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The role of Alexa in clinical practice

by Catherine Hayden, Member of The OT Practice Functional Rehabilitation team, MA in Design for Disability.

Virtual personal assistants such as Amazon’s ‘Alexa’ are changing the way people live and as Occupational Therapists (OT) this type of assistive technology provides an exciting opportunity to enhance our practice. Rapid developments in this type of technology coupled with OT expertise in function and our problem-solving approach could open up a whole new level of independence for our clients.

Who or what is Alexa?

Alexa is a virtual personal assistant which is housed in a smart speaker and follows voice commands to carry out tasks for its owner. It is just one type of virtual assistant, with Google, Apple and others having developed their own versions.

One in twenty Britons (5%) owned a smart speaker in quarter 3 of 2017 with this increasing to 10% by quarter 1 of 2018 (1) . The Amazon Echo with Alexa virtual assistant is the original smart speaker and has dominated the sales market. Amazon sold 2.8 million devices in 2017, compared to the 1.14 million sold by the other market leader, Google Home(2). YouGov research shows that so far, the most common uses of such devices are to play music, answer general questions, set alarms and reminders, make lists and use calendars(1). However, use of such technology is developing rapidly with Alexa being used in health care in the US(3) and the UK government recently announcing plans to work with Amazon to provide health advice to Alexa owners(4).

The smart speaker is modern and commonplace in many homes, it has the ability to link with other speakers and equipment. They are affordable. The cheapest smart speakers cost around £50 and once set up, the speaker is activated simply by talking into the air. There is no need to be able to use your hands, leave the bed or chair or see to activate it as long so as the individual is able to hear, understand and remember how to use the product.

How can OTs use Alexa?

Assistive technology is not a new concept for OTs, with technology such as telecare and communication devices being utilised to enable client safety and maximise independence for many years. But there has been a step change in regard to the use and acceptance of such technology in the home and many healthcare professionals are now keen to use this as an opportunity to enhance and develop their practice.

What virtual assistants actually do and how they may benefit OT clients varies between products as do their strengths and weaknesses, with new features being developed and improved all the time. The table below summarises some of the main attributes, possible OT use and the potential benefits for clients and carers.

Table to show the potential clinical use for key virtual assistant product functions

Product function Possible clincial use Possible advantage to client / carers
Alarm • Reminders to take medication, attend appointments, do exercises or carry out daily activities

• Prompt to get up in the morning and encourage regular routine

• Reminder to move more during the working day or when at home and reduce sedentary behaviour

• Timer for activities such as cooking or exercises
• Reduces the need for carers to visit for medication or to prompt other tasks

• Increase participation in rehabilitation programmes

• Increases independence

• Encourages daily routine

• Reduction in health issues related to sedentary behaviour (eg pressure areas, musculoskeletal issues, reduction in mobility)
Calendar requests • Appointment reminders

• Alerts to complete daily activities

• Medication reminders

• Create lists of things to do

• Share appointments with family members and be aware of family commitments
• Supports memory and planning of day

• Increases independence and participation in activities

• Increased involvement and awareness of family and friend’s day to day responsibilities
Call function • To get help

• Contact relatives

• Order a taxi

• Order food

• Book appointments

• Dictate texts

• Allow the provision of vital statistics to a remote nurse

• Allow provision of an update on achievement of OT rehabilitation goals
• Although unable to call an ambulance with the right apps in place a relative could be called for help / support

• Increase independence (organising own food, transports, appointments etc)

• Reduced carer or family visits due to ability to call if support is needed

• Reduction in the need for other devices such as telecare and therefore saves costs

• Reduction in need for nurses to call to monitor vital statistics

• Increased contact and update in therapy goals without the need for extra visits
Control function • Control lights

• Control heating

• Open doors

• Switch on TV / audiobooks / music

• Link with other devices
• Aids independence

• Allows participation in meaningful activities

• Lets visitors in so no need to give out keys or use a key safe

• Provides entertainment and allows participation in meaningful activities therefore may reduce loneliness or low mood

• Reduction in need for carers or family to visit to carry out such tasks
Internet access • Use for independent studying, shopping, and activity

• Ask questions regarding illness

• Help plan ahead regarding the weather and what to wear
• Aids independence with daily activities

• Enables studying

• Reduces loneliness through participation in activity

• Answers questions (for children and adult users)

• May be beneficial in the workplace

• Empowers individual and increases knowledge

These features add convenience and aid everyday life for all product users but have the potential to be life changing for those with disabilities. The addition of downloadable apps, known as ‘skills’ on Alexa, allow additional functions to be activated, expanding the rehabilitation potential as the technology evolves. For example, some of the additional Alexa skills could be used to address the developmental needs of children and assist with their rehabilitation for executive functioning and sensory processing goals(5). The OT may wish to add apps specific to their clients’ rehabilitation needs in order to assist therapy goals.

Who may benefit?

Any individual who requires assistance using technology or physically controlling their environment may benefit from the use of a virtual assistant. For example, for people with visual impairments use of touch screens is problematic, but smart speakers allow easier access to audio content on the web, choice of radio or TV station to listen to and the development of the Amazon ‘Echo Look’ may assist with choice of clothing in the longer term(6).

The potential use of virtual assistants for those with movement difficulties (for example spinal cord injuries or neurological diseases) are vast, allowing individuals increased independence with many tasks. Smart speakers can also be used with voice activated software increasing usability for people who may be unable to speak to the device. Those with mild cognitive disorders such as head injury, stroke, learning disability or early dementia may find the virtual assistant provides the prompts required to manage their daily activities with a higher level of independence, although they would need to be able to remember how to use the product which may limit accessibility.

The OT role may include teaching clients to use the technology to aid their independence, provision of apps to meet the individual’s rehabilitation needs and virtual monitoring of progress between therapy sessions.

As well as aiding rehabilitation and increasing independence, use of a virtual assistant may cover the tasks previously aided by several technological solutions, therefore simplifying the process, reducing the amount of equipment in a client’s house and possibly reducing the costs of running more than one system. The increase in independence is likely to have a positive impact on quality of life for both the client and their family.

On a larger scale, there is potential to reduce the number of healthcare visits a client requires for prompting with daily activities, health monitoring and rehabilitation. Hampshire County Council claim that distributing Amazon Alexa’s to elderly and disabled residents has reduced costs by £43 million over a two-year period(8). Use for banking is being developed(9) which should increase independence for those unable to use a keyboard. KidsMD has been developed by Boston Children’s Hospital, US to ask child health related questions(9) and a similar service between Amazon and NHS Choices website is being developed for adults and children in the UK(5).

Which to buy?

This seems to be down to individual preference although my research has led me to believe that the Google Home call function may have more flexibility and the search engine from google is a more reliable source of information than Amazon’s use of Bing. However, if you are already an Amazon Prime subscriber or your family and friends all have the Echo then this may be the one to go for.

A word of caution

Clearly the potential for Alexa and other smart speakers is almost limitless. Especially when considered with the potential of linking these devices to other appliances in the home in the much hyped ‘Internet of things’ but what are downsides to such devices?

Alexa only calls Alexa, so the whole family must buy-in to allow it to be used fully. To be able to use the smart speaker individuals must be able to understand and remember how to use it. There are language limitations and of course the individual needs to be able to hear sufficiently to use the product. While virtual assistants reduce the need to use technology, to operate the product the client must be comfortable talking to it and accept a way of functioning which may be completely alien to them.

Confidentiality could be an issue. This is an important consideration especially when data protection is taken into account, the potential to hack these devices to collect data for criminal use is a major concern. If used as a healthcare reminder for medications, exercises etc what are the ramifications for the clinician if the device does not perform this function? Finally, what if the device fails to recognise the patient’s request and inaccurate advice is given, should and can human contact be replaced by use of a device?

All of the above problems are not limited to the clinical use of such devices. However, as they become increasingly common in our homes their abilities will increase and will address many if not all of the issues above.

Should I use Alexa in my clinical practice?

The use of virtual assistants has huge potential to change the way we interact and treat patients now and in the future. There are simple tasks and functions that the device is already assisting hundreds of thousands of people with. This list will expand as the legal, ethical and technological barriers are broken down. OT’s should continue to be involved in the development and use of such practice as the potential to assist with OT rehabilitation and enable client independence is huge.



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