Remote Patient Monitoring via Non-Invasive Digital Technologies: A Systematic Review

Post-acute care management of a patient with COVID-19 using remote cardiorespiratory monitoring

Hospital discharge planning can be complex and hospital space is often limited. Patients, including those with COVID-19, can have prolonged symptoms after discharge and often require ongoing monitoring. Furthermore, prolonging hospital stays primarily for monitoring can expose patients to iatrogenic and infectious risks. The patient's overall condition and their home support system factor into the decisions of when and where to discharge patients. Innovations in remote patient monitoring (RPM) now allow for more options in the discharge process. This case report presents a patient with severe COVID-19 pneumonia where RPM was used at discharge to improve home monitoring and clinical follow-up. Additional experience with RPM is necessary to refine its role in post-acute care monitoring.

Wearable Activity Monitoring in Day-to-Day Stroke Care: A Promising Tool but Not Widely Used

Physical activity monitoring with wearable technology has the potential to support stroke rehabilitation. Little is known about how physical therapists use and value the use of wearable activity monitors. This cross-sectional study explores the use, perspectives, and barriers to wearable activity monitoring in day-to-day stroke care routines amongst physical therapists. Over 300 physical therapists in primary and geriatric care and rehabilitation centers in the Netherlands were invited to fill in an online survey that was developed based on previous studies and interviews with experts. In total, 103 complete surveys were analyzed. Out of the 103 surveys, 27% of the respondents were already using activity monitoring. Of the suggested treatment purposes of activity monitoring, 86% were perceived as useful by more than 55% of the therapists. The most recognized barriers to clinical implementation were lack of skills and knowledge of patients (65%) and not knowing what brand and type of monitor to choose (54%). Of the non-users, 79% were willing to use it in the future. In conclusion, although the concept of remote activity monitoring was perceived as useful, it was not widely adopted by physical therapists involved in stroke care. To date, skills, beliefs, and attitudes of individual therapists determine the current use of wearable technology.

Mobile Health Application for Patients Undergoing Breast Cancer Surgery: Feasibility Study

PURPOSE

Contemporary breast cancer surgery often requires hospital stays of 1 day or less, presenting challenges to delivery of high-quality care. Without sufficient time for proper education and guidance, patients may delay seeking care, experience anxiety, or seek unnecessary care, leading to poorer outcomes and increased costs. To address this, we evaluated the feasibility of a planning-, outcomes-, and analytics-based mobile health application called Manage My Surgery (MMS) for patients undergoing elective breast cancer surgery.

METHODS

Patients undergoing breast cancer surgery at an academic health center were invited to use MMS. Those who used the application received pre- and postoperative surveys, which recorded and reported patient satisfaction and outcomes related to the application.

RESULTS

Thirty-three female patients undergoing elective breast cancer surgery used MMS. The median age was 58 years. Nineteen patients underwent lumpectomy, and 14 underwent mastectomy. Users logged on to the application an average of 3.5 times. The median number of questions viewed was 12 (range 2-35). Of 17 patients who completed the feedback survey, 100% said that MMS was helpful during preparation for surgery, 82.3% said that MMS was helpful postoperatively, and 94.1% would recommend MMS to others. Preliminary data on patient-reported outcomes collected by MMS suggest improvements in anxiety and depression over time.

CONCLUSION

Implementation of a digital care navigation tool in breast cancer surgery patients is feasible. Patients found the tool helpful in both the pre- and postoperative period. Additional ongoing work will focus on patients' self-management skills, long-term outcomes, and health system costs.

Advancement in biosensor: "Telediagnosis" and "remote digital imaging"

Current developments in sensors and actuators are heralding a new era to facilitate things to happen effortlessly and efficiently with proper communication. On the other hand, Internet of Things (IoT) has been boomed up with er potential and occupies a wide range of disciplines. This study has choreographed to design of an algorithm and a smart data-processing scheme to implement the obtained data from the sensing system to transmit to the receivers. Technically, it is called "telediagnosis" and "remote digital monitoring," a revolution in the field of medicine and artificial intelligence. For the proof of concept, an algorithmic approach has been implemented for telediagnosis with one of the degenerative diseases, that is, Parkinson's disease. Using the data acquired from an improved interdigitated electrode, sensing surface was evaluated with the attained sensitivity of 100 fM (n = 3), and the limit of detection was calculated with the linear regression value coefficient. By the designed algorithm and data processing with the assistance of IoT, further validation was performed and attested the coordination. This proven concept can be ideally used with all sensing strategies for immediate telemedicine by end-to-end communications.

Interoperability frameworks linking mHealth applications to electronic record systems

BACKGROUND

mHealth presents innovative approaches to enhance primary healthcare delivery in developing countries like Botswana. The impact of mHealth solutions can be improved if they are interoperable with eRecord systems such as electronic health records, electronic medical records and patient health records. eHealth interoperability frameworks exist but their availability and utility for linking mHealth solutions to eRecords in developing world settings like Botswana is unknown. The recently adopted eHealth Strategy for Botswana recognises interoperability as an issue and mHealth as a potential solution for some healthcare needs, but does not address linking the two.

AIM

This study reviewed published reviews of eHealth interoperability frameworks for linking mHealth solutions with eRecords, and assessed their relevance to informing interoperability efforts with respect to Botswana's eHealth Strategy.

METHODS

A structured literature review and analysis of published reviews of eHealth interoperability frameworks was performed to determine if any are relevant to linking mHealth with eRecords. The Botswanan eHealth Strategy was reviewed.

RESULTS

Four articles presented and reviewed eHealth interoperability frameworks that support linking of mHealth interventions to eRecords and associated implementation strategies. While the frameworks were developed for specific circumstances and therefore were based upon varying assumptions and perspectives, they entailed aspects that are relevant and could be drawn upon when developing an mHealth interoperability framework for Botswana. Common emerging themes of infrastructure, interoperability standards, data security and usability were identified and discussed; all of which are important in the developing world context such as in Botswana. The Botswana eHealth Strategy recognises interoperability, mHealth, and eRecords as distinct issues, but not linking of mHealth solutions with eRecords.

CONCLUSIONS

Delivery of healthcare is shifting from hospital-based to patient-centered primary healthcare and community-based settings, using mHealth interventions. The impact of mHealth solutions can be improved if data generated from them are converted into digital information ready for transmission and incorporation into eRecord systems. The Botswana eHealth Strategy stresses the need to have interoperable eRecords, but mHealth solutions must not be left out. Literature insight about mHealth interoperability with eRecords can inform implementation strategies for Botswana and elsewhere.

Towards Detecting Pneumonia Progression in COVID-19 Patients by Monitoring Sleep Disturbance Using Data Streams of Non-Invasive Sensor Networks

Pneumonia caused by COVID-19 is a severe health risk that sometimes leads to fatal outcomes. Due to constraints in medical care systems, technological solutions should be applied to diagnose, monitor, and alert about the disease's progress for patients receiving care at home. Some sleep disturbances, such as obstructive sleep apnea syndrome, can increase the risk for COVID-19 patients. This paper proposes an approach to evaluating patients' sleep quality with the aim of detecting sleep disturbances caused by pneumonia and other COVID-19-related pathologies. We describe a non-invasive sensor network that is used for sleep monitoring and evaluate the feasibility of an approach for training a machine learning model to detect possible COVID-19-related sleep disturbances. We also discuss a cloud-based approach for the implementation of the proposed system for processing the data streams. Based on the preliminary results, we conclude that sleep disturbances are detectable with affordable and non-invasive sensors.

Barriers to Use of Remote Monitoring Technologies Used to Support Patients With COVID-19: Rapid Review

Background

The COVID-19 pandemic has acted as a catalyst for the development and adoption of a broad range of remote monitoring technologies (RMTs) in health care delivery. It is important to demonstrate how these technologies were implemented during the early stages of this pandemic to identify their application and barriers to adoption, particularly among vulnerable populations.

Objective

The purpose of this knowledge synthesis was to present the range of RMTs used in delivering care to patients with COVID-19 and to identify perceived benefits of and barriers to their use. The review placed a special emphasis on health equity considerations.

Methods

A rapid review of published research was conducted using Embase, MEDLINE, and QxMD for records published from the inception of COVID-19 (December 2019) to July 6, 2020. Synthesis involved content analysis of reported benefits of and barriers to the use of RMTs when delivering health care to patients with COVID-19, in addition to health equity considerations.

Results

Of 491 records identified, 48 publications that described 35 distinct RMTs were included in this review. RMTs included use of existing technologies (eg, videoconferencing) and development of new ones that have COVID-19–specific applications. Content analysis of perceived benefits generated 34 distinct codes describing advantages of RMTs, mapped to 10 themes overall. Further, 52 distinct codes describing barriers to use of RMTs were mapped to 18 themes. Prominent themes associated with perceived benefits included a lower burden of care (eg, for hospitals, health care practitioners; 28 records), reduced infection risk (n=33), and support for vulnerable populations (n=14). Prominent themes reflecting barriers to use of RMTs included equity-related barriers (eg, affordability of technology for users, poor internet connectivity, poor health literacy; n=16), the need for quality “best practice” guidelines for use of RMTs in clinical care (n=12), and the need for additional resources to develop and support new technologies (n=11). Overall, 23 of 48 records commented on equity characteristics that stratify health opportunities and outcomes, including general characteristics that vary over time (eg, age, comorbidities; n=17), place of residence (n=11), and socioeconomic status (n=7).

Conclusions

Results of this rapid review highlight the breadth of RMTs being used to monitor and inform treatment of COVID-19, the potential benefits of using these technologies, and existing barriers to their use. Results can be used to prioritize further efforts in the implementation of RMTs (eg, developing “best practice” guidelines for use of RMTs and generating strategies to improve equitable access for marginalized populations).

Harnessing Mobile Health Technology for Secondary Cardiovascular Disease Prevention in Older Adults: A Scientific Statement From the American Heart Association

Secondary prevention of cardiovascular disease (CVD), the leading cause of morbidity and mortality, is critical to improving health outcomes and quality of life in our aging population. As mobile health (mHealth) technology gains universal leverage and popularity, it is becoming more user-friendly for older adults and an adjunct to manage CVD risk and improve overall cardiovascular health. With the rapid advances in mHealth technology and increasing technological engagement of older adults, a comprehensive understanding of the current literature and knowledge of gaps and barriers surrounding the impact of mHealth on secondary CVD prevention is essential. After a systematic review of the literature, 26 studies that used mHealth for secondary CVD prevention focusing on lifestyle behavior change and medication adherence in cohorts with a mean age of ≥60 years were identified. Improvements in health behaviors and medication adherence were observed, particularly when there was a short message service (ie, texting) component involved. Although mobile technologies are becoming more mainstream and are starting to blend more seamlessly with standard health care, there are still distinct barriers that limit implementation particularly in older adults, including affordability, usability, privacy, and security issues. Furthermore, studies on the type of mHealth that is the most effective for older adults with longer study duration are essential as the field continues to grow. As our population ages, identifying and implementing effective, widely accepted, cost-effective, and time-efficient mHealth interventions to improve CVD health in a vulnerable demographic group should be a top health priority.

El-Bakry H, Abdelrazek S. Mobile Health in Remote Patient Monitoring for Chronic Diseases: Principles, Trends, and Challenges

Chronic diseases are becoming more widespread. Treatment and monitoring of these diseases require going to hospitals frequently, which increases the burdens of hospitals and patients. Presently, advancements in wearable sensors and communication protocol contribute to enriching the healthcare system in a way that will reshape healthcare services shortly. Remote patient monitoring (RPM) is the foremost of these advancements. RPM systems are based on the collection of patient vital signs extracted using invasive and noninvasive techniques, then sending them in real-time to physicians. These data may help physicians in taking the right decision at the right time. The main objective of this paper is to outline research directions on remote patient monitoring, explain the role of AI in building RPM systems, make an overview of the state of the art of RPM, its advantages, its challenges, and its probable future directions. For studying the literature, five databases have been chosen (i.e., science direct, IEEE-Explore, Springer, PubMed, and science.gov). We followed the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA, which is a standard methodology for systematic reviews and meta-analyses. A total of 56 articles are reviewed based on the combination of a set of selected search terms including RPM, data mining, clinical decision support system, electronic health record, cloud computing, internet of things, and wireless body area network. The result of this study approved the effectiveness of RPM in improving healthcare delivery, increase diagnosis speed, and reduce costs. To this end, we also present the chronic disease monitoring system as a case study to provide enhanced solutions for RPMs.

Possible favorable lifestyle changes owing to the coronavirus disease 2019 (COVID-19) pandemic among middle-aged Japanese women: An ancillary survey of the TRF-Japan study using the original "Taberhythm" smartphone app

Coronavirus disease 2019 (COVID-19) has had a global effect on people's lifestyles. Many people have become physically inactive and developed irregular eating patterns, which leads to unhealthier lifestyles and aggravation of lifestyle-related diseases; these in turn increase the severity of COVID-19. Prior to the COVID-19 pandemic, we developed a smartphone application called "Taberhythm" to investigate eating patterns, physical activity, and subjective feelings of happiness. We aimed to compare lifestyle data before and during the first phase of the COVID-19 pandemic to objectively assess lifestyle changes during quarantine. A total of 464 smartphone users (346 women, 35 ± 12 years old, body mass index [BMI] 23.4 ± 4.5) participated in Period A (January 7 to April 28, 2019) and 622 smartphone users (533 women, 32 ± 11 years old, BMI 23.3 ± 4.0) participated in Period B (January 6 to April 26, 2020). Compared with Period A, there was a sharp decline in physical activity during Period B (4642 ± 3513 vs. 3814 ± 3529 steps/day, p<0.001), especially during the final 9 weeks in both periods (4907 ± 3908 vs. 3528 ± 3397 steps/day, p<0.001); however, there were large variations in physical activity among participants. We found a surprising trend during Period B toward increased happiness among women aged 30-50 years, the group most affected by stay-at-home policies that led to working from home and school closure. Moreover, daily eating duration declined in this population. Additionally, there was a positive association of happiness with steps per day in Period B (ρ = 0.38, p = 0.02). Despite the many negative effects of the COVID-19 pandemic, subjective feelings of happiness among middle-aged Japanese women tended to increase, which indicates that some favorable lifestyle changes that could be adopted during quarantine in the ongoing COVID-19 pandemic.

COVID-19 and Orthodontics: An Approach for Monitoring Patients at Home

Aim:

The aim of this study was to test an experimental approach involving the remote monitoring of orthodontic patients through the use of their smartphones.

Background:

Due to the COVID-19 emergency, dental offices were asked to stop elective treatments; suddenly orthodontic patients found themselves isolated at home, without the possibility of monitoring by their orthodontists. The use of telemonitoring via smartphones can be a quick way to recover the orthodontist-patient relationship, monitor and continue the treatment.

Objective:

The purpose of this study was to propose an innovative, simple and reliable approach for the remote management of orthodontic patients.

Methods:

137 patients were contacted verbally by phone and via WhatsApp®; they were asked to send a set of photographs taken with their smartphone. They were asked to complete a questionnaire to evaluate the effectiveness of the approach. Descriptive statistics (frequency with percent) of questionnaire results and the presence of procedural errors while taking pictures were calculated. Correlations between different questionnaire answers were analyzed with the Chi-Square test. Variables with p < 0:05 were declared as significant.

Results:

The majority of patients considered that this approach was positive and they did not feel abandoned. Difficulties emerged from a technical point of view, that is, in terms of photoshoot, and part of the patients expressed perplexity regarding the fact that telemonitoring can replace completely an outpatient visit.

Conclusion:

The use of telemonitoring managed to recreate a relationship with the orthodontist, especially in emergency periods.

Validity of a Novel Research-Grade Physical Activity and Sleep Monitor for Continuous Remote Patient Monitoring

In the midst of the COVID-19 pandemic, Remote Patient Monitoring technologies are highly important for clinicians and researchers. These connected-health technologies enable monitoring of patients and facilitate remote clinical trial research while reducing the potential for the spread of the novel coronavirus. There is a growing requirement for monitoring of the full 24 h spectrum of behaviours with a single research-grade sensor. This research describes a free-living and supervised protocol comparison study of the Verisense inertial measurement unit to assess physical activity and sleep parameters and compares it with the Actiwatch 2 actigraph. Fifteen adults (11 males, 23.4 ± 3.4 years and 4 females, 29 ± 12.6 years) wore both monitors for 2 consecutive days and nights in the free-living study while twelve adults (11 males, 23.4 ± 3.4 years and 1 female, 22 ± 0 years) wore both monitors for the duration of a gym-based supervised protocol study. Agreement of physical activity epoch-by-epoch data with activity classification of sedentary, light and moderate-to-vigorous activity and sleep metrics were evaluated using Spearman's rank-order correlation coefficients and Bland-Altman plots. For all activity, Verisense showed high agreement for both free-living and supervised protocol of r = 0.85 and r = 0.78, respectively. For physical activity classification, Verisense showed high agreement of sedentary activity of r = 0.72 for free-living but low agreement of r = 0.36 for supervised protocol; low agreement of light activity of r = 0.42 for free-living and negligible agreement of r = -0.04 for supervised protocol; and moderate agreement of moderate-to-vigorous activity of r = 0.52 for free-living with low agreement of r = 0.49 for supervised protocol. For sleep metrics, Verisense showed moderate agreement for sleep time and total sleep time of r = 0.66 and 0.54, respectively, but demonstrated high agreement for determination of wake time of r = 0.83. Overall, our results showed moderate-high agreement of Verisense with Actiwatch 2 for assessing epoch-by-epoch physical activity and sleep, but a lack of agreement for activity classifications. Future validation work of Verisense for activity cut-point potentially holds promise for 24 h continuous remote patient monitoring.

Does remote patient monitoring reduce acute care use? A systematic review

OBJECTIVE

Chronic diseases are associated with increased unplanned acute hospital use. Remote patient monitoring (RPM) can detect disease exacerbations and facilitate proactive management, possibly reducing expensive acute hospital usage. Current evidence examining RPM and acute care use mainly involves heart failure and omits automated invasive monitoring. This study aimed to determine if RPM reduces acute hospital use.

METHODS

A systematic literature review of PubMed, Embase and CINAHL electronic databases was undertaken in July 2019 and updated in October 2020 for studies published from January 2015 to October 2020 reporting RPM and effect on hospitalisations, length of stay or emergency department presentations. All populations and disease conditions were included. Two independent reviewers screened articles. Quality analysis was performed using the Joanna Briggs Institute checklist. Findings were stratified by outcome variable. Subgroup analysis was undertaken on disease condition and RPM technology.

RESULTS

From 2050 identified records, 91 studies were included. Studies were medium-to-high quality. RPM for all disease conditions was reported to reduce admissions, length of stay and emergency department presentations in 49% (n=44/90), 49% (n=23/47) and 41% (n=13/32) of studies reporting each measure, respectively. Remaining studies largely reported no change. Four studies reported RPM increased acute care use. RPM of chronic obstructive pulmonary disease (COPD) was more effective at reducing emergency presentation than RPM of other disease conditions. Similarly, invasive monitoring of cardiovascular disease was more effective at reducing hospital admissions versus other disease conditions and non-invasive monitoring.

CONCLUSION

RPM can reduce acute care use for patients with cardiovascular disease and COPD. However, effectiveness varies within and between populations. RPM's effect on other conditions is inconclusive due to limited studies. Further analysis is required to understand underlying mechanisms causing variation in RPM interventions. These findings should be considered alongside other benefits of RPM, including increased quality of life for patients.

PROSPERO REGISTRATION NUMBER

CRD42020142523.

Investigator Experiences Using Mobile Technologies in Clinical Research: Qualitative Descriptive Study

Background

The successful adoption of mobile technology for use in clinical trials relies on positive reception from key stakeholders, including clinical investigators; however, little information is known about the perspectives of investigators using mobile technologies in clinical trials.

Objective

The aim of this study was to seek investigators’ insights on the advantages and challenges of mobile clinical trials (MCTs); site-level budgetary, training, and other support needs necessary to adequately prepare for and implement MCTs; and the advantages and disadvantages for trial participants using mobile technologies in clinical trials.

Methods

Using a qualitative descriptive study design, we conducted in-depth interviews with investigators involved in the conduct of MCTs. Data were analyzed using applied thematic analysis.

Results

We interviewed 12 investigators who represented a wide variety of clinical specialties and reported using a wide range of mobile technologies. Investigators most commonly cited 3 advantages of MCTs over traditional clinical trials: more streamlined study operations, remote data capture, and improvement in the quality of studies and data collected. Investigators also reported that MCTs can be designed around the convenience of trial participants, and individuals may be more willing to participate in MCTs because they can take part from their homes. In addition, investigators recognized that MCTs can also involve additional burden for participants and described that operational challenges, technology adoption barriers, uncertainties about data quality, and time burden made MCTs more challenging than traditional clinical trials. Investigators stressed that additional training and dedicated staff effort may be needed to select a particular technology for use in a trial, helping trial participants learn and use the technology, and for staff troubleshooting the technology. Investigators also expressed that sharing data collected in real time with investigators and trial participants is an important aspect of MCTs that warrants consideration and potentially additional training and education.

Conclusions

Investigator perspectives can inform the use of mobile technologies in future clinical trials by proactively identifying and addressing potential challenges.

Addressing Implementation Challenges to Digital Care Delivery for Adults With Multiple Chronic Conditions: Stakeholder Feedback in a Randomized Controlled Trial

BACKGROUND

Digital tools accessed via smartphones can promote chronic condition management, reduce disparities in health care and hospital readmissions, and improve quality of life. However, whether digital care strategies can be implemented successfully on a large scale with traditionally underserved populations remains uncertain.

OBJECTIVE

As part of a randomized trial comparing care delivery strategies for Medicaid and Medicare-Medicaid beneficiaries with multiple chronic conditions, our stakeholders identified implementation challenges, and we developed stakeholder-driven adaptions to improve a digitally delivered care management strategy (high-tech care).

METHODS

We used 4 mechanisms (study support log, Patient Partners Work Group log, case interview log, and implementation meeting minutes) to capture stakeholder feedback about technology-related challenges and solutions from 9 patient partners, 129 participants, and 32 care managers and used these data to develop and implement solutions. To assess the impact, we analyzed high-tech care exit surveys and intervention engagement outcomes (video visits and condition-specific text message check-ins sent at varying intervals) before and after each solution was implemented.

RESULTS

Challenges centered around 2 themes: difficulty using both smartphones and high-tech care components and difficulty using high-tech care components due to connectivity issues. To respond to the first theme's challenges, we devised 3 solutions: tech visits (eg, in-person technology support visits), tech packet (eg, participant-facing technology user guide), and tailored condition-specific text message check-ins. During the first 20 months of implementation, 73 participants received at least one tech visit. We observed a 15% increase in video call completion for participants with data before and after the tech visit (n=25) and a 7% increase in check-in completion for participants with data before and after the tech visit (n=59). Of the 379 participants given a tech packet, 179 completed care during this timeframe and were eligible for an exit survey. Of the survey respondents, 76% (73/96) found the tech packet helpful and 64% (62/96) actively used it during care. To support condition-specific text message check-in completion, we allowed for adaption of day and/or time of the text message with 31 participants changing the time they received check-ins and change in standard biometric settings with 13 physicians requesting personalized settings for participants. To respond to the second theme's challenges, tech visits or phone calls were made to demonstrate how to use a smartphone to connect or disconnect from the internet, to schedule video calls, or for condition-specific text message check-ins in a location with broadband/internet.

CONCLUSIONS

Having structured stakeholder feedback mechanisms is key to identify challenges and solutions to digital care engagement. Creating flexible and scalable solutions to technology-related challenges will increase equity in accessing digital care and support more effective engagement of chronically ill populations in the use of these digital care tools.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03451630; https://clinicaltrials.gov/ct2/show/NCT03451630.

Cost analysis of a remote patient monitoring programme for post-discharge patients with type 2 diabetes

INTRODUCTION

Assessing costs of an evidence-based health promotion programme is crucial to understand the economic feasibility of adopting or sustaining the programme. This study conducted a cost analysis of a remote patient monitoring (RPM) programme to enhance the post-discharge management of type 2 diabetes.

METHODS

Using retrospective data collected during RPM implementation from September 2014 to February 2018, we estimated the costs of implementing an RPM in the primary care setting. Measures included total and average annual costs, costs per participant who was enrolled or completed the programme, and costs per person-day. We further conducted sensitivity and scenario analyses to examine variations in estimated programme costs associated with varying programme efficiencies and alternative personnel compositions of the RPM team.

RESULTS

The total RPM implementation costs were estimated at US$4,374,544 with an average annual programme costs of US$1,249,870, which translated to US$3207 per participant (n = 1364) completing the three-month programme. The per person-day cost was averaged at US$24 (182,932 person-days). Sensitivity and scenario analyses results indicate that the sustainment costs were approximately US$1.6 million annually and the per-person-day costs were between US$21 and US$29 with each nurse coach on average serving a panel of 62-93 patients.

CONCLUSION

The implementation and sustainment costs of an RPM programme, estimated under various assumptions of programme efficiency and care team compositions, as exemplified in this study, will help healthcare organizations make informed decisions in budgeting for and sustaining telehealth programmes to enhance diabetes management.

Nurse navigators' telemonitoring for cancer patients with COVID-19: a French case study

Purpose

The Gustave Roussy Cancer Institute implemented a patient-reported outcome platform (CAPRI-COVID) for cancer patients with coronavirus disease 2019 (COVID-19) to quarantine patients at home while ensuring monitoring of COVID-related symptoms and securing the care pathway. In this study, we described the CAPRI-COVID intervention, evaluated its use, and presented results of the tracking indicators with a focus on the nurse navigators’ (NNs) activities and the experience of patients.

Methods

Data of 130 cancer patients with COVID-19 diagnosed from March 23 to June 5, 2020, were collected. Six COVID-related symptoms were monitored daily, either by the patient via the CAPRI mobile application (CAPRI App) or by NNs via telemonitoring. In the cases of worsening or new-onset symptoms, an automated alert was sent to the platform, and NNs could immediately consult an emergency physician for future course of action.

Results

All 130 patients (median age: 59 years; 59.2% female) were monitored during the study period. There were no deaths or admissions to the intensive care unit attributable to COVID-19; 7.8% of patients were hospitalized (excluding scheduled hospitalization), and 17.1% were admitted to the emergency department at least once during the monitoring period. NNs carried out 1412 regular monitoring calls (average of 10.9 calls per patient), while 55% of the patients downloaded the CAPRI App.

Conclusions

Most patients monitored with CAPRI-COVID were quarantined during the first wave of the pandemic. In addition to the CAPRI App, which helped limit phone calls, NNs played an essential role in patient management.

Clinical outcomes of digital sensor alerting systems in remote monitoring: a systematic review and meta-analysis

Advances in digital technologies have allowed remote monitoring and digital alerting systems to gain popularity. Despite this, limited evidence exists to substantiate claims that digital alerting can improve clinical outcomes. The aim of this study was to appraise the evidence on the clinical outcomes of digital alerting systems in remote monitoring through a systematic review and meta-analysis. A systematic literature search, with no language restrictions, was performed to identify studies evaluating healthcare outcomes of digital sensor alerting systems used in remote monitoring across all (medical and surgical) cohorts. The primary outcome was hospitalisation; secondary outcomes included hospital length of stay (LOS), mortality, emergency department and outpatient visits. Standard, pooled hazard ratio and proportion of means meta-analyses were performed. A total of 33 studies met the eligibility criteria; of which, 23 allowed for a meta-analysis. A 9.6% mean decrease in hospitalisation favouring digital alerting systems from a pooled random effects analysis was noted. However, pooled weighted mean differences and hazard ratios did not reproduce this finding. Digital alerting reduced hospital LOS by a mean difference of 1.043 days. A 3% mean decrease in all-cause mortality from digital alerting systems was noted. There was no benefit of digital alerting with respect to emergency department or outpatient visits. Digital alerts can considerably reduce hospitalisation and length of stay for certain cohorts in remote monitoring. Further research is required to confirm these findings and trial different alerting protocols to understand optimal alerting to guide future widespread implementation.

Understanding Technology Preferences and Requirements for Health Information Technologies Designed to Improve and Maintain the Mental Health and Well-Being of Older Adults: Participatory Design Study

Background

Worldwide, the population is aging rapidly; therefore, there is a growing interest in strategies to support and maintain health and well-being in later life. Although familiarity with technology and digital literacy are increasing among this group, some older adults still lack confidence in their ability to use web-based technologies. In addition, age-related changes in cognition, vision, hearing, and perception may be barriers to adoption and highlight the need for digital tools developed specifically to meet the unique needs of older adults.

Objective

The aim of this study is to understand the use of technology by older adults in general and identify the potential barriers to and facilitators of the adoption of health information technologies (HITs) to support the health and well-being of older adults to facilitate implementation and promote user uptake. In addition, this study aims to co-design and configure the InnoWell Platform, a digital tool designed to facilitate better outcomes for people seeking mental health services, to meet the needs of adults 50 years and older and their supportive others (eg, family members, caregivers) to ensure the accessibility, engagement, and appropriateness of the technology.

Methods

Participants were adults 50 years and older and those who self-identified as a supportive other (eg, family member, caregiver). Participants were invited to participate in a 3-hour participatory design workshop using a variety of methods, including prompted discussion, creation of descriptive artifacts, and group-based development of user journeys.

Results

Four participatory design workshops were conducted, including a total of 21 participants, each attending a single workshop. Technology use was prevalent, with a preference indicated for smartphones and computers. Factors facilitating the adoption of HITs included personalization of content and functionality to meet and be responsive to a consumer’s needs, access to up-to-date information from reputable sources, and integration with standard care practices to support the relationship with health professionals. Concerns regarding data privacy and security were the primary barriers to the use of technology to support mental health and well-being.

Conclusions

Although HITs have the potential to improve access to cost-effective and low-intensity interventions at scale for improving and maintaining mental health and well-being, several strategies may improve the uptake and efficacy of technologies by the older adult community, including the use of co-design methodologies to ensure usability, acceptability, and appropriateness of the technology; support in using and understanding the clinical applications of the technology by a digital navigator; and ready availability of education and training materials.

Effectiveness of IT-based interventions on self-management in adult kidney transplant recipients: a systematic review

Background

Kidney transplant outcomes are broadly associated with transplant recipients’ capacity in following a complex and continuous self-management regimen. Health information technology has the potential to empower patients. This systematic review aimed to determine the impacts of IT-based interventions for self-management in kidney transplant recipients.

Methods

A comprehensive investigation was performed in MEDLINE (via PubMed) and EMBASE (via Scopus) in April 2019. Eligible studies were the randomized controlled trials which aimed to design an automated IT-based intervention. All English papers including adult kidney transplant recipients were included. To assess the clinical trial’s quality, Cochrane Collaboration’s assessment tool was employed. The articles were integrated based on category of outcomes, characteristics of interventions, and their impact. The interventions were classified based on the used IT-based tools, including smart phones, coverage tools, computer systems, and a combination of several tools. The impact of interventions was defined as: (1) positive effect (i.e. statistically significant), and (2) no effect (i.e. not statistically significant).

Results

A total of 2392 articles were retrieved and eight publications were included for full-text analysis. Interventions include those involving the use of computerized systems (3 studies), smart phone application (3 studies), and multiple components (2 studies). The studies evaluated 30 outcomes in total, including 24 care process and 6 clinical outcomes. In 18 (80%) out of 30 outcomes, interventions had a statistically significant positive effect, 66% in process and 33% in clinical outcomes.

Conclusions

IT-based interventions (e.g. mobile health applications, wearable devices, and computer systems) can improve self-management in kidney transplant recipients (including clinical and care process outcomes). However, further evaluation studies are required to quantify the impact of IT-based self-management interventions on short- and long-term clinical outcomes as well as health care costs and patients' quality of life.

Organizational Health Literacy: Opportunities for Patient-Centered Care in the Wake of COVID-19

BACKGROUND AND OBJECTIVES

The coronavirus disease-2019 (COVID-19) pandemic is transforming the health care sector. As health care organizations move from crisis mobilization to a new landscape of health and social needs, organizational health literacy offers practical building blocks to provide high-quality, efficient, and meaningful care to patients and their families. Organizational health literacy is defined by the Institute of Medicine as "the degree to which an organization implements policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health."

METHODS

This article synthesizes insights from organizational health literacy in the context of current major health care challenges and toward the goal of innovation in patient-centered care. We first provide a brief overview of the origins and outlines of organizational health literacy research and practice. Second, using an established patient-centered innovation framework, we show how the existing work on organizational health literacy can offer a menu of effective, patient-centered innovative options for care delivery systems to improve systems and outcomes. Finally, we consider the high value of management focusing on organizational health literacy efforts, specifically for patients in health care transitions and in the rapid transformation of care into myriad distance modalities.

RESULTS

This article provides practical guidance for systems and informs decisions around resource allocation and organizational priorities to best meet the needs of patient populations even in the face of financial and workforce disruption.

CONCLUSIONS

Organizational health literacy principles and guidelines provide a road map for promoting patient-centered care even in this time of crisis, change, and transformation. Health system leaders seeking innovative approaches can have access to well-established tool kits, guiding models, and materials toward many organizational health literacy goals across treatment, diagnosis, prevention, education, research, and outreach.

Role of technology in COVID-19 pandemic

Novel Corona Virus is the most recent pandemic, which has struck more than 210 countries and territories all over the world placing states in a perilous position. Enormous research are being done on the virus detection, providing treatments to relief symptoms and developing its vaccine, which, according to an estimate, might take one to two more years. Therefore, WHO has laid stress upon the governments worldwide to guarantee competent surveillance and identification of infected individuals to control severity of COVID-19 pandemic effects. Latest technologies, such as IoMT, drones, robots, UVs, GPS, and Bluetooth, can play a primary role in such circumstances to mitigate the impact of COVID-19 outbreak. Therefore, our study highlights numerous technological solutions, which are of great help in controlling disease spread and facing challenges caused by it.

Computational medicine, present and the future: obstetrics and gynecology perspective

Medicine is, in its essence, decision making under uncertainty; the decisions are made about tests to be performed and treatments to be administered. Traditionally, the uncertainty in decision making was handled using expertise collected by individual providers and, more recently, systematic appraisal of research in the form of evidence-based medicine. The traditional approach has been used successfully in medicine for a very long time. However, it has substantial limitations because of the complexity of the system of the human body and healthcare. The complex systems are a network of highly coupled components intensely interacting with each other. These interactions give those systems redundancy and thus robustness to failure and, at the same time, equifinality, that is, many different causative pathways leading to the same outcome. The equifinality of the complex systems of the human body and healthcare system demand the individualization of medical care, medicine, and medical decision making. Computational models excel in modeling complex systems and, consequently, enabling individualization of medical decision making and medicine. Computational models are theory- or knowledge-based models, data-driven models, or models that combine both approaches. Data are essential, although to a different degree, for computational models to successfully represent complex systems. The individualized decision making, made possible by the computational modeling of complex systems, has the potential to revolutionize the entire spectrum of medicine from individual patient care to policymaking. This approach allows applying tests and treatments to individuals who receive a net benefit from them, for whom benefits outweigh the risk, rather than treating all individuals in a population because, on average, the population benefits. Thus, the computational modeling-enabled individualization of medical decision making has the potential to both improve health outcomes and decrease the costs of healthcare.

Wearable Devices for Ambulatory Cardiac Monitoring: JACC State-of-the-Art Review

Ambulatory monitoring devices are enabling a new paradigm of health care by collecting and analyzing long-term data for reliable diagnostics. These devices are becoming increasingly popular for continuous monitoring of cardiac diseases. Recent advancements have enabled solutions that are both affordable and reliable, allowing monitoring of vulnerable populations from the comfort of their homes. They provide early detection of important physiological events, leading to timely alerts for seeking medical attention. In this review, the authors aim to summarize the recent developments in the area of ambulatory and remote monitoring solutions for cardiac diagnostics. The authors cover solutions based on wearable devices, smartphones, and other ambulatory sensors. The authors also present an overview of the limitations of current technologies, their effectiveness, and their adoption in the general population, and discuss some of the recently proposed methods to overcome these challenges. Lastly, we discuss the possibilities opened by this new paradigm, for the future of health care and personalized medicine.

Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic

To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.

The Collaborative Aging Research Using Technology Initiative: An Open, Sharable, Technology-Agnostic Platform for the Research Community

Introduction

Future digital health research hinges on methodologies to conduct remote clinical assessments and in-home monitoring. The Collaborative Aging Research Using Technology (CART) initiative was introduced to establish a digital technology research platform that could widely assess activity in the homes of diverse cohorts of older adults and detect meaningful change longitudinally. This paper reports on the built end-to-end design of the CART platform, its functionality, and the resulting research capabilities.

Methods

CART platform development followed a principled design process aiming for scalability, use case flexibility, longevity, and data privacy protection while allowing sharability. The platform, comprising ambient technology, wearables, and other sensors, was deployed in participants' homes to provide continuous, long-term (months to years), and ecologically valid data. Data gathered from CART homes were sent securely to a research server for analysis and future data sharing.

Results

The CART system was created, iteratively tested, and deployed to 232 homes representing four diverse cohorts (African American, Latinx, low-income, and predominantly rural-residing veterans) of older adults (n = 301) across the USA. Multiple measurements of wellness such as cognition (e.g., mean daily computer use time = 160-169 min), physical mobility (e.g., mean daily transitions between rooms = 96-155), sleep (e.g., mean nightly sleep duration = 6.3-7.4 h), and level of social engagement (e.g., reports of overnight visitors = 15-45%) were collected across cohorts.

Conclusion

The CART initiative resulted in a minimally obtrusive digital health-enabled system that met the design principles while allowing for data capture over extended periods and can be widely used by the research community. The ability to monitor and manage health digitally within the homes of older adults is an important alternative to in-person assessments in many research contexts. Further advances will come with wider, shared use of the CART system in additional settings, within different disease contexts, and by diverse research teams.

Remote Patient Monitoring Program for Hospital Discharged COVID-19 Patients

OBJECTIVE

We deployed a Remote Patient Monitoring (RPM) program to monitor patients with coronavirus disease 2019 (COVID-19) upon hospital discharge. We describe the patient characteristics, program characteristics, and clinical outcomes of patients in our RPM program.

METHODS

We enrolled COVID-19 patients being discharged home from the hospital. Enrolled patients had an app, and were provided with a pulse oximeter and thermometer. Patients self-reported symptoms, O₂ saturation, and temperature daily. Abnormal symptoms or vital signs were flagged and assessed by a pool of nurses. Descriptive statistics were used to describe patient and program characteristics. A mixed-effects logistic regression model was used to determine the odds of a combined endpoint of emergency department (ED) or hospital readmission.

RESULTS

A total of 295 patients were referred for RPM from five participating hospitals, and 225 patients were enrolled. A majority of enrolled patients (66%) completed the monitoring period without triggering an abnormal alert. Enrollment was associated with a decreased odds of ED or hospital readmission (adjusted odds ratio: 0.54; 95% confidence interval: 0.3-0.97; p = 0.039). Referral without enrollment was not associated with a reduced odds of ED or hospital readmission.

CONCLUSION

RPM for COVID-19 provides a mechanism to monitor patients in their home environment and reduce hospital utilization. Our work suggests that RPM reduces readmissions for patients with COVID-19 and provides scalable remote monitoring capabilities upon hospital discharge. RPM for postdischarge patients with COVID-19 was associated with a decreased risk of readmission to the ED or hospital, and provided a scalable mechanism to monitor patients in their home environment.

Enabling Remote Patient Monitoring Through the Use of Smart Thermostat Data in Canada: Exploratory Study

Background

Advances in technology have made the development of remote patient monitoring possible in recent years. However, there is still room for innovation in the types of technologies that are developed, used, and implemented. The smart thermostat solutions provided in this study can expand beyond typically defined features and be used for improved holistic health monitoring purposes.

Objective

The aim of this study is to validate the hypothesis that remote motion sensors could be used to quantify and track an individual’s movements around the house. On the basis of our results, the next step would be to determine if using remote motion sensors could be a novel data collection method compared with the national census-level surveys administered by governmental bodies. The results will be used to inform a more extensive implementation study of similar smart home technologies to gather data for machine learning algorithms and to build upon pattern recognition and comprehensive health monitoring.

Methods

We conducted a pilot study with a sample size of 8 to validate the use of remote motion sensors to quantify movement in the house. A large database containing data from smart home thermostats was analyzed to compare the following indicators; sleep, physical activity, and sedentary behavior. These indicators were developed by the Public Health Agency of Canada and are collected through traditional survey methods.

Results

The results showed a significant Spearman rank correlation coefficient of 0.8 (P<.001), which indicates a positive linear association between the total number of sensors activated and the total number of indoor steps traveled by study participants. In addition, the indicators of sleep, physical activity, and sedentary behavior were all found to be highly comparable with those attained by the Public Health Agency of Canada.

Conclusions

The findings demonstrate that remote motion sensors data from a smart thermostat solution are a viable option when compared with traditional survey data collection methods for health data collection and are also a form of zero-effort technology that can be used to monitor the activity levels and nature of activity of occupants within the home.

The Role of Heart Rate Variability in the Future of Remote Digital Biomarkers

Heart rate variability (HRV) offers insights into humoral, neural and neurovisceral processes in health and disorders of brain, body and behavior but has yet to be fully potentiated in the digital age. Remote measurement technologies (RMTs), such as, smartphones, wearable sensors or home-based devices, can passively capture HRV as a nested parameter of neurovisceral integration and health during everyday life, providing insights across different contexts, such as activities of daily living, therapeutic interventions and behavioral tasks, to compliment ongoing clinical care. Many RMTs measure HRV, even consumer wearables and smartphones, which can be deployed as wearable sensors or digital cameras using photoplethysmography. RMTs that measure HRV provide the opportunity to identify digital biomarkers indicative of changes in health or disease status in disorders where neurovisceral processes are compromised. RMT-based HRV therefore has potential as an adjunct digital biomarker in neurovisceral digital phenotyping that can add continuously updated, objective and relevant data to existing clinical methodologies, aiding the evolution of current "diagnose and treat" care models to a more proactive and holistic approach that pairs established markers with advances in remote digital technology.

Advanced Symptom Management System for Patients with Malignant Pleural Mesothelioma (ASyMSmeso): Mixed Methods Study

BACKGROUND

Patients with malignant pleural mesothelioma (MPM) have a life-limiting illness and short prognosis and experience many debilitating symptoms from early in the illness. Innovations such as remote symptom monitoring are needed to enable patients to maintain wellbeing and manage symptoms in a proactive and timely manner. The Advanced Symptom Management System (ASyMS) has been successfully used to monitor symptoms associated with cancer.

OBJECTIVE

This study aimed to determine the feasibility and acceptability of using an ASyMS adapted for use by patients with MPM, called ASyMSmeso, enabling the remote monitoring of symptoms using a smartphone.

METHODS

This was a convergent mixed methods study using patient-reported outcome measures (PROMs) at key time points over a period of 2-3 months with 18 patients. The Sheffield Profile for Assessment and Referral for Care (SPARC), Technology Acceptance Model (TAM) measure for eHealth, and Lung Cancer Symptom Scale-Mesothelioma (LCSS-Meso) were the PROMs used in the study. Patients were also asked to complete a daily symptom questionnaire on a smartphone throughout the study. At the end of the study, semistructured interviews with 11 health professionals, 8 patients, and 3 carers were conducted to collect their experience with using ASyMSmeso.

RESULTS

Eighteen patients with MPM agreed to participate in the study (33.3% response rate). The completion rates of study PROMs were high (97.2%-100%), and completion rates of the daily symptom questionnaire were also high, at 88.5%. There were no significant changes in quality of life, as measured by LCSS-Meso. There were statistically significant improvements in the SPARC psychological need domain (P=.049) and in the "Usefulness" domain of the TAM (P=.022). End-of-study interviews identified that both patients and clinicians found the system quick and easy to use. For patients, in particular, the system provided reassurance about symptom experience and the feeling of being listened to. The clinicians largely viewed the system as feasible and acceptable, and areas that were mentioned included the early management of symptoms and connectivity between patients and clinicians, leading to enhanced communication.

CONCLUSIONS

This study demonstrates that remote monitoring and management of symptoms of people with MPM using a mobile phone are feasible and acceptable. The evidence supports future trials using remote symptom monitoring to support patients with MPM at home.

The Use of Wearables in Clinical Trials During Cancer Treatment: Systematic Review

Background

Interest in the use of wearables in medical care is increasing. Wearables can be used to monitor different variables, such as vital signs and physical activity. A crucial point for using wearables in oncology is if patients already under the burden of severe disease and oncological treatment can accept and adhere to the device. At present, there are no specific recommendations for the use of wearables in oncology, and little research has examined the purpose of using wearables in oncology.

Objective

The purpose of this review is to explore the use of wearables in clinical trials during cancer treatment, with a special focus on adherence.

Methods

PubMed and EMBASE databases were searched prior and up to October 3, 2019, with no limitation in the date of publication. The search strategy was aimed at studies using wearables for monitoring adult patients with cancer during active antineoplastic treatment. Studies were screened independently by 2 reviewers by title and abstract, selected for inclusion and exclusion, and the full-text was assessed for eligibility. Data on study design, type of wearable used, primary outcome, adherence, and device outcome were extracted. Results were presented descriptively.

Results

Our systematic search identified 1269 studies, of which 25 studies met our inclusion criteria. The types of cancer represented in the studies were breast (7/25), gastrointestinal (4/25), lung (4/25), and gynecologic (1/25); 9 studies had multiple types of cancer. Oncologic treatment was primarily chemotherapy (17/25). The study-type distribution was pilot/feasibility study (12/25), observational study (10/25), and randomized controlled trial (3/25). The median sample size was 40 patients (range 7-180). All studies used a wearable with an accelerometer. Adherence varied across studies, from 60%-100% for patients wearing the wearable/evaluable sensor data and 45%-94% for evaluable days, but was differently measured and reported. Of the 25 studies, the most frequent duration for planned monitoring with a wearable was 8-30 days (13/25). Topics for wearable outcomes were physical activity (19/25), circadian rhythm (8/25), sleep (6/25), and skin temperature (1/25). Patient-reported outcomes (PRO) were used in 17 studies; of the 17 PRO studies, only 9 studies reported correlations between the wearable outcome and the PRO.

Conclusions

We found that definitions of outcome measures and adherence varied across studies, and limited consensus among studies existed on which variables to monitor during treatment. Less heterogeneity, better consensus in terms of the use of wearables, and established standards for the definitions of wearable outcomes and adherence would improve comparisons of outcomes from studies using wearables. Adherence, and the definition of such, seems crucial to conclude on data from wearable studies in oncology. Additionally, research using advanced wearable devices and active use of the data are encouraged to further explore the potential of wearables in oncology during treatment. Particularly, randomized clinical studies are warranted to create consensus on when and how to implement in oncological practice.

Remote symptom monitoring integrated into electronic health records: A systematic review

OBJECTIVE

People with long-term conditions require serial clinical assessments. Digital patient-reported symptoms collected between visits can inform these, especially if integrated into electronic health records (EHRs) and clinical workflows. This systematic review identified and summarized EHR-integrated systems to remotely collect patient-reported symptoms and examined their anticipated and realized benefits in long-term conditions.

MATERIALS AND METHODS

We searched Medline, Web of Science, and Embase. Inclusion criteria were symptom reporting systems in adults with long-term conditions; data integrated into the EHR; data collection outside of clinic; data used in clinical care. We synthesized data thematically. Benefits were assessed against a list of outcome indicators. We critically appraised studies using the Mixed Methods Appraisal Tool.

RESULTS

We included 12 studies representing 10 systems. Seven were in oncology. Systems were technically and functionally heterogeneous, with the majority being fully integrated (data viewable in the EHR). Half of the systems enabled regular symptom tracking between visits. We identified 3 symptom report-guided clinical workflows: Consultation-only (data used during consultation, n = 5), alert-based (real-time alerts for providers, n = 4) and patient-initiated visits (n = 1). Few author-described anticipated benefits, primarily to improve communication and resultant health outcomes, were realized based on the study results, and were only supported by evidence from early-stage qualitative studies. Studies were primarily feasibility and pilot studies of acceptable quality.

DISCUSSION AND CONCLUSIONS

EHR-integrated remote symptom monitoring is possible, but there are few published efforts to inform development of these systems. Currently there is limited evidence that this improves care and outcomes, warranting future robust, quantitative studies of efficacy and effectiveness.

Day and night comfort and stability on the body of four wearable devices for seizure detection: A direct user-experience

PURPOSE

Wearable devices are progressively becoming an available tool for continuous seizure detection. Motivation to use wearables is not only driven by the accuracy and reliability of the performance but also by the form factor, comfort, and stability on the body. We collected direct feedback and device placement-related issues experienced by a cohort of people with epilepsy (PWE) to investigate to what extent available devices are nonintrusive, comfortable, and stable on the body.

METHODS

Four models of wearable devices (E4 wrist band, Everion upper arm band, IMEC upper arm band, and Epilog scalp patch electrodes) were worn by PWE who were admitted to two epilepsy monitoring units (EMUs) in London and Freiburg. Participants were periodically reviewed, and accidental displacements of the devices were annotated. Participants' experience was assessed using the Technology Acceptance Model Fast Form (TAM-FF) plus two additional questions on comfort. A thematic analysis was also performed on the free text of the questionnaire.

RESULTS

One hundred and fifteen participants were enrolled. The devices had a good stability on the body including during seizures. Overall, all the devices were considered comfortable to be worn, including during sleep. However, devices containing wires and patches demonstrated a lesser degree of stability on the body and were judged less positively. Participants age was correlated with TAM-FF mean scores, and older participants judged the devices less favorably compared with younger participants.

DISCUSSION

Removable but securely fitted, wireless, and comfortable designs were considered more appropriate for a continuous monitoring aimed at seizure detection. Some caution may be required when patch electrodes and electrodes glued to the skin or to the scalp are used, as those evaluated in the present study demonstrated a lower level of acceptability and a lower degree of stability to the body, especially at night. These factors could limit a continuous monitoring decreasing the device performance for nocturnal, unsupervised seizures which are at higher risk of lethality.

A Smartphone App With a Digital Care Pathway for Patients Undergoing Spine Surgery: Development and Feasibility Study

BACKGROUND

There is a great unmet clinical need to provide patients undergoing spinal surgery and their caregivers with ongoing, high-quality care before and after surgery in an efficiency-focused health care environment.

OBJECTIVE

The objective of this study is to design, develop, and evaluate the acceptability and feasibility of a novel planning-, outcomes-, and analytics-based smartphone app called ManageMySurgery (MMS) in patients undergoing elective spine surgery (MMS-Spine).

METHODS

The development process of the MMS app was conducted over 2 sequential stages: (1) an evidence-based intervention design with refinement from surgeon and patient feedback and (2) feasibility testing in a clinical pilot study. We developed a novel, mobile-based, Health Insurance Portability and Accountability Act-compliant platform for interventional and surgical procedures. It is a patient-centric mobile health app that streamlines patients' interactions with their care team. MMS divides the patient journey into phases, making it feasible to provide customized care pathways that meet patients' unique needs. Patient-reported outcomes are easily collected and conform to the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) standard.

RESULTS

We tested the feasibility of the MMS-Spine app with patients undergoing elective spine surgery at a large academic health system. A total of 47 patients undergoing elective spine surgery (26 cervical spine and 21 lumbar spine surgeries) downloaded and used MMS-Spine to navigate their surgical journey, quantify their baseline characteristics and postoperative outcomes, and provide feedback on the utility of the app in preparing for and recovering from their spinal surgery. The median age was 59.0 (range 33-77) years, 22 of the 47 patients (47%) were women, and 26 patients (55%) had commercial insurance. Of the 47 patients, a total of 33 (70%) logged in on an iOS device, 11 (23%) on an Android device, and 3 (6%) on a computer or tablet. A total of 17 of the 47 patients (36%) added a caregiver, of which 7 (41%) logged in. The median number of sign-ins was 2. A total of 38 of 47 patients (81%) completed their baseline preoperative PROMIS-29 outcomes, and 14 patients (30%) completed at least one PROMIS-29 survey during the postoperative period. Of the 24 patients who completed the MMS survey, 21 (88%) said it was helpful during preparation for their procedure, 16 (67%) said it was helpful during the postoperative period, and 23 (96%) said that they would recommend MMS to a friend or family member.

CONCLUSIONS

We used a patient-centered approach based on proven behavior change techniques to develop a comprehensive smartphone app for patients undergoing elective spine surgery. The optimized version of the app is ready for formal testing in a larger randomized clinical study to establish its cost-effectiveness and effect on patients' self-management skills and long-term outcomes.

Feasibility of remote digital monitoring using wireless Bluetooth monitors, the Smart Angel™ app and an original web platform for patients following outpatient surgery: a prospective observational pilot study

Background

Remote monitoring of mean arterial blood pressure (MAP), heart rate (HR) or oxygen saturation (SpO₂) remains a challenge in outpatient surgery. This study evaluates a new digital technology (Smart Angel™) for remotely monitoring hemodynamic data in real time: data transmitted from the patient’s home to a central server, using a dedicated web-based software package.

Methods

Adults scheduled for elective outpatient surgery were prospectively enrolled. In the first 5 postoperative days, patients completed a self-report questionnaire (pain, comfort, nausea, vomiting) and recorded SpO₂, HR and MAP via two wireless Bluetooth monitors connected to a 4G tablet to transmit the data to a website, in real time, using Smart Angel™ software. Before transmission to the website, these data were also self-reported by the patient on a paper form. The primary outcome was the proportion of variables (self-monitored physiological data + questionnaire scores) correctly transmitted to the hospital via the system compared with the paper version.

On Day 5, a system usability scale survey (SUS score 1–100) was also attributed.

Results

From May 2018 to September 2018, data were available for 29 out of 30 patients enrolled (1 patient was not discharged from hospital after surgery). The remote monitoring technology recorded 2038 data items (62%) compared with 2656 (82%) items recorded on the paper form (p = 0.001). The most common errors with the remote technology were software malfunctioning when starting the MAP monitor and malfunctioning between the tablet and the Bluetooth monitor. No serious adverse events were noted. The SUS score for the system was 85 (68–93) for 26 patients.

Conclusion

This work evaluates the ability of a pilot system for monitoring remote physiological data using digital technology after ambulatory surgery and highlights the digital limitations of this technology. Technological improvements are required to reduce malfunctioning (4G access, transmission between apps).

Trial registration

ClinicalTrials.gov (NCT03464721) (March 8, 2018).

Building on the momentum: Sustaining telehealth beyond COVID-19

The current coronavirus pandemic (COVID-19) has resulted in tremendous growth in telehealth services in Australia and around the world. The rapid uptake of telehealth has mainly been due to necessity – following social distancing requirements and the need to reduce the risk of transmission. Although telehealth has been available for many decades, the COVID-19 experience has resulted in heightened awareness of telehealth amongst health service providers, patients and society overall. With increased telehealth uptake in many jurisdictions during the pandemic, it is timely and important to consider what role telehealth will have post-pandemic. In this article, we highlight five key requirements for the long-term sustainability of telehealth. These include: (a) developing a skilled workforce; (b) empowering consumers; (c) reforming funding; (d) improving the digital ecosystems; and (e) integrating telehealth into routine care.

Gold-Nanohybrid Biosensors for Analyzing Blood Circulating Clinical Biomacromolecules: Current Trend toward Future Remote Digital Monitoring

Mortality level is worsening the situation worldwide thru blood diseases and greatly jeopardizes the human health with poor diagnostics. Due to the lack of successful generation of early diagnosis, the survival rate is currently lower. To overcome the present hurdle, new diagnostic methods have been choreographed for blood disease biomarkers analyses with the conjunction of ultra-small ideal gold nanohybrids. Gold-hybrids hold varieties of unique features, such as high biocompatibility, increased surface-to-volume ratio, less-toxicity, ease in electron transfer and have a greater localized surface plasmon resonance. Gold-nanocomposites can be physically hybrid on the sensor surface and functionalize with the biomolecules using appropriate chemical conjugations. Revolutionizing biosensor platform can be prominently linked for the nanocomposite applications in the current research on medical diagnosis. This review encloses the new developments in diagnosing blood biomarkers by utilizing the gold-nanohybrids. Further, the current state-of-the-art and the future envision with digital monitoring for facile telediagnosis were narrated.

A COVID-19-Based Modified Epidemiological Model and Technological Approaches to Help Vulnerable Individuals Emerge from the Lockdown in the UK

COVID-19 has shown a relatively low case fatality rate in young healthy individuals, with the majority of this group being asymptomatic or having mild symptoms. However, the severity of the disease among the elderly as well as in individuals with underlying health conditions has caused significant mortality rates worldwide. Understanding this variance amongst different sectors of society and modelling this will enable the different levels of risk to be determined to enable strategies to be applied to different groups. Long-established compartmental epidemiological models like SIR and SEIR do not account for the variability encountered in the severity of the SARS-CoV-2 disease across different population groups. The objective of this study is to investigate how a reduction in the exposure of vulnerable individuals to COVID-19 can minimise the number of deaths caused by the disease, using the UK as a case study. To overcome the limitation of long-established compartmental epidemiological models, it is proposed that a modified model, namely SEIR-v, through which the population is separated into two groups regarding their vulnerability to SARS-CoV-2 is applied. This enables the analysis of the spread of the epidemic when different contention measures are applied to different groups in society regarding their vulnerability to the disease. A Monte Carlo simulation (100,000 runs) along the proposed SEIR-v model is used to study the number of deaths which could be avoided as a function of the decrease in the exposure of vulnerable individuals to the disease. The results indicate a large number of deaths could be avoided by a slight realistic decrease in the exposure of vulnerable groups to the disease. The mean values across the simulations indicate 3681 and 7460 lives could be saved when such exposure is reduced by 10% and 20% respectively. From the encouraging results of the modelling a number of mechanisms are proposed to limit the exposure of vulnerable individuals to the disease. One option could be the provision of a wristband to vulnerable people and those without a smartphone and contact-tracing app, filling the gap created by systems relying on smartphone apps only. By combining very dense contact tracing data from smartphone apps and wristband signals with information about infection status and symptoms, vulnerable people can be protected and kept safer.

Telehealth Training Is Essential to Care for Underserved Populations: a Medical Student Perspective

Telehealth is an area of medicine which has magnified the ability to treat patients remotely. Presently the education of medical professionals pertaining to the value, use, and implementation of telehealth is not adequate to harness the potential of available technologies. Patients engaging in telehealth experience time and cost savings, improved disease management through remote monitoring programs, and high-quality care regardless of geographic location. Despite this, medical education has been slow to evolve. It is therefore imperative that medical curricula incorporate training for this rapidly advancing mode of healthcare delivery to enable students to best care for their future patient population.

Health Care Professionals' Views on Using Remote Measurement Technology in Managing Central Nervous System Disorders: Qualitative Interview Study

Background

Remote measurement technologies (RMT) can be used to collect data on a variety of bio-behavioral variables, which may improve the care of patients with central nervous system disorders. Although various studies have explored their potential, prior work has highlighted a knowledge gap in health care professionals’ (HCPs) perceptions of the value of RMT in clinical practice.

Objective

This study aims to understand HCPs’ perspectives on using RMT in health care practice for the care of patients with depression, epilepsy, or multiple sclerosis (MS).

Methods

Semistructured interviews were conducted with 26 multidisciplinary primary and secondary care HCPs who care for patients with epilepsy, depression, or MS. Interviews were transcribed verbatim and analyzed using thematic analysis.

Results

A total of 8 main themes emerged from the analysis: (1) potential clinical value of RMT data; (2) when to use RMT in care pathways; (3) roles of health care staff who may use RMT data; (4) presentation and accessibility of data; (5) obstacles to successful use of RMT; (6) limits to the role of RMT; (7) empowering patients; and (8) considerations around alert-based systems.

Conclusions

RMT could add value to the system of care for patients with central nervous system disorders by providing clinicians with graphic summaries of data in the patient record. Barriers of both technical and human nature should be considered when using these technologies, as should the limits to the benefits they can offer.

Exploring how virtual primary care visits affect patient burden of treatment

BACKGROUND

There is growing emphasis on the role of digital solutions in supporting chronic disease management. This has the potential to increase the burden patients experience in managing their health by offloading care from the health system to patients. This paper explores the effects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden.

METHODS

This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients' feedback on their experience to the framework on patient burden.

MAIN FINDINGS

Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by improving continuity of care, experience of care, and providing some cost savings.

CONCLUSIONS

Virtual visits reduced overall patient burden of treatment by decreasing the required patient effort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of benefit. There is need for further research on the generalizability of the findings herein, particularly for high-needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations.

Wearable Monitoring and Interpretable Machine Learning Can Objectively Track Progression in Patients during Cardiac Rehabilitation

Cardiovascular diseases (CVD) are often characterized by their multifactorial complexity. This makes remote monitoring and ambulatory cardiac rehabilitation (CR) therapy challenging. Current wearable multimodal devices enable remote monitoring. Machine learning (ML) and artificial intelligence (AI) can help in tackling multifaceted datasets. However, for clinical acceptance, easy interpretability of the AI models is crucial. The goal of the present study was to investigate whether a multi-parameter sensor could be used during a standardized activity test to interpret functional capacity in the longitudinal follow-up of CR patients. A total of 129 patients were followed for 3 months during CR using 6-min walking tests (6MWT) equipped with a wearable ECG and accelerometer device. Functional capacity was assessed based on 6MWT distance (6MWD). Linear and nonlinear interpretable models were explored to predict 6MWD. The t-distributed stochastic neighboring embedding (t-SNE) technique was exploited to embed and visualize high dimensional data. The performance of support vector machine (SVM) models, combining different features and using different kernel types, to predict functional capacity was evaluated. The SVM model, using chronotropic response and effort as input features, showed a mean absolute error of 42.8 m (±36.8 m). The 3D-maps derived using the t-SNE technique visualized the relationship between sensor-derived biomarkers and functional capacity, which enables tracking of the evolution of patients throughout the CR program. The current study showed that wearable monitoring combined with interpretable ML can objectively track clinical progression in a CR population. These results pave the road towards ambulatory CR.

Available Technologies, Applications and Benefits of Teleorthodontics. A Literature Review and Possible Applications during the COVID-19 Pandemic

Background: COVID-2019 spread rapidly throughout the world from China. This infection is highly contagiousness, has a high morbidity, and is capable of evolving into a potentially lethal form of interstitial pneumonia. Numerous countries shut-down various activities that were considered “not essential.” Dental treatment was in this category and, at the time of writing, only non-deferrable emergencies are still allowed in many countries. Therefore, follow-up visits of ongoing active therapies (e.g., orthodontic treatment) must be handled taking special precautions. This literature review aims at reducing in-office appointments by providing an overview of the technologies available and their reliability in the long-distance monitoring of patients, i.e., teledentistry. Methods: A literature review was made according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. Randomized clinical trials, cross sectional, observational, and case-control studies were evaluated with the Mixed Methods Appraisal Tool for quality assessment and study limitations. Results: A primary search found 80 articles, 69/80 were excluded as non-relevant on the basis of: the abstract, title, study design, bias, and/or lack of relevance. Twelve articles were included in the qualitative analysis. Conclusions: Teleorthodontics can manage most emergencies, reassuring and following patients remotely. The aim set by dental teleassistance was met as it reduced patients’ office visits whilst maintaining regular monitoring, without compromising the results. Although our preliminary findings should be further investigated to objectively evaluate the efficacy, cost-effectiveness, and long-term results, we are confident that teleassistance in orthodontics will have a role to play in the near future.

A Smartphone App With a Digital Care Pathway for Patients Undergoing Spine Surgery: Development and Feasibility Study (Preprint).. [DOI: 10.2196/preprints.21138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

There is a great unmet clinical need to provide patients undergoing spinal surgery and their caregivers with ongoing, high-quality care before and after surgery in an efficiency-focused health care environment.

OBJECTIVE

The objective of this study is to design, develop, and evaluate the acceptability and feasibility of a novel planning-, outcomes-, and analytics-based smartphone app called ManageMySurgery (MMS) in patients undergoing elective spine surgery (MMS-Spine).

METHODS

The development process of the MMS app was conducted over 2 sequential stages: (1) an evidence-based intervention design with refinement from surgeon and patient feedback and (2) feasibility testing in a clinical pilot study. We developed a novel, mobile-based, Health Insurance Portability and Accountability Act–compliant platform for interventional and surgical procedures. It is a patient-centric mobile health app that streamlines patients’ interactions with their care team. MMS divides the patient journey into phases, making it feasible to provide customized care pathways that meet patients’ unique needs. Patient-reported outcomes are easily collected and conform to the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) standard.

RESULTS

We tested the feasibility of the MMS-Spine app with patients undergoing elective spine surgery at a large academic health system. A total of 47 patients undergoing elective spine surgery (26 cervical spine and 21 lumbar spine surgeries) downloaded and used MMS-Spine to navigate their surgical journey, quantify their baseline characteristics and postoperative outcomes, and provide feedback on the utility of the app in preparing for and recovering from their spinal surgery. The median age was 59.0 (range 33-77) years, 22 of the 47 patients (47%) were women, and 26 patients (55%) had commercial insurance. Of the 47 patients, a total of 33 (70%) logged in on an iOS device, 11 (23%) on an Android device, and 3 (6%) on a computer or tablet. A total of 17 of the 47 patients (36%) added a caregiver, of which 7 (41%) logged in. The median number of sign-ins was 2. A total of 38 of 47 patients (81%) completed their baseline preoperative PROMIS-29 outcomes, and 14 patients (30%) completed at least one PROMIS-29 survey during the postoperative period. Of the 24 patients who completed the MMS survey, 21 (88%) said it was helpful during preparation for their procedure, 16 (67%) said it was helpful during the postoperative period, and 23 (96%) said that they would recommend MMS to a friend or family member.

CONCLUSIONS

We used a patient-centered approach based on proven behavior change techniques to develop a comprehensive smartphone app for patients undergoing elective spine surgery. The optimized version of the app is ready for formal testing in a larger randomized clinical study to establish its cost-effectiveness and effect on patients’ self-management skills and long-term outcomes.

Postoperative Remote Monitoring with a Transcutaneous Biosensing Patch: Preliminary Evaluation of Data Collection

Introduction. Connected systems transmitting vital parameters could well represent a tool to shorten postoperative hospital stay while providing continuous remote patient monitoring and potentially detect the onset of complications. Our aim was to analyze the functionality of a transcutaneous biosensing data collection patch in morbidly obese patients. Materials and Methods. An adhesive patch (The HealthPatch MD™) was applied to patients' chests postoperatively. The patch was connected to a tablet via a bluetooth network to collect the heart rate, respiratory rate, skin temperature, and posture recognition data. The tablet conveyed data to a secure health data central server by means of a WiFi or 3G/4G transmission. Data were stored in a digital health platform to which health care professionals could connect. The evaluation focused on the volume, quality, and security of data transmission. A pilot phase involved 10 patients. Thirty-three additional patients undergoing bariatric surgery were included in the experimental phase. Results. The mean length of stay was 2.28 days (range: 2-5 days). The mean time of patch application was 51 ± 25.2 hours per patient (range: 19-139 hours), totalizing 1,683 hours of recording for the 33 patients included. During this time, a total of 7.562.531 data measurement points were collected and transmitted to the e-health platform via the patch. Two total disconnections and two partial disconnections were observed. The acquisition of patient postural data was unreliable. Conclusions. Connected telemetry for remote postoperative monitoring is promising. However, it is still limited by data transmission problems.

Assessment of remote patient monitoring (RPM) systems for patients with type 2 diabetes: a systematic review and meta-analysis

INTRODUCTION

The objective of this study is to conduct an assessment of Remote Patient Monitoring (RPM) systems compared to usual care for controlling glycosylated hemoglobin in type 2 diabetes.

METHODS

The study was a systematic review with meta-analysis and meta-regression. A systematic search was performed via the most important electronic databases of medical resources, such as PubMed, Scopus and Cochrane library. The main outcome was HbA1C. The heterogeneity sources were examined using Chi-square (Q) and I2 tests. Meta-analyses were done using Stata version 11 software. Statistical significance was defined as P < 0.05. Random effects model was used in meta-analysis, and the heterogeneity more than 50% was considered as significant.

RESULTS

The results of the systematic review and meta-analysis indicated that the effect size index (Difference of Pre-test/Post-test Control Design-2nd method "using pooled pretest SD" (DPPC2)) among users of RPM for type 2 diabetic patients was -0.32 with a confidence interval of 95% (from -0.45 to -0.19) as compared to the control group. The current study declared a vital role of RPM technology in reduction of hemoglobin glycogen levels. The results of the subgroup analysis showed that RPM is more effective for patients who are residents of cities, having intervention lengths less than 6 months, getting the orders from the physician and using the websites as their intervention type.

CONCLUSION

The current study indicted the efficacy of RPM in reducing HbA1c among type 2 diabetic patients, which could be a base for policymakers to decide on the introduction of this technology in Iran.

Remote Patient Monitoring Technologies for Predicting Chronic Obstructive Pulmonary Disease Exacerbations: Review and Comparison

Background

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death by disease worldwide and has a 30-day readmission rate of 22.6%. In 2015, COPD was added to the Medicare Hospital Readmission Reductions Program.

Objective

The objective of this paper was to survey the current medical technologies for remote patient monitoring (RPM) tools that forecast COPD exacerbations in order to reduce COPD readmissions.

Methods

We searched literature and digital health news to find commercially available RPM devices focused on predicting COPD exacerbations. These technologies were reviewed and compared according to four criteria: forecasting ability, cost, ease of use, and appearance. A rating system was developed to facilitate the evaluation process.

Results

As of June 2019, a list of handheld and hands-free devices was compiled. We compared features and found substantial variations. Devices that ranked higher on all criteria tended to have a high or unlisted price. Commonly mass-marketed devices like the pulse oximeter and spirometer surprisingly fulfilled the least criteria.

Conclusions

The COPD RPM technologies with most technological promise and compatibility with daily living appear to have high or unlisted prices. Consumers and providers need better access to product information to make informed decisions.

How to Design a Remote Patient Monitoring System? A French Case Study

BACKGROUND

Remote Patient Monitoring Systems (RPMS) based on e-health, Nurse Navigators (NNs) and patient engagement can improve patient follow-up and have a positive impact on quality of care (by limiting adverse events) and costs (by reducing readmissions). However, the extent of this impact depends on effective implementation which is often restricted. This is partly due to the lack of attention paid to the RPMS design phase prior to implementation. The content of the RPMS can be carefully designed at this stage and various obstacles anticipated. Our aim was to report on an RPMS design case to provide insights into the methodology required in order to manage this phase.

METHODS

This study was carried out at Gustave Roussy, a comprehensive cancer centre, in France. A multidisciplinary team coordinated the CAPRI RPMS design process (2013-2015) that later produced positive outcomes. Data were collected during eight studies conducted according to the Medical Research Council (MRC) framework. This project was approved by the French National Data Protection Authorities.

RESULTS

Based on the study results, the multidisciplinary team defined strategies for resolving obstacles prior to the implementation of CAPRI. Consequently, the final CAPRI design includes a web app with two interfaces (patient and health care professionals) and two NNs. The NNs provide regular follow-up via telephone or email to manage patients' symptoms and toxicity, treatment compliance and care packages. Patients contact the NNs via a secure messaging system. Eighty clinical decision support tools enable NNs to prioritise and decide on the course of action to be taken.

CONCLUSION

In our experience, the RPMS design process and, more generally, that of any complex intervention programme, is an important phase that requires a sound methodological basis. This study is also consistent with the notion that an RPMS is more than a technological innovation. This is indeed an organizational innovation, and principles identified during the design phase can help in the effective use of a RPMS (e.g. locating NNs if possible within the care organization; recruiting NNs with clinical and managerial skills; defining algorithms for clinical decision support tools for assessment, but also for patient decision and orientation).