TOUCH’N’DOCUMENT

A Nutrition Management System on an NFC-tagged TFT-display

Philip Koene

, Felix Köbler

Technische Universität München, Boltzmannstr. 3, 85748 Garching bei Müchen, Germany

Jan Marco Leimeister

, Helmut Krcmar

Kassel University, Nora-Platiel-Str. 4, 34127 Kassel, Germany

Keywords: Telemedicine, Near field communication, Electronic data capture, Nutrition management.

Abstract: Self-reporting of patient data is a valuable tool for data capture in clinical trial studies and to support

ailment treatment. However, traditional paper-based self-reporting is cost- and time-consuming and

consequently suffers from low patient compliance. NFC-based electronic data capture methods allow a

quick and easy self-reporting for patients and the real-time presentation of patient data enables direct

medical intervention by physicians. Malnutrition, for example can be attenuated by continuous medical

supervision of nutrition data. Consequently, we introduce an NFC-based prototype system called

Touch’n’Document (TnD) that supports automatic aggregation and measurement of self-reported nutrition

status. The hardware of TnD consists of a TFT-display that was outfitted with an array of NFC-tags on the

backside. These allow an NFC-enabled mobile phone to be used as an input device to any software system,

running on the TFT-display. The patients simply have to touch the display with their mobile device to log

into the system and report and analyze their current nutrition. This ensures an adequate usability of the

nutrition management system, especially for non tech-savvy or physically impaired patients, consequently

increasing patient compliance. The technical feasibility, benefits, limitations and future research prospects

of the prototype system are discussed in this manuscript.

1 INTRODUCTION

Patients suffering from chronic diseases, e.g.,

dementia, Parkinson´s disease, motor neuron

diseases, such as amyotrophic lateral sclerosis (ALS)

and Multiple Sclerosis or spinal and bulbar muscular

atrophy (SBMA), often have to cope with limitations

and a reduced quality of life. In particular, patients

diagnosed with a motor neuron disease suffer from

progressive paralysis. Therefore patients are

seriously affected by an insufficient dietary intake

which in the long run leads to an (unnoticed)

reduction of weight due to malnutrition or cachexia

(Cleveland and Rothstein, 2001). The loss of weight

is affiliated with high morbidity and mortality, and

negatively affects the quality of life (Desport, Preux,

Truong, J. M. Vallat, Sautereau et al., 1999) of

patients and family members. Due to medical

complications and social consequences, malnutrition

and cachexia are of significant socio-economic

importance (Ludolph, 2006). In many cases,

supplementary nutrition by increased calories or the

use of percutaneous endoscopic gastrostomy (PEG)

tubes for enteral nutrition becomes inevitable in the

course of most motor neuron diseases. This

intervention not only causes a dramatic decrease in

patients’ quality of life (Löser, Lübbers, Mahlke and

Lankisch, 2007) but significantly affects personal,

logistical and financial expenditures for service

providers, as well as insurance and funding agencies.

The total financial impact on the German public

health and welfare system caused by malnutrition is

estimated to 17 billion Euros while the annual costs

for enteral nutrition amount to a total of

approximately 15,000 Euros (Löser et al., 2007) per

patient and year. This estimation excludes additional

costs of complex care expenses which result to total

expenditures of 50,000 Euros per patient and year

(Schauder, 2006).

In order to guarantee highly qualitative treatment

329

Koene P., Köbler F., Leimeister J. and Krcmar H..

TOUCH’N’DOCUMENT - A Nutrition Management System on an NFC-tagged TFT-display.

DOI: 10.5220/0003172803290336

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 329-336

ISBN: 978-989-8425-34-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

procedures, attending physicians need to be

adequately supplied with information regarding their

patients’ actual state and well-being. The differing

logistic challenges of capturing, archiving, analyzing

and interpreting health status information in routine

clinical practice are well recognized (Wolfe and

Pincus, 1995). For patients with impaired motor

control, resulting from chronic or motor neuron

diseases, this implies an even greater challenge, as

patients are usually living at home and relevant

contemporaneous information supporting the

therapeutic decision-making is not available in real

time.

Therefore, the objective of our work is to provide

a simple, effective and efficient electronic data

capture (EDC) system, which can be used by

patients with impaired fine motor skills by using a

mobile phone implementing Near Field

Communication (NFC) technology. NFC is an

extension of the ISO/IEC 14443 (ISO/IEC, 2000)

proximity-card standard (such as contactless card,

RFID, etc.) that allows data exchange between

devices that are about four inches apart.

The motivation for the underlying prototype

derives from the unobtrusive integration of

applications following ambient assistant living

(AAL) concepts into everyday life environments-

enabled by radio frequency identification (RFID) -

for the purpose of real time and accurate data

collection. RFID technology features seamless and

non-intrusive integration of novel applications and

services into everyday life environments (Köbler,

Koene, Goswami, Leimeister and Krcmar, 2010,

Köbler, Koene, Krcmar, Altmann and Leimeister,

2010, Leimeister, Knebel and Krcmar, 2007,

Resatsch, Sandner, Leimeister and Krcmar, 2008,

Uhrich, Sandner, Resatsch, Leimeister and Krcmar,

2008) and thus supporting AAL environments. In

addition, mobile networks allow a flexible, location-

independent monitoring of the patients in real time.

An intelligent EDC system thus can improve

productivity of medical processes not only by being

more cost efficient, but also by accounting for

improved standards of medical care as well as

quality of life.

In the subsequent chapters we will first give an

overview of related research on NFC technology and

EDC methods, used in clinical trials, patient care

and AAL scenarios. We then elaborate on the

Touch’n’Document (TnD) prototype system, its

functionalities, application environment and

technical implementation, along with a potential use

case scenario. The benefits of the proposed system

for patient self-reporting and EDC in ailment

treatment are presented. We close with a discussion

of the contributions from this research, its

implications and the derived recommendations for

future research on contactless electronic capture of

self-reported patient data for different use cases

(e.g., fitness and dietary programs).

2 RELATED WORK ON EDC IN

HEALTH CARE

A vast number of literature elaborates on various

occurrences of EDC for the acquisition of

quantitative and qualitative data in surveys

(Bischoff-Ferrari, Vondechend, Bellamy and

Theiler, 2005, Blake H., 2008, Dale and Hagen,

2007, Palmblad and Tiplady, 2004, Richter, Nixdorf,

Koch, Schneider, Becker et al., 2006). A number of

studies (El Emam, Jonker, Sampson, Krleza-Jerić

and Neisa, 2009, Hyde, 1998) document the basic

advantages of EDC in panel surveys and trial

studies, which are the decrease in costs and increase

in data quality due to the digital form of data

collection.

Another set of advantages of EDC are brought to

bear within the domain of clinical and population

sciences, including medicine, health-care, health

services, epidemiology and demography. These

areas of research often “depend on self-reported

states, characteristics and behaviours” (Stone,

Shiffman, Atienz and Nebeling, 2007) of patients in

order to understand, e.g., disease progression,

treatment outcomes or gerontological requirements.

Self-reporting is described as “the only window on

the inner states” (Schwarz, 2007) of patients. In

comparison to traditional, paper-based

questionnaires, the application of EDC for the self-

reporting of patient data is shown to increase the

patient´s compliance, since it “has the potential to

dramatically reduce the time taken to acquire (…)

data” (Nyholm, Kowalski and Aquilonius, 2004).

Electronically captured, self-reported patient data

can furthermore be compiled in real-time and thus

provide cues for possible medical interventions

(Velikova, Wright, Smith, Cull, Gould et al., 1999).

Clinical trial studies, an area of widespread EDC

application, currently see a noticeable trend going

from remote, web-based data entry by the patients or

care-personnel to a direct capture of the data using

barcode scanning, or most recently, NFC or RFID

tags. This allows further improvement of generated

data quality and enables cost-reduction (Hyde, 1998,

Morak, Hayn, Kastner, Drobics and Schreier, 2009,

Smith and Offodile, 2002) . The application of RFID

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330

technology for data capture in retail business

processes, solving complex tracking and tracing

problems of objects within the supply chain, is well

documented (Fleisch and Thiesse, 2007, Knebel,

Leimeister and Krcmar, 2007, Loebbecke and

Palmer, 2006, Murphy-Hoye, Lee and Rice, 2005).

More recent publications also describe the

employment of RFID-based EDC for marketing

purposes, either from a consumer and retail

perspective (Resatsch, Karpischek, Sandner and

Hamacher, 2007) or focusing on the generation of

media usage data, vital to for publishers and

advertisers (Koene, Köbler, Burgner, Resatsch,

Sandner et al., 2010).

Employing NFC technology for the capture of

self-reported patient data in disease and ailment

treatment is an emerging practice without

widespread application. Fikry (2006) and Morak

(2009) employ NFC technology for the collection of

medical data in hospitals. Their systems envision

hospital personnel touching medical devices with

NFC-enabled mobile phones for the purpose of data

capture. The prototype system, described by Lahtela

(2008) is an NFC-based solution for the control and

distribution of medication in hospitals. The data

acquisition with the mobile device is conducted in

these systems exclusively by health-care personnel

and only within medical facilities, limiting their

suitability for long term disease and ailment

treatment that commonly involves patients, residing

at home. However, Iglesias (2009) describe a NFC-

based health monitoring system for elderly patients,

that can be conducted as a self-management process,

using mobile communication technology at home.

The authors concentrate however, on the capture of

vital signs and parameters like weight or blood

pressure with their proposed system solution and

exclude self-reported, subjective patient data. A

similar concept with similar limitations is developed

by Morak (2007) for the monitoring of heart failure

patients.

Few research projects focus on the support of

ailment treatment through electronic capture of self-

reported patient data on disease progression

(Nyholm et al., 2004), quality of life (Velikova et

al., 1999) or nutrition management (Denning,

Andrew, Chaudhri, Hartung, Lester et al., 2009,

Jarvinen, Jarvinen, Lahteenmaki and Sodergard,

2008, Siek, Connelly, Rogers, Rohwer, Lambert et

al., 2006). Nyholm et al. (2004) and Siek et al.

(2006) implement EDC systems by employing

mobile communication technology, highlighting the

increased patient compliance, when compared to

paper-based self-reporting, and the convenient, real

time access to patient data for medical personnel.

However, none of those research projects tap into

beneficial effects of NFC technology on the usability

of mobile applications.

Therefore this research paper presents the

Touch’n’Document (TnD) nutrition tracking

prototype application for patient self-reporting via

NFC technology. The TnD prototype is designed to

enable easy and highly usable electronic self-

reporting of patients´ nutritional data with the goal

of providing cues to physicians for possible medical

interventions in between practice appointments.

3 THE TOUCH’N’DOCUMENT

PROTOTYPE SYSTEM

Before we outline the technical solution of the

nutrition management prototype system, we will

describe the application environment, use case, basic

features and functionality of the prototype.

The application environment for the conceptual

prototype builds on GSM cellular phones equipped

with NFC antennas, mobile internet broadband

connectivity enabled through EDGE or UMTS

technologies and sufficient display measurements.

These mobile telephones interact with NFC-tags

(e.g., Mifare Ultralight, Standard 1k and DESfire)

attached to the backside of the screen of a standard

TFT-display in combination with a personal

computer equipped with Internet connection. The

personal computer is connected to a web server,

running the nutrition management system.

3.1 Use Case Scenario

In the following a use case scenario for a possible

employment of the presented TnD prototype or

similar applications is outlined:

Several months ago, John was diagnosed with spinal

and bulbar muscular atrophy (SBMA), which started

with a hypotension and atrophy of his musculature

in his upper legs and hip area. In addition to the

diagnosis, John has shown a tendency to be

overweight since his adolescence. His attending

physician, Dave, advises him to reduce his weight by

a long-term adjustment of nourishment to

cholesterol-low whole food. Dave knows that in

some cases of SBMA, patients tend to resort to

extreme measures to control their body weight, e.g.,

starvation diets and fasting cures, which can be

potentially dangerous for the patient and should be

avoided. In a therapy session, Dave reports to John

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331

about a new nutritional management system (TnD),

featuring the simple and uncomplicated possibility

of recording and analyzing daily nourishment. The

physician devises a nutrition plan, setting and

documenting daily lower and upper limits of calorie

and cholesterol intake within the TnD system.

Although John has never been interested in technical

equipment in his life, he is fascinated by the non-

intrusive integration of this new system: all

functionalities are operated from his mobile phone

by touching an NFC-tag equipped TFT displaying

food icons. Touching the screen twice is sufficient to

send nutrition data to the system, which is then

processed for the attending physician and patient.

Dave has set a minimum and maximum limit for

calories within the system. This enables the system

to warn the physician, patient and care giver of a

possible malnutrition or supernutrition of the

patient. Through the constant supervision and

guidance from his physician, enabled by the TnD

self-reporting, John was able to continuously reduce

his weight over the last months.

A potential prototype system and its implemented

functionalities that support the described health care

environment are described in the following chapters.

3.2 Prototype Functionality

The current prototype system provides a simple set

of features:

Figure 1: Interaction Process of the TnD prototype system.

1. The user can log into the nutrition management

system and can operate it through a simple touch-

based interface. She uses his cell phone to touch the

specific area on the TFT-display and her cell phone

gives a short haptic and visual feedback that the

control-input was successful.

2. The nutrition management interface allows her to

select different kinds of food and amounts in order

to specify and log her food intake. For the sake of an

intuitive user interface and a quick interaction, the

selection of food will be example-based. A

comparative study will be necessary to confirm,

whether the results of an example-based input of

nutrition data coincides with the real nutrition intake

within an acceptable margin of error. In this step, the

system could also provide the user with specific

information on food characteristics (e.g., calories

and ingredient information) of his example-based

input of nutritional data.

3. Both user and physician/nutrition manager can

access the nutrition data in the form of reports and

statistics on a web-browser.

From a technical point of view, the data input

component of the prototype is implemented as a

J2ME midlet and Grails web server (see technical

description for details).

3.3 Technical Description

The hardware prototype we constructed for the

nutrition management system consists of a regular

17-inch TFT display that was equipped with NFC-

tags. The display was dismantled and the tags were

attached directly to the back of the Perspex sheet

that distributes the backlighting for the display. The

Perspex layer and the liquid crystal layer of the

display are together approximately half an inch thick

and high quality NFC-tags can be read through

them. The electronics of the TFT-display had to be

moved about one inch away from the back of the

screen to allow operation of the NFC-tags.

The interaction process description in Figure 1

outlines the communication routine of the hard- and

software components of the conceptual nutrition

management system prototype.

The mobile component of the prototype system

is implemented as a J2ME midlet that can facilitate

the communication with the NFC reader of the

mobile device on the one hand and on the other hand

gain access to functions and data of the web server

component through a RESTful API (representational

state transfer application programming interface).

The web server component is implemented as a

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Grails web server with a Flash graphical user

interface (GUI) (see

Figure 2 and Figure 3). The basic

communication routine of the prototype consists of

four steps (see also

Figure 1). The NFC-tagged

display is connected to a personal computer with a

browser opened and connected to the nutrition

management web server:

1. The user touches the login button or another GUI

element of the nutrition management system

displayed on the TFT-screen with her NFC-enabled

mobile device.

2. The NFC-enabled mobile device reads the

corresponding NFC-tag on the backside of the

display and the J2ME midlet component of the

nutrition management software is started (if not

running already). The midlet sends the ID of the tag

and the ID of the user (stored on the mobile device)

to the nutrition management web server through a

mobile internet connection, using the RESTful API.

3. The web server component looks up the tag ID

and the user ID in its database to determine what

button was pressed and by whom. The GUI (or

updated for that specific instance of the nutrition

management system interface.

4. Physicians, nutrition consultants or users with an

affinity to technology can also access the nutrition

management system through a web interface that is

not meant for easy data entry, but for data analysis.

Figure 2: Login-Screen of TnD.

In a next step, we elaborate and discuss the benefits of the

proposed concept in the domain of telemedicine.

4 BENEFITS OF

THE PROPOSED CONCEPT

FOR TELEMEDICINE

The following gives an overview over the major

benefits of the integration of NFC technology,

mobile devices and a client-server-architecture for

telemedicine applications:

 The TnD prototype system could be easily

expanded to capture patient data, different from

nutrition data, e.g., weight, heart rate, blood

pressure, quality of life measures, etc.

 The utilization of NFC and mobile devices, as

well as the implementation of a client-server-

architecture lowers technological barriers of and

costs for integration in established hospital

information systems (HIS).

 The presented prototype solution offers the

possibility for the easy integration of NFC equipped

medical devices such as blood pressure instruments,

for direct capture of medical data.

 Novel mobile devices (e.g., smartphones) and

mobile computing devices similar to the Apple iPad

could be enhanced with NFC technology in the near

future and provide users (patients and medical

personnel) with an adequate user interface.

 The utilization of mobile devices, in particular of

mobile phones, guarantees an absolute mobile and

ubiquitous data transmission but and additionally

enables a voice channel for real time support for

patients or medical personnel.

Figure 3: Main Menu of TnD.

 The TnD prototype provides an intuitive and

secure solution for the user to (1) simple data

capture by touching, to (2) initiate data capturing

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333

and transmitting processes and to (3) secure login

and authentication without entering login and

password information. The usability and

consequently the acceptance of the proposed system

need to be evaluated in further research, however.

 In terms of usability, the utilization of mobile

devices and NFC for the capturing of data results in

a: (1) high usability, (2) minimal interaction with the

display and keypad of the mobile device and (3)

avoidance of erroneous data entries.

5 NEXT STEPS AND FUTURE

RESEARCH IDEAS

From a technical point of view, both soft- and

hardware of the data input component of the

nutrition management prototype system demonstrate

the concept of using NFC-tagged TFT-displays in

conjunction with NFC-enabled mobile phones for

simple, efficient and usable data entry. The system is

currently in a refinement phase of the GUI design. In

a next step we plan to setup focus groups with

patients suffering from motor neuron diseases to

collect improvements for the usability and data

capture process. In this step, we additionally plan to

evaluate the degree of functionality that could be

implemented on the mobile device itself, in order to

make the system less dependent on a stationary

desktop personal computer and a fixed or mobile

Internet connection. A field test with a larger

number of participants is continuatively planned to

be conducted in a German hospital specializing on

motor neuron diseases. The evaluation will focus on

technology acceptance and usability of the proposed

prototype system.

Future versions of the hardware device could

serve different purposes, besides a nutrition

management system, for example to capture patient

data different from nutrition data, e.g., weight, heart

rate, blood pressure, quality of life measures.

The prototype system could also be applied in

environments uncoupled form medical use case

scenarios, e.g., supporting and expanding campus

management systems in universities.

We see the proposed prototype system as a first

step and proof of concept, to develop autonomous

and dynamic smart posters by utilizing NFC

technology and electronic ink foil (E-Ink) or organic

light emitting diode displays (OLED) (Payne and

Macdonald, 2004). In our vision, novel dynamic

smart posters are autonomous in the sense that

electronic ink foil in front of the NFC-tags of the

smart poster is charged by using power of the mobile

device through an adapter or induction and that the

data displayed on this electronic ink foil is requested

through the internet link of a mobile device from a

server. This technical setup allows a dynamic mode

of operation, in the sense that the poster can be used

for multiple and different sessions (in contrast to

paper based smart posters) by displaying different

information in front of NFC-Tags, thus changing the

data-input command that is activated by touching

them with an NFC-enabled mobile device.

6 LIMITATIONS

AND CONCLUSION

The TnD prototype system can enhance the

productivity of telemedicine processes by improving

the information logistics between the involved

stakeholders in nutrition management, thus fulfilling

the seamless healthcare paradigm, postulated by

Schweiger (2007). With TnD, an active participation

and integration of patients into ailment treatment

processes, a better documentation of disease

progression and therefore an improved

communication basis for treatment and nursing can

be achieved. Furthermore, we predict, that the

proactive participation of malnutrition patients,

while recording their nutrition status, can foster their

ability to cooperate in the treatment and consultation

processes by enabling a deeper understanding of the

disease and condition itself. Our results at present

and the prognosticated benefits of the TnD system

are, however, not yet verified in a real world setting.

Beyond this stage, studies are necessary to evaluate

the acceptance of the proposed system by patients,

family members, care personnel, physicians and

funding agencies. In addition, the effects of the

proposed system on patient compliance with

nutrition plans and in a second step the

consequences of an improved nutrition situation for

the progression of, e.g., motor neuron diseases need

to be assessed. For further iterations of the prototype

system, issues like data security and privacy,

robustness, stability and scalability will be subject to

close scrutiny.

ACKNOWLEDGEMENTS

The Touch’n’Document prototype was developed in

the context of the research project Mobile

HybriCare. Mobile HybriCare is funded by the

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German Federal Ministry of Education and Research

(BMBF - FKZ: 01FG08001). It is a joint project of

the Technische Universität München and various

partners. For further information, see

www.mobilehybricare.de.

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