A preliminary study of a cloud-computing model for chronic illness self-care support in an underdeveloped country

Knowledge, attitude, and practice of artificial intelligence applications in medicine among physicians in Sudan: a national cross-sectional survey

Background and aims

Artificial intelligence (AI) has emerged as a rapidly developing tool within the medical landscape, globally aiding in diagnosis and healthcare management. However, its integration within healthcare systems remains varied across different regions. In Sudan, there exists a burgeoning interest in AI potential applications within medicine. This study aims to evaluate the knowledge, attitudes, and practices of AI applications in medicine among physicians in Sudan.

Methods

The authors conducted a web-based survey cross-sectional analytical study using an online questionnaire-based survey regarding demographic details, knowledge, attitudes, and practice of AI distributing through various e-mail listings and social media platforms. A sample of 825 Physicians including doctors in Sudan with different ranks and specialties were selected using the convenient non-probability sampling technique.

Result

Out of 825 Physicians, 666 (80.7%) of Physicians have previous knowledge about AI. However, only a small number 123 (14.9%) were taught about AI during their time in medical school, even fewer, just 120 (14.5%) had AI-related lessons in their training program. Regarding attitude, 675 (81.8%) agree that AI is very important in medicine, almost the same number, 681 (82.6%) support the idea of teaching AI in medical schools. Practically, 535 (64.8%) of doctors, think that should get special training in using AI tools in healthcare. Excitingly 651 (78.9%) of physicians are interested in working with AI in future. Based on different ranks of doctors toward AI; Medical Officers exhibited the highest proportion at (32.7%) of knowledge and understanding of AI concepts, followed by House Officers at (16.7%) (p=0.076); regarding attitude, Medical Officers demonstrated the highest (31.6%) favorable attitude, followed by House Officers at (17.5%) (p=0.229); In practice also, Medical Officer showed the highest portion (28.0%) among participants (p=0.129).

Conclusion

While there is a positive attitude and some level of AI practice, there remains a considerable gap in knowledge that needs addressing.

Analysis of Healthy Coping Feedback Messages from Diabetes Mobile Apps: Validation Against an Evidence-Based Framework

BACKGROUND

In this study, we focused on Healthy Coping, a key principle of ADCES7 Self-Care Behaviors^® (ADCES7^®) that enables people with diabetes to achieve health goals for self-care. We aimed to validate Healthy Coping-related feedback messages from diabetes mobile apps against the framework based on behavioral change theories.

METHODS

We searched apps using the search terms: "diabetes," "blood sugar," "glucose," and "mood" from iTunes and Google Play stores. We entered a range of values on 3 Healthy Coping domains: (1) diabetes-related measures including blood glucose, blood pressure, HbA1c, weight, (2) physical exercise/activity, and (3) mood to generate feedback messages. We used a framework by adopting validated behavioral change theory-based models to evaluate the feedback messages against 3 dimensions of timing, intention, and content (feedback purpose and feedback response). The feedback purposes in this study were categorized into 7 purposes; warning, suggestion, self-monitoring, acknowledging, reinforcement, goal setting, and behavior contract.

RESULTS

We identified 1,749 apps from which 156 diabetes mobile apps were eligible and generated 473 feedback messages. The majority of generated feedback messages were related to blood sugar measurement. Only feedback messages on blood sugar under diabetes-related measures and mood domains encompassed all 7 feedback purposes under the content dimension.

CONCLUSIONS

Many feedback messages neither supported Healthy Coping domains nor followed the behavioral theory-based framework. It is important that feedback messages be structured around the dimensions of the behavioral theory-based framework to promote behavior change. Furthermore, our framework had the generalizability that can be used in other clinical areas.

Do mothers pick up a phone? A cross-sectional study on delivery of MCH voice messages in Lagos, Nigeria

Background

Voice messages have been employed as an effective and efficient approach for increasing health service utilization and health promotion in low- and middle-income countries. However, unlike SMS, voice message services require their users to pick up a phone call at its delivery time. Furthermore, voice messages are difficult for the users to review their contents afterward. While recognizing that voice messages are more friendly to specific groups (eg, illiterate or less literate populations), there should be several challenges in successfully operationalizing its intervention program.

Objective

This study is aimed to estimate the extent to which voice message service users pick up the phone calls of voice messages and complete listening up to or beyond the core part of voice messages.

Methods

A voice message service program composed of 14 episodes on maternal, newborn, and child health was piloted in Lagos, Nigeria, from 2018 to 2019. A voice message call of each of 14 episodes was delivered to the mobile phones of the program participants per day for 14 consecutive days. A total of 513 participants in the voice message service chose one of five locally spoken languages as the language to be used for voice messages. Two multilevel logistic regression models were created to understand participants’ adherence to the voice message: (a) Model 1 for testing whether a voice message call is picked up; and (b) Model 2 for testing whether a voice message call having been picked up is listened to up to the core messaging part.

Results

The greater the voice message episode number became, the smaller proportion of the participants picked up the phone calls of voice message (aOR: 0.98; 95% CI: 0.97–0.99; P = .01). Only 854 of 3765 voice message calls having been picked up by the participants (22.7%) were listened to up to their core message parts. It was found that picking up a phone call did not necessarily ensure listening up to the core message part. This indicates a discontinuity between these two actions.

Conclusions

The participants were likely to stop picking up the phone as the episode number of voice messages progressed. In view of the discontinuity between picking up a phone call and listening up to the core message part, we should not assume that those picking up the phone would automatically complete listening to the entire or core voice message.

Mortality attributable to type 2 diabetes mellitus in Latin America and the Caribbean: a comparative risk assessment analysis

INTRODUCTION

We quantified the proportion and the absolute number of deaths attributable to type 2 diabetes mellitus (T2DM) in Latin America and the Caribbean (LAC) using an estimation approach.

RESEARCH DESIGN AND METHODS

We combined T2DM prevalence estimates from the NCD Risk Factor Collaboration, relative risks between T2DM and all-cause mortality from a meta-analysis of cohorts in LAC, and death rates from the Global Burden of Disease Study 2019. We estimated population-attributable fractions (PAFs) and computed the absolute number of attributable deaths in 1990 and 2019 by multiplying the PAFs by the total deaths in each country, year, sex, and 5-year age group.

RESULTS

Between 1985 and 2014 in LAC, the proportion of all-cause mortality attributable to T2DM increased from 12.2% to 16.9% in men and from 14.5% to 19.3% in women. In 2019, the absolute number of deaths attributable to T2DM was 349 787 in men and 330 414 in women. The highest death rates (deaths per 100 000 people) in 2019 were in Saint Kitts and Nevis (325 in men, 229 in women), Guyana (313 in men, 272 in women), and Haiti (269 in men, 265 in women).

CONCLUSIONS

A substantial burden of all deaths is attributed to T2DM in LAC. To decrease the mortality attributable to T2DM in LAC, policies are needed to strengthen early diagnosis and management, along with the prevention of complications.

Knowledge, attitudes, and practices towards artificial intelligence among young pediatricians: A nationwide survey in France

OBJECTIVE

To assess the knowledge, attitudes, and practices (KAP) towards artificial intelligence (AI) among young pediatricians in France.

METHODS

We invited young French pediatricians to participate in an online survey. Invitees were identified through various email listings and social media. We conducted a descriptive analysis and explored whether survey responses varied according to respondents' previous training in AI and level of clinical experience (i.e., residents vs. experienced doctors).

RESULTS

In total, 165 French pediatricians participated in the study (median age 27 years, women 78%, residents 64%). While 90% of participants declared they understood the term "artificial intelligence", only 40% understood the term "deep learning". Most participants expected AI would lead to improvements in healthcare (e.g., better access to healthcare, 80%; diagnostic assistance, 71%), and 86% declared they would favor implementing AI tools in pediatrics. Fifty-nine percent of respondents declared seeing AI as a threat to medical data security and 35% as a threat to the ethical and human dimensions of medicine. Thirty-nine percent of respondents feared losing clinical skills because of AI, and 6% feared losing their job because of AI. Only 5% of respondents had received specific training in AI, while 87% considered implementing such programs would be necessary. Respondents who received training in AI had significantly better knowledge and a higher probability of having encountered AI tools in their medical practice (p < 0.05 for both). There was no statistically significant difference between residents' and experienced doctors' responses.

CONCLUSION

In this survey, most young French pediatricians had favorable views toward AI, but a large proportion expressed concerns regarding the ethical, societal, and professional issues linked with the implementation of AI.

Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent

PURPOSE OF REVIEW

Latin America is the scenario of great inequalities where about 32 million human beings live with diabetes. Through this review, we aimed at describing the current state of the prevalence, awareness, treatment, and control of diabetes mellitus and completion of selected guidelines of care across Latin America and identify opportunities to advance research that promotes better health outcomes.

RECENT FINDINGS

The prevalence of diabetes mellitus has been consistently increasing across the region, with some variation: higher prevalence in Mexico, Haiti, and Puerto Rico and lower in Colombia, Ecuador, Dominican Republic, Peru, and Uruguay. Prevalence assessment methods vary, and potentially underestimating the real number of persons with diabetes. Diabetes unawareness varies widely, with up to 50% of persons with diabetes who do not know they may have the disease. Glycemic, blood pressure, and LDL-C control and completion of guidelines to prevent microvascular complications are not consistently assessed across studies, and the achievement of control goals is suboptimal. On the other hand, multiple interventions, point-of-care/rapid assessment tools, and alternative models of health care delivery have been proposed and tested throughout Latin America. The prevalence of diabetes mellitus continues to rise across Latin America, and the number of those with the disease may be underestimated. However, some local governments are embedding more comprehensive diabetes assessments in their local national surveys. Clinicians and public health advocates in the region have proposed and initiated various multi-level interventions to address this enormous challenge in the region.

The Challenges in the Development of Diabetes Prevention and Care Models in Low-Income Settings

In low- and middle-income countries (LMICs), the burden of non-communicable diseases such as diabetes is rapidly rising, overpassing the existing burden of communicable diseases. Patients with diabetes living in low-income communities face unique challenges related to lack of awareness, difficulty in accessing health care systems and medications, and consequently failure in achieving optimal diabetes management and preventing complications. Effective diabetes prevention and care models could help reduce the rising burden by standardizing guidelines for prevention and management, improving access to care, engaging community and peers, improving the training of professionals and patients and using the newest technology in the management of the disease. In this article, we review the latest research and evidence on effective models of diabetes prevention and diabetes care delivery in low- income settings. We also provide existing evidence relating to the effectiveness of these models in low-resource contexts, with the aim to highlight characteristics and strengths that make their implementation successful and long-lasting.

Security and Privacy Requirements for Cloud Computing in Healthcare

Cloud computing promises essential improvements in healthcare delivery performance. However, its wide adoption in healthcare is yet to be seen, one main reason being patients’ concerns for security and privacy of their sensitive medical records. These concerns can be addressed through corresponding security and privacy requirements within the system engineering process. Despite a plethora of related research, security and privacy requirements for cloud systems and services have seldomly been investigated methodically so far, whereas their individual priorities to increase the system success probability have been neglected. Against this background, this study applies a systematic requirements engineering process: First, based on a systematic literature review, an extensive initial set of security and privacy requirements is elicited. Second, an online survey based on the best-worst scaling method is designed, conducted, and evaluated to determine priorities of security and privacy requirements.

Our results show that confidentiality and integrity of medical data are ranked at the top of the hierarchy of prioritized requirements, followed by control of data use and modification, patients’ anonymity, and patients’ control of access rights. Availability, fine-grained access control, revocation of access rights, flexible access, clinicians’ anonymity, as well as usability, scalability, and efficiency of the system complete the ranking. The level of agreement among patients is rather small, but statistically significant at the 0.01 level.

The main contribution of the present research comprises the study method and results highlighting the role of strong security and privacy and excluding any trade-offs with system usability. Enabling a richer understanding of patients’ security and privacy requirements for adopting cloud computing in healthcare, these are of particular importance to researchers and practitioners interested in supporting the process of security and privacy engineering for health-cloud solutions. It further represents a supplement that can support time-intensive negotiation meetings between the requirements engineers and patients.

What is Blockchain Technology and its Significance in the Current Healthcare System? A Brief Insight

Background:

The promising eventual fate of blockchain in healthcare has a lot more extensive prospect. Blockchain is a novel structure that gives another design to storage and trade of data among different members of a particular network. In case of a hospital, blockchain takes into consideration the creation of a better treatment structure by the expert doctor in order to arrange the meeting based on the symptoms of patients throughout the world by the electronic system. Blockchain technology is crucial for biomedical and human services applications as social insurance has turned out to be a standout among the most essential rising application areas of the blockchain distributed ledger technology.

Result:

By and large, blockchain is treated as a conveyed record to store social insurance related information for allocation, trading, dissecting, footage, and affirming purposes among accomplices. The advantage of blockchain databases versus traditional dispersed databases is that they are decentralized, permanent, and perfected with advanced digital payment frameworks and hash chain occasion structure. The blockchain code is an unlocked resource and can be utilized, altered, and customized by its clients.

Conclusion:

Nowadays, blockchain is expected to be almost universally adopted across medical organizations around the world. The purpose of this review article is to comprehend the current explored subjects, difficulties, and future headings in regards to blockchain innovation from the specialized perspective in the health care system.

Artificial intelligence (AI) and global health: how can AI contribute to health in resource-poor settings?

The field of artificial intelligence (AI) has evolved considerably in the last 60 years. While there are now many AI applications that have been deployed in high-income country contexts, use in resource-poor settings remains relatively nascent. With a few notable exceptions, there are limited examples of AI being used in such settings. However, there are signs that this is changing. Several high-profile meetings have been convened in recent years to discuss the development and deployment of AI applications to reduce poverty and deliver a broad range of critical public services. We provide a general overview of AI and how it can be used to improve health outcomes in resource-poor settings. We also describe some of the current ethical debates around patient safety and privacy. Despite current challenges, AI holds tremendous promise for transforming the provision of healthcare services in resource-poor settings. Many health system hurdles in such settings could be overcome with the use of AI and other complementary emerging technologies. Further research and investments in the development of AI tools tailored to resource-poor settings will accelerate realising of the full potential of AI for improving global health.

Theories Applied to m-Health Interventions for Behavior Change in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Recently there has been dramatic increase in the use of mobile technologies for health (m-Health) in both high and low- and middle-income countries (LMICs). However, little is known whether m-Health interventions in LMICs are based on relevant theories critical for effective implementation of such interventions. This review aimed to systematically identify m-Health studies on health behavioral changes in LMICs and to examine how each study applied behavior change theories.

MATERIALS AND METHODS

A systematic review was conducted using the standard method from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. By searching electronic databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials [CENTRAL]), we identified eligible studies published in English from inception to June 30, 2017. For the identified m-Health studies in LMICs, we examined their theoretical bases, use of behavior change techniques (BCTs), and modes of delivery.

RESULTS

A total of 14 m-Health studies on behavioral changes were identified and, among them, only 5 studies adopted behavior change theory. The most frequently cited theory was the health belief model, which was adopted in three studies. Likewise, studies have applied only a limited number of BCTs. Among the seven BCTs identified, the most frequently used one was the social support (practical) technique for medication reminder and medical appointment. m-Health studies in LMICs most commonly used short messaging services and phone calls as modes of delivery for behavior change interventions.

CONCLUSIONS

m-Health studies in LMICs are suboptimally based on behavior change theory yet. To maximize effectiveness of m-Health, rigorous delivery methods as well as theory-based intervention designs will be needed.

mHealth Application Areas and Technology Combinations*. A Comparison of Literature from High and Low/Middle Income Countries

BACKGROUND

With the continuous and enormous spread of mobile technologies, mHealth has evolved as a new subfield of eHealth. While eHealth is broadly focused on information and communication technologies, mHealth seeks to explore more into mobile devices and wireless communication. Since mobile phone penetration has exceeded other infrastructure in low and middle-income countries (LMICs), mHealth is seen as a promising component to provide pervasive and patient-centered care.

OBJECTIVES

The aim of our research work for this paper is to examine the mHealth literature to identify application areas, target diseases, and mHealth service and technology types that are most appropriate for LMICs.

METHODS

Based on the 2011 WHO mHealth report, a combination of search terms, all including the word "mHealth", was identified. A literature review was conducted by searching the PubMed and IEEE Xplore databases. Articles were included if they were published in English, covered an mHealth solution/ intervention, involved the use of a mobile communication device, and included a pilot evaluation study. Articles were excluded if they did not provide sufficient detail on the solution covered or did not focus on clinical efficacy/effectiveness. Cross-referencing was also performed on included articles.

RESULTS

842 articles were retrieved and analyzed, 255 of which met the inclusion criteria. North America had the highest number of applications (n=74) followed by Europe (n=50), Asia (n=44), Africa (n=25), and Australia (n=9). The Middle East (n=5) and South America (n=3) had the least number of studies. The majority of solutions addressed diabetes (n=51), obesity (n=25), CVDs (n=24), HIV (n=18), mental health (n=16), health behaviors (n=16), and maternal and child's health (MCH) (n=11). Fewer solutions addressed asthma (n=7), cancer (n=5), family health planning (n=5), TB (n=3), malaria (n=2), chronic obtrusive pulmonary disease (COPD) (n=2), vision care (n=2), and dermatology (n=2). Other solutions targeted stroke, dental health, hepatitis vaccination, cold and flu, ED prescribed antibiotics, iodine deficiency, and liver transplantation (n=1 each). The remainder of solutions (n=14) did not focus on a certain disease. Most applications fell in the areas of health monitoring and surveillance (n=93) and health promotion and raising awareness (n=88). Fewer solutions addressed the areas of communication and reporting (n=11), data collection (n=6), telemedicine (n=5), emergency medical care (n=3), point of care support (n=2), and decision support (n=2). The majority of solutions used SMS messaging (n=94) or mobile apps (n=71). Fewer used IVR/phone calls (n=8), mobile website/email (n=5), videoconferencing (n=2), MMS (n=2), or video (n=1) or voice messages (n=1). Studies were mostly RCTs, with the majority suffering from small sample sizes and short study durations. Problems addressed by solutions included travel distance for reporting, self-management and disease monitoring, and treatment/medication adherence.

CONCLUSIONS

SMS and app solutions are the most common forms of mHealth applications. SMS solutions are prevalent in both high and LMICs while app solutions are mostly used in high income countries. Common application areas include health promotion and raising awareness using SMS and health monitoring and surveillance using mobile apps. Remaining application areas are rarely addressed. Diabetes is the most commonly targeted medical condition, yet remains deficient in LMICs.

Public Policies and Interventions for Diabetes in Latin America: a Scoping Review

PURPOSE OF REVIEW

Successful interventions are needed to diagnose and manage type 2 diabetes (T2DM) in Latin America, a region that is experiencing a significant rise in rates of T2DM. Complementing an earlier review exploring diabetes prevention efforts in Latin America, this scoping review examines the literature on (1) policies and governmental programs intended to improve diabetes diagnosis and treatment in Latin America and (2) interventions to improve diabetes management in Latin America. It concludes with a brief discussion of promising directions for future research.

RECENT FINDINGS

Governmental policies and programs for the diagnosis and treatment of diabetes in different Latin American countries have been implemented, but their efficacy to date has not been rigorously evaluated. There are some promising intervention approaches in Latin America to manage diabetes that have been evaluated. Some of these utilize multidisciplinary teams, a relatively resource-intensive approach difficult to replicate in low-resource settings. Other evaluated interventions in Latin America have successfully leveraged mobile health tools, trained peer volunteers, and community health workers (CHWs) to improve diabetes management and outcomes. There are some promising approaches and large-scale governmental efforts underway to curb the growing burden of type 2 diabetes in Latin America. While some of these interventions have been rigorously evaluated, further research is warranted to determine their effectiveness, cost, and scalability in this region.

[CYTED-RITMOS network: toward the search for solutions to promote mobile health in Latin America]

El ámbito de las tecnologías móviles aplicadas a la salud (mSalud) es una tendencia en auge a nivel mundial que ha generado enormes expectativas para paliar los problemas de prestación de servicios médicos y de salud pública ocasionados por la escasez de recursos y el reducido número de especialistas. Las numerosas posibilidades que aportan las tecnologías móviles, junto con su facilidad de uso, han atraído el interés tanto de los gobiernos políticos como el de las universidades. Es el caso de la Red Iberoamericana de Tecnologías Móviles y Salud (Red CYTED-RITMOS). Como resultado del primer año de actividad de la Red, en octubre de 2015 tuvo lugar en Barcelona el Internacional Workshop RITMOS con el objeto de presentar las áreas prioritarias de América Latina donde podrían desarrollarse proyectos de investigación, desarrollo e innovación (I+D+i) en salud móvil y posibles soluciones. El objetivo de este trabajo es mostrar las potencialidades y la aplicabilidad de la mSalud en la región de las Américas.

An investigation of users' attitudes, requirements and willingness to use mobile phone-based interactive voice response systems for seeking healthcare in Ghana: a qualitative study

OBJECTIVES

In implementing mobile health interventions, user requirements and willingness to use are among the most crucial concerns for success of the investigation and have only rarely been examined in sub-Saharan Africa. This study aimed to specify the requirements of caregivers of children in order to use a symptom-based interactive voice response (IVR) system for seeking healthcare. This included (i) the investigation of attitudes towards mobile phone use and user experiences and (ii) the assessment of facilitators and challenges to use the IVR system.

STUDY DESIGN

This is a population-based cross-sectional study.

METHODS

Four qualitative focus group discussions were conducted in peri-urban and rural towns in Shai Osudoku and Ga West district, as well as in Tema- and Accra Metropolitan Assembly. Participants included male and female caregivers of at least one child between 0 and 10 years of age. A qualitative content analysis was conducted for data analysis.

RESULTS

Participants showed a positive attitude towards the use of mobile phones for seeking healthcare. While no previous experience in using IVR for health information was reported, the majority of participants stated that it offers a huge advantage for improvement in health performance. Barriers to IVR use included concerns about costs, lack of familiarly with the technology, social barriers such as lack of human interaction and infrastructural challenges. The establishment of a toll-free number as well as training prior to IVR system was discussed for recommendation.

CONCLUSIONS

This study suggests that caregivers in the socio-economic environment of Ghana are interested and willing to use mobile phone-based IVR to receive health information for child healthcare. Important identified users' needs should be considered by health programme implementers and policy makers to help facilitate the development and implementation of IVR systems in the field of seeking healthcare.

Improving Individual Acceptance of Health Clouds through Confidentiality Assurance

BACKGROUND

Cloud computing promises to essentially improve healthcare delivery performance. However, shifting sensitive medical records to third-party cloud providers could create an adoption hurdle because of security and privacy concerns.

OBJECTIVES

This study examines the effect of confidentiality assurance in a cloud-computing environment on individuals' willingness to accept the infrastructure for inter-organizational sharing of medical data.

METHODS

We empirically investigate our research question by a survey with over 260 full responses. For the setting with a high confidentiality assurance, we base on a recent multi-cloud architecture which provides very high confidentiality assurance through a secret-sharing mechanism: Health information is cryptographically encoded and distributed in a way that no single and no small group of cloud providers is able to decode it.

RESULTS

Our results indicate the importance of confidentiality assurance in individuals' acceptance of health clouds for sensitive medical data. Specifically, this finding holds for a variety of practically relevant circumstances, i.e., in the absence and despite the presence of conventional offline alternatives and along with pseudonymization. On the other hand, we do not find support for the effect of confidentiality assurance in individuals' acceptance of health clouds for non-sensitive medical data. These results could support the process of privacy engineering for health-cloud solutions.

Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country

BACKGROUND

Patients' engagement in mobile health (m-health) interventions using interactive voice response (IVR) calls is less in low- and middle-income countries (LMICs) than in industrialized ones. We conducted a study to determine whether automated telephone feedback to informal caregivers ("CarePartners") increased engagement in m-health support among diabetes and hypertension patients in Bolivia.

MATERIALS AND METHODS

Patients with diabetes and/or hypertension were identified through ambulatory clinics affiliated with four hospitals. All patients enrolled with a CarePartner. Patients were randomized to weekly IVR calls including self-management questions and self-care education either alone ("standard m-health") or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ("m-health+CP").

RESULTS

The 72 participants included 39 with diabetes and 53 with hypertension, of whom 19 had ≤6 years of education. After 1,225 patient-weeks of attempted IVR assessments, the call completion rate was higher among patients randomized to m-health+CP compared with standard m-health (62.0% versus 44.9%; p < 0.047). CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy (p < 0.001 for both). M-health+CP patients were more likely to report excellent health via IVR (adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI], 1.07, 6.32) and less likely to report days in bed due to illness (AOR = 0.42; 95% CI, 0.19, 0.91).

CONCLUSIONS

In this study we found that caregiver feedback increased engagement in m-health and may improve patients' health status relative to standard approaches. M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs.

Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management

We examined evidence on whether mobile health (mHealth) tools, including interactive voice response calls, short message service, or text messaging, and smartphones, can improve lifestyle behaviors and management related to cardiovascular diseases throughout the world. We conducted a state-of-the-art review and literature synthesis of peer-reviewed and gray literature published since 2004. The review prioritized randomized trials and studies focused on cardiovascular diseases and risk factors, but included other reports when they represented the best available evidence. The search emphasized reports on the potential benefits of mHealth interventions implemented in low- and middle-income countries. Interactive voice response and short message service interventions can improve cardiovascular preventive care in developed countries by addressing risk factors including weight, smoking, and physical activity. Interactive voice response and short message service-based interventions for cardiovascular disease management also have shown benefits with respect to hypertension management, hospital readmissions, and diabetic glycemic control. Multimodal interventions including Web-based communication with clinicians and mHealth-enabled clinical monitoring with feedback also have shown benefits. The evidence regarding the potential benefits of interventions using smartphones and social media is still developing. Studies of mHealth interventions have been conducted in >30 low- and middle-income countries, and evidence to date suggests that programs are feasible and may improve medication adherence and disease outcomes. Emerging evidence suggests that mHealth interventions may improve cardiovascular-related lifestyle behaviors and disease management. Next-generation mHealth programs developed worldwide should be based on evidence-based behavioral theories and incorporate advances in artificial intelligence for adapting systems automatically to patients' unique and changing needs.

Secure Cloud-Based Solutions for Different eHealth Services in Spanish Rural Health Centers

Background

The combination of eHealth applications and/or services with cloud technology provides health care staff—with sufficient mobility and accessibility for them—to be able to transparently check any data they may need without having to worry about its physical location.

Objective

The main aim of this paper is to put forward secure cloud-based solutions for a range of eHealth services such as electronic health records (EHRs), telecardiology, teleconsultation, and telediagnosis.

Methods

The scenario chosen for introducing the services is a set of four rural health centers located within the same Spanish region. iCanCloud software was used to perform simulations in the proposed scenario. We chose online traffic and the cost per unit in terms of time as the parameters for choosing the secure solution on the most optimum cloud for each service.

Results

We suggest that load balancers always be fitted for all solutions in communication together with several Internet service providers and that smartcards be used to maintain identity to an appropriate extent. The solutions offered via private cloud for EHRs, teleconsultation, and telediagnosis services require a volume of online traffic calculated at being able to reach 2 Gbps per consultation. This may entail an average cost of €500/month.

Conclusions

The security solutions put forward for each eHealth service constitute an attempt to centralize all information on the cloud, thus offering greater accessibility to medical information in the case of EHRs alongside more reliable diagnoses and treatment for telecardiology, telediagnosis, and teleconsultation services. Therefore, better health care for the rural patient can be obtained at a reasonable cost.

A scoping review of cloud computing in healthcare

BACKGROUND

Cloud computing is a recent and fast growing area of development in healthcare. Ubiquitous, on-demand access to virtually endless resources in combination with a pay-per-use model allow for new ways of developing, delivering and using services. Cloud computing is often used in an "OMICS-context", e.g. for computing in genomics, proteomics and molecular medicine, while other field of application still seem to be underrepresented. Thus, the objective of this scoping review was to identify the current state and hot topics in research on cloud computing in healthcare beyond this traditional domain.

METHODS

MEDLINE was searched in July 2013 and in December 2014 for publications containing the terms "cloud computing" and "cloud-based". Each journal and conference article was categorized and summarized independently by two researchers who consolidated their findings.

RESULTS

102 publications have been analyzed and 6 main topics have been found: telemedicine/teleconsultation, medical imaging, public health and patient self-management, hospital management and information systems, therapy, and secondary use of data. Commonly used features are broad network access for sharing and accessing data and rapid elasticity to dynamically adapt to computing demands. Eight articles favor the pay-for-use characteristics of cloud-based services avoiding upfront investments. Nevertheless, while 22 articles present very general potentials of cloud computing in the medical domain and 66 articles describe conceptual or prototypic projects, only 14 articles report from successful implementations. Further, in many articles cloud computing is seen as an analogy to internet-/web-based data sharing and the characteristics of the particular cloud computing approach are unfortunately not really illustrated.

CONCLUSIONS

Even though cloud computing in healthcare is of growing interest only few successful implementations yet exist and many papers just use the term "cloud" synonymously for "using virtual machines" or "web-based" with no described benefit of the cloud paradigm. The biggest threat to the adoption in the healthcare domain is caused by involving external cloud partners: many issues of data safety and security are still to be solved. Until then, cloud computing is favored more for singular, individual features such as elasticity, pay-per-use and broad network access, rather than as cloud paradigm on its own.

Redesigning primary care to tackle the global epidemic of noncommunicable disease

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Personal health technology: A new era in cardiovascular disease prevention

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide yet the majority of related risk factors are largely preventable (primary prevention [PP]) and effectively treatable (secondary prevention [SP]) with healthy lifestyle behaviors. The use of information and communication technology (ICT) offers a unique approach to personal health and CVD prevention, as these mediums are relatively affordable, approachable, and accessible. The purpose of this review is to provide an overview of ICT-driven personal health technologies and their potential role in promoting and supporting self-care behaviors for PP and SP of CVD. In this review, we focus on technological interventions that have been successful at supporting positive behavior change in order to determine which tools, resources, and methods are most appropriate for delivering interventions geared towards CVD prevention. We conducted a literature search from a range of sources including scholarly, peer-reviewed journal articles indexed in PubMed and CINAHL, gray literature, and reputable websites and other Internet-based media. A synthesis of existing literature indicates that the overall efficacy of ICT-driven personal health technologies is largely determined by: 1) the educational resources provided and the extent to which the relayed information is customized or individually tailored; and 2) the degree of self-monitoring and levels of personalized feedback or other interactions (e.g. interpersonal communications). We conclude that virtually all the technological tools and resources identified (e.g. Internet-based communications including websites, weblogs and wikis, mobile devices and applications, social media, and wearable monitors) can be strategically leveraged to enhance self-care behaviors for CVD risk reduction and SP but further research is needed to evaluate their efficacy, cost-effectiveness, and long-term maintainability.

mHealth adoption in low-resource environments: a review of the use of mobile healthcare in developing countries

The acknowledged potential of using mobile phones for improving healthcare in low-resource environments of developing countries has yet to translate into significant mHealth policy investment. The low uptake of mHealth in policy agendas may stem from a lack of evidence of the scalable, sustainable impact on health indicators. The mHealth literature in low- and middle-income countries reveals a burgeoning body of knowledge; yet, existing reviews suggest that the projects yield mixed results. This article adopts a stage-based approach to understand the varied contributions to mHealth research. The heuristic of inputs-mechanism-outputs is proposed as a tool to categorize mHealth studies. This review (63 articles comprising 53 studies) reveals that mHealth studies in developing countries tend to concentrate on specific stages, principally on pilot projects that adopt a deterministic approach to technological inputs (n = 32), namely introduction and implementation. Somewhat less studied were research designs that demonstrate evidence of outputs (n = 15), such as improvements in healthcare processes and public health indicators. The review finds a lack of emphasis on studies that provide theoretical understanding (n = 6) of adoption and appropriation of technological introduction that produces measurable health outcomes. As a result, there is a lack of dominant theory, or measures of outputs relevant to making policy decisions. Future work needs to aim for establishing theoretical and measurement standards, particularly from social scientific perspectives, in collaboration with researchers from the domains of information technology and public health. Priorities should be set for investments and guidance in evaluation disseminated by the scientific community to practitioners and policymakers.

Use of mHealth systems and tools for non-communicable diseases in low- and middle-income countries: a systematic review

With the rapid adoption of mobile devices, mobile health (mHealth) offers the potential to transform health care delivery, especially in the world's poorest regions. We systematically reviewed the literature to determine the impact of mHealth interventions on health care quality for non-communicable diseases in low- and middle-income countries and to identify knowledge gaps in this rapidly evolving field. Overall, we found few high-quality studies. Most studies narrowly focused on text messaging systems for patient behavior change, and few studies examined the health systems strengthening aspects of mHealth. There were limited literature reporting clinical effectiveness, costs, and patient acceptability, and none reporting equity and safety issues. Despite the bold promise of mHealth to improve health care, much remains unknown about whether and how this will be fulfilled. Encouragingly, we identified some registered clinical trial protocols of large-scale, multidimensional mHealth interventions, suggesting that the current limited evidence base will expand in coming years.

Engaging Patients through Mobile Phones: Demonstrator Services, Success Factors, and Future Opportunities in Low and Middle-income Countries

OBJECTIVES

Evolving technology and infrastructure can benefit patients even in the poorest countries through mobile health (mHealth). Yet, what makes mobile-phone-based services succeed in low and middle-income countries (LMIC) and what opportunities does the future hold that still need to be studied. We showcase demonstrator services that leverage mobile phones in the hands of patients to promote health and facilitate health care.

METHODS

We surveyed the recent biomedical literature for demonstrator services that illustrate well-considered examples of mobile phone interventions for consumer health. We draw upon those examples to discuss enabling factors, scalability, reach, and potential of mHealth as well as obstacles in LMIC.

RESULTS

Among the 227 articles returned by a PubMed search, we identified 55 articles that describe services targeting health consumers equipped with mobile phones. From those articles, we showcase 19 as demonstrator services across clinical care, prevention, infectious diseases, and population health. Services range from education, reminders, reporting, and peer support, to epidemiologic reporting, and care management with phone communication and messages. Key achievements include timely adherence to treatment and appointments, clinical effectiveness of treatment reminders, increased vaccination coverage and uptake of screening, and capacity for efficient disease surveillance. We discuss methodologies of delivery and evaluation of mobile-phone-based mHealth in LMIC, including service design, social context, and environmental factors to success.

CONCLUSION

Demonstrated promises using mobile phones in the poorest countries encourage a future in which IMIA takes a lead role in leveraging mHealth for citizen empowerment through Consumer Health Informatics.

Establishing an independent mobile health program for chronic disease self-management support in bolivia

Background: Mobile health (m-health) work in low- and middle-income countries (LMICs) mainly consists of small pilot programs with an unclear path to scaling and dissemination. We describe the deployment and testing of an m-health platform for non-communicable disease (NCD) self-management support in Bolivia.

Methods: Three hundred sixty-four primary care patients in La Paz with diabetes or hypertension completed surveys about their use of mobile phones, health and access to care. One hundred sixty-five of those patients then participated in a 12-week demonstration of automated telephone monitoring and self-management support. Weekly interactive voice response (IVR) calls were made from a platform established at a university in La Paz, under the direction of the regional health ministry.

Results: Thirty-seven percent of survey respondents spoke indigenous languages at home and 38% had six or fewer years of education. Eighty-two percent had a mobile phone, 45% used text messaging with a standard phone, and 9% had a smartphone. Smartphones were least common among patients who were older, spoke indigenous languages, or had less education. IVR program participants completed 1007 self-management support calls with an overall response rate of 51%. IVR call completion was lower among older adults, but was not related to patients’ ethnicity, health status, or healthcare access. IVR health and self-care reports were consistent with information reported during in-person baseline interviews. Patients’ likelihood of reporting excellent, very good, or good health (versus fair or poor health) via IVR increased during program participation and was associated with better medication adherence. Patients completing follow-up interviews were satisfied with the program, with 19/20 (95%) reporting that they would recommend it to a friend.

Conclusion: By collaborating with LMICs, m-health programs can be transferred from higher-resource centers to LMICs and implemented in ways that improve access to self-management support among people with NCDs.

Multidisciplinary sleep centers: strategies to improve care of sleep disorders patients

Current emphasis on patient outcomes within sleep medicine, with a particular focus on quality improvement and contained costs, calls for sleep specialists to develop innovative models for long-term care and management of sleep disorders patients. Multidisciplinary sleep centers can facilitate highest-quality care that is timely and cost-effective. Effective resource use in a multidisciplinary sleep center can help minimize fragmentation of care, reduce effort duplication, and control costs. Proposed strategies to help achieve a balance between quality of care and cost-effectiveness include: (1) multidisciplinary specialty clinics, (2) optimized use of information technology, and (3) adoption of reliable performance measures.

Analysis of the security and privacy requirements of cloud-based electronic health records systems

BACKGROUND

The Cloud Computing paradigm offers eHealth systems the opportunity to enhance the features and functionality that they offer. However, moving patients' medical information to the Cloud implies several risks in terms of the security and privacy of sensitive health records. In this paper, the risks of hosting Electronic Health Records (EHRs) on the servers of third-party Cloud service providers are reviewed. To protect the confidentiality of patient information and facilitate the process, some suggestions for health care providers are made. Moreover, security issues that Cloud service providers should address in their platforms are considered.

OBJECTIVE

To show that, before moving patient health records to the Cloud, security and privacy concerns must be considered by both health care providers and Cloud service providers. Security requirements of a generic Cloud service provider are analyzed.

METHODS

To study the latest in Cloud-based computing solutions, bibliographic material was obtained mainly from Medline sources. Furthermore, direct contact was made with several Cloud service providers.

RESULTS

Some of the security issues that should be considered by both Cloud service providers and their health care customers are role-based access, network security mechanisms, data encryption, digital signatures, and access monitoring. Furthermore, to guarantee the safety of the information and comply with privacy policies, the Cloud service provider must be compliant with various certifications and third-party requirements, such as SAS70 Type II, PCI DSS Level 1, ISO 27001, and the US Federal Information Security Management Act (FISMA).

CONCLUSIONS

Storing sensitive information such as EHRs in the Cloud means that precautions must be taken to ensure the safety and confidentiality of the data. A relationship built on trust with the Cloud service provider is essential to ensure a transparent process. Cloud service providers must make certain that all security mechanisms are in place to avoid unauthorized access and data breaches. Patients must be kept informed about how their data are being managed.

Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries

OBJECTIVE

Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries (LMICs). Mobile health technologies may improve noncommunicable disease outcomes, but LMICs lack resources to provide these services. We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure (BP) monitoring as a strategy for improving systolic BPs (SBPs) and other outcomes of hypertensive patients in two LMICs.

SUBJECTS AND METHODS

This was a randomized trial with a 6-week follow-up. Participants with high SBPs (≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic) were enrolled from clinics in Honduras and Mexico. Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States, plus a home BP monitor. At baseline, control patients received BP results, hypertension information, and usual healthcare. The primary outcome, SBP, was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs. Secondary outcomes included perceived health status and medication-related problems.

RESULTS

Of the 200 patients recruited, 181 (90%) completed follow-up, and 117 of 181 had low literacy or high hypertension information needs. The median annual income was $2,900 USD, and average educational attainment was 6.5 years. At follow-up intervention patients' SBPs decreased 4.2 mm Hg relative to controls (95% confidence interval -9.1, 0.7; p=0.09). In the subgroup with high information needs, intervention patients' average SBPs decreased 8.8 mm Hg (-14.2, -3.4, p=0.002). Compared with controls, intervention patients at follow-up reported fewer depressive symptoms (p=0.004), fewer medication problems (p<0.0001), better general health (p<0.0001), and greater satisfaction with care (p≤0.004).

CONCLUSIONS

Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs. A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support.

Spanish-speaking patients' engagement in interactive voice response (IVR) support calls for chronic disease self-management: data from three countries

We measured Spanish-speaking patients' engagement in Interactive Voice Response (IVR) calls using data from self-management support studies in Honduras, Mexico and the US. A total of 268 patients with diabetes or hypertension participated in 6-12 weeks of weekly IVR follow-up. Participants had an average of 6.1 years of education, and 73% of them were women. After 2443 person-weeks of follow-up, patients had completed 1494 IVR assessments. The call completion rates were higher in the US (75%) than in Honduras (59%) or Mexico (61%; P < 0.001). Patients participating with an informal caregiver were more likely to complete calls (adjusted odds ratio 1.5; P = 0.03) while patients reporting fair or poor health at enrolment were less likely (adjusted odds ratio 0.59; P = 0.02). Satisfaction rates were high, with 98% of patients reporting that the system was easy to use, and 86% reporting that the calls helped them a great deal in managing their health problems. IVR self-management support is feasible among Spanish-speaking patients with chronic disease, including those living in less-developed countries. Involving informal caregivers may increase patient engagement.

Engagement with automated patient monitoring and self-management support calls: experience with a thousand chronically ill patients

BACKGROUND

Patient self-care support via Interactive Voice Response (IVR) can improve disease management. However, little is known about the factors affecting program engagement.

METHODS

We compiled data on IVR program engagement for 1173 patients with: heart failure, depression, diabetes, or cancer who were followed for 28,962 person-weeks. Patients in programs for diabetes or depression (N=727) had the option of participating along with an informal caregiver who received electronic feedback based on the patient's IVR assessments. Analyses focused on factors associated with completing weekly IVR calls.

RESULTS

Patients were on average 61 years old, 37% had at most a high school education, and 48% reported incomes of ≤$30,000. Among patients given the option of participating with an informal caregiver, 65% chose to do so. Patients completed 83% of attempted IVR assessments, with rates higher for heart failure (90%) and cancer programs (90%) than for the diabetes (81%) or depression programs (71%) (P<0.001). Among patients in diabetes or depression programs, those opting to have feedback provided to an informal caregiver were more likely to complete assessments [adjusted odds ratio, 1.37; 95% confidence interval, 1.07-1.77]. Older patients had higher call completion rates, even among patients aged 75 years and older. Missed clinic appointments, prior hospitalizations, depression program participation, and poorer mental health were associated with lower completion rates.

CONCLUSIONS

Patients with a variety of chronic conditions will complete IVR self-care support calls regularly. Risk factors for missed IVR calls overlap with those for missed appointments. Involvement of informal caregivers may significantly increase engagement.

Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

A cloud computing based 12-lead ECG telemedicine service

Background

Due to the great variability of 12-lead ECG instruments and medical specialists’ interpretation skills, it remains a challenge to deliver rapid and accurate 12-lead ECG reports with senior cardiologists’ decision making support in emergency telecardiology.

Methods

We create a new cloud and pervasive computing based 12-lead Electrocardiography (ECG) service to realize ubiquitous 12-lead ECG tele-diagnosis.

Results

This developed service enables ECG to be transmitted and interpreted via mobile phones. That is, tele-consultation can take place while the patient is on the ambulance, between the onsite clinicians and the off-site senior cardiologists, or among hospitals. Most importantly, this developed service is convenient, efficient, and inexpensive.

Conclusions

This cloud computing based ECG tele-consultation service expands the traditional 12-lead ECG applications onto the collaboration of clinicians at different locations or among hospitals. In short, this service can greatly improve medical service quality and efficiency, especially for patients in rural areas. This service has been evaluated and proved to be useful by cardiologists in Taiwan.

Analysis of cloud-based solutions on EHRs systems in different scenarios

Nowadays with the growing of the wireless connections people can access all the resources hosted in the Cloud almost everywhere. In this context, organisms can take advantage of this fact, in terms of e-Health, deploying Cloud-based solutions on e-Health services. In this paper two Cloud-based solutions for different scenarios of Electronic Health Records (EHRs) management system are proposed. We have researched articles published between the years 2005 and 2011 about the implementation of e-Health services based on the Cloud in Medline. In order to analyze the best scenario for the deployment of Cloud Computing two solutions for a large Hospital and a network of Primary Care Health centers have been studied. Economic estimation of the cost of the implementation for both scenarios has been done via the Amazon calculator tool. As a result of this analysis two solutions are suggested depending on the scenario: To deploy a Cloud solution for a large Hospital a typical Cloud solution in which are hired just the needed services has been assumed. On the other hand to work with several Primary Care Centers it's suggested the implementation of a network, which interconnects these centers with just one Cloud environment. Finally it's considered the fact of deploying a hybrid solution: in which EHRs with images will be hosted in the Hospital or Primary Care Centers and the rest of them will be migrated to the Cloud.

Interactive voice response systems for medication identification requests: poison or cure?

Interactive voice response systems (IVR) have traditionally been used by banking and credit card industries to rapidly process information requests for their customers. Today IVR technology is being used in clinical medicine to randomize patients in clinical studies, to collect patient data, and to follow-up on recently discharged patients. Use of IVR systems by poison centers is relatively new. This commentary explores the advantages and disadvantages of applying IVR technology to the medication identification requests in poison centers.