30
ClockReader: Investigating SeniorFriendly Computer Interaction through
Pen-based Computing
Hyungsin Kim
Human Centered Computing
College of Computing
Georgia Institute of Technology
hyungsin@gatech.edu
Ellen Yi-Luen Do
College of Architecture
College of Computing
Georgia Institute of Technology
ellendo@gatech.edu
Copyright is held by the author/owner(s).
CHI 2010, April 10–15, 2010, Atlanta, Georgia, USA.
ACM 978-1-60558-930-5/10/04.
Abstract
Increasingly, we see the use of assistive technology to
enhance the lives of elders. Memory aids and health
monitoring systems are popular applications. In
addition to health-related tasks, the medical community
has realized the need of computerized screening tests
in clinical practice. There are two major benefits of a
computerized screening test. With electronic records,
doctors can easily follow the progress of a patient’s
condition for disease diagnosis and treatment. Patients
can save time and money by decreasing the frequency
of clinical visits. This paper presents our efforts in
developing a computerized sketching tool, the
ClockReader for detecting cognitive impairment. We
are investigating senior-friendly computer interaction
through pen-based computing. In this workshop, we
wish to share our experiences in designing a system for
the elderly, and exchange ideas about the
methodological and contextual issues of designing
senior–friendly technology.
Keywords
Elderly friendly design, Pen-based computing, Sketch
recognition, Human Centered Design, Usability
31
Introduction
Technology has influenced the quality of our everyday
lives. People have connected to each other through the
Internet, mobile phones, and virtual reality systems. At
the same time, the elderly population has been
dramatically increasing. However, studies on the
design, development, and use of technology have been
mostly limited to young adults, particularly aged 20-40
years old [4]. We see a need for guidelines and studies
that consider the elderly population when designing
technology. Physical and cognitive decline of the elderly
require different methodologies and designing factors.
With the strong need for research on aging and
technology, Gerontechnology has been established as
an interdisciplinary field [1]. Gerontechnology
combines gerontology and technology. The approach
comes from a deep understanding of the underlying
characteristics of aging human beings in their social
context in order to develop technological innovations
[2]. How can technology improve the everyday lives of
older adults? Fisk et al. have investigated designing
technology based on cognitive aging principles [3].
They argue that cognitive aging is a critical means by
which to meet a user-centered design approach.
Because aging can influence task performance in
several domains, technology designers should be truly
aware of older adults’ abilities.
Much research in Gerontechnology involves healthrelated applications. Aiding memory, monitoring health
conditions, and supporting communications with distant
family members are exemplary applications supporting
older adults [3]. Indeed, health is one of the most
demanding issues for older adults. This also extends to
the design of medical applications, such as the
development of a screening tool for detecting cognitive
impairment. In order to prevent the progression of
cognitive dysfunction, older adults are encouraged to
take several screening tools, such as the Clock Drawing
Test [6]. The ultimate goal of the ClockReader Project
is to develop an automated recording and analysis of
the Clock Drawing Test for the elderly. In the process of
developing the ClockReader system, a computerized
sketch-based screening tool, we have investigated
senior-friendly computer interaction through pen-based
computing with the preliminary usability testing of
ClockReader.
User Analysis
When we design and develop a system, especially in
clinical settings, there are always challenging factors.
One challenge in developing the ClockReader System is
that we should take into consideration two different
target users. Our main users are (1) patients who need
to take the Clock Drawing Test and (2) clinical staff
who administer the tests and analyze the results. Even
though this position paper focuses on the interaction
with technology by one target user group (the elderly
patients), here we briefly describe the perspectives of
two different users to provide an in-depth
understanding of the goal of the system.
We expect that the system usage by patients and
clinical staff would be different. For patients, we aim to
offer a computing environment that is similar to the
familiar paper-and-pen interaction. Patients will draw
with a stylus on the surface of a Tablet PC. For
clinicians, our goal is to offer a well-organized data
collection device, as well as an automated analysis of
the results. By using a computerized system in a
clinical setting, doctors or clinical staff can easily
32
retrieve and monitor the progress of patients’ cognitive
impairment. Especially in a busy hospital environment,
a system like this can enable non-clinician or selfadministered clock-drawing tests to be performed as
frequently as needed.
and monitor the progression of cognitive impairment.
In the next section, we will introduce the ClockReader
System and the plan to study how elderly users interact
with the pen-based system.
Clock Drawing Test
One purpose of the ClockReader System is to enable
patients to take the Clock Drawing Test without the
presence of a human evaluator. The system consists of
three main components: data collection, sketch
recognition, and data analysis. First, the system should
record and recognize a patient’s freehand drawing and
collect the data. Then, based on the scoring criteria,
the system should automatically analyze the drawing
and report the score.
The Clock Drawing Test (CDT) is one of the simplest,
but most commonly used screening tools to detect
cognitive impairment in the elderly. Our collaborators
at Emory Alzheimer’s Disease Research Center recently
developed and validated a screening test capable of
identifying individuals with mild cognitive impairment
(MCI) and dementia with a sensitivity of 89% and a
specificity of 90%, with a positive predictive value of
95% [6]. The screening test combines a brief cognitive
screening instrument (Mini-Cog) with a functional scale
(Functional Activities Questionnaire; FAQ). The CDT is
one of the main parts of Mini-Cog together with the 3item recall task.
Despite the widespread use of the Clock Drawing Test
in clinical settings, the test is still administered the
same way decades ago. Patients are asked to draw a
clock face by using a pencil on a given sheet of paper.
The clinicians such as neuropsychologists then handscore each test results. This is not only time-consuming
but also error-prone. Therefore, it is critical to develop
a computerized system to conduct this screening
process. A computerized tool will be able to provide
more frequent access to testing while reducing the time
the clinical staff will need to perform the analysis. It will
help identify the early process of cognitive impairment,
and to prevent or delay the progression of cognitive
dysfunction. Furthermore, the data collected from the
test can be a valuable asset for doctors to understand
ClockReader using Pen-based Computing
ClockReader is developed in C# programming language
and is supported by “Microsoft Windows XP Tablet PC
Edition Software Development Kit 1.7” and “Microsoft
Visual Studio 2008.” For the first release, the running
environment of the program is limited to the Microsoft
Windows platform, equivalent to or better than
“Windows 2000 Service Pack 4” with “Microsoft .Net
Framework 3.5 Service Pack 1.” Every coordinate of
cusps and intersections of each stroke (even if it
represents a character) will be stored in the memory.
Then the processor captures a rectangle-shape dynamic
recognition region for each stroke, except for two
hands in the middle of the clock, and recognizes it to
the best-matched character. After the recognition
process, the program then analyzes the relative
position between each number and scores it under the
given criteria. For our initial implementation, we adopt
the grading system proposed by Joshua Shua-Haim [5].
Figure 2 shows a screen shot of our ClockReader
system.
33
Our goal is not only to develop the ClockReader
System, but also to investigate HCI issues for elders
through pen-based computing. Drawing with a stylus
can have a different feeling, and drawing on the surface
of a tablet PC is also very different compared to
drawing on a piece of paper. Because the drawing
quality can influence the screening test results, one
concern is the possibility of negative effects using
Tablet PC. Therefore, we have decided to conduct a
usability study. The main tasks are: (1) to write down
ten numbers; (2) to draw a sun or house; and (3) to
draw a clock with hands representing the time of
11:10. We expect to learn how users interact with the
systems by observing the ways in which they draw
(process), as well as their final drawings (product).
Currently we are in the process of obtaining IRB
approval to conduct this usability test with the help of
our collaborators at the Emory University.
Pen-based computing can be the next generation of
new interaction techniques for the elderly [7]. A recent
study shows that older adults have better interaction
with a touch screen and digital pen compared to
indirect manipulation devices, such as a mouse and
keyboard [8]. Unlike WIMP (Windows, Icons, Menus,
and Pointers)-based interaction, a pen can provide the
elderly with more direct interaction in using the system.
We can put the stylus the exact place where the cursor
is unlike a relative pointing device such as a mouse that
requires hand-eye coordination (moving the mouse on
the desktop while looking at the screen to find the
curse location). By attending this workshop, we hope to
learn from fellow researchers’ experiences in design
and developing systems for the elderly. We also hope
to share our usability results of using pen-based
computing for the elderly to develop a computerized
screening tool.
References
[1] Bouma, H., Ed. (1992). Gerontechnology. Studies in
health technology and informatics. Amsterdam;
Washington, DC :, IOS Press.
[2] Burdick, D. and S. Kwon (2004). Gerotechnology:
research and practice in technology and aging New York,
Springer Publishing Company, Inc.
[3] Charness, N., D. C. Parks, et al., Eds. (2001).
Communication, technology and aging: opportunities and
challenges for the future. New York:, Springer Pub.
[4] Lindley, S. E., R. Harper, et al. (2008). Designing for
elders: exploring the complexity of relationships in later
life. Proceedings of the 22nd British HCI Group Annual
Conference on HCI 2008: People and Computers XXII:
Culture, Creativity, Interaction - Volume 1. Liverpool,
United Kingdom, British Computer Society: 77-86.
[5] Shua-Haim, J., G. Koppuzha, et al. (1996). "A simple
scoring system for clock drawing in patients with
Alzheimer's disease." J Am Geriatr Soc 44(3): 335.
[6] Steenland, N. K., C. M. Auman, et al. (2008).
"Development of a rapid screening instrument for mild
cognitive impairment and undiagnosed dementia." J
Alzheimers Dis 15(3): 419-427.
[7] Torres, D. A. (2006). The Design and Evaluation of a
Pen-Based Computer Interface for Novice Older Users. In
Seventh Mexican International Conference on Computer
Science, 2006. ENC '06. . San Luis, Potosi, IEEE: 142-150.
[8] Torres, D. A. (2006). Evaluating a pen-based computer
interface for novice older users. Proceedings of the 8th
international ACM SIGACCESS conference on Computers
and accessibility. Portland, Oregon USA, ACM: 249-250.