Adoption of telemedicine: from pilot stage to routine delivery

Overcoming bias in estimating epidemiological parameters with realistic history-dependent disease spread dynamics

Epidemiological parameters such as the reproduction number, latent period, and infectious period provide crucial information about the spread of infectious diseases and directly inform intervention strategies. These parameters have generally been estimated by mathematical models that involve an unrealistic assumption of history-independent dynamics for simplicity. This assumes that the chance of becoming infectious during the latent period or recovering during the infectious period remains constant, whereas in reality, these chances vary over time. Here, we find that conventional approaches with this assumption cause serious bias in epidemiological parameter estimation. To address this bias, we developed a Bayesian inference method by adopting more realistic history-dependent disease dynamics. Our method more accurately and precisely estimates the reproduction number than the conventional approaches solely from confirmed cases data, which are easy to obtain through testing. It also revealed how the infectious period distribution changed throughout the COVID-19 pandemic during 2020 in South Korea. We also provide a user-friendly package, IONISE, that automates this method.

Towards an early warning system for monitoring of cancer patients using hybrid interactive machine learning

Background

The use of smartphone apps in cancer patients undergoing systemic treatment can promote the early detection of symptoms and therapy side effects and may be supported by machine learning (ML) for timely adaptation of therapies and reduction of adverse events and unplanned admissions.

Objective

We aimed to create an Early Warning System (EWS) to predict situations where supportive interventions become necessary to prevent unplanned visits. For this, dynamically collected standardized electronic patient reported outcome (ePRO) data were analyzed in context with the patient's individual journey. Information on well-being, vital parameters, medication, and free text were also considered for establishing a hybrid ML model. The goal was to integrate both the strengths of ML in sifting through large amounts of data and the long-standing experience of human experts. Given the limitations of highly imbalanced datasets (where only very few adverse events are present) and the limitations of humans in overseeing all possible cause of such events, we hypothesize that it should be possible to combine both in order to partially overcome these limitations.

Methods

The prediction of unplanned visits was achieved by employing a white-box ML algorithm (i.e., rule learner), which learned rules from patient data (i.e., ePROs, vital parameters, free text) that were captured via a medical device smartphone app. Those rules indicated situations where patients experienced unplanned visits and, hence, were captured as alert triggers in the EWS. Each rule was evaluated based on a cost matrix, where false negatives (FNs) have higher costs than false positives (FPs, i.e., false alarms). Rules were then ranked according to the costs and priority was given to the least expensive ones. Finally, the rules with higher priority were reviewed by two oncological experts for plausibility check and for extending them with additional conditions. This hybrid approach comprised the application of a sensitive ML algorithm producing several potentially unreliable, but fully human-interpretable and -modifiable rules, which could then be adjusted by human experts.

Results

From a cohort of 214 patients and more than 16'000 available data entries, the machine-learned rule set achieved a recall of 19% on the entire dataset and a precision of 5%. We compared this performance to a set of conditions that a human expert had defined to predict adverse events. This "human baseline" did not discover any of the adverse events recorded in our dataset, i.e., it came with a recall and precision of 0%. Despite more plentiful results were expected by our machine learning approach, the involved medical experts a) had understood and were able to make sense of the rules and b) felt capable to suggest modification to the rules, some of which could potentially increase their precision. Suggested modifications of rules included e.g., adding or tightening certain conditions to make them less sensitive or changing the rule consequences: sometimes further monitoring the situation, applying certain test (such as a CRP test) or applying some simple pain-relieving measures was deemed sufficient, making a costly consultation with the physician unnecessary. We can thus conclude that it is possible to apply machine learning as an inspirational tool that can help human experts to formulate rules for an EWS. While humans seem to lack the ability to define such rules without such support, they are capable of modifying the rules to increase their precision and generalizability.

Conclusions

Learning rules from dynamic ePRO datasets may be used to assist human experts in establishing an early warning system for cancer patients in outpatient settings.

A retrospective analysis of e-prescriptions for non-communicable diseases on a telehealth platform in Malaysia

BACKGROUND

The management of non-communicable diseases (NCDs) has benefited from telehealth services. As these services which include teleconsultation services and e-prescriptions are relatively new in Malaysia, the data generated provide an unprecedented opportunity to study medication use patterns for the management of NCDs in the country. We analyze e-prescriptions from a local telehealth service to identify medication use patterns and potential areas to optimize medication use in relation to clinical practice guidelines.

METHODS

A cross sectional observational study was conducted by retrieving e-prescription records retrospectively from a telehealth service. 739,482 records from January 2019 to December 2021 were extracted using a designated data collection form. Data cleaning, standardization and data analysis were performed using Python version 3.11. The diagnoses were classified according to the International Classification of Disease 10 (ICD-10), while medications were classified using the Anatomical Therapeutic Chemical (ATC) system. Diagnoses, frequency of use for medication classes and individual medications were analyzed and compared to clinical practice guidelines.

RESULTS

The top five NCD diagnoses utilized by the service were hypertension (37.7%), diabetes mellitus (25.1%), ischemic heart disease (24.3%), asthma (14.4%), and dyslipidemia (11.7%). Medications were prescribed mostly in accordance with guideline recommendations. However, angiotensin receptor blockers (ARBs) were significantly more frequently prescribed compared to angiotensin converting enzyme inhibitors (ACEIs). Several medication classes appeared underutilized, including ACEIs in hypertensive patients with diabetes or ischemic heart disease, sodium glucose cotransporter 2 inhibitors in diabetic patients with ischemic heart disease, and metformin in patients with diabetes.

CONCLUSIONS

Telehealth services are currently being utilized for the management of NCDs. Medication use for the management of NCDs through these services are mostly in accordance with guideline recommendations, but there exist areas that would warrant further investigation to ensure optimal clinical and economic outcomes are achieved.

Arrhythmia detection by the graph convolution network and a proposed structure for communication between cardiac leads

One of the most common causes of death worldwide is heart disease, including arrhythmia. Today, sciences such as artificial intelligence and medical statistics are looking for methods and models for correct and automatic diagnosis of cardiac arrhythmia. In pursuit of increasing the accuracy of automated methods, many studies have been conducted. However, in none of the previous articles, the relationship and structure between the heart leads have not been included in the model. It seems that the structure of ECG data can help develop the accuracy of arrhythmia detection. Therefore, in this study, a new structure of Electrocardiogram (ECG) data was introduced, and the Graph Convolution Network (GCN), which has the possibility of learning the structure, was used to develop the accuracy of cardiac arrhythmia diagnosis. Considering the relationship between the heart leads and clusters based on different ECG poles, a new structure was introduced. In this structure, the Mutual Information(MI) index was used to evaluate the relationship between the leads, and weight was given based on the poles of the leads. Weighted Mutual Information (WMI) matrices (new structure) were formed by R software. Finally, the 15-layer GCN network was adjusted by this structure and the arrhythmia of people was detected and classified by it. To evaluate the performance of the proposed new network, sensitivity, precision, specificity, accuracy, and confusion matrix indices were used. Also, the accuracy of GCN networks was compared by three different structures, including WMI, MI, and Identity. Chapman's 12-lead ECG Dataset was used in this study. The results showed that the values of sensitivity, precision, specificity, and accuracy of the GCN-WMI network with 15 intermediate layers were equal to 98.74%, 99.08%, 99.97% & 99.82%, respectively. This new proposed network was more accurate than the Graph Convolution Network-Mutual Information (GCN-MI) with an accuracy equal to 99.71% and GCN-Id with an accuracy equal to 92.68%. Therefore, utilizing this network, the types of arrhythmia were recognized and classified. Also, the new network proposed by the Graph Convolution Network-Weighted Mutual Information (GCN-WMI) was more accurate than those conducted in other studies on the same data set (Chapman). Based on the obtained results, the structure proposed in this study increased the accuracy of cardiac arrhythmia diagnosis and classification on the Chapman data set. Achieving such accuracy for arrhythmia diagnosis is a great achievement in clinical sciences.

The roles of health literacy and social support in the association between smartphone ownership and frailty in older adults: a moderated mediation model

BACKGROUND

Understanding the role of smartphones to promote the health status of older adults is important in the digital society. Little is known about the effects of having smartphones on physical frailty despite its positive effect on the well-being of older adults. This study aimed to explore the association between smartphone ownership and frailty in community-dwelling older adults and its underlying mechanism.

METHODS

We used data from the Korean Frailty and Aging Cohort Study and analyzed 2,469 older adults aged 72-86 years. Frailty, health literacy, and social support were assessed by Fried's frailty phenotype, the Behavioral Risk Factor Surveillance System health literacy module, and the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Instrument, respectively. The mediation model and moderated mediation model were estimated, where the mediator was health literacy and the moderator was social support, to explore the relationship between smartphone ownership and frailty.

RESULTS

Of our study participants, 58.9% owned smartphones, and 10.9% were classified as frail. Smartphone ownership was negatively associated with frailty (β = -0.623, p < 0.001). Health literacy mediated the relationship between smartphone ownership and frailty (β = -0.154, boot confidence interval [CI] = - 0.222, - 0.096), and social support moderated the mediation effect (β = -0.010, Boot CI = - 0.016, - 0.004).

CONCLUSIONS

Owning smartphones among older adults could reduce the risk of frailty. Promoting health literacy and social support among older adults with smartphones would be effective to prevent frailty.

The use of medical health applications by primary care physicians in Israel: a cross-sectional study

BACKGROUND

The use of medical health applications (mHealth apps) by patients, caregivers, and physicians is widespread. mHealth apps are often employed by physicians to quickly access professional knowledge, guide treatment, easily retrieve medical records, and monitor and manage patients. This study sought to characterize the use of mHealth apps among primary care physicians (PCPs) in Israel. The reasons for using apps and barriers to their use were also investigated.

METHODS

From all MHS' PCPs, we randomly selected 700 PCPs and invited them to complete a questionnaire regarding the use of mHealth apps and attitudes toward them.

RESULTS

From August 2020 to December 2020, 191 physicians completed the questionnaire (response rate 27.3%). 68.0% of PCPs reported using mHealth apps. Telemedicine service apps were the most frequently used. Medical calculators (used for clinical scoring) and differential diagnosis apps were the least frequently used. The most common reason for mHealth app use was accessibility, followed by time saved and a sense of information reliability. Among infrequent users of apps, the most common barriers reported were unfamiliarity with relevant apps and preference for using a computer. Concerns regarding information reliability were rarely reported by PCPs. Physician gender and seniority were not related to mHealth app use. Physician age was related to the use of mHealth apps.

CONCLUSIONS

mHealth apps are widely used by PCPs in this study, regardless of physician gender or seniority. Information from mHealth apps is considered reliable by PCPs. The main barrier to app use is unfamiliarity with relevant apps and preference for computer use.

Users' involvement in digital health collaborative projects

PURPOSE

This research analyzes the roles of users in innovative digital health collaborative projects from the perspective of the user by considering three dimensions: their motivation, project activities and the support of the partnership for their effective involvement.

DESIGN/METHODOLOGY/APPROACH

The authors unraveled profiles of users by using a Q-methodological analysis of 24 statements and 44 service users. The statements for the three dimensions were designed according to previous models of stakeholder identification and customer participation in new product management.

FINDINGS

The authors obtained two profiles that advocate active participation of users, though with a different degree of involvement. One of them supports the role of users as "advisors" of users' preferences and needs, and the other indicates a higher involvement of users as "cocreators" of the innovation, with the same contribution and responsibility as the other partners.

ORIGINALITY/VALUE

Previous research has analyzed user involvement in digital health, as part of wider research on factors leading to the success and adoption of innovations. Moreover, previous research has analyzed user involvement in innovation projects, but without differentiating between projects carried out by an individual organization and those conducted by a partnership. This research contributes to filling this gap by revealing users' expectations about their involvement and how they think they will fit in with the dynamics of collaborative projects.

The Role of Initial Trust in the Behavioral Intention to Use Telemedicine Among Filipino Older Adults

This study investigated the behavioral intention of Filipino older adults toward using telemedicine and the pivotal role of initial trust in influencing this intention. A cross-sectional method was employed, involving a questionnaire administered to 180 participants using convenience sampling. The structural model test results indicate that subjective norm, attitude, and notably, initial trust positively impact the behavioral intention to use telemedicine, whereas perceived behavioral control does not significantly affect intention. This underscores the significance of subjective norm and attitude in shaping behavioral intention, consistent with the Theory of Planned Behavior (TPB), while the extended construct of initial trust played a crucial role in influencing the attitude and intention of older adults, highlighting its importance in technology adoption. The study aligns with the trend of increased telemedicine adoption during the COVID-19 pandemic, emphasizing the need for trust in sensitive healthcare contexts. Establishing initial trust is vital for successful telemedicine implementation among Filipino older adults, enhancing healthcare accessibility and well-being.

Advances in artificial intelligence, robotics, augmented and virtual reality in neurosurgery

Neurosurgical practitioners undergo extensive and prolonged training to acquire diverse technical proficiencies, while neurosurgical procedures necessitate a substantial amount of pre-, post-, and intraoperative clinical data acquisition, making decisions, attention, and convalescence. The past decade witnessed an appreciable escalation in the significance of artificial intelligence (AI) in neurosurgery. AI holds significant potential in neurosurgery as it supplements the abilities of neurosurgeons to offer optimal interventional and non-interventional care to patients by improving prognostic and diagnostic outcomes in clinical therapy and assisting neurosurgeons in making decisions while surgical interventions to enhance patient outcomes. Other technologies including augmented reality, robotics, and virtual reality can assist and promote neurosurgical methods as well. Moreover, they play a significant role in generating, processing, as well as storing experimental and clinical data. Also, the usage of these technologies in neurosurgery is able to curtail the number of costs linked with surgical care and extend high-quality health care to a wider populace. This narrative review aims to integrate the results of articles that elucidate the role of the aforementioned technologies in neurosurgery.

The Case Manager: An Agent Controlling the Activation of Knowledge Sources in a FHIR-Based Distributed Reasoning Environment

BACKGROUND

Within the CAPABLE project the authors developed a multi-agent system that relies on a distributed architecture. The system provides cancer patients with coaching advice and supports their clinicians with suitable decisions based on clinical guidelines.

OBJECTIVES

As in many multi-agent systems we needed to coordinate the activities of all agents involved. Moreover, since the agents share a common blackboard where all patients' data are stored, we also needed to implement a mechanism for the prompt notification of each agent upon addition of new information potentially triggering its activation.

METHODS

The communication needs have been investigated and modeled using the HL7-FHIR (Health Level 7-Fast Healthcare Interoperability Resources) standard to ensure proper semantic interoperability among agents. Then a syntax rooted in the FHIR search framework has been defined for representing the conditions to be monitored on the system blackboard for activating each agent.

RESULTS

The Case Manager (CM) has been implemented as a dedicated component playing the role of an orchestrator directing the behavior of all agents involved. Agents dynamically inform the CM about the conditions to be monitored on the blackboard, using the syntax we developed. The CM then notifies each agent whenever any condition of interest occurs. The functionalities of the CM and other actors have been validated using simulated scenarios mimicking the ones that will be faced during pilot studies and in production.

CONCLUSION

The CM proved to be a key facilitator for properly achieving the required behavior of our multi-agent system. The proposed architecture may also be leveraged in many clinical contexts for integrating separate legacy services, turning them into a consistent telemedicine framework and enabling application reusability.

Medical imaging consultation practices and challenges at public hospitals in the Amhara regional state, Northwest Ethiopia: a descriptive phenomenological study

BACKGROUND

Medical imaging plays a vital role in the accurate diagnosis, treatment and outcome prediction of many diseases and injuries. However, in many African countries, deserving populations do not have access to the proper medical imaging specialists' services. As a result, clinicians continue to struggle to provide medical imaging via consultation. However, little is known about conventional referral consultation practices and their challenges. This study, therefore, aimed to explore the practice and challenges of medical imaging service consultation among health professionals and patients in the context of the Ethiopian public healthcare delivery system.

METHODS

Descriptive phenomenological study was employed to explore the practice of medical imaging service consultation among health professionals and patients in public hospitals of Amhara region from October 12, 2021 to December 29, 2021. Semi-structured interview guides were prepared separately for key-informant and in-depth interviews. A total of 21 participants (6 hospital managers, 4 medical directors, 4 department heads, 3 medical imaging coordinators and 4 patients) were selected using the maximum variation sampling technique. All interviews were audio-recorded, transcribed verbatim and subjected to inductive thematic analysis using Open Code 4.02 software.

RESULTS

Six major themes emerged following the thematic analysis: (1) medical image service delivery practices; (2) medical imaging consultation modalities; (3) benefits and drawbacks of the consultation modalities; (4) challenges; (5) challenge mitigation strategies; and (6) future recommendations. Image films, compact disks, and telegram apps were the consultation modalities used by the referring clinicians to send the medical images to radiologists. Frequent failure of imaging machines, delayed equipment maintenance, inadequate infrastructure, shortage of budget, lack of radiologists, and low-quality of printed image films were among the challenges influencing the medical imaging consultation service.

CONCLUSIONS

This research explored onsite and referral imaging consultation practices. However, there are many challenges encountered by the referring clinicians and the radiologists during the consultation process. These challenges could potentially affect clinicians' ability to provide timely diagnosis and treatment services which would ultimately affects patient health status and service delivery. Virtual consultation via teleradiology and enhancing clinicians' competence through long-term and short-term trainings are recommended to improve the referral consultation practice.

Experiences with the quality of telemedical care in an offshore setting - a qualitative study

BACKGROUND

The evaluation and the improvement of the quality of telemedical care become increasingly important in times where this type of care is offered to a broad number of patients more and more. As telemedical care in an offshore setting has already been in use for decades, analyzing the extensive experience of offshore paramedics using telemedical care can help identify determinants of quality. Therefore, the aim of this study was to explore determinants of the quality of telemedical care using the experiences of experienced offshore paramedics.

METHODS

We conducted a qualitative analysis of 22 semi-structured interviews with experienced offshore paramedics. The results were categorized in a hierarchical category system using content analysis as described by Mayring.

RESULTS

All 22 participants were males, having a mean of 3.9 years of experience working with telemedicine support offshore. Generally, participants stated that for them telemedical interaction did not differ much from personal interaction. However, the offshore paramedics personality and way to communicate were mentioned to impact the quality of telemedical care as it influenced the way cases were presented. Furthermore, interviewees described it to be impossible to use telemedicine in cases of an emergency as it was too time-consuming, technically too complex, and lead to cognitive overload as other tasks with higher priority needed their attention. Three determinants of a successful consultation were mentioned: low levels of complexity in the reason for consultation, telemedical guidance training for the teleconsultant physician and for the delegatee.

CONCLUSION

Appropriate indications for telemedical consultation, communication training of consultation partners, and the impact of personality need to be addressed to enhance the quality of future telemedical care.

Factors that influence the adoption of rehabilitation technologies: a multi-disciplinary qualitative exploration

BACKGROUND

Technological innovation is recognised as having the potential to enhance rehabilitation for people with disability. Yet, resistance to, and abandonment of, rehabilitation technology is prevalent and the successful translation of technology into rehabilitation settings remains limited. Therefore, the aim of this work was to develop an in-depth, multi-stakeholder perspective on what influences the adoption of rehabilitation technologies.

METHODS

Semi-structured focus groups were conducted as part of a larger research project aiming to facilitate the co-design of a novel neurorestorative technology. Focus group data were analysed using a five-phase hybrid deductive-inductive approach to qualitative data analysis.

RESULTS

Focus groups were attended by 43 stakeholders with expertise in one or more of the following fields: people with disability, allied health, human movement science, computer science, design, engineering, ethics, funding, marketing, business, product development, and research development. Six main themes influencing the adoption of technology in rehabilitation were identified: cost beyond the purchase price, benefits to all stakeholders, trust to be earned in technology, ease of technology operation, ability to access technology, and the 'co' in co-design. All six themes were found to be interrelated; in particular, the importance of direct stakeholder engagement in the development of rehabilitation technologies (the 'co' in co-design) was prevalent in all themes.

CONCLUSIONS

A range of complex and interrelated factors influence the adoption of rehabilitation technologies. Importantly, many of the issues that have the potential to negatively impact rehabilitation technology adoption may be addressed during development by utilising the experience and expertise of stakeholders who influence its supply and demand. Our findings state that a wider cohort of stakeholders needs to be actively engaged in the development of rehabilitation technologies to better address the factors that contribute to technology underutilisation and abandonment and facilitate better outcomes for people with disability.

Implementing interprofessional video consultations with general practitioners and psychiatrists in correctional facilities in Germany: results from a mixed-methods study

BACKGROUND

Adequate health care in correctional facilities is often limited by staff shortage, which entails time-consuming consultations with physicians outside of these facilities. Video consultations (VC) have been implemented in many different health care settings and may also be useful in correctional facilities. As part of a pilot project, synchronous VC were implemented in five correctional facilities in Germany in June 2018. The aim of this study was to describe the implementation process from the providers' perspective and to identify factors promoting or inhibiting the implementation process of VC with a focus on interprofessional collaboration between nursing staff and telemedicine physicians.

METHODS

As part of the mixed-methods evaluation of the pilot project, site visits to the five correctional facilities were carried out. Nursing staff from the five correctional facilities (n=49) and telemedicine physicians (n=10) were asked to participate in interviews and a questionnaire survey. Interviews were analyzed using qualitative content analysis and questionnaires were evaluated using descriptive statistical methods. The results from both data sources were integrated and discussed in the framework of Normalization Process Theory.

RESULTS

Interviews were conducted with 24.5% (n=12) of nursing staff and 20.0% (n=2) of telemedicine physicians, while questionnaires were returned by 22.5% (n=11) of nursing staff and 33.3% (n=3) of telemedicine physicians. VC with general practitioners and psychiatrists were perceived as an additional support during times when physicians were absent from the correctional facilities. Allocating telemedicine physicians to specific correctional facilities might further improve interprofessional collaboration with nursing staff during VC. Inhibiting factors comprised the lack of integrating nursing staff into the implementation process, increased workload, insufficient training and the implementation of VC at an inconvenient time.

CONCLUSIONS

To summarize, VC are a promising supplement to face-to-face health care in correctional facilities despite several limitations. These might be compensated by improving interprofessional cooperation and by integrating telemedicine physicians into local health care teams.

Telehealth services for global emergencies: implications for COVID-19: a scoping review based on current evidence

INTRODUCTION

The availability of low-cost computing and digital telecommunication in the 1980s made telehealth practicable. Telehealth has the capacity to improve healthcare access and outcomes for patients while reducing healthcare costs across a wide range of health conditions and situations.

OBJECTIVE

This study compares the adoption, advantages, and challenges of telehealth services between high-income (HICs) and low-and-middle-income countries (LMICs) before and during the COVID-19 pandemic.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The key search terms were: "Telehealth", "Telehealth in HICs", "Telehealth in LMICs", "Telehealth before COVID-19", "Telehealth during COVID-19". We searched exhaustively ProQuest, Scopus, Web of Science, Google Scholar, CINAHL, and EMBASE databases from 2012. Booleans OR/AND were combined with key search terms to increase relevant search results. The literature search and selection process followed the Sample, Phenomena of Interest, Design, Evaluation, and Research (SPIDER) question format.

RESULTS

The adoption of telehealth before COVID-19 was generally low in both HICs and LMICs. The impact of COVID-19 accelerated the adoption of telehealth at the facility level but not nationwide in both high-income countries and LMICs. The rapid adoption of telehealth at the facility level in both high-income and LMICs introduced several challenges that are unique to each country and need to be addressed.

CONCLUSION

The lack of national policies and regulations is making the adoption of telehealth at the national level challenging in both high and low-middle-income countries. Governments and Stakeholders of healthcare must consider telehealth as a healthcare procedure that should be deployed in clinical working procedures. Primary quantitative and qualitative studies must be conducted to address challenges encountered during the pilot implementation of telehealth services in both high-income countries and LMICs before and during pandemics.

Contributions of digital social research to develop Telemedicine in Calabria (Southern Italy): identification of inequalities in post-COVID-19

The paper discusses the role that sociology and digital social research methods could play in developing E-health and Telemedicine, specifically after the COVID-19 pandemic, and the possibility of dealing with new pandemics. In this article, we will reflect on an interdisciplinary research pilot project carried out by a team of sociologists, medical doctors, and software engineers at The University of Calabria (Italy), to give a proof of concept of the importance to develop Telemedicine through the contribution of digital social research. We apply a web and app survey to administrate a structured questionnaire to a self-selected sample of the University Community. Digital social research has highlighted socioeconomic and cultural gaps that affect the perception of Telemedicine in the University Community. In particular, gender, age, educational, and professional levels influence medical choices and behaviors during Covid-19. There is often an unconscious involvement in Telemedicine (people use it but don't know it is Telemedicine), and an optimistic perception grows with age, education, professional, and income levels; equally important are the comprehension of digital texts and the effective use of Telemedicine. Limited penetration of technological advances must be addressed primarily by overcoming sociocultural and economic barriers and developing knowledge and understanding of digital environments. The key findings of this study could help direct public and educational policies to reduce existing gaps and promote Telemedicine in Calabria.

Auditing the Audits: A Systematic Review on Different Procedures in Telemedicine

Telemedicine is a process of delivering health care using information and communication technologies. Audit and feedback (A&F) constitute a systematic intervention that is aimed at collecting data, which are subsequently compared with reference standards and then returned to health care operators through feedback meetings. The aim of this review is to analyse different audit procedures on and by mean of telemedicine services and to identify a practice that is more effective than the others. Systematic searches were performed in three databases evaluating studies focusing on clinical audits performed on and by means of telemedicine systems. Twenty-five studies were included in the review. Most of them focused on telecounselling services with an audit and a maximum duration of one year. Recipients of the audit were telemedicine systems and service users (general practitioners, referring doctors, and patients). Data resulting from the audit were inherent to the telemedicine service. The overall data collected concerned the number of teleconsultations, service activity, reasons for referral, response times, follow-up, reasons why treatment was not completed, technical issues, and other information specific to each telemedicine service. Only two of the considered studies dealt with organizational aspects, and of these, only one analysed communicative aspects. The complexity and heterogeneity of the treatments and services provided meant that no index of uniformity could be identified. Certainly, some audits were performed in an overlapping manner in the different studies, and these show that although attention is often paid to workers' opinions, needs, and issues, little interest was shown in communicative/organizational and team dynamics. Given the importance and influence that communication has in teamwork and care settings, an audit protocol that takes into account intra- and extra-team communication processes could be essential to improving the well-being of operators and the quality of the service provided.

Inequities and Research Gaps in Ophthalmology: A Scoping Review

Importance

Deficient ophthalmologic care is costly to patients, making the identification of groups not receiving adequate care of vital importance. The current landscape of equity in ophthalmic care has yet to be thoroughly investigated and is important to ensure inclusivity and patient-centered care.

Objective

To perform a scoping review of the literature pertaining to health care inequities in the field of ophthalmology.

Evidence Review

A comprehensive database search using MEDLINE (via PubMed) and Ovid Embase was done in July 2022. English-language articles published from 2016 to 2021 were included and encompassed all article types except commentaries or correspondence. The search modeled the National Institutes of Health list of designated US health inequity populations, which includes income, education level, occupational status, rural and underresourced area, sex and gender, lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity, and race and ethnicity. A total of 8170 abstracts and titles were screened by 2 independent investigators, and 189 studies were assessed in full text for eligibility. For inclusion, articles needed to be an ophthalmic study discussing health inequities. In a masked, duplicate fashion, 2 independent investigators screened 75 full-text studies for data extraction using a pilot-tested form. Data extraction included general publication characteristics and health inequity data based on the National Institutes of Health's defined inequity groups.

Findings

A total of 75 publications were included. Notable inequities were found among Black and Hispanic patients associated with negative ophthalmic outcomes and mixed associations regarding sex or gender. Overall, lower-income patients were more likely to have vision impairment, use eye care services less, and have lower adherence to eye examinations. No articles within our sample examined LGBTQ inequities among ophthalmology patients since the 2016 National Institutes of Health classification of sexual and gender minority populations. Substantial research gaps were observed within the ophthalmic literature pertaining to the LGBTQ community, race and ethnicity, and rural and underresourced areas.

Conclusions and Relevance

This scoping review found substantial findings associated with the LGBTQ community, race and ethnicity, and the role of telemedicine in rural and underresourced areas. Because of the importance of ophthalmic care in overall patient health, it is vital to understand the various inequities present and strive to improve the current gaps in the literature. Future studies should (1) examine barriers to clinical study and medical trainee recruitment as well as patient values and preference studies and (2) investigate the implementation of telemedicine in underresourced areas.

Telemedicine and health disparities: Association between patient characteristics and telemedicine, in-person, telephone and message-based care during the COVID-19 pandemic

Telemedicine has been an essential form of care since the onset of the COVID-19 pandemic. However, telemedicine may exacerbate disparities for populations with limited digital literacy or access, such as older adults, racial minorities, patients of low income, rural residences, or limited English proficiency. From March 2020 to March 2022, this retrospective cohort study analyzed the use of in-person, phone/message, and telemedical care at a single tertiary care center in an oncology department. We investigated the association between economic, racial, ethnic, socioeconomic factors and forms of care, including in-person visits, telemedicine-based visits, and telephone/messages. The study results show that telemedicine utilization is lower among patients 65 and older, female patients, American Indian or Alaska Native patients, uninsured patients, and patients who require interpreters during clinical visits. As a result, it is unlikely that telemedicine will provide equal access to clinical care for all populations. On the other hand, in-person care utilization remains low in low-income and rural-living patients compared to the general population, while telephone and message use remains high in low-income and rural-living patients. We conclude that telemedicine is currently unable to close the utilization gap for populations of low socioeconomic status. Patients with low socioeconomic status use in-person care less frequently. For the disadvantaged, unusually high telephone or message utilization is unlikely to provide the same quality as in-person or telemedical care. Understanding the causes of disparity and promoting a solution to improve equal access to care for all patients is critical.

Gross tumour volume radiomics for prognostication of recurrence & death following radical radiotherapy for NSCLC

Recurrence occurs in up to 36% of patients treated with curative-intent radiotherapy for NSCLC. Identifying patients at higher risk of recurrence for more intensive surveillance may facilitate the earlier introduction of the next line of treatment. We aimed to use radiotherapy planning CT scans to develop radiomic classification models that predict overall survival (OS), recurrence-free survival (RFS) and recurrence two years post-treatment for risk-stratification. A retrospective multi-centre study of >900 patients receiving curative-intent radiotherapy for stage I-III NSCLC was undertaken. Models using radiomic and/or clinical features were developed, compared with 10-fold cross-validation and an external test set, and benchmarked against TNM-stage. Respective validation and test set AUCs (with 95% confidence intervals) for the radiomic-only models were: (1) OS: 0.712 (0.592–0.832) and 0.685 (0.585–0.784), (2) RFS: 0.825 (0.733–0.916) and 0.750 (0.665–0.835), (3) Recurrence: 0.678 (0.554–0.801) and 0.673 (0.577–0.77). For the combined models: (1) OS: 0.702 (0.583–0.822) and 0.683 (0.586–0.78), (2) RFS: 0.805 (0.707–0.903) and 0·755 (0.672–0.838), (3) Recurrence: 0·637 (0.51–0.·765) and 0·738 (0.649–0.826). Kaplan-Meier analyses demonstrate OS and RFS difference of >300 and >400 days respectively between low and high-risk groups. We have developed validated and externally tested radiomic-based prediction models. Such models could be integrated into the routine radiotherapy workflow, thus informing a personalised surveillance strategy at the point of treatment. Our work lays the foundations for future prospective clinical trials for quantitative personalised risk-stratification for surveillance following curative-intent radiotherapy for NSCLC.

Application and Challenges of IoT Healthcare System in COVID-19

The importance of the IoT is increasing in every field of life, and it especially has a significant role in improving the efficiency of the healthcare system. Its demand further increased during COVID-19 to facilitate the patient remotely from their home digitally. Every time the COVID-19 patient visited the doctor for minor complications, it increased the risk of spreading the virus and the cost for the patient. Another alarming situation arose when a patient was in a critical position and may not claim an emergency service from the nearby healthcare system, increasing the death rate. The IoT uses healthcare services to properly monitor COVID-19 patients by using the interconnected network to overcome these issues. Through the IoT, the patient is facilitated by the health care system without spreading the virus, decreasing the death ratio during COVID-19. This paper aims to discuss different applications, technologies, and challenges of the IoT healthcare system, related to COVID-19. Different databases were searched using keywords in PubMed, ResearchGate, Scopus, ACM, Springer, Elsevier, Google Scholar, etc. This paper is trying to discuss, identify, and highlight the useful applications of the IoT healthcare system to provide guidelines to the researchers, healthcare institutions, and scientists to overcomes the hazards of COVID-19 pandemics. Hence, IoT is beneficial by identifying the symptoms of COVID-19 patients and by providing better treatments that use the healthcare system efficiently. At the end of the paper, challenges and future work are discussed, along with useful suggestions through which scientists can benefit from the IoT healthcare system during COVID-19 and in a severe pandemic. The survey paper is not limited to the healthcare system and COVID-19, but it can be beneficial for future pandemics or in a worse situation.

A longitudinal assessment of chronic care pathways in real-life: self-care and outcomes of chronic heart failure patients in Tuscany

BACKGROUND

Worldwide healthcare systems face challenges in assessing and monitoring chronic care pathways and, even more, the value generated for patients. Patient-reported outcomes measures (PROMs) represent a valid Real-World Evidence (RWE) source to fully assess health systems' performance in managing chronic care pathways.

METHODS

The originality of the study consists in the chance of adopting PROMs, as a longitudinal assessment tool for continuous monitoring of patients' adherence to therapies and self-care behavior recommendations in clinical practice and as a chance to provide policy makers insights to improve chronic pathways adopting a patient perspective. The focus was on PROMs of patients with chronic heart failure (CHF) collected in the Gabriele Monasterio Tuscan Foundation (FTGM), a tertiary referral CHF centre in Pisa, Italy. During the hospital stay, CHF patients were enrolled and received a link (via SMS or email) to access to the first questionnaire. Follow-up questionnaires were sent 1, 7 and 12 months after the index hospitalisation. Professionals invited 200 patients to participate to PROMs surveys. 174 answers were digitally collected at baseline from 2018 to 2020 and analysed. Quantitative and qualitative analyses were conducted, using Chi2, t-tests and regression models together with narrative evidence from free text responses.

RESULTS

Both quantitative and qualitative results showed FTGM patients declared to strongly adhere to the pharmacological therapy across the entire pathway, while seemed less careful to adhere to self-care behavior recommendations (e.g., physical activity). CHF patients that performed adequate Self-Care Maintenance registered outcome improvements. Respondents declared to be supported by family members in managing their adherence.

CONCLUSIONS

The features of such PROMs collection model are relevant for researchers, policymakers and for managers to implement interventions aimed at improving pathway adherence dimensions. Among those, behavioral economics interventions could be implemented to increase physical activity among CHF patients since proven successful in Tuscany. Strategies to increase territorial care and support patients' caregivers in their daily support to patients' adherence should be further explored. Systematic PROMs collection would allow to monitor changes in the whole pathway organization. This study brings opportunities for extending such monitoring systems to other organizations to allow for reliable benchmarking opportunities.

On the demand for telemedicine: Evidence from the COVID-19 pandemic

Telemedicine can expand access to health care at relatively low cost. Historically, however, demand for telemedicine has remained low. Using administrative records and a difference-in-differences methodology, we estimate the change in demand for telemedicine experienced after the onset of the COVID-19 epidemic and the imposition of mobility restrictions. We find that the number of telemedicine calls made during the pandemic increased by 230 percent compared to the pre-pandemic period. The effects were mostly driven by older individuals with preexisting conditions who used the service for internal medicine consultations. The demand for telemedicine remained relatively high even after mobility restrictions were relaxed, which is consistent with telemedicine being an "experience good." These results are a proof of concept for policy makers to use such relatively low-cost medical consultations, made possible by new technologies, to provide needed expansion of access to health care.

Epidemic spreading with migration in networked metapopulation

Migration plays a crucial role in epidemic spreading, and its dynamic can be studied by metapopulation model. Instead of the uniform mixing hypothesis, we adopt networked metapopulation to build the model of the epidemic spreading and the individuals' migration. In these populations, individuals are connected by contact network and populations are coupled by individuals migration. With the network mean-field and the gravity law of migration, we establish the N-seat intertwined SIR model and obtain its basic reproduction number ℛ 0 . Meanwhile, we devise a non-markov Node-Search algorithm for model statistical simulations. Through the static network migration ansatz and ℛ 0 formula, we discover that migration will not directly increase the epidemic replication capacity. But when ℛ 0 > 1 , the migration will make the susceptive population evolve from metastable state (disease-free equilibrium) to stable state (endemic equilibrium), and then increase the influence area of epidemic. Re-evoluting the epidemic outbreak in Wuhan, top 94 cities empirical data validate the above mechanism. In addition, we estimate that the positive anti-epidemic measures taken by the Chinese government may have reduced 4 million cases at least during the first wave of COVID-19, which means those measures, such as the epidemiological investigation, nucleic acid detection in medium-high risk areas and isolation of confirmed cases, also play a significant role in preventing epidemic spreading after travel restriction between cities.

Analysis and prediction of worldwide novel coronavirus (COVID-19) infections, using neural network-based techniques

The novel coronavirus (COVID-19) outbreak has recently become a major public health concern around the world. It is commonly known that some of the world's most powerful countries, such as Iran and the United States, are suffering more than others from the effects of this horrific pandemic. It has spread throughout communities and has endangered the health of many people. Governments must take the necessary steps to stop the virus from spreading globally. The three most widely used backpropagation neural network (BPNN) techniques, i.e., Levenberg–Marquardt, Bayesian regularization (BR), and scaled conjugate gradient (SCG), are used to either predict the future or evaluate the current status of COVID-19 in this research. This study uses a real-time COVID-19 dataset from the Worldometer website, which contains 204 samples from 30 January to 15 April 2020. The 12 most important parameters are selected for study purposes, including country, total cases (TC), new cases (NC), total deaths (TD), new deaths (ND), total recoveries (TREV), active cases (AC), serious cases (SC), total tests (TT), death rate (DR), recovery rate (RR), and case rate (CR). Finally, countries are classified into three risk levels, i.e., high, medium, and low, based on the above parameters. In addition, some new countries are discovered at these levels.

The Current Status of Telehealth and Distance Learning in Palau

In 2017 the Republic of Palau installed fiber optic cables, allowing access to high speed internet for the first time and the capacity for growth in telehealth. Given Palau's poor access to specialists and resources, telehealth has the potential to radically change health care delivery. Currently, the status of telehealth in Palau is unknown. This study describes telehealth resources utilized at the Ministry of Health in Palau and potential future directions for telehealth. Thirty-four people, mostly health professionals at the Belau National Hospital in Palau were interviewed, including physicians, information technology personnel, public health department staff, department managers of allied health, and telehealth experts in the Pacific. Standardized questions and surveys were conducted in-person during July 2019. All departments utilized some form of telehealth. Common needs for the advancement of telehealth included: a telehealth champion, a resource facilitator, successful distance learning for auxiliary staff, dedicated telehealth space, technological help, and better telehealth communication with rural clinics. Survey respondents indicated that they would like to use some sort of distance learning, most commonly for professional betterment (86%) and upskilling of staff (86%). There are numerous distance learning and telehealth opportunities available, yet recurrent barriers to these opportunities were noted across all departments. The barriers identified in the current study and recommendations to overcome them may be applicable to other Pacific nations who face similar challenges.

Enhancing cancer prevention and survivorship care with a videoconferencing model for continuing education: a mixed-methods study to identify barriers and incentives to participation

OBJECTIVE

To enhance cancer prevention and survivorship care by local health care providers, a school of public health introduced an innovative telelearning continuing education program using the Extension for Community Healthcare Outcomes (ECHO) model. In ECHO's hub and spoke structure, synchronous videoconferencing connects frontline health professionals at various locations ("spokes") with experts at the facilitation center ("hub"). Sessions include experts' didactic presentations and case discussions led by spoke site participants. The objective of this study was to gain a better understanding of the reasons individuals choose or decline to participate in the Cancer ECHO program and to identify incentives and barriers to doing so.

MATERIALS AND METHODS

Study participants were recruited from the hub team, spoke site participants, and providers who attended another ECHO program but not this one. Participants chose to take a survey or be interviewed. The Consolidated Framework for Implementation Research guided qualitative data coding and analysis.

RESULTS

We conducted 22 semistructured interviews and collected 30 surveys. Incentives identified included the program's high-quality design, supportive learning climate, and access to information. Barriers included a lack of external incentives to participate and limited time available. Participants wanted more adaptability in program timing to fit providers' busy schedules.

CONCLUSION

Although the merits of the Cancer ECHO program were widely acknowledged, adaptations to facilitate participation and emphasize the program's benefits may help overcome barriers to attending. As the number of telelearning programs grows, the results of this study point to ways to expand participation and spread health benefits more widely.

Maternal disease factors associated with neonatal jaundice: a case-control study

Background

Neonatal jaundice is common, and despite the considerable medical costs associated with it, there are still few studies on the maternal factors associated with it. Identification of maternal factors associated with neonatal jaundice is very important in terms of prevention, screening and management of neonatal jaundice. The current study aimed to identify maternal disease factors associated with neonatal jaundice.

Methods

We compared the maternal disease diagnostic codes during pregnancy (study A) and 1 year before conception (study B) in mothers whose insurance claims data included newborns treated for neonatal jaundice before birth registration via the National Health Insurance Service–National Sample Cohort (control group). To decrease the effect of confounding variables, the neonatal jaundice and control groups were matched at a ratio of 1:10 via propensity score matching using covariates including age and income.

Results

The matched samples for studies A and B included 4,026 and 3,278 (jaundice group: 366 and 298) delivery cases, respectively. In both studies, the jaundice group had a higher proportion of patients who underwent cesarean section than the control group. In study A, other diseases of the digestive system had the highest odds ratio (OR) (K92; adjusted OR: 14.12, 95% confidence interval [CI]: 2.70–82.26). Meanwhile, gastritis and duodenitis had the lowest OR (K29; adjusted OR: 0.39, 95% CI: 0.22–0.69). In study B, salpingitis and oophoritis had the highest OR (N70; adjusted OR: 3.33, 95% CI: 1.59–6.94). Heartburn had the lowest OR (R12; adjusted OR: 0.29, 95% CI:0.12–0.71).

Conclusions

This study identified maternal disease factors correlated with neonatal jaundice during pregnancy and 1 year before conception. Maternal risk factors for neonatal jaundice included syphilis and leiomyoma during pregnancy, and salpingo-oophoritis before pregnancy. The protective factors included infection, inflammatory diseases, and dyspepsia.

A Novel Machine Learning Based Probabilistic Classification Model for Heart Disease Prediction

Cardiovascular disease (CVD) is most dreadful disease that results in fatal-threats like heart attacks. Accurate disease prediction is very essential and machine-learning techniques contribute a major part in predicting occurrence. In this paper, a novel machine learning based model for accurate prediction of cardiovascular disease is developed that applies unique feature selection technique called Chronic Fatigue Syndrome Best Known Method (CFSBKM). Each feature is ranked based on the feature importance scores. The new learning model eliminates the most irrelevant and low importance features from the datasets thereby resulting in the robust heart disease risk prediction model. The multi-nominal Naive Bayes classifier is used for the classification. The performance of the CFSBKM model is evaluated using the Benchmark dataset Cleveland dataset from UCI repository and the proposed models out-perform the existing techniques.

Telehealth Education: Impact on Provider Experience and Adoption

BACKGROUND

COVID-19 propelled telehealth to the forefront of health care, forcing many advanced practice registered nurses (APRNs) to incorporate telehealth into their practice without sufficient education. Lack of training has been cited as a barrier to telehealth adoption.

PURPOSE

This study evaluated provider adoption of telehealth based on the type of telehealth education received.

METHODS

A quantitative survey of telehealth providers (n = 224) was distributed through the listservs of 4 national organizations to determine whether there was a significant difference in provider levels of perceived usefulness, self-efficacy, perceived knowledge, satisfaction, and use of telehealth based on the type of telehealth education received.

RESULTS

Telehealth adoption was significantly associated with the type of telehealth education received (vendor, online, written instructions only, and on the spot).

CONCLUSION

With telehealth utilization expected to endure postpandemic, faculty should incorporate the most effective telehealth education methods into APRN curricula, ensuring successful adoption by the future workforce.

Correlation between functional MRI techniques and early disability in ambulatory patients with relapsing–remitting MS

Background

Multiple sclerosis (MS) is a common neurological disorder which can lead to an occasional damage to the central nervous system. Conventional magnetic resonance imaging (cMRI) is an important modality in the diagnosis of MS; however, correlation between cMRI findings and clinical impairment is weak. Non-conventional MRI techniques including apparent diffusion coefficient (ADC) and magnetic resonance spectroscopy (MRS) investigate the metabolic changes over the course of MS and overcome the limits of cMRI.

A total of 80 patients with MS and 20 age and sex-matched healthy control subjects were enrolled in this cross-sectional study. Ambulatory patients with relapsing–remitting MS (RRMS) were recruited. Expanded Disability Status Scale (EDSS) was used to assess the disability and the patients were categorized into three groups “no disability”, “minimal disability” and “moderate disability”. All patients underwent cMRI techniques. ADC was measured in MS plaques and in normal appearing white matter (NAWM) adjacent and around the plaque. All metabolites concentrations were expressed as ratios including N-acetyl-aspartate/creatine (NAA/Cr), choline/N-acetyl-aspartate (Cho/NAA) and choline/creatine (Cho/Cr). ADC and metabolite concentrations were measured in the normal white matter of 20 healthy control subjects.

Results

The study was carried on 80 MS patients [36 males (45%) and 44 females (55%)] and 20 healthy control [8 males (40%) and 12 females (60%)]. The ADC values and MRS parameters in NAWM of patients with MS were significantly different from those of the control group. The number of the plaques on T2 images and black holes were significantly higher at “Minimal disability” group. Most of the enhanced plaques were at the “Moderate disability” group with P value < 0.001. The mean of ADC in the group 1, 2 and 3 of disability was 1.12 ± 0.19, 1.50 ± 0.35, 1.51 ± 0.36, respectively, with P value < 0. 001. In the group 1, 2 and 3 of disability, the mean of NAA/Cr ratio at the plaque was 1.34 ± 0.44, 1.59 ± 0.51 and 1.11 ± 0.15, respectively, with P value equal 0.001.

Conclusion

The non-conventional quantitative MRI techniques are useful tools for detection of early disability in MS patients.

Natural Language Processing Applications in the Clinical Neurosciences: A Machine Learning Augmented Systematic Review

Natural language processing (NLP), a domain of artificial intelligence (AI) that models human language, has been used in medicine to automate diagnostics, detect adverse events, support decision making and predict clinical outcomes. However, applications to the clinical neurosciences appear to be limited. NLP has matured with the implementation of deep transformer models (e.g., XLNet, BERT, T5, and RoBERTa) and transfer learning. The objectives of this study were to (1) systematically review NLP applications in the clinical neurosciences, and (2) explore NLP analysis to facilitate literature synthesis, providing clear examples to demonstrate the potential capabilities of these technologies for a clinical audience. Our NLP analysis consisted of keyword identification, text summarization and document classification. A total of 48 articles met inclusion criteria. NLP has been applied in the clinical neurosciences to facilitate literature synthesis, data extraction, patient identification, automated clinical reporting and outcome prediction. The number of publications applying NLP has increased rapidly over the past five years. Document classifiers trained to differentiate included and excluded articles demonstrated moderate performance (XLNet AUC = 0.66, BERT AUC = 0.59, RoBERTa AUC = 0.62). The T5 transformer model generated acceptable abstract summaries. The application of NLP has the potential to enhance research and practice in the clinical neurosciences.

Culture-Specific Observations in a Saudi Arabian Digital Home Health Care Program: Focus Group Discussions With Patients and Their Caregivers

Background

There is growing evidence of the need to consider cultural factors in the design and implementation of digital health interventions. However, there is still inadequate knowledge pertaining to the aspects of the Saudi Arabian culture that need to be considered in the design and implementation of digital health programs, especially in the context of home health care services for patients who are chronically and terminally ill.

Objective

This study aims to explore the specific cultural factors related to patients and their caregivers from the perspective of physicians, nurses, and trainers that have influenced the pilot implementation of Remotely Accessible Healthcare At Home, a connected health program in the Home Health Care department at King Saud University Medical City, Riyadh, Saudi Arabia.

Methods

A qualitative study design was adopted to conduct a focus group discussion in July 2019 using a semistructured interview guide with 3 female and 4 male participants working as nurses, family physicians, and information technologists. Qualitative data obtained were analyzed using a thematic framework analysis.

Results

A total of 2 categories emerged from the focus group discussion that influenced the experiences of digital health program intervention: first, culture-related factors including language and communication, cultural views on using cameras during consultation, nonadherence to web-based consultations, and family role and commitment and second, caregiver characteristics in telemedicine that includes their skills and education and electronic literacy. Participants of this study revealed that indirect contact with patients and their family members may work as a barrier to proper communication through the Remotely Accessible Healthcare At Home program.

Conclusions

We recommend exploring the use of interpreters in digital health, creating awareness among the local population regarding privacy in digital health, and actively involving direct family members with the health care providers.

Professional decision making with digitalisation of patient contacts in a medical advice setting: a qualitative study of a pilot project with a chat programme in Sweden

OBJECTIVES

Patient e-services are increasingly launched globally to make healthcare more efficient and digitalised. One area that is digitalised is medical advice, where patients asynchronously chat with nurses and physicians, with patients having filled in a form with predefined questions before the chat. This study aimed to explore how occupational professionalism and the possibility of professional judgement are affected when clinical patient contact is digitalised. The study's overall question concerns whether and how the scope of the healthcare staff's professional judgement and occupational professionalism are affected by digitalisation.

DESIGN AND SETTING

A qualitative study of healthcare professionals working in a pilot project with a chat programme for patients in a medical advice setting in Sweden.

PARTICIPANTS AND ANALYSIS

Contextual inquiries and 17 interviews with nurses (n=9) and physicians (n=8). The interviews were thematically analysed. The analysis was inductive and based on theories of decision making.

RESULTS

Three themes emerged: (1) Predefined questions to patients not tailored for healthcare professionals' work, (2) reduced trust in written communication and (3) reduced opportunity to obtain information through chat communication.

CONCLUSIONS

The results indicate that asynchronous chat with patients might reduce the opportunity for nurses and physicians to obtain and use professional knowledge and discretionary decision making. Furthermore, the system's design increases uncertainty in assessments and decision making, which reduces the range of occupational professionalism.

Driving digital health transformation in hospitals: a formative qualitative evaluation of the English Global Digital Exemplar programme

BACKGROUND

There is currently a strong drive internationally towards creating digitally advanced healthcare systems through coordinated efforts at a national level. The English Global Digital Exemplar (GDE) programme is a large-scale national health information technology change programme aiming to promote digitally-enabled transformation in secondary healthcare provider organisations by supporting relatively digitally mature provider organisations to become international centres of excellence.

AIM

To qualitatively evaluate the impact of the GDE programme in promoting digital transformation in provider organisations that took part in the programme.

METHODS

We conducted a series of in-depth case studies in 12 purposively selected provider organisations and a further 24 wider case studies of the remaining organisations participating in the GDE programme. Data collected included 628 interviews, non-participant observations of 190 meetings and workshops and analysis of 9 documents. We used thematic analysis aided by NVivo software and drew on sociotechnical theory to analyse the data.

RESULTS

We found the GDE programme accelerated digital transformation within participating provider organisations. This acceleration was triggered by: (1) dedicated funding and the associated requirement for matched internal funding, which in turn helped to prioritise digital transformation locally; (2) governance requirements put in place by the programme that helped strengthen existing local governance and project management structures and supported the emergence of a cadre of clinical health informatics leaders locally; and (3) reputational benefits associated with being recognised as a centre of digital excellence, which facilitated organisational buy-in for digital transformation and increased negotiating power with vendors.

CONCLUSION

The GDE programme has been successful in accelerating digital transformation in participating provider organisations. Large-scale digital transformation programmes in healthcare can stimulate local progress through protected funding, putting in place governance structures and leveraging reputational benefits for participating provider organisations, around a coherent vision of transformation.

User Experience in Remote Surgical Consultation: Survey Study of User Acceptance and Satisfaction in Real-Time Use of a Telemedicine Service

Background

Teleguidance, a promising telemedicine service for intraoperative surgical consultation, was planned to scale up at a major academic hospital in partnership with 5 other hospitals. If the service was adopted and used over time, it was expected to provide educational benefits and improve clinical outcomes during endoscopic retrograde cholangiopancreatography (ERCP), which is a technically advanced procedure for biliary and pancreatic disease. However, it is known that seemingly successful innovations can play out differently in new settings, which might cause variability in clinical outcomes. In addition, few telemedicine services survive long enough to deliver system-level outcomes, the causes of which are not well understood.

Objective

We were interested in factors related to usability and user experience of the telemedicine service, which might affect adoption. Therefore, we investigated perceptions and responses to the use and anticipated use of a system. Technology acceptance, a construct referring to how users perceive a technology’s usefulness, is commonly considered to indicate whether a new technology will actually be used in a real-life setting. Satisfaction measures were used to investigate whether user expectations and needs have been met through the use of technology. In this study, we asked surgeons to rate the perceived usefulness of teleguidance, and their satisfaction with the telemedicine service in direct conjunction with real-time use during clinical procedures.

Methods

We designed domain-specific measures for perceived usefulness and satisfaction, based on performance and outcome measures for the clinical procedure. Surgeons were asked to rate their user experience with the telemedicine service in direct conjunction with real-time use during clinical procedures.

Results

In total, 142 remote intraoperative consultations were conducted during ERCP procedures at 5 hospitals. The demand for teleguidance was more pronounced in cases with higher complexity. Operating surgeons rated teleguidance to have contributed to performance and outcomes to a moderate or large extent in 111 of 140 (79.3%) cases. Specific examples were that teleguidance was rated as having contributed to intervention success and avoiding a repeated ERCP in 23 cases, avoiding 3 PTC, and 11 referrals, and in 11 cases, combinations of these outcomes. Preprocedure beliefs about the usefulness of teleguidance were generally lower than postprocedure satisfaction ratings. The usefulness of teleguidance was mainly experienced through practical advice from the consulting specialist (119/140, 85%) and support with assessment and decision-making (122/140, 87%).

Conclusions

Users’ satisfaction with teleguidance surpassed their initial expectations, mainly through contribution to nontechnical aspects of performance, and through help with general assessment. Teleguidance shows the potential to improve performance and outcomes during ERCP. However, it takes hands-on experience for practitioners to understand how the new telemedicine service contributes to performance and outcomes.

Non-use of telemedicine: A scoping review

Many telemedicine interventions fail to be implemented in medical care with non-use and discontinued use by patients being among the major reasons. The aim of this scoping review was to provide an overview of barriers associated with non-use and discontinued use of telemedicine. An electronic search was conducted in Pubmed in October 2019 and updated in November 2020, followed by a hand search in the beginning of 2021. All potential articles were screened by two independent reviewers based on predefined inclusion and exclusion criteria. A qualitative content analysis according to Mayring was carried out. The topics 'intervention', 'context of use' and 'user' were chosen as overarching themes. Out of 1377 potentially relevant articles, 73 were included. User-related barriers were mentioned in most of the analysed studies, followed by barriers related to the intervention. The analysis provides the basis for overcoming non-use issues in telemedicine.

Patient satisfaction in Home care services through e-Palliative Care -An experience of tertiary cancer centre from Kerala

Objectives:

e-palliative care (PC) is an evolving concept wherein technological interface is used to deliver PC to the patients with advanced cancer at their doorstep. This study aims to find out the level of satisfaction of patients receiving e-palliative homecare (e-PHC) service from a tertiary Cancer Center using the validated e-Palliative Patient Satisfaction Questionnaire –Malayalam (PSQM).

Materials and Methods:

In this prospective study, patients/caregivers on home care were given the e - Palliative PSQM by the homecare nurse after the patient had consulted the doctor through e-PHC service. The questionnaire had 15 statements with response graded using Likert scale. Descriptive analysis was performed to compute the distribution of observed responses to obtain the level of satisfaction among patients or caregivers receiving e-PHC service.

Results:

This study was done among 120 homecare patients whose median age was 69 (62-79) with almost equal prevalence of both genders. Stage 4 malignancy was seen in 107 (89.2%) patients with the commonest being gastrointestinal malignancy (N=34, 28.3%) The mean score of response for General satisfaction, Technical quality, Communication, Financial aspect, Time spent with doctor and Accessibility and convenience were observed as 4.52, 3.92, 4.48, 4.55, 4.52 and 4.49 respectively. The overall satisfaction was found to be 4.39.

Conclusion:

The overall satisfaction of patients receiving e-PHC service from our Institution is seen to be high. e- palliative care is a feasible option for providing excellent PC in developing countries with limited resources and financial constraints.

Patient satisfaction with a pharmacist-led best possible medication discharge plan via tele-robot in a remote and rural community hospital

Introduction

Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described.

Methods

This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented.

Results

Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively.

Conclusion

Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.

Evaluating Technology-Mediated Collaborative Workflows for Telehealth

GOALS

This paper discusses the need for a predictable method to evaluate gains and gaps of collaborative technology-mediated workflows and introduces an evaluation framework to address this need.

METHODS

The Collaborative Space Analysis Framework (CS-AF), introduced in this research, is a cross-disciplinary evaluation method designed to evaluate technology-mediated collaborative workflows. The 5-step CS-AF approach includes: (1) current-state workflow definition, (2) current-state (baseline) workflow assessment, (3) technology-mediated workflow development and deployment, (4) technology-mediated workflow assessment, (5) analysis, and conclusions. For this research, a comprehensive, empirical study of hypertension exam workflow for telehealth was conducted using the CS-AF approach.

RESULTS

The CS-AF systemized approach reveals critical cross-disciplinary evaluation data concerning gains and gaps of collaborative workflows when technology-mediated enhancements are characterized and compared with a baseline workflow for the goal of continuous workflow improvement.

CONCLUSION

The CS-AF is an effective approach that can be adapted for use in multiple domains.

Virtual orthopedic assessment: Main principles and specific regions

Telemedicine was originally created as a way to treat patients who were located in remote places far away from local health facilities or in areas with shortages of medical professionals. Telemedicine is still used today to address those problems, and is increasingly becoming a tool for convenient medical care. With the emergence of pandemics, telemedicine became almost a mandatory and valuable option for continuing to provide medical care in various specialties. As the threat of pandemic progress has continued for months and may continue for years, it is essential to validate existing tools to maintain clinical assessment and patient treatment to avoid negative consequences of the lack of medical follow-up. Therefore, the establishment of a virtual assessment technique that can be conducted effectively is of outmost importance as a way of adapting to the current situation. This study evaluated the role of telemedicine in the assessment of various orthopedic pathologies by means of a systematic virtual evaluation.

The Quality of Medical Care in the Conditions of the COVID-19 Pandemic, with Particular Emphasis on the Access to Primary Healthcare and the Effectiveness of Treatment in Poland

Health has a significant influence on the quality of life of a society. The COVID-19 pandemic has forced many countries to implement restrictive measures to prevent its wider spread, including, inter alia, the introduction of remote healthcare in the form of teleconsultations. Therefore, there is the question of how such a change affects the quality of treatment and the primary healthcare of patients during the COVID-19 pandemic. The article aims to examine patient satisfaction with the access to primary healthcare and the effectiveness of treatment in a condition of remote medical care caused by the COVID-19 pandemic. We also analyse the impact of access to primary healthcare on the treatment effectiveness. Patient satisfaction was measured using a questionnaire assessing the quality of primary medical care. Of the 36 items studied, seven were related to the accessibility dimension and four were related to the treatment effectiveness dimension. Our results suggest that the treatment effectiveness and the access to primary healthcare services during the COVID-19 pandemic through telemedicine are quite highly rated by patients. Hence, further implementation of telemedicine in primary healthcare should improve the quality of lives of the wide society. We have also identified the access to primary healthcare has a considerable impact on the treatment effectiveness. Therefore, we recommend increasing the contact between patients and GPs via telemedicine under lockdown conditions.

Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders

INTRODUCTION

The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS.

METHODS

Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software.

RESULTS

Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage.

CONCLUSION

The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

Disparities in Telemedicine Access: A Cross-Sectional Study of a Newly Established Infrastructure during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic led to dramatic increases in telemedicine use to provide outpatient care without in-person contact risks. Telemedicine increases options for health care access, but a "digital divide" of disparate access may prevent certain populations from realizing the benefits of telemedicine.

OBJECTIVES

The study aimed to understand telemedicine utilization patterns after a widespread deployment to identify potential disparities exacerbated by expanded telemedicine usage.

METHODS

We performed a cross-sectional retrospective analysis of adults who scheduled outpatient visits between June 1, 2020 and August 31, 2020 at a single-integrated academic health system encompassing a broad range of subspecialties and a large geographic region in the Upper Midwest, during a period of time after the initial surge of COVID-19 when most standard clinical services had resumed. At the beginning of this study period, approximately 72% of provider visits were telemedicine visits. The primary study outcome was whether a patient had one or more video-based visits, compared with audio-only (telephone) visits or in-person visits only. The secondary outcome was whether a patient had any telemedicine visits (video-based or audio-only), compared with in-person visits only.

RESULTS

A total of 197,076 individuals were eligible (average age = 46 years, 56% females). Increasing age, rural status, Asian or Black/African American race, Hispanic ethnicity, and self-pay/uninsured status were significantly negatively associated with having a video visit. Digital literacy, measured by patient portal activation status, was significantly positively associated with having a video visit, as were Medicaid or Medicare as payer and American Indian/Alaskan Native race.

CONCLUSION

Our findings reinforce previous evidence that older age, rural status, lower socioeconomic status, Asian race, Black/African American race, and Hispanic/Latino ethnicity are associated with lower rates of video-based telemedicine use. Health systems and policies should seek to mitigate such barriers to telemedicine when possible, with efforts such as digital literacy outreach and equitable distribution of telemedicine infrastructure.

Implementing video visits into an orthopedic hip arthroscopy practice: a case study

Telehealth videoconferencing has been shown to be feasible, cost-effective and safe in numerous fields of medicine. In an effort to increase access and improve the quality of care offered to patients we implemented a telehealth initiative allowing for remote orthopedic clinic visits at a major academic medical center. Here we report on our experience and early outcomes. A telehealth platform was launched for a single fellowship trained orthopedic surgeon at a major academic hospital in August 2018. New patients residing outside the metro area, all return patients and patients with an uncomplicated post-operative course were offered the option to complete patient encounters remotely via a telehealth platform. Each patient was offered a Patient Satisfaction Survey following video visit. Patient zip codes were used to estimate patient commutes. Ninety-six percent of patients agreed/strongly agreed with the statement 'I was satisfied with my Telehealth experience' while 51% agreed/strongly agreed with the statement 'This visit was just as good as a face to face visit'. In all, 94% of patients agreed/strongly agreed with the statement 'Having a telehealth visit made receiving care more accessible for me'. The median miles saved on commutes were 123.3 miles. The no show rate for telehealth visits was 8.2% versus 3.2% for in-person (P < 0.001). Telehealth video visits provided patients with a modality for completing orthopedic clinic visits while maintaining a high-quality care and patient satisfaction. Patient convenience was optimized with video visits with elimination of long commutes. Level of evidence: IV.

Provider, Staff, and Patient Perspectives on medical Visits Using Clinical Video Telehealth: A Foundation for Educational Initiatives to Improve Medical Care in Telehealth

Clinical Video Telehealth (CVT) use is increasing and allows geographically separated care; however, this separation may affect participants behaviors. Using semi-structured in-depth interviews, we asked CVT nurse practitioners (NP), staff and patients at a VA Medical Center about perspectives on how CVT effects communication and identified three themes. They remarked on the complexity of scheduling appointments, local barriers to care, and acutely ill patients. NPs discussed how CVT altered sensory collection during the physical exam and differences in building provider-patient relationships. Patients perceptions mirrored these themes. NPs identified how CVT requires different workflow, behaviors, and use of their senses. Patients expressed similar concerns with CVT.

Rheumatology Clinicians' Perceptions of Telerheumatology Within the Veterans Health Administration: A National Survey Study

INTRODUCTION

The Department of Veterans Affairs Veterans Health Administration (VA) Strategic Plan (Fiscal Year 2018-2024) identified four priorities for care including easy access, timely and integrated care, accountability, and modernization, all of which can be directly or indirectly impacted by telemedicine technologies. These strategic goals, coupled with an anticipated rheumatology workforce shortage, has created a need for additional care delivery methods such as clinical video telehealth application to rheumatology (ie, telerheumatology). Rheumatology clinician perceptions of clinical usefulness telerheumatology have received limited attention in the past. The present study aimed to evaluate rheumatologists' perceptions of and experiences with telemedicine, generally, and telerheumatology, specifically, within the VA.

MATERIALS AND METHODS

A 38-item survey based on an existing telehealth providers' satisfaction survey was developed by two VA rheumatologists with experience in telemedicine as well as a social scientist experienced in survey development and user experience through an iterative process. Questions probed VA rheumatology clinician satisfaction with training and information technology (IT) supports, as well as barriers to using telemedicine. Additionally, clinician perceptions of the impact and usefulness of and appropriate clinical contexts for telerheumatology were evaluated. The survey was disseminated online via VA REDCap to members of the VA Rheumatology Consortium (VARC) through a LISTSERV. The study protocol was approved by the host institution IRB through expedited review. Survey responses were analyzed using descriptive statistics.

RESULTS

Forty-five anonymous responses (20% response rate) were collected. Of those who responded, 47% were female, 98% were between 35 and 64 years old, 71% reported working at an academic center, and the majority was physician-level practitioners (98%). Respondents generally considered themselves to be tech savvy (58%). Thirty-six percent of the sample reported past experience with telemedicine, and, of those, 29% reported experience with telerheumatology specifically. Clinicians identified the greatest barrier to effective telerheumatology as the inability to perform a physical exam (71%) but agreed that telerheumatology is vital to increasing access to care (59%) and quality of care (40%) in the VA. Overall, regardless of experience with telemedicine, respondents reported that telerheumatology was more helpful for management of rheumatologic conditions rather than initial diagnosis.

CONCLUSIONS

While the majority of rheumatology clinicians did not report past experience with telerheumatology, they agreed that it has potential to further the VA mission of improved access and quality of care. Rheumatology clinicians felt the suitability of telerheumatology is dependent on the phase of care. As remote care technologies continue to be rapidly adopted into clinic, clinician perceptions of and experiences with telemedicine will need to be addressed in order to maintain high-quality and clinician- and patient-centric care within VA rheumatology.