Development of ClickClinica: a novel smartphone application to generate real-time global disease surveillance and clinical practice data

On the use of telemedicine in the context of COVID-19: legal aspects and a systematic review of technology

Purpose

The aim of this study was to carry out a systematic review of telemedicine technology and to discuss the role of legislation in the application of telemedicine technology within the scope of COVID-19.

Methods

The search for papers was conducted in the databases Cochrane Central, MEDLINE, and Embase. The keywords considered for this systematic review were (coronavirus OR “2019-nCoV” OR 2019nCoV OR nCoV2019 OR “nCoV-2019” OR “COVID-19” OR COVID19 OR “HCoV-19” OR HCoV19 OR CoV OR “2019 novel*” OR Ncov OR “n-cov” OR “SARS-CoV-2” OR “SARSCoV-2” OR “SARSCoV2” OR “SARSCoV2” OR SARSCov19 OR “SARS-Cov19” OR “SARS-Cov-19” OR “severe acute respiratory syndrome*” OR ((corona* OR corono*) AND (virus* OR viral* OR virinae*))) AND ((telemedicine OR telehealth OR “remote assessment” OR telemonitoring)). The review process was carried out by six independent reviewers, using the PRISMA-P method.

Results

As a result, a total of 34 papers were selected, which addressed the study of telemedicine technologies used in times of endemics, epidemics, and pandemics, focusing on COVID-19.

Conclusion

Telemedicine allows for care in remote areas and at a lower cost to the patient and, in the current situation, it can reduce the number of contagions as well as the occupation of beds in health facilities. Telemedicine may suffer from limitations, mainly due to current legislation, but in this pandemic era of COVID-19, several countries around the world have made their laws more flexible to allow more widespread use of telemedicine.

Birth and death notification via mobile devices: a mixed methods systematic review

BACKGROUND

Ministries of health, donors, and other decision-makers are exploring how they can use mobile technologies to acquire accurate and timely statistics on births and deaths. These stakeholders have called for evidence-based guidance on this topic. This review was carried out to support World Health Organization (WHO) recommendations on digital interventions for health system strengthening.

OBJECTIVES

Primary objective: To assess the effects of birth notification and death notification via a mobile device, compared to standard practice. Secondary objectives: To describe the range of strategies used to implement birth and death notification via mobile devices and identify factors influencing the implementation of birth and death notification via mobile devices.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Global Health Library, and POPLINE (August 2, 2019). We searched two trial registries (August 2, 2019). We also searched Epistemonikos for related systematic reviews and potentially eligible primary studies (August 27, 2019). We conducted a grey literature search using mHealthevidence.org (August 15, 2017) and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies in Web of Science and Google Scholar (May 15, 2020). We searched for studies published after 2000 in any language.  SELECTION CRITERIA: For the primary objective, we included individual and cluster-randomised trials; cross-over and stepped-wedge study designs; controlled before-after studies, provided they have at least two intervention sites and two control sites; and interrupted time series studies. For the secondary objectives, we included any study design, either quantitative, qualitative, or descriptive, that aimed to describe current strategies for birth and death notification via mobile devices; or to explore factors that influence the implementation of these strategies, including studies of acceptability or feasibility. For the primary objective, we included studies that compared birth and death notification via mobile devices with standard practice. For the secondary objectives, we included studies of birth and death notification via mobile device as long as we could extract data relevant to our secondary objectives. We included studies of all cadres of healthcare providers, including lay health workers; administrative, managerial, and supervisory staff; focal individuals at the village or community level; children whose births were being notified and their parents/caregivers; and individuals whose deaths were being notified and their relatives/caregivers.

DATA COLLECTION AND ANALYSIS

For the primary objective, two authors independently screened all records, extracted data from the included studies and assessed risk of bias. For the analyses of the primary objective, we reported means and proportions, where appropriate. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a 'Summary of Findings' table. For the secondary objectives, two authors screened all records, one author extracted data from the included studies and assessed methodological limitations using the WEIRD tool and a second author checked the data and assessments. We carried out a framework analysis using the Supporting the Use of Research Evidence (SURE) framework to identify themes in the data. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in the evidence and we prepared a 'Summary of Qualitative Findings' table.

MAIN RESULTS

For the primary objective, we included one study, which used a controlled before-after study design. The study was conducted in Lao People's Democratic Republic and assessed the effect of using mobile devices for birth notification on outcomes related to coverage and timeliness of Hepatitis B vaccination. However, we are uncertain of the effect of this approach on these outcomes because the certainty of this evidence was assessed as very low. The included study did not assess resource use or unintended consequences. For the primary objective, we did not identify any studies using mobile devices for death notification. For the secondary objective, we included 21 studies. All studies were conducted in low- or middle-income settings. They focussed on identification of births and deaths in rural, remote, or marginalised populations who are typically under-represented in civil registration processes or traditionally seen as having poor access to health services. The review identified several factors that could influence the implementation of birth-death notification via mobile device. These factors were tied to the health system, the person responsible for notifying, the community and families; and include: - Geographic barriers that could prevent people's access to birth-death notification and post-notification services - Access to health workers and other notifiers with enough training, supervision, support, and incentives - Monitoring systems that ensure the quality and timeliness of the birth and death data - Legal frameworks that allow births and deaths to be notified by mobile device and by different types of notifiers - Community awareness of the need to register births and deaths - Socio-cultural norms around birth and death - Government commitment - Cost to the system, to health workers and to families - Access to electricity and network connectivity, and compatibility with existing systems - Systems that protect data confidentiality We have low to moderate confidence in these findings. This was mainly because of concerns about methodological limitations and data adequacy.

AUTHORS' CONCLUSIONS

We need more, well-designed studies of the effect of birth and death notification via mobile devices and on factors that may influence its implementation.

Bovine mastitis prevention and control in the post-antibiotic era

Mastitis is the most important disease in the dairy industry. Antibiotics are considered to be the first choice in the treatment of the disease. However, the problem of antibiotic residue and antimicrobial resistance, in addition to the impact of antibiotic abuse on public health, leads to many restrictions on uncontrolled antibiotic therapy in the dairy sector worldwide. Researchers have investigated novel therapeutic approaches to replace the use of antibiotics in mastitis control. These efforts, supported by the revolutionary development of nanotechnology, stem cell assays, molecular biological tools, and genomics, enabled the development of new approaches for mastitis-treatment and control. The present review discusses recent concepts to control mastitis such as breeding of mastitis-resistant dairy cows, the development of novel diagnostic and therapeutic tools, the application of communication technology as an educational and epidemiological tool, application of modern mastitis vaccines, cow drying protocols, teat disinfection, housing, and nutrition. These include the application of nanotechnology, stem cell technology, photodynamic and laser therapy or the use of traditional herbal medical plants, nutraceuticals, antibacterial peptides, bacteriocins, antibodies therapy, bacteriophages, phage lysins, and probiotics as alternatives to antibiotics.

A smartphone-based teleconsultation system for the management of chronic pressure injuries

We investigated the accuracy of pressure injury evaluation using tele-devices and examined the concordance between automatically generated recommendations and primary manual recommendations. Caregivers took photos and videos of pressure injuries using smartphones with built-in cameras and uploaded the media to the application. The wound team evaluated the wound using a specially modified version of the Pressure Sore Status Tool. This was compared with the Pressure Sore Status Tool score assessed during the actual examination of the patient. We developed an automatic algorithm for dressing based on the Pressure Sore Status Tool score, checking for consistency between this and the primary manual recommendation. A total of 60 patients diagnosed with pressure injuries were included. The κ coefficients indicated substantial agreement for wound size and total score, and excellent for all other items. We found that the overall concordance rates were statistically significant for all items (p < 0.001). For the primary dressing, the κ coefficient for the concordance rate of automatic algorithm and manual recommendation was 0.771, while that of teleconsultation system and manual recommendation was 0.971. For the secondary dressing, the figures were 0.798 and 0.989, respectively. All values were statistically significant (p < 0.001). We presented strong evidence documenting the utilization of a smartphone, patient-driven system, and demonstrated that the measurements obtained were comparable to the ones obtained by a trained, on-site, wound team. Furthermore, we confirmed agreement between automatically generated recommendations and primary manual recommendations.

Applications of crowdsourcing in health: an overview

Background

Crowdsourcing is a nascent phenomenon that has grown exponentially since it was coined in 2006. It involves a large group of people solving a problem or completing a task for an individual or, more commonly, for an organisation. While the field of crowdsourcing has developed more quickly in information technology, it has great promise in health applications. This review examines uses of crowdsourcing in global health and health, broadly.

Methods

Semantic searches were run in Google Scholar for “crowdsourcing,” “crowdsourcing and health,” and similar terms. 996 articles were retrieved and all abstracts were scanned. 285 articles related to health. This review provides a narrative overview of the articles identified.

Results

Eight areas where crowdsourcing has been used in health were identified: diagnosis; surveillance; nutrition; public health and environment; education; genetics; psychology; and, general medicine/other. Many studies reported crowdsourcing being used in a diagnostic or surveillance capacity. Crowdsourcing has been widely used across medical disciplines; however, it is important for future work using crowdsourcing to consider the appropriateness of the crowd being used to ensure the crowd is capable and has the adequate knowledge for the task at hand. Gamification of tasks seems to improve accuracy; other innovative methods of analysis including introducing thresholds and measures of trustworthiness should be considered.

Conclusion

Crowdsourcing is a new field that has been widely used and is innovative and adaptable. With the exception of surveillance applications that are used in emergency and disaster situations, most uses of crowdsourcing have only been used as pilots. These exceptions demonstrate that it is possible to take crowdsourcing applications to scale. Crowdsourcing has the potential to provide more accessible health care to more communities and individuals rapidly and to lower costs of care.

A Smartphone-Based Application Improves the Accuracy, Completeness, and Timeliness of Cattle Disease Reporting and Surveillance in Ethiopia

Accurate disease reporting, ideally in near real time, is a prerequisite to detecting disease outbreaks and implementing appropriate measures for their control. This study compared the performance of the traditional paper-based approach to animal disease reporting in Ethiopia to one using an application running on smartphones. In the traditional approach, the total number of cases for each disease or syndrome was aggregated by animal species and reported to each administrative level at monthly intervals; while in the case of the smartphone application demographic information, a detailed list of presenting signs, in addition to the putative disease diagnosis were immediately available to all administrative levels via a Cloud-based server. While the smartphone-based approach resulted in much more timely reporting, there were delays due to limited connectivity; these ranged on average from 2 days (in well-connected areas) up to 13 days (in more rural locations). We outline the challenges that would likely be associated with any widespread rollout of a smartphone-based approach such as the one described in this study but demonstrate that in the long run the approach offers significant benefits in terms of timeliness of disease reporting, improved data integrity and greatly improved animal disease surveillance.

How does the cellular phone help in epidemiological surveillance? A review of the scientific literature

BACKGROUND

In the field of epidemiological surveillance, no systematic literature review appears to exist of implemented projects using cellular phone technology.

METHOD

We performed a systematic literature review using the Pubmed and Scopus databases to retrieve articles published up to December 2015. We analyzed information reported in these publications according to the mobile health (mHealth) evidence reporting and assessment (mERA) checklist, and complemented this work with specific items related to epidemiology, in order to clarify the types of results reported and summarized in this context.

RESULTS

Thirty-three articles were selected and reviewed. Each article was related to a different project. Two mERA items were systematically and fully reported, while two others were never reported. Three projects were deployed in very specific zones. Most of the projects were implemented in Africa. Infectious diseases were the elements most monitored. Most projects were based on daily data collection and SMS transmission. Economic assessment was limited to SMS, mobile phone, and implementation costs.

DISCUSSION-CONCLUSION

Although suitable for epidemiologic surveillance, the mERA checklist needs further interpretation. The technical and transmission modes of cellular phone use varied greatly from one study to another. No evaluation of the interoperability capabilities of cellular phones with other applications or sub-systems was possible.

Taking mHealth Forward: Examining the Core Characteristics

The emergence of mobile health (mHealth) offers unique and varied opportunities to address some of the most difficult problems of health. Some of the most promising and active efforts of mHealth involve the engagement of mobile phone technology. As this technology has spread and as this technology is still evolving, we begin a conversation about the core characteristics of mHealth relevant to any mobile phone platform. We assert that the relevance of these characteristics to mHealth will endure as the technology advances, so an understanding of these characteristics is essential to the design, implementation, and adoption of mHealth-based solutions. The core characteristics we discuss are (1) the penetration or adoption into populations, (2) the availability and form of apps, (3) the availability and form of wireless broadband access to the Internet, and (4) the tethering of the device to individuals. These collectively act to both enable and constrain the provision of population health in general, as well as personalized and precision individual health in particular.

The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis

Background

Central nervous system infections can have devastating clinical outcomes if not diagnosed and treated promptly. There is a documented gap between recommended and actual practice and a limited understanding of its causes. We identified and explored the reasons for this gap, focusing on points in the patient pathway most amenable to change and the development of a tailored intervention strategy to improve diagnosis and treatment.

Methods

Using theoretically-informed semi-structured interviews, we explored barriers and enablers to diagnosing and managing patients with suspected encephalitis, specifically performing lumbar punctures and initiating antiviral therapy within 6 h. We purposively sampled hospitals and hospital staff in the UK. We audio recorded and transcribed all interviews prior to a framework analysis. We mapped identified barriers and enablers to the patient pathway. We matched behaviour change techniques targeting clinicians to the most salient barriers and enablers and embedded them within an intervention package.

Results

We interviewed 43 staff in six hospitals. Clinical staff expressed uncertainty when and how to perform lumbar punctures and highlighted practical difficulties in undertaking them within busy clinical settings. Once treatment need was triggered, clinicians generally felt able to take appropriate therapeutic action, albeit within organisational and resource constraints. Matched behaviour change techniques largely targeted antecedents of treatment. These included decision support to prompt recognition, highlighting the consequences of missed diagnoses for clinicians and patients, and practical support for lumbar punctures. We subsequently devised an evidence-informed package comprising ‘core’ interventions and, to allow for local flexibility, ‘optional’ interventions.

Conclusions

We identified several points in the patient pathway where practice could improve, the most critical being around clinical suspicion and initial investigation. Interventions targeting professional beliefs and behaviours whilst optimising their clinical environment were amongst the most promising approaches to improve the care of suspected encephalitis.

Trial registration

Randomised trial registered with Controlled Trials ISRCTN06886935.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0224-2) contains supplementary material, which is available to authorized users.

Citizen science: Exploring its application as a tool for prodromic surveillance of vector-borne disease

Citizen science is the systematic collection and analysis of data, development of technology, testing of natural phenomena and the dissemination of these activities by researchers on a primarily avocational or voluntary basis. The application of citizen science-informed mobile applications (apps) provides a means for Canadians to participate in the surveillance of infectious disease. This article makes the case for a mobile application that can be used to enhance the surveillance of vector-borne diseases in Canada. Lyme disease is used as an example due to its increasing incidence and lack of available real-time information. The authors also suggest how such an app could be designed and used in a way that would attract end users to download and use it as a public health tool. If successful, these type of apps could serve as supplements to active surveillance programs as well as a means for bidirectional communication between public health professionals and citizens.

The evaluation of a tailored intervention to improve the management of suspected viral encephalitis: protocol for a cluster randomised controlled trial

Background

Viral encephalitis is a devastating condition for which delayed treatment is associated with increased morbidity and mortality. Clinical audits indicate substantial scope for improved detection and treatment. Improvement strategies should ideally be tailored according to identified needs and barriers to change. The aim of the study is to evaluate the effectiveness and cost-effectiveness of a tailored intervention to improve the secondary care management of suspected encephalitis.

Methods/Design

The study is a two-arm cluster randomised controlled trial with allocation by postgraduate deanery. Participants were identified from 24 hospitals nested within 12 postgraduate deaneries in the United Kingdom (UK). We developed a multifaceted intervention package including core and flexible components with embedded behaviour change techniques selected on the basis of identified needs and barriers to change. The primary outcome will be a composite of the proportion of patients with suspected encephalitis receiving timely and appropriate diagnostic lumbar puncture within 12 h of hospital admission and aciclovir treatment within 6 h. We will gather outcome data pre-intervention and up to 12 months post-intervention from patient records. Statistical analysis at the cluster level will be blind to allocation. An economic evaluation will estimate intervention cost-effectiveness from the health service perspective.

Trial registration

Controlled Trials: ISRCTN06886935.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0201-1) contains supplementary material, which is available to authorized users.

Technology for trauma: testing the validity of a smartphone app for pre-hospital clinicians

INTRODUCTION

With the introduction of regional trauma networks in England, ambulance clinicians have been required to make triage decisions relating to severity of injury, and appropriate destination for the patient, which may require 'bypassing' the nearest Emergency Department. A 'Trauma Unit Bypass Tool' is utilised in this process. The Major Trauma Triage tool smartphone application (App) is a digital representation of a tool, available for clinicians to use on their smartphone. Prior to disseminating the application, validity and performance against the existing paper-based tool was explored.

METHODS

A case-based study using clinical scenarios was conducted. Scenarios, with appropriate triage decisions, were agreed by an expert panel. Ambulance clinicians were assigned to either the paper-based tool or smartphone app group and asked to make a triage decision using the available information. The positive predictive value (PPV) of each tool was calculated.

RESULTS

The PPV of the paper tool was 0.76 and 0.86 for the smartphone app. User comments were mainly positive for both tools with no negative comments relating to the smartphone app.

CONCLUSION

The smartphone app version of the Trauma Unit Bypass Tool performs at least as well as the paper version and can be utilised safely by pre-hospital clinicians in supporting triage decisions relating to potential major trauma.