« The goal is to develop research projects in Singapore in connection with what our teams perform in France to establish a win-win relationship between the two countries in the scientific field. The idea is to bring together people, practices and methods to facilitate discoveries. » (Mounir Mokhtari)
Mounir Mokhtari, IPAL (Image & Pervasive Access Lab) director, and Fabien Clavier, project manager, talked to H&TI about key solutions developed by the French-Singapore laboratory. They are currently working on two main projects: City4Age and Pulse, two programs focused on prevention through the integration of new technologies.
They also talked about the purpose of the exchanges between French research teams and Singapore teams, an inspiring collaboration in the field of health tech.
IPAL: an advanced laboratory based on a close collaboration between French and Singaporean researchers
At IPAL, research is focused on understanding medical images, well-being and home assistance management. Fabien Clavier, what is your role in the laboratory as a project manager?
Fabien Clavier (FC): I am originally an urbanist. I work at IPAL on the field of smart cities and how eHealth can be opened on the city and can connect all urban actors in terms of mobility, quality of life, environment, etc.
Why have you chosen to locate in Singapore and not in another Asian country?
Mounir Mokhtari (MM): The choice of Singapore as our host country was made because the CNRS and French academies had identified the city-state as a promising ecosystem in view of the policy pursued in the scientific field.
We were among the first academic teams to develop projects in Singapore. We were there at a time when there was still nobody. The Americans, the British, the Germans and other international institutions came here a few years after us.
FC: The laboratory will celebrate its 20th anniversary in 2018. This is a significant presence!
The purpose of IPAL is to create a link between France and Singapore, to create projects in Singapore but also in Europe?
MM: That’s right. The goal is to create a link between the two countries to develop research projects in Singapore in connection with what the teams perform in France to establish a win-win relationship between the two regions in the scientific field. The idea is to bring together people, practices and methods to make discoveries easier.
We are about thirty in the lab. Half are researchers from France and the other half researchers from Singapore.
City4Age: ensure the independence of older people through the use of connected devices
The goal of the City4Age program (Elderly-friendly city services for active and healthy aging) is to maintain the independence of the elderly at home and in the city by the integration of new technologies. Apparently, the project seems more focused on maintaining social ties than improving health.
FC: It’s a bit of both. At IPAL, we do not have a health approach but more a lifestyle one. We will not deploy medical or invasive devices, that part is handled by health professionals. We are focused on prevention, on quality of life in daily activities, on socialization …
MM: Our goal is not to cure diseases – hospitals know very well how to do this – but to prevent them.
You have notably developed an app encouraging people living in HDB apartments to go out by sending them a notification when, for example, their friends are having lunch at food court (very common in Asia). Can you tell us a bit more about this device?
MM: We have indeed deployed sensors within the homes of the people observed. The purpose of the device is to detect the activities of daily living (preparing a meal, eating, drinking, sleeping, getting up, washing, performing physical activity…).
We have tested the tool in real conditions, in apartments, in nursing homes too. We pay particular attention to problems associated with accompanying the person: how do we motivate people to get out, to exercise, to socialize?
Fabien worked extensively with senior activity centers to test the Touch Community Services tool: these centers have become the main partners of the program. They have a human approach to help people through physical activities, workshops. The idea is to find how to help these people do a better job through technology integration.
FC: We work a lot with the HDB under City4Age. HDB units are organized in neighborhood in which you can find everything: there are apartments and a lot of services available on the ground floor, such as a senior activity center but also a food court, a post office, a small supermarket, etc. Thus, the elderly tend to live in their HDB neighborhood in Singapore.
We work on this scale by integrating all these places of life in our study to try to understand what the person is doing, what his is routine and, then, to identify a possible change of behavior. For example, if the person observed goes to the community center every day and one day does not go there, we look at his case because this might be the sign of a problem or the beginning of a symptom that may be serious.
Do you observe the elderly in general or the elderly with diseases or disorders related to aging?
MM: We observe the dependent elderly and other sensitive people, who are not necessarily dependent.
FC: It can be lonely or isolated people but not necessarily with a disease. We are also interested in people affected by the loss of social ties and active seniors with healthy behaviors.
What are your goals with Touch?
FC: We conducted tests on twenty people in community centers. This was a first deployment. We aim to deploy the tool more widely and touch a hundred homes. I want to clarify that we include families in the process, not just the elderly. The program also concerns children, caregivers, senior activity center members and social services around the people observed. When we recruit someone, we recruit four people in the end, or even more. That is why the development of a solution takes time. In Singapore, it is simpler because « community spirit » is very integrated.
We ambition, with the HDB, to touch a hundred people, on a site or on multiple sites – we’re still discussing this. The idea is to grow, from a quantitative point of view, in order to have more data to analyze, to compare them more easily. Studying twenty people allowed us to achieve the proof-of-concept. As the system works, we now need to go further to stabilize it and then work with partners to deploy the device on a larger scale.
You have made other concrete applications of the City4Age program, including tests focused on sleep management in the Singaporean Khoo Teck Puat hospital. Do you already have any feedback on this experience?
MM: Currently, there are medical devices that are used to analyze sleep. The people examined must spend a night in the hospital. The doctor puts sensors on their body to measure their heart rate and breathing, he also uses an oximeter… Then, the person must fall asleep. It is an observation overnight.
Our system is noninvasive. We put it under the mattress and we almost get the same parameters. We are in the process of performing a clinical validation of this device in a hospital setting. Our ambition is to deploy the tool at home. Instead of observing a person for one or two nights, we analyze his data over several months. Thus, we perform a much more thorough sleep analysis, even if the collected information is not as accurate as that generated by sensors put on the body. The technique is still more natural. That’s innovation!
As part of the validation phase, we use both models. When a patient suffers from sleep apnea for example, a fairly common disorder, both devices are installed – one used by health professionals and ours – then, we compare the data to see if we can get the same conclusions.
The project was launched a few months ago. A dozen people are testing the system. We have not published the results yet but it is quite promising.
Do you have other other test projects of the kind in progress?
MM: Yes, we deployed in Basse-Normandie (West of France) another test project in a residential accommodation for dependent elderly people and three detached houses – actually nine right now.
The goal, again, was to find out what their daily activities were in order to see how we could intervene. We focus on different cases, like sleepwalkers, people who have poor sleep or who skip meals. After analyzing this type of behavior, we have demonstrated that our technology was useful.
Clearly, we notify caregivers and health professionals [an abnormal or at-risk] situation, an exchange which improves the quality of the caregiver’s work and the quality of life of the assisted. The positive effects of our device have been proven and the region now wants to develop it on more homes to touch all of Basse-Normandie.
And ultimately, perhaps consider a national scale deployment?
MM: That’s our ambition. Our role is to establish proof of concepts. Our team proves that the concept works, provides scientific data detailing the project, tests it in the field to validate it and, then, industry players measure the contribution of this solution to the concerned problem.
After that, it is up to the industrialists to develop the product on a large scale, it is no longer our responsibility.
City4Age: a European project extended to Singapore
This concept is one of the projects included under City4Age, a program supported by the European Commission. Can you tell us more about the ambitions of the European Union on this?
MM: The principle of City4Age is to observe the person at home and find out what he does when he goes out. Through this program, the European Commission seeks to understand how it is possible to detect a risk if there is a behavior change. The idea is to detect the risk before the doctor diagnoses the disease.
You don’t work in Europe, but in Singapore. Is the goal to extend City4Age to Asia?
FC: The program is based on a scientific background. There are several pilot sites to test different parts of the City4Age solution in different contexts. We have six pilot sites: five in Europe and one in Singapore. It’s interesting to be in Singapore because the city-state is quite ahead on the integration of new technologies within the urban environment, administrations and public services. For Europe, it is a very attractive benchmark. This implementation allows us to visualize how a European solution can be developed in Asia, and, why not, elsewhere. It also offers an interesting commercial benchmark for marketing.
On the other side, it is also interesting for Singapore to take a look at what Europe does on aging population management, demographic transition, the development of new services and new products because they now have an Asian vision of the market with links with Japan, South Korea and Taiwan for example. They would also like to look in other directions.
The European Union is an area where there is a lot going on in the field of research: the Singapore government is interested in sharing experiences with the EU, through the exchange of solutions and services produced in the EU to find out how they are received there, how they could be developed in Singapore and vice versa.
MM: Singapore is already identified as a leader in the sectors related to new technologies and the notion of « smart city ». There are so many concepts that are experienced in Singapore and there is also this ease of doing business, which is characteristic of the city-state: unlike other countries, we have here a very active ecosystem and have much easier access to patient data, to quality infrastructure, to academic partnerships… It is very easy to achieve scientific validations.
In other countries, such as France, the system is more procedural, it is more difficult to access the data, etc. All the research process is very complicated.
Health data sharing: « Individuals are less reluctant to collaborate [in Singapore] than in France » (Fabien Clavier)
Do you feel that patients are less reluctant to share their health data in Singapore, and more generally in Asia, than in Europe?
FC: I think there is a greater trust of Singaporeans towards this type of scientific approaches based on data, which are generally supported by government agencies. People are less reluctant to collaborate than in France, where it is more difficult to recruit patients because we must convince them of the interest and seriousness of the project, but we do not necessarily have guarantees to present them at the beginning.
MM: Personnal data are also protected in Singapore but are more easily accessible. In France, access is more limited when it comes to health information.
You should also know that the French and European legislations are very complex in terms of the inclusion of patients in scientific experiments, whereas here, they are very open on issues of innovations, therefore the regulatory framework is more flexible. That is part of the reason why we have set up in Singapore.
FC: Singapore is a smart nation. All these outreach programs to new technologies help us a lot.
Pulse: a health tech project to help the fight against diabetes
Are you working on other projects outside City4Age?
FC: Our second main European project is Pulse (2020). Here, we work throughout the community via the analysis of big data. We focus on type 2 diabetes and asthma.
Our job is to look at the city level how we can aggregate all the data, all environmental parameters (air quality, urban mobility, PSI in Singapore …) to analyze the impact of these factors on specific communities, here people with diabetes, with asthma or healthy people but with a risk of developing such chronic diseases.
Through this study, the goal is to help prevention by establishing risk models. Thus, we would be able to observe the evolution of the disease in a diabetic person, from his pre-diabetic stage to the onset of the disease and then to the development of complications. The idea is the same for people with asthma.
The project is based on the same foundations as City4Age. There are five pilot sites in Europe, in the US and in Singapore. Each site focuses on chronic disease. In Singapore, we are interested in diabetes, in particular because there has been a major effort made by the government for some time to fight against this disease.
We seek to understand how people with diabetes live in Singapore, what difficulties they face and how it is possible to analyze the trajectory of these people in order to make prevention and allow them to remain active in the city. It’s the same principle as the device created for the elderly, but the program is implemented here on a wider scale.
For this particular project, do you work closely with the government?
MM: Yes, IPAL works in constant collaboration with the government. The HDB, the URA , the MOH , etc. are our natural partners, as well as hospitals and other government agencies.
Through this project, Singapore has once again demonstrated that it is one of the global leaders in the fight against diabetes
MM: The world leaders in the health sector have identified the problem of diabetes before, it is the case of France for example, but the nuance is that when Singapore identifies a problem, it launches without delay a strong program, it finds money to deploy it effectively and the whole process goes very fast. The whole ecosystem (academic, industrial, etc.) is mobilized to solve the problem. And then they move on.
This is what makes the difference with other countries, including in Asia, where the progress of some countries in the healthcare industry is slowed down by a heavier bureaucracy, where each action is difficult to achieve and resources are not necessarily available…
This is why having a pilot site in Singapore is highly appreciated by the European Commission. By learning what is done here, how things work here, EU officials realize there is a lot to learn in the city-state and ideas to take from here recover to develop innovations in Europe.
« There is also a structural difference between Singapore and France, which influences the way eHealth is developing » (Fabien Clavier)
What are the major differences that you identify between Singapore and France in the health tech sector?
MM: The major difference is essentially that in France, we are very good in the treatment of disease. When the disease is identified, the health insurance system works well. In Singapore, the government is currently investing on prevention: how to improve urban environment and home environment to prevent development of the disease? This system is not implemented in France. Prevention is not supported by Social Security.
Here, the country is reorganizing its healthcare system to facilitate prevention and thereby reduce health care costs. This is a major difference but it’s the only choice today. The European Commission has understood that.
In France, as the system is more or less decentralized with the ARS (regional health agencies) and as budgets are decreasing, the ARS will never fund prevention if they are asked to do so because it entails an additional cost. To evolve at this level, industry players in France would like us to show them that investing in prevention will drastically reduce the costs of the disease. And that is not easy to prove because you have to think in the long term. For example, if you perform tests on a 50 year old person, you have to wait until she is about 75 years old to know the preventive action effect.
FC: There is also a structural difference between Singapore and France, which influences the way eHealth is developing: in Singapore, there is a tradition of Anglo-Saxon care. You have the medical system, the medical infrastructure but also many medical and social infrastructure, such as senior activity centers and community centers. Here, there is a community approach to health (which is less common in France).
This structuring of the sector made a difference in the development of eHealth in the country because it creates more relays that can be activated during the development of preventive solutions.
The HDB is quite active on this. For its first technology deployment campaign, led in Jurong East (West of Singapore), they integrated the families of patients into the process. The project was community-centered and this made the success of such programs in Singapore: families and caregivers are immediately integrated into the prevention and care pathway. There is a powerful ecosystem, it is a great strength of the country.