Personalized Technologies in Chronic Gastrointestinal Disorders: Self-monitoring and Remote Sensor Technologies

Optimizing educational methods for the low FODMAP diet in disorders of gut-brain interaction: A feasibility randomized controlled trial

BACKGROUND

A diet low in fermentable oligo-saccharides, di-saccharides, mono-saccharides and polyols (low FODMAP diet) is complex and clinical effectiveness is achieved with dietitian-led education, although dietitian availability in clinical practice varies. This study aimed to assess the feasibility of undertaking a trial to investigate the clinical and cost-effectiveness of different education delivery methods of the low FODMAP diet in patients with disorders of gut-brain interaction (DGBI).

METHODS

In this feasibility randomized controlled trial, patients with DGBI requiring the low FODMAP diet were randomized to receive one of the following education delivery methods: booklet, app, or dietitian. Recruitment and retention rates, acceptability, symptoms, stool output, quality of life, and dietary intake were assessed.

KEY RESULTS

Fifty-one patients were randomized with a recruitment rate of 2.4 patients/month and retention of 48 of 51 (94%). Nobody in the booklet group strongly agreed that this education delivery method enabled them to self-manage symptoms without further support, compared to 7 of 14 (50%) in the dietitian group (p = 0.013). More patients reported adequate relief of symptoms in the dietitian group (12, 80%) compared with the booklet group (7, 39%; p = 0.026), but not when compared to the app group (10, 63%, p > 0.05). There was a greater decrease in the IBS-SSS score in the dietitian group (mean -153, SD 90) compared with the booklet group (mean -90, SD 56; p = 0.043), but not when compared with the app group (mean -120, SD 62; p = 0.595).

CONCLUSIONS & INFERENCES

Booklets were the least acceptable education delivery methods. Dietitian-led consultations led to high levels of clinical effectiveness, followed by the app, while the dietitian was superior to booklets alone. However, an adequately powered clinical trial is needed to confirm clinical effectiveness of these education delivery methods.

Systematic review of co-design in digital health for COVID-19 research

Improving the quality of digital health care through information and communication technology can mainly contribute to the clinical, social, financial, and economic systems' success, especially during the COVID-19 pandemic period. The co-design approach, which unleashes the end-user power, can contribute actively in improving the healthcare systems. It deals with understanding the user behaviors, requirements, and motivations through observation, inspection, task analysis, and feedback techniques. Consequently, both the co-design and digital technologies might empower the management of patients' health and that of their families. The research strategy is based on a systematic literature review and meta-analysis to summarize how the co-design methodologies handled the existing technology-based health systems for their improvement. Based on the findings, we establish the following hypotheses: (i) A user-centered methodology for service implementation might offer a promising tool to enhance the healthcare services quality before they be launched; (ii) Several limitations can affect the co-design approach in digital health, such as a bias for a patients' group. Efforts have been made to reduce this risk by identifying bias at an early stage, or different groups should be included in the test phase for example; (iii) Use decision-making devices that handle technologies for patient and clinical healthcare solution.

Mobile Apps for the Management of Gastrointestinal Diseases: Systematic Search and Evaluation Within App Stores

Background

Gastrointestinal diseases are associated with substantial cost in health care. In times of the COVID-19 pandemic and further digitalization of gastrointestinal tract health care, mobile health apps could complement routine health care. Many gastrointestinal health care apps are already available in the app stores, but the quality, data protection, and reliability often remain unclear.

Objective

This systematic review aimed to evaluate the quality characteristics as well as the privacy and security measures of mobile health apps for the management of gastrointestinal diseases.

Methods

A web crawler systematically searched for mobile health apps with a focus on gastrointestinal diseases. The identified mobile health apps were evaluated using the Mobile Application Rating Scale (MARS). Furthermore, app characteristics, data protection, and security measures were collected. Classic user star rating was correlated with overall mobile health app quality.

Results

The overall quality of the mobile health apps (N=109) was moderate (mean 2.90, SD 0.52; on a scale ranging from 1 to 5). The quality of the subscales ranged from low (mean 1.89, SD 0.66) to good (mean 4.08, SD 0.57). The security of data transfer was ensured only by 11 (10.1%) mobile health apps. None of the mobile health apps had an evidence base. The user star rating did not correlate with the MARS overall score or with the individual subdimensions of the MARS (all P>.05).

Conclusions

Mobile health apps might have a positive impact on diagnosis, therapy, and patient guidance in gastroenterology in the future. We conclude that, to date, data security and proof of efficacy are not yet given in currently available mobile health apps.

Hurdles to developing and scaling remote patients' health management tools and systems: a scoping review

BACKGROUND

Despite all the excitement and hype generated regarding the expected transformative impact of digital technology on the healthcare industry, traditional healthcare systems around the world have largely remained unchanged and resultant improvements in developed countries are slower than anticipated. One area which was expected to significantly improve the quality of and access to primary healthcare services in particular is remote patient monitoring and management. Based on a combination of rapid advances in body sensors and information and communication technologies (ICT), it was hoped that remote patient management tools and systems (RPMTSs) would significantly reduce the care burden on traditional healthcare systems as well as health-related costs. However, the uptake or adoption of above systems has been extremely slow and their roll out has not yet properly taken off especially in developing countries where they ought to have made the greatest positive impact.

AIM

The aim of the study was to assess whether or not recent, relevant literature would support the development of in-community, design, deployment and implementation framework based on three factors thought to be important drivers and levers of RPMTS's adoption and scalability.

METHODS

A rapid, scoping review conducted on relevant articles obtained from PubMed, MEDLINE, PMC and Cochrane databases and grey literature on Google and published between 2012 and May 2020, by combining a number of relevant search terms and phrases.

RESULTS

Most RPMTSs are targeted at and focused on a single disease, do not extensively involve patients and clinicians in their early planning and design phases, are not designed to best serve a specific catchment area and are mainly directed at post-hospital, disease management settings. This may be leading to a situation where patients, potential patients and clinicians simply do not make use of these tools, leading to low adoption and scalability thereof.

CONCLUSION

The development of a user-centred, context-dependent, customizable design and deployment framework could potentially increase the adoption and scalability of RPMTSs, if such framework addressed a combination of diseases, prevalent in a given specific catchment area, especially in developing countries with limited financial resources.

Experience of Telemedicine in Gastroenterology Out-Patient Practice During the COVID-19 Pandemic: Experiences from a Tertiary-Care Hospital in a Developing Country

Objective

Telemedicine is being widely implemented in the COVID-19 pandemic to avoid infection risk. However, its effectiveness has not been evaluated, especially in developing countries, where it is invaluable for healthcare access. This study assesses physicians’ and patients’ perspectives of the usefulness and challenges of telemedicine in the gastroenterology department to identify its pitfalls.

Methods

A cross-sectional telephonic survey was conducted on patients presenting to the gastroenterology department at a tertiary care hospital in Pakistan. An online survey was sent to physicians in the department.

Results

A total of 160 patients participated, with a mean age 49.8 years, and 42.8% (n=68) males. There were 23.8% (n=38) initial visits and 76.3% (n=122) follow-ups. More than 85% of patients agreed telemedicine saved cost and time, 46.5% (n=74) said it improved healthcare access, and 76.3% (n=122) wanted to use it again. More than 80% were satisfied with the physician-patient interaction. Of the 7 physicians who participated, most felt telemedicine was inadequately facilitated, but felt comfortable with technology. Most felt it did not negatively affect healthcare, but thought it was complex for patients and that lack of physical interaction is a limitation. Nearly half were in favor of continuing its use after the pandemic.

Conclusion

Telemedicine is an effective alternative to in-person visits. Patients find it convenient, with adequate interaction. Physicians have reservations that need addressal, such as poor administration. Most patients and half of physicians are welcome to using telemedicine in the post-COVID era.

Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound

Breaking through the biologic therapy efficacy plateau for inflammatory bowel disease requires the strategic development of personalized biomarkers in the tight control model. After risk stratification early in the disease course, targeted serial monitoring consistently to assess clinical outcomes in response to therapy allows for quick therapeutic adjustments before bowel damage can occur. Point-of-care intestinal ultrasound performed by the treating gastroenterologist is an accurate cross- sectional biomarker that monitors intestinal inflammation in real-time, enhances patient care, and increases shared understanding to help achieve common treatment goals. Combining intestinal ultrasound during a clinic visit with existing serum and stool biomarkers in a home testing setup with electronic health monitoring allows for an optimized, patient-centered personalized treatment algorithm that may improve treatment outcomes. Here, we review the current state, pragmatic considerations, and future implications of point-of-care testing and home testing for noninvasive inflammatory bowel disease monitoring in the tight control model.

The Role of Unobtrusive Home-Based Continuous Sensing in the Management of Post-Acute Sequelae of SARS CoV-2

UNSTRUCTURED

Amid the COVID-19 pandemic, it has been reported that greater than 35% of patients with confirmed or suspected COVID-19 develop post-acute sequelae of SARS CoV-2 (PASC). PASC is still a disease for which preliminary medical data is being collected-mostly measurements collected during hospital or clinical visits-and pathophysiological understanding is yet in its infancy. The disease is notable for its prevalence and its variable symptom presentation and as such, management plans could be more holistically made if health care providers had access to unobtrusive home-based wearable and contactless continuous physiologic and physical sensor data. Such between-hospital or between-clinic data can quantitatively elucidate a majority of the temporal evolution of PASC symptoms. While not universally of comparable accuracy to gold-standard medical devices, home-deployed sensors offer great insights into the development and progression of PASC. Suitable sensors include those providing vital signs and activity measurements that correlate directly or by proxy to documented PASC symptoms. Such continuous, home-based data can give care providers contextualized information from which symptom exacerbation or relieving factors may be classified. Such data can also improve the collective academic understanding of PASC by providing temporally and activity-associated symptom cataloging. In this viewpoint, we make a case for the utilization of home-based continuous sensing that can serve as a foundation from which medical professionals and engineers may develop and pursue long-term mitigation strategies for PASC.

Telemedicine in clinical gastroenterology practice: what do patients prefer?

BACKGROUND

The Coronavirus Disease 2019 pandemic has forced major changes on healthcare systems. Maintaining regular patients' surveillance became a major challenge. Telemedicine has been promoted as an economic and effective way for long distance patient care. Our aim was to study patients' acceptance and perspectives on telemedicine.

METHODS

Patients scheduled for clinic appointments were offered telemedicine. Those who agreed were asked to fill in a questionnaire assessing their satisfaction with the medical consultation. Patients' demographic characteristics and answers were collected and reviewed.

RESULTS

Out of 358 patients approached 71 agreed to use telemedicine. Of them, 59 completed the questionnaire and were included in the study. All patients' basic demographic data were collected. Patients' included in the study mean age was: 43 ± 16.3 years, 35 (59.3%) women. Patients who chose not to use telemedicine were significantly older, mean age: 61 ± 15.2 years (p = 0.036), 134 (46.7%) women. Most patients included (38; 64.4%) had inflammatory bowel disease (IBD). Most patients who chose not to use telemedicine were non-IBD patients (206, 72%). Fifty-one patients (86.4%) assessed their experience as 'good' or 'excellent'. Satisfied patients had significantly less time under medical follow-up (3.7 versus 6.1 years, p = 0.028) and tended to be younger (p = non-significant). Women were statistically significantly more satisfied than men (33 versus 18, p = 0.05). Advantages reported were 'time saving' (31.3%), accessibility (26.1%), availability (25%). The main disadvantage was absence of physical examination (70%).

CONCLUSIONS

Telemedicine gained a high satisfaction rate among patients under regular medical surveillance. Most patients stated this that method is convenient, time saving and increases their compliance. Patients who agreed to telecare were younger, and tended to be of female gender and experiencing IBD. Further studies are needed to characterize specific barriers to telecare usage.

Impact of Digital Health Monitoring in the Management of Inflammatory Bowel Disease

Technological advances now permit self-management strategies using mobile applications which could greatly benefit patient care. The purpose of this study was to investigate whether the use of the inflammatory bowel disease (IBD) digital health monitoring platform, HealthPROMISE, leads to better quality of care and improved health outcomes in IBD patients. IBD patients were recruited in gastroenterology clinics and asked to install the HealthPROMISE application onto their smartphones. Patient satisfaction, quality of care, quality of life, patient symptoms, and resource utilization metrics were collected throughout the study and sent directly to their healthcare teams. Patients with abnormal symptom/SIBDQ scores were flagged for their physicians to follow up. After one-year, patient outcome metrics were compared to baseline values. Overall, out of 59 patients enrolled in the study, 32 patients (54%) logged into the application at least once during the study period. The number of IBD-related ER visits/hospitalizations in the year of use compared to the prior year demonstrated a significant decrease from 25% of patients (8/32) to 3% (1/32) (p = 0.03). Patients also reported an increase in their understanding of the nature/causes of their condition after using the application (p = 0.026). No significant changes were observed in the number of quality indicators met (p = 0.67) or in SIBDQ scores (p = 0.48). Given the significant burden of IBD, there is a need to develop effective management strategies. This study demonstrated that digital health monitoring platforms may aid in reducing the number of ER visits and hospitalizations in IBD patients.

Self-monitoring with home based fecal calprotectin is associated with increased medical treatment. A randomized controlled trial on patients with inflammatory bowel disease

OBJECTIVES

Self-monitoring of inflammatory bowel disease (IBD) with the assistant of telemedicine and home-based fecal calprotectin (FC) tests is evolving in the management of IBD. We performed a randomized controlled trial to investigate the compliance and effects of the model IBD-Home in patients with IBD.

MATERIALS AND METHODS

Patients were randomized to IBD-Home + standard care (n = 84) or standard care alone (n = 74). Intervention with IBD-Home included IBDoc^® FC test kits and a digital application used for answering symptom questionnaires (Abbvie/Telia). They were instructed to use these on demand during a 12-month period. Data was collected retrospectively from medical records. Patients who completed the intervention were phoned and asked to answer a survey about the experience of IBD-Home.

RESULTS

The compliance to IBD-Home was low (29%). Women were more compliant compared with men (43% vs 17%, p < .001). A significantly higher proportion of patients in the IBD-Home group increased their medical treatment during the study period in comparison to control subjects (33% vs 15% p = .007) and there was an association between an increase in treatment and compliance to IBD home (multivariate odds ratio 3.22; 95^th confidence interval 1.04 - 9.95). Overall patients reported a positive experience with slight technical difficulties.

CONCLUSION

Self-monitoring with home based fecal calprotectin and a digital application was found feasible and appreciated by compliers. Compliance to the IBD-Home model was more common in women and associated with an increased treatment for IBD.

Smart Data Collection for the Assessment of Treatment Effects in Irritable Bowel Syndrome: Observational Study

BACKGROUND

End-of-day symptom diaries are recommended by drug regulatory authorities to assess treatment response in patients with irritable bowel syndrome. We developed a smartphone app to measure treatment response.

OBJECTIVE

Because the employment of an app to measure treatment response in irritable bowel syndrome is relatively new, we aimed to explore patients' adherence to diary use and characteristics associated with adherence.

METHODS

A smartphone app was developed to serve as a symptom diary. Patients with irritable bowel syndrome (based on Rome IV criteria) were instructed to fill out end-of-day diary questionnaires during an 8-week treatment. Additional online questionnaires assessed demographics, irritable bowel syndrome symptom severity, and psychosocial comorbidities. Adherence rate to the diary was defined as the percentage of days completed out of total days. Adherence to the additional web-based questionnaires was also assessed.

RESULTS

Overall, 189 patients were included (age: mean 34.0 years, SD 13.3 years; female: 147/189, 77.8%; male: 42/189, 22.2%). The mean adherence rate was 87.9% (SD 9.4%). However, adherence to the diary decreased over time (P<.001). No significant association was found between adherence and gender (P=.84), age (P=.22), or education level (lower education level: P=.58, middle education level: P=.46, versus high education level), while higher anxiety scores were associated with lower adherence (P=.03). Adherence to the online questionnaires was also high (>99%). Missing data due to technical issues were limited.

CONCLUSIONS

The use of a smartphone app as a symptom diary to assess treatment response resulted in high patient adherence. The data-collection framework described led to standardized data collection with excellent completeness and can be used for future randomized controlled trials. Due to the slight decrease in adherence to diary use throughout the study, this method might be less suitable for longer trials.

MyHealthyGut: Findings from a pilot randomized controlled trial on adherence to a gluten-free diet and quality of life among adults with celiac disease or gluten intolerance

Aims

The purpose of this study was to assess the effectiveness of a smartphone app (MyHealthyGut) in helping adults self-manage celiac disease or gluten intolerance and improve their gut health.

Methods

Adults diagnosed with celiac disease or gluten intolerance (N = 115) were randomized into two groups: experimental group 1 (had access to the app for a one-month period) or wait list control (WLC). After one month, WLC participants were given one-month access to the app (experimental group 2). An online questionnaire was administered to assess (a) user satisfaction with the app and (b) changes in the following patient-reported outcomes: adherence to a gluten-free diet, quality of life (QoL), self-regulatory efficacy, and feelings of depression and anxiety. Generalized estimating equations were used to assess changes in the outcome variables over time between the groups.

Results

Participants reported high levels of app usability, were satisfied with features of the app, and felt that the app was best suited for people newly diagnosed with celiac disease. Participants in the experimental groups reported improvements in adherence, gastrointestinal symptoms (experimental group 1 only), QoL, self-regulatory efficacy (experimental group 2 only), anxiety (experimental group 1 only), and depression (experimental group 2 only). Experimental group 1 and the WLC group reported significantly worse adherence after using the app based on the Celiac Dietary Adherence Test, which was in contrast to the accidental and purposeful measures of gluten consumption and symptoms for experimental group 1 but consistent with reports of accidental and purposeful gluten consumption and symptoms for the WLC group.

Conclusions

Based on feedback from the participants, the app may be best suited for individuals newly diagnosed or struggling with celiac disease or gluten intolerance. After using the MyHealthyGut app for a one-month period, adults with celiac disease reported improvements in psychosocial outcomes. Further iterations of the app are needed to meet the needs of this population better. MyHealthyGut is the first evidence-based app designed to help people with celiac disease or gluten intolerance.

Mobile Apps for Helping Patient-Users: Is It Still Far-Fetched?

Emergence of health-related smartphone applications and their wide dissemination in public as well as healthcare practitioners has undergone criticism under the scope of public health. Still, despite methodological issues curbing the initial enthusiasm, availability, safety and, in certain cases, documented efficacy of these measures has secured regulatory approval. Bearing in mind these pitfalls, we describe the necessary steps towards implementation of deep learning techniques in the specific clinical context of women’s health and infertility in particular.

Transforming Access to Specialist Care for Inflammatory Bowel Disease: The PACE Telemedicine Program

Background

There are significant geographic disparities in the delivery of IBD healthcare in Ontario which may ultimately impact health outcomes. Telemedicine-based health services may potentially bridge gaps in access to gastroenterologists in remote and underserved areas.

Methods

We conducted a needs assessment for IBD specialist care in Ontario using health administrative data. As part of a separate initiative to address geographic disparities in access to care, we described the development and implementation of our Promoting Access and Care through Centres of Excellence (PACE) Telemedicine Program. Over the first 18 months, we measured wait times and potential cost savings.

Results

We found substantial deficiencies in specialist care early in the course of IBD and continuous IBD care in regions where the number of gastroenterologists per capita were low. The PACE Telemedicine Program enabled new IBD consultations within a median time of 17 days (interquartile range [IQR], 7–32 days) and visits for active IBD symptoms with a median time of 8.5 days (IQR, 4–14 days). Forty-five percent of new consultations and 83% of patients with active IBD symptoms were seen within the target wait time of two weeks. Telemedicine services resulted in an estimated cost savings of $47,565 among individuals who qualified for Ontario’s Northern Travel Grant.

Conclusions

The implementation of telemedicine services for IBD is highly feasible and can reduce wait times to see gastroenterologists that meet nationally recommended targets and can lead to cost savings.

Outcome measures in coeliac disease trials: the Tampere recommendations

OBJECTIVE

A gluten-free diet is the only treatment option of coeliac disease, but recently an increasing number of trials have begun to explore alternative treatment strategies. We aimed to review the literature on coeliac disease therapeutic trials and issue recommendations for outcome measures.

DESIGN

Based on a literature review of 10 062 references, we (17 researchers and 2 patient representatives from 10 countries) reviewed the use and suitability of both clinical and non-clinical outcome measures. We then made expert-based recommendations for use of these outcomes in coeliac disease trials and identified areas where research is needed.

RESULTS

We comment on the use of histology, serology, clinical outcome assessment (including patient-reported outcomes), quality of life and immunological tools including gluten immunogenic peptides for trials in coeliac disease.

CONCLUSION

Careful evaluation and reporting of outcome measures will increase transparency and comparability of coeliac disease therapeutic trials, and will benefit patients, healthcare and the pharmaceutical industry.

Can Smartphones Help Deliver Smarter Care for Patients With Inflammatory Bowel Disease?

The addition of smartphone applications to the armamentarium of tools to help manage patients with inflammatory bowel disease (IBD) has the potential to improve care in multiple ways, including enhanced disease understanding, improved adherence to medications, accessible support networks, and earlier interventions by medical professionals when problems arise. However, at present, for patients with IBD, the development of such mobile applications is still in its infancy. We conducted a review of the literature and online resources including phone application stores (Apple and Android app stores) to assess the current availability of mobile health applications for IBD patients and opportunities to increase patient engagement. We also addressed the limitations and challenges of patient and provider adoption of mobile-based technologies for IBD self-management and remote monitoring.

Remote Patient Monitoring in IBD: Current State and Future Directions

PURPOSE OF REVIEW

Mobile apps are now increasingly used in conjunction with telemedicine and wearable devices to support remote patient monitoring (RPM). The goal of this paper is to review the available evidence and assess the scope of RPM integration into standard practices for care and management of chronic disease in general and, more specifically, inflammatory bowel disease (IBD).

RECENT FINDINGS

RPM has been associated with improvements in health outcomes and indicators across a broad range of chronic diseases. However, there is limited data on the effectiveness of RPM in IBD care. From the emerging literature and body of research, we found promising results about the feasibility of integrating RPM in IBD care and RPM's capacity to support IBD improvement in key process and outcome metrics. Concerns regarding privacy and provider acceptability have limited the mass integration of RPM to date. However, with the healthcare industry's move toward value-based population care and the advent of novel payment models for RPM reimbursement, the adoption of RPM into standard IBD care practices will likely increase as the technology continues to improve and become a mainstream tool for healthcare delivery in the near future.

Leveraging Social Networking Sites for an Autoimmune Hepatitis Genetic Repository: Pilot Study to Evaluate Feasibility

Background

Conventional approaches to participant recruitment are often inadequate in rare disease investigation. Social networking sites such as Facebook may provide a vehicle to circumvent common research limitations and pitfalls. We report our preliminary experience with Facebook-based methodology for participant recruitment and participation into an ongoing study of autoimmune hepatitis (AIH).

Objective

The goal of our research was to conduct a pilot study to assess whether a Facebook-based methodology is capable of recruiting geographically widespread participants into AIH patient-oriented research and obtaining quality phenotypic data.

Methods

We established a Facebook community, the Autoimmune Hepatitis Research Network (AHRN), in 2014 to provide a secure and reputable distillation of current literature and AIH research opportunities. Quarterly advertisements for our ongoing observational AIH study were posted on the AHRN over 2 years. Interested and self-reported AIH participants were subsequently enrolled after review of study materials and completion of an informed consent by our study coordinator. Participants returned completed study materials, including epidemiologic questionnaires and genetic material, to our facility via mail. Outside medical records were obtained and reviewed by a study physician.

Results

We successfully obtained all study materials from 29 participants with self-reported AIH within 2 years from 20 different states. Liver biopsy results were available for 90% (26/29) of participants, of which 81% (21/29) had findings consistent with AIH, 15% (4/29) were suggestive of AIH with features of primary biliary cholangitis (PBC), and 4% (1/29) had PBC alone. A total of 83% (24/29) had at least 2 of 3 proposed criteria: positive autoimmune markers, consistent histologic findings of AIH on liver biopsy, and reported treatment with immunosuppressant medications. Self-reported and physician records were discrepant for immunosuppressant medications or for AIH/PBC diagnoses in 4 patients.

Conclusions

Facebook can be an effective ancillary tool for facilitating patient-oriented research in rare diseases. A social media-based approach transcends established limitations in rare disease research and can further develop research communities.

E-health in inflammatory bowel diseases: More challenges than opportunities?

Patients with inflammatory bowel disease need close monitoring for an optimal disease management. For this, e-health technologies are promising tools. But the current evidence for the implementation of e-health in inflammatory bowel disease is weak. For this a critical evaluation of the existing evidence is presented. Furthermore some essential conditions need to be full-filled. We need a robust digital infrastructure that is workable for the patient and the healthcare provider. Important legal issues need to be solved to protect the patient. And the e-health technologies will have to proof their durability, feasibility and acceptance for the patient on the long term.

White Paper AGA: The Impact of Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel Disease

Patients with chronic medically complex disorders like inflammatory bowel diseases (BD) often have mental health and psychosocial comorbid conditions. There is growing recognition that factors other than disease pathophysiology impact patients' health and wellbeing. Provision of care that encompasses medical care plus psychosocial, environmental and behavioral interventions to improve health has been termed "whole person care" and may result in achieving highest health value. There now are multiple methods to survey patients and stratify their psychosocial, mental health and environmental risk. Such survey methods are applicable to all types of IBD programs including those at academic medical centers, independent health systems and those based within independent community practice. Once a practice determines that a patient has psychosocial needs, a variety of resources are available for referral or co-management as outlined in this paper. Included in this white paper are examples of psychosocial care that is integrated into IBD practices plus innovative methods that provide remote patient management.

Digital Technology Healthcare Solutions in an Era of Moving Populations and Chronic Illnesses: Are We Being Realistically Smart?

In 2015, the world recorded its highest numbers of international migrants and forced displacement since World War II. With this historic rise in migrants, refugees, and displaced persons around the world, there is a huge risk of chronic illness burden on healthcare systems. Thus, healthcare systems may need to incorporate innovative digital healthcare solutions into their processes and procedures. The purpose of this article is to present the argument that for effective prevention and management of chronic illnesses in ever-increasing migrant societies to be achieved, mobile digital healthcare technologies must be realistically smart and strategically adopted. Beginning with an overview of the current global migration trend, this article considers the implications of this trend for chronic illnesses and the potential for mobile health technologies to support achievement of healthcare outcomes. It highlights three core reasons why digital innovations may be limited as tools for helping to address the global chronic illness challenge and identifies important directions for mobile health technology developers, healthcare professionals, researchers, government and funding agencies, and public health ministries, with a focus on the strategic development and adoption of ‘realistically smart’ phones. The article concludes with recommendations for research and public health education.

Transforming Gastroenterology Care With Telemedicine

Health care is changing rapidly, so we must change with the times to develop more efficient, practical, cost-effective, and, importantly, high-quality methods to care for patients. We teach medical students that optimal patient care requires face-to-face interaction to collect information on the patient's history and perform the physical examination. However, management of many patients-especially those with chronic diseases-does not always require physical examination. Telemedicine offers an opportunity to take advantage of technology while leveraging the progressive push toward efficiency and value but also requires the belief that excellent patient care is not always provided in person. Telemedicine can include a variety of aspects of patient care adapted to be performed remotely, such as telemonitoring, tele-education, teleconsultation, and telecare. All of these have been evaluated in gastroenterology practice and have demonstrated feasibility and patient preference but have produced mixed results regarding patient outcomes. By combining telemedicine tools and new care models, we can redesign chronic disease management to include fewer in-person visits when patients are well yet increase access for patients who need to be seen. This change could lead to higher-value care by improving the experience of care, decreasing costs, and improving the health of the population. Barriers include reimbursement, licensing, and fear of litigation. However, if we hope to meet the needs of patients within our changing health care system, telemedicine should be incorporated into our strategy.