An Internet of Things-Based Home Telehealth System for Smart Healthcare by Monitoring Sleep and Water Usage: A Preliminary Study

Round 1

Reviewer 1 Report

Authors proposed a home telehealth system by monitoring sleep and water usage. The following are the comments that need to be addressed in the revised version. The novelty of the paper is not clear. The authors measured data from few sensors but does not provided any analysis useful to imporve the quality of life. There are many such system exists in the literature. How this system is different from those systems.

1. Abstract: The purpose of water usage sensor is not clear. Is it only to detect the death event? 

2. Figures 1 and 2 are not clear. Provide high resolution figures.

3. A better related literature review is required I the introduction section. A comparative table of different IoT based systems and type of sensors used I the system with the advantages and disadvantages.

4. Explain the research gap that this paper will address. 

5. What is the purpose of histograms in the figures 7 and 8.

6. Line 195: How the proposed solution will increase quality of life of the elderly persons? 

7. The reliability of the measurement system is not proved in the paper. 

8. Line 221: What are the normal states and how abnormal state will be detected? Is there any algorithm that will perform such a detection.

9. Line 230: How the system will identify the death and how it will prevent the death?

10. References should included recent papers from 2022 and 2023.

Language of the paper can be improved.

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We considered the reviewer’s intentions and made corrections to improve the paper.

Reviewer 1

Authors proposed a home telehealth system by monitoring sleep and water usage. The following are the comments that need to be addressed in the revised version.

The novelty of the paper is not clear. The authors measured data from few sensors but does not provide any analysis useful to improve the quality of life. There are many such system exists in the literature. How this system is different from those systems.

Reply: Thank you for pointing out these problems. In the original draft, we overlooked the importance of resulting feedback to users. In the revised version, we have incorporated the relevant content. The primary objective of this study is to collect a small amount of biological and lifestyle data through a low-cost IoT system in order to assess users' well-being and preliminary health status. Through regular gatherings organized by us, the analyzed results are provided as feedback to the users. When they require assistance, designated care administrators or physicians offered help, suggestions, and care plans. These gatherings also offer them an opportunity for mutual communication, preventing isolation and reducing the risk of solitary deaths. By utilizing daily water usage and nighttime sleep information, we establish 24-hour continuous monitoring of the users' health states. With just two relatively inexpensive sensors, we create seamless health and well-being monitoring while maximizing the protection of users’ privacy (in comparison to cameras, audio devices, and similar technologies). This is the novelty of the proposed system.

 

1. Abstract: The purpose of water usage sensor is not clear. Is it only to detect the death event? 

Reply: Thank you for bringing this matter to our attention. We have made corresponding changes in the abstract as “Each client node of the system is mainly composed of an electronic water meter that records the user's daily water usage, in order to analyze their living patterns and lifestyle as well as ascertain their well-being, and…”. While monitoring unexpected accidents or sudden deaths is an important function, it is not the sole purpose. Activities such as cooking, laundry, bathing, and cleaning all require a certain level of physical effort. By analyzing changes and patterns in water usage, it is possible to assess whether users, especially those living alone, require support and care in their daily lives. This approach can serve as an indicator of an individual's ability to carry out daily activities, particularly for elderly individuals living alone.

 

2. Figures 1 and 2 are not clear. Provide high resolution figures.

Reply: Thank you for bringing this matter to our attention. We have addressed the issue by recreating Figures 1 and 2 with improved resolution.

 

3. A better related literature review is required I the introduction section. A comparative table of different IoT based systems and type of sensors used I the system with the advantages and disadvantages.

Reply: Thank you for your advice. We have reviewed the relevant literature again and, following your advice, summarized the methods closely related to ours in a single table. Please refer to Table 1 for more details.

 

4. Explain the research gap that this paper will address. 

Reply: Thank you for bringing this matter to our attention. By developing a system that utilizes water and sleep sensors to monitor the elderly 24/7, our research aims to contribute to the prevention of caregiving needs in the future, support for daily living, early detection of changes in the elderly's health condition, prevention of solitary deaths, and extension of healthy life expectancy. All of this while maximizing user privacy protection. There is still limited and insufficient research and practice in this field, particularly concerning methods to address solitary deaths.

 

5. What is the purpose of histograms in the figures 7 and 8.

Reply: As explained above, the long-term characteristics of daily water usage and various indicators during sleep can serve as materials for assessing an individual's functional capacity and overall health. Having access to these materials makes it possible to offer them more targeted advice and care plans.

 

6. Line 195: How the proposed solution will increase quality of life of the elderly persons? 

Reply: Thank you for pointing out the problem. The system analyzes individual outcomes from the collected data and provides feedback to users or their family members through monthly scheduled gatherings led by the designated care manager and physicians. During these gatherings, they receive advice for improving and maintaining their health, as well as personalized care plans to address their health concerns. Although there is no specific data demonstrating an enhancement in their Quality of Life (QoL), the active participation of residents in each meeting objectively indicates that such gatherings and feedback are helpful and conducive to improving their health. In the revised version, we have also added the details of these regular gatherings in the methodology section to highlight how regular feedback through these gatherings contributes to enhancing their QoL.

 

7. The reliability of the measurement system is not proved in the paper. 

Reply: Thank you for bringing up this concern. This proposed system has only been validated in a preliminary empirical trial, and there is a lack of data regarding the reliability of the system. In the revised version, we have omitted this aspect and presented it as a research limitation to address the research gaps in our study.

 

8. Line 221: What are the normal states and how abnormal state will be detected? Is there any algorithm that will perform such a detection.

Reply: Here, the term "normal state" refers to the pattern of daily water usage exhibiting two peaks, reflecting routine activities such as cooking, laundry, and bathing at specific times each day. On the other hand, a relatively "abnormal state" indicates a lack of habitual routines, irregular cooking with frequent reliance on takeout, and infrequent laundering or bathing. These abnormal states could be attributed to changes in physical or health conditions, as well as poor lifestyle habits. During the validation phase, detecting these states was achieved by offline comparison of histogram graphs. It's important to note that the concepts of normal and abnormal states are relative and lack absolute significance.

 

9. Line 230: How the system will identify the death and how it will prevent the death?

Reply: Here, what we refer to as "solitary death" is not synonymous with sudden death. Solitary death refers to the demise of individuals living alone due to lack of social connections and inadequate physical and mental health care. This can result from the weakening caused by various chronic illnesses, sudden death due to unforeseen diseases or accidents, and often remains undiscovered for an extended period after death. Through such a system, we aim to maintain their connection with society, provide timely assistance when needed, offer health advice and medical treatment, and prevent solitary deaths – which is the true purpose of this system. Therefore, we assert that this system is helpful in preventing solitary deaths.

When significant changes in water usage records are detected, such as prolonged absence of water usage, it is statistically possible that this interruption is due to sudden death. By alerting the system's coordinator, who can then make contact via phone or on-site verification, it becomes possible to distinguish whether it is a case of solitary death or an extended absence for other reasons. Thus, we contend that this system is also beneficial for identifying cases of solitary death.

 

10. References should include recent papers from 2022 and 2023.

Reply: Thank you for your advice. In the revised manuscript, we have incorporated additional references from the years 2022 and 2023.

In addition, we have applied for the free English proofreading service within our university. Due to the high demand and their busy schedule, it may take around 3 to 4 weeks. We appreciate your understanding.

Author Response File: Author Response.pdf

Reviewer 2 Report

The paper is about an IoT-based home telehealth system for smart healthcare. The system consists of client nodes with an electronic water meter and a sleep sensor. The sleep sensor monitors physiological parameters during sleep such as heart rate, respiratory rate, body movement, and states on the bed or outside the bed. The Internet of Things (IoT) has potential in the healthcare field and has been explored by researchers.

The authors propose an IoT-based telehealth monitoring system to monitor healthcare and potentially reduce solitary deaths.

The system includes an electronic water meter for measuring daily water usage and a sleep monitoring device for collecting vital signs at night. The system is built using Node-RED for data collection and storage on a CentOS server. The collected data is analyzed and visualized for feedback to users.

The study recruited 18 local older people, 10 of whom had electronic water meters installed in their homes. Table 1: Main Takeaways from the Text. Sleep monitoring devices were placed under the mattress or bed quilt of the subjects.

An electronic water meter was installed to measure daily water usage.

Home gateways with 3G communication units were set up at each subject's household.

The study was approved by the Ethics Committee of Nihon University and informed consent was obtained from each subject. I suggest to include on references and some evident explanations with documents about this approvement for the respect of ethict of the investigation 139 objective.

Some minor improvement for the quality of english language in the paper have to be done in figure 2 that show Node-RED for data collection from the bed sensor and electronic water meter in real-time in the picture are some words in japan language and in figure 10 that show the trends of HR, RR, and BM from the subject with ID 13 during sleep for four days are displayed in a web-based GUI are some words in japan language, too. So, I suggest to translate in english language these parts.

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We considered the reviewer’s intentions and made corrections to improve the paper.

Reviewer 2

 

Comment: The paper is about an IoT-based home telehealth system for smart healthcare. The system consists of client nodes with an electronic water meter and a sleep sensor. The sleep sensor monitors physiological parameters during sleep such as heart rate, respiratory rate, body movement, and states on the bed or outside the bed. The Internet of Things (IoT) has potential in the healthcare field and has been explored by researchers.

 

The authors propose an IoT-based telehealth monitoring system to monitor healthcare and potentially reduce solitary deaths.

 

The system includes an electronic water meter for measuring daily water usage and a sleep monitoring device for collecting vital signs at night. The system is built using Node-RED for data collection and storage on a CentOS server. The collected data is analyzed and visualized for feedback to users.

 

The study recruited 18 local older people, 10 of whom had electronic water meters installed in their homes. Table 1: Main Takeaways from the Text. Sleep monitoring devices were placed under the mattress or bed quilt of the subjects.

 

An electronic water meter was installed to measure daily water usage.

 

Home gateways with 3G communication units were set up at each subject's household.

 

1. The study was approved by the Ethics Committee of Nihon University and informed consent was obtained from each subject. I suggest to include on references and some evident explanations with documents about this approvement for the respect of ethics of the investigation 139 objective.

Reply: Thank you for your invaluable guidance. We have taken your advice into account and made significant improvements. Firstly, we rectified an error regarding the ethics review process for our study. It's important to clarify that the study received approval from the Ethics Committee of Southern TOHOKU Hospital, Fukushima, Japan, rather than the Ethics Committee of Nihon University. The complexity arises from the involvement and support of multiple entities in this project, such as Nihon University, Southern TOHOKU Hospital, and Koriyama City Hall. Therefore, the project management structure appears intricate. For your reference, we have provided the approved Japanese document below (Although an English version is not available, we have provided a translation done by us. Please refer to the right side.).

 

By the way, the “Brain Functional Measurement Method Using NIRS” study is not included in the current study, as it falls under a separate sub-research topic.

 

2. Some minor improvement for the quality of english language in the paper have to be done in figure 2 that show Node-RED for data collection from the bed sensor and electronic water meter in real-time in the picture are some words in japan language and in figure 10 that show the trends of HR, RR, and BM from the subject with ID 13 during sleep for four days are displayed in a web-based GUI are some words in japan language, too. So, I suggest to translate in english language these parts.

Reply: Thank you for bringing these issues to our attention. In response, we have addressed the concerns in Figures 2 and 10 by translating all Japanese text into English in the revised manuscript.

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Good paper, some aspects need to be considered:

1.important to specified the details about sensors used

2.about results, in graphics need add not only the average, but also standard desviation and variance.

3.also about results, i think is needed a comparation with commercial/lab equipment, to give some support to your results

4. Is not clear the use of IoT network, 3G is not IoT network....8n your Implementation you use LoRa? Sigfox? NB-IoT?

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We considered the reviewer’s intentions and made corrections to improve the paper.

Reviewer 3:

 

Good paper, some aspects need to be considered:

 

1.important to specified the details about sensors used

Reply: Thank you for your suggestion. In the revised manuscript, we added more descriptions about the two kinds sensors.

 

2.about results, in graphics need add not only the average, but also standard deviation and variance.

Reply: Thank you for your valuable suggestion. In response, we have made revisions to Figure 7, including the incorporation of average values and their corresponding deviations in the updated manuscript.

 

3.also about results, I think is needed a comparation with commercial/lab equipment, to give some support to your results

Reply: Thank you for your valuable suggestion. In fact, both the sleep sensor and water meter utilized in this research are commercially available products. The electronic water meter requires a specialized installation setup, which prevented us from conducting validation within our laboratory. However, the obtained measurement results remain reliable due to the adherence to standard specifications and certification by the Ministry of Land, Infrastructure, Transport and Tourism, Japan.

Regarding the sleep sensor, it is a medical-grade equipment certified by the Minister of Health, Labor and Welfare, Japan. In a prior study, we validated its performance against a standard ECG device. As outlined in Line 110 on Page 3 of the manuscript, the sensor demonstrated highly accurate measurements, achieving a 96.9 ± 0.1% accuracy for heart rate (HR) and 90.5 ± 0.7% for respiratory rate (RR).

 

4. Is not clear the use of IoT network, 3G is not IoT network....8n your Implementation you use LoRa? Sigfox? NB-IoT?

Reply: Thank you for bringing up this concern. In our study, we employed the "SORACOM Air for cellular" wireless connectivity service provided by SORACOM INC., a prominent global supplier of smart IoT connectivity. This particular service is tailored to meet the connectivity requirements of connected devices, featuring a cloud-native wireless infrastructure.

It's worth noting that the "SORACOM Air for cellular" IoT connectivity utilizes the 3G network of KDDI INC. in Japan. However, it's important to be aware that data transfer speeds are capped at a maximum of 512 kbps. In the updated manuscript, we have included relevant remarks to acknowledge the involvement of the 3G communication unit.

Author Response File: Author Response.pdf

Reviewer 4 Report

In the paper,  an IoT-based home telehealth system for providing smart healthcare management for individuals, especially older people. The problem is significant and falls within the scope of the journal.

In the Introduction, the most important notions to the paper such as telemedicine, telehealth, Internet of Things, etc. are briefly mentioned.  The Introduction in my view is too short for such a paper, especially since there is no Related work section. I, therefore, recommend to the authors to extend the Introduction and include other approaches to telemedicine/telecare which were used recently in connection to the next generation networks.

For example, the recent paper:

 Kalogeropoulos D, Kalogeropoulos C, Stefaniotou M, Neofytou M. The role of tele-ophthalmology in diabetic retinopathy screening. J Optom. 2020 Oct-Dec;13(4):262-268.

 examines the role of telemedicine in the detection  of the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system.

 Many various approaches to the telemedicine services have been described in the literature in recent years. One such approach that reduces the costs and has been proven to be economically efficient is based on the Generalized Nets, an extension of the Petri Nets. This approach is described in the paper:

Stefanova-Pavlova, M. et al. (2017). Modeling Telehealth Services with Generalized Nets. In: Sgurev, V., Yager, R., Kacprzyk, J., Atanassov, K. (eds) Recent Contributions in Intelligent Systems. Studies in Computational Intelligence, vol 657. Springer, Cham.

It has been proven to increase the Quality of Servic (QoS) and Quality of Experience (QoE) by the patients. Also, the Generalized Nets approach has been used for providing telemedicine services for people with diabetes.

Another important work that must be mentioned is the paper:

 Bouabida, K. et al.,  Telehealth and COVID-19 Pandemic: An Overview of the Telehealth Use, Advantages, Challenges, and Opportunities during COVID-19 Pandemic. Healthcare 2022, 10, 2293. https://doi.org/10.3390/healthcare10112293.

which represents a thorough review of the literature on healthcare (in the context of COVID-19) aimed to provide  effective and affordable approaches to health systems and to facilitate access to care, maintain quality and safety of care, and engage patients and health professionals and users of health services.

Other than that, the materials and methods are excellently described. The statistical analysis is correctly performed and correct conclusions have been drawn.

I recommend that the paper be published once the authors address adequately my critical remarks.

Minor spell check is required. 

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We considered the reviewer’s intentions and made corrections to improve the paper.

Reviewer ４:

In the paper, an IoT-based home telehealth system for providing smart healthcare management for individuals, especially older people. The problem is significant and falls within the scope of the journal.

 

In the Introduction, the most important notions to the paper such as telemedicine, telehealth, Internet of Things, etc. are briefly mentioned. The Introduction in my view is too short for such a paper, especially since there is no Related work section. I, therefore, recommend to the authors to extend the Introduction and include other approaches to telemedicine/telecare which were used recently in connection to the next generation networks.

 

For example, the recent paper:

 

 Kalogeropoulos D, Kalogeropoulos C, Stefaniotou M, Neofytou M. The role of tele-ophthalmology in diabetic retinopathy screening. J Optom. 2020 Oct-Dec;13(4):262-268.

 

 examines the role of telemedicine in the detection of the most cost-effective tools for DR screening, so as to manage this surge in demand and the socioeconomic burden it places on the health care system.

 

 Many various approaches to the telemedicine services have been described in the literature in recent years. One such approach that reduces the costs and has been proven to be economically efficient is based on the Generalized Nets, an extension of the Petri Nets. This approach is described in the paper:

 

Stefanova-Pavlova, M. et al. (2017). Modeling Telehealth Services with Generalized Nets. In: Sgurev, V., Yager, R., Kacprzyk, J., Atanassov, K. (eds) Recent Contributions in Intelligent Systems. Studies in Computational Intelligence, vol 657. Springer, Cham.

 

It has been proven to increase the Quality of Service (QoS) and Quality of Experience (QoE) by the patients. Also, the Generalized Nets approach has been used for providing telemedicine services for people with diabetes.

 

Another important work that must be mentioned is the paper:

 

 Bouabida, K. et al., Telehealth and COVID-19 Pandemic: An Overview of the Telehealth Use, Advantages, Challenges, and Opportunities during COVID-19 Pandemic. Healthcare 2022, 10, 2293. https://doi.org/10.3390/healthcare10112293.

 

which represents a thorough review of the literature on healthcare (in the context of COVID-19) aimed to provide effective and affordable approaches to health systems and to facilitate access to care, maintain quality and safety of care, and engage patients and health professionals and users of health services.

 

Other than that, the materials and methods are excellently described. The statistical analysis is correctly performed and correct conclusions have been drawn.

I recommend that the paper be published once the authors address adequately my critical remarks.

Reply: Thank you very much for your advice and comments. In the revised manuscript, we have incorporated the references you suggested and have provided a review of the research advancements in this area within the introduction section.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Authors have answered most of my comments but they have not provided the manuscript with marked changes. These comments should also be addressed properly,

Comment 1 References have problems. In the text they are appearing as ?

Comment 2 an algorithm to identify normal and abnormal states is required. It is important to include such algorithm in the paper.

Some minor mistakes

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We have applied for the English proofreading service within our university. Due to the high demand and their busy schedule, it may take around 4 weeks. We will submit the manuscript that has been checked through English proofreading around September 27th, 2023. We will greatly appreciate your understanding.

 

 

Authors have answered most of my comments but they have not provided the manuscript with marked changes. These comments should also be addressed properly,

Reply: Thank you very much for kind and useful comments to improve our manuscript. In fact, we have already provided the revised manuscript with annotations. Please check the attached file again.

 

Comment 1 References have problems. In the text they are appearing as ?

Reply: Thank you for pointing out the problem. Actually, the “？” mark is due to an error in the operation of latex on the online management system. The editor has already corrected and updated the latest version on the system for all reviewers.

 

Comment 2 an algorithm to identify normal and abnormal states is required. It is important to include such algorithm in the paper.

Reply: Thank you very much for your suggestions. We consider your advice to be highly valuable, especially when the number of system users is significant. Having an algorithm that can automatically determine whether a user's water usage is abnormal proves to be very helpful. This not only enhances the efficiency of the system but also adds a certain level of intelligence to it. 

However, in the current system, there are only ten users utilizing the electronic water sensors, and the histogram graph depicting water usage data is generated from a year's worth of data and is not frequently updated. Due to these factors, we have not yet implemented an algorithm in the current system to automatically identify normal and abnormal water usage; we are relying on manual observation for now.

In our future work, we will certainly take your suggestion into serious consideration. In the present manuscript, we are extremely grateful for your understanding of this matter.

Author Response File: Author Response.pdf

Reviewer 3 Report

Paper complete after your corrections.

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We have applied for the English proofreading service within our university. Due to the high demand and their busy schedule, it may take around 4 weeks. We will submit the manuscript that has been checked through English proofreading around September 27th, 2023. We will greatly appreciate your understanding.

Reviewer 4 Report

I would like to thank the authors for improving the paper as per my recommendation. I recommend that the paper be published in the present form.

Minor spell check is needed.

Author Response

Thank you very much for kind and useful comments to improve our manuscript. We have applied for the English proofreading service within our university. Due to the high demand and their busy schedule, it may take around 4 weeks. We will submit the manuscript that has been checked through English proofreading around September 27th, 2023. We will greatly appreciate your understanding.

Round 3

Reviewer 1 Report

The authors have answered my comments.