial - to direct dialing - to touch tone - to teleconferencing and video phones, tele- phones have been iteratively refined to improve the quality and convenience of more and more remote communication. The most recent com- mercial advance provides an image of the person you are conversing with in addition to a realistic, high quality voice. Communication with astro- nauts in space added an entirely new, expanded dimension to "tele"communication. One goal of the CHSR Smart Home project is to develop a demonstration home environment (which could be mobile) based on the premise that artificial intelligence and robotic technology can be utilized to create a forgiving environment for individuals with severe to moderate impairments [13]. Creating a functional, aesthetically, smart environment for this subpopulation will lead to a

222 K. G. Engelhardt / Health and Human Service Robotics television without physically touching it. The

Fig. 5. System diagram of the robotic nutrition system.

K.G. Engelhardt /

Health and Human Service Robotics

223

design that will appeal to young and middle-aged persons without apparent disabilities. Such a for- giving home incorporated not only the conveni- ence and efficiency component of Smart House TM efforts, but also socio-medical, human factors and product design expertise as well. It is anticipated that such an environment could engender a ther- apeutic, rehabilitative life space approach that helps compensate for declining human capabili- ties. Since many professionals feel that the kitchen environment is the "interface between independ- ence and institutionalization", we are focusing our initial efforts on meal-related tasks and on expert nutrition systems. Such a smart kitchen is relevant to addressing the meal-related needs of other 'con- strained' individuals, such as astronauts. There- fore, this advanced application development is significant across the service domain from the general consumer to the homebound senior to residents of the space station. The goal of the flexible Robotic Nutrition Sys- tem project (Fig. 5) is to employ advanced tech- nologies and methodologies for development of a unique prototypic system which will store, pre- pare, and serve meals. The time presently spent by volunteers and staff with meal delivery could be rechanneled into time spent on socializing, or tasks or errands. Innovative approaches to solving some of the chronic problems of older people are needed because existing resources can barely service pre- sent disabled; the burgeoning numbers of vulner- able elderly that will increase in the coming de- cades will compound this problem [39]. The capa- bility for in-home smart technology - especially related to nutrition and meals - to be bonded back to the central caregiving facility will help insure that both human and technological care provision work in concert to increase the quality of life and independence of the carereceiver and not to use technology to further alienate our older citizens.

4. Conclusion

Our

growing

older

population

with

its

wide

spectrum

of abilities

and

characteristics presents

new challenges

to human

factors and

aging spe-

cialists regarding

reduction

and

prevention of

accidents

and

hazards.

Little

effort

has

been

directed toward technological interventions based on existing and emerging innovations. We need to examine, on an international basis, how these innovations may be utilized to increase human safety and security. The utility of smart technology to reduce hazards has begun to be recognized in the auto- mobile industry. For example, manufacturers have pursued implementation of safety features such as brakes which do not lock during a skid. Such "hazard reduction" potential for technology has not been considered specifically to address the needs of our aging population. Furthermore, robotics and artificial intelligence technology offer new possibilities that were unavailable several years ago [15]. Advanced technology - from transponders to voice output warnings and queries, from perimeter alerts to camera surveillance needs to be carefully considered and researched by informed groups composed of multidisciplin- arily trained professionals and users. Hazards (tech assessments need to be) from phone cords can be completely eliminated with cordless (remote) tele- phones. Hot water burns can be prevented by a "smart" sensor that mixes water to safe tempera- tures. Personal help button systems can offer ad- ded security for both its users and their caregivers. An underlying assumption of such interventions is that these devices are not simply "gadgets" but rather useful tools that can help increase the safety and independence of humans from octogenarians to young children. Such efforts create safer en- vironments for all of us from toddlers to absent- minded middle-aged professors to vulnerable elderly persons. Creative methods for investigating and implementing such innovations are mandated before change can occur [11].

In the future we will be seeing new classes of durable medical equipment that will have to be categorized as "SMART" or "'INTELLIGENT" durable medical equipment (SDME). We need to have persons at all levels aware of the potentials and the drawbacks of these innovations. Although this paper can only discuss single dimensions of our own work, the research encompasses a broad spectrum of environments in which robotic tech- nology might work to serve human needs. Smart Skilled Nursing Facilities (SSNFs) could provide many kinds of cognitive retraining and reminding capabilities along with robotic assistance in

transfer~lift~transport,

ambulation, housekeep-

  • 224 K.G. Engelhardt /

Health and Human Service Robotics

ing, monitoring, physical therapy, fetch and carry tasks, and vital signs monitoring [19]. Acute care and rehabilitation facilities encompass additional application domains for smart technology such as the management and transfer of hazardous, conta- gious materials. Each environment requires thoughtful approaches to utilization of robotic

technologies. There have been many critical issues that this paper has not addressed. In order to have success- ful applications for robots that work in close proximity with humans, the human factors must be given highest priority [11]. Personal attitudes and potential resistance, the division of labor be- tween the robot and the human [10] the frequent mismatch of equipment to potential users, reliabil- ity and maintenance, easy to use interfaces, ethical and social considerations [29] will all need to be carefully considered. I also did not discuss edu- cation of robotic scientists, engineers, designers, and only briefly mentioned training end-users. It will be important to prepare future consumers, educators, and students to utilize these smart tools to best human advantage. Legislation and regulation of employee safety and acceptable working conditions are inherently

part of all industries. The health

care

milieu is

a

unique 'industry' in that patients with significant, often fife-threatening, vulnerabilities also require protection along with employees. In some respects the health care environment can be considered a "hazardous environment" (exposure to communi- cable disease and x-rays are two examples of hazards) which is traditionally the type of environ- ment for which robots are well suited. Successful introduction of robotic technology into health care settings will require knowledge of extant regu- lations for particular health care environments and for specific device designs. Prospects look favorable from the point of identifying potential applications in health and human service areas and the technology that will be amenable to these needs. Utility and cost-ef- fectiveness will be among the primary issues. Suc- cessful dissemination will be incumbent upon re- searching and designing reliable, appropriate sys- tems for well-defined task areas. Cost justification may be expanded to include cost and care justifi- cations. This paper has presented research results of my work over the last seven years. I do feel there is

firm grounds for hope to help replace functional disfunctions with this class of technology. The future will bring many new conceptualizations and products. Many will be inappropriately and hurriedly designed and manufactured and guided overwhelmingly by profit motivations, Great cau- tion is required in adopting any advanced techno- logical "hype" from companies eager to make a "fast buck" off robots. Such endeavors have greatly damaged industrial robots in America. With caution and evaluation, this need not happen with the nascent service robotic industry. Thoughtful, careful consideration and evalua- tion must occur at every stage of the research, design, development, and dissemenation process. The major challenge in designing these intelligent devices will derive from how acceptable they are to a wide range of users. The creation of smart, innovative tools that can work safely and interac- tive in a human environment is the mandate. Whether it is an extra hand or pair of hands to serve a patient or an extra set of legs to help a nurse or a robotic device to assist a therapist, the characteristics of the system will need to be de- fined by the task sets that are to be performed. Task taxonomies must be precise, representative, and useful. The worldwide challenge is to incorporate na- ture's gifts of "sand and lightning - silicon and electricity - " [12] into systems that can assist in the perpetuation of autonomous, dignified life, not just in isolated university labs and exotic trips to space but in the quest for more humane caregiv- ing. The spectre of "big brother" need no longer haunt our implementation of technological ad- vances. The balancing concept of "big sister" [12] technology can help guide our efforts to develop nurturing, supportive innovations which enhance the living, working, and playing activities for hu- mans of all ages.

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