Remote Patient Management: Technology-Enabled Innovation And Evolving Business Models For Chronic Disease Care

Patient and Staff Experience of Remote Patient Monitoring-What to Measure and How: Systematic Review

BACKGROUND

Patient and staff experience is a vital factor to consider in the evaluation of remote patient monitoring (RPM) interventions. However, no comprehensive overview of available RPM patient and staff experience-measuring methods and tools exists.

OBJECTIVE

This review aimed at obtaining a comprehensive set of experience constructs and corresponding measuring instruments used in contemporary RPM research and at proposing an initial set of guidelines for improving methodological standardization in this domain.

METHODS

Full-text papers reporting on instances of patient or staff experience measuring in RPM interventions, written in English, and published after January 1, 2011, were considered for eligibility. By "RPM interventions," we referred to interventions including sensor-based patient monitoring used for clinical decision-making; papers reporting on other kinds of interventions were therefore excluded. Papers describing primary care interventions, involving participants under 18 years of age, or focusing on attitudes or technologies rather than specific interventions were also excluded. We searched 2 electronic databases, Medline (PubMed) and EMBASE, on February 12, 2021.We explored and structured the obtained corpus of data through correspondence analysis, a multivariate statistical technique.

RESULTS

In total, 158 papers were included, covering RPM interventions in a variety of domains. From these studies, we reported 546 experience-measuring instances in RPM, covering the use of 160 unique experience-measuring instruments to measure 120 unique experience constructs. We found that the research landscape has seen a sizeable growth in the past decade, that it is affected by a relative lack of focus on the experience of staff, and that the overall corpus of collected experience measures can be organized in 4 main categories (service system related, care related, usage and adherence related, and health outcome related). In the light of the collected findings, we provided a set of 6 actionable recommendations to RPM patient and staff experience evaluators, in terms of both what to measure and how to measure it. Overall, we suggested that RPM researchers and practitioners include experience measuring as part of integrated, interdisciplinary data strategies for continuous RPM evaluation.

CONCLUSIONS

At present, there is a lack of consensus and standardization in the methods used to measure patient and staff experience in RPM, leading to a critical knowledge gap in our understanding of the impact of RPM interventions. This review offers targeted support for RPM experience evaluators by providing a structured, comprehensive overview of contemporary patient and staff experience measures and a set of practical guidelines for improving research quality and standardization in this domain.

Six Months of Remote Patient Monitoring Is Associated with Blood Pressure Reduction in Hypertensive Patients: An Uncontrolled Observational Study

Background: Remote physiological monitoring (RPM) is a form of telehealth that measures vital signs at home and automatically reports the results to providers, thereby possibly improving chronic disease management. Medicare payment for RPM began in 2019. Two potential obstacles to RPM growth are the paucity of published clinical outcomes data and the Medicare requirement that monitoring be done at least 16 days per month to bill for the service. To help address these issues, we report the following uncontrolled observational study. Methods: A total of 1,102 consecutive patients enrolled in RPM were divided into four groups based on initial average mean arterial pressure (MAP) and into six groups based on the number of days per month MAP was measured. We report changes in MAP after 6 months of RPM as a function of initial MAP, and number of days per month MAP was monitored. Results: After 6 months of RPM, average MAP dropped from 97 to 93 (p < 0.01). This drop was greatest in the 50% of patients initially hypertensive. These patients saw average MAP reductions from 106 to 97 (p < 0.001) and became normotensive. Although MAP reduction was greatest the more frequently patients measured, significant reduction occurred in the hypertensive patients whether they measured more or less than 16 days per month (p < 0.001). No minimum threshold of measurements was found that predicted failure of RPM to lower MAP. Conclusions: RPM is associated with clinically and statistically significant reductions in average MAP in patients who were initially hypertensive. This benefit occurred irrespective of the number of days per month patients measured MAP.

Exploring flexible polynomial regression as a method to align routine clinical outcomes with daily data capture through remote technologies

BACKGROUND

Clinical outcomes are normally captured less frequently than data from remote technologies, leaving a disparity in volumes of data from these different sources. To align these data, flexible polynomial regression was investigated to estimate personalised trends for a continuous outcome over time.

METHODS

Using electronic health records, flexible polynomial regression models inclusive of a 1st up to a 4th order were calculated to predict forced expiratory volume in 1 s (FEV₁) over time in children with cystic fibrosis. The model with the lowest AIC for each individual was selected as the best fit. The optimal parameters for using flexible polynomials were investigated by comparing the measured FEV₁ values to the values given by the individualised polynomial.

RESULTS

There were 8,549 FEV₁ measurements from 267 individuals. For individuals with > 15 measurements (n = 178), the polynomial predictions worked well; however, with < 15 measurements (n = 89), the polynomial models were conditional on the number of measurements and time between measurements. The method was validated using BMI in the same population of children.

CONCLUSION

Flexible polynomials can be used to extrapolate clinical outcome measures at frequent time intervals to align with daily data captured through remote technologies.

Usability and Satisfaction Outcomes from a Pilot Open Trial Examining Remote Patient Monitoring to Treat Pediatric Obesity during the COVID-19 Pandemic

BACKGROUND

Pediatric obesity is common and a significant burden. Supplementing pediatric obesity treatment with technology is needed. This manuscript examines the usability and satisfaction, as well as explores initial effectiveness, of a remote patient monitoring system (RPMS) designed for youth presenting for pediatric weight management treatment.

METHODS

47 youth, 10 to 17 years old, with obesity and a caregiver participated. For three months, families received treatment via the RPMS. Usability and satisfaction outcomes were examined. Exploratory analyses were conducted to examine initial effectiveness from baseline and post-treatment (month 3) assessments.

RESULTS

More than 80% of patients used the RPMS, and overall, patients completed 27 out of 90 daily sessions (30%). Youth and caregivers reported high satisfaction. Non-parametric tests revealed no significant improvements for youth or caregiver weight status after the RPMS treatment. Significant improvements in other outcomes examined were limited.

CONCLUSIONS

Families were satisfied with the RPMS, but use of the system was limited. Initial effectiveness was not able to be determined due to the amount of missing data, which was impacted by the COVID-19 pandemic. Modifications of the RPMS and future evaluation of usability and effectiveness are warranted to determine utility in supplementing pediatric obesity clinical treatment.

Remote monitoring of cancer patients during the Covid-19 pandemic - an interview study of nurses' and physicians' experiences

Background

Due to the Covid-19 pandemic, remote monitoring of patients outside hospitals rapidly increased. Previous studies show that healthcare professionals’ competence in digitalization needs to be improved. Little is known about how Covid-19 has affected the use of remote monitoring of cancer patients. The purpose of the study was therefore to explore healthcare personnels’ experiences with remote monitoring of cancer patients during the Covid-19 pandemic. 

Methods

The study had an explorative and descriptive design using semi-structured individual interviews for data collection. Data was analyzed by content analysis.

Results

A total of ten healthcare personnel working in the cancer department and out-patient cancer clinic in the hospital participated; four physicians and six registered nurses. Two categories and four subcategories were identified: 1) «Maintaining personalized healthcare services» comprising the subcategories a) «Adjusting services to patients’ health condition» and b) «Ensuring continuity»; and 2) «A supplement, but not a replacement» comprising the subcategories a) «Impact on interpersonal relations» and b) «The importance of clinical assessment».

Conclusions

This study indicates that remote monitoring through telephone was preferred by both healthcare personnel and patients. The nurses and physicians experienced a more frequent contact with their patients, but emphasized the importance of physical meetings for building relationship, and for thorough clinical examination. Our findings indicate a need to facilitate a work environment where healthcare personnel can be fast learners in using digital tools to provide best possible healthcare quality. Moreover, it is imperative to develop a workplace suitable for the use of digital technology for remote monitoring, and to provide digital tools that is easy to use for both healthcare personnel and patients.

Design, Implementation, and Examination of a Remote Patient Monitoring System for Pediatric Obesity: Protocol for an Open Trial Pilot Study

BACKGROUND

Pediatric obesity is a critical public health issue. Augmenting care in multidisciplinary pediatric obesity clinics with innovative evidence-based technology to improve weight status and health outcomes is needed.

OBJECTIVE

This study describes the design and methods of an open trial pilot study to examine a remote patient monitoring system (RPMS) for children aged 8-17 years who are receiving treatment in a multidisciplinary pediatric obesity clinic.

METHODS

Participants will include 45 youth with obesity and their parents. Families will receive standard care in the clinic and the RPMS for 3 months. The RPMS consists of a tablet, weight scale, and pedometer. The system provides daily educational content and involves the use of the pedometer and weekly weigh-ins. Children and parents will complete baseline, posttreatment (month 3), and follow-up assessments (month 6). The primary aim of the study is to examine feasibility and satisfaction with the RPMS and assess its initial effectiveness.

RESULTS

We hypothesize high feasibility and satisfaction, with rates over 75%. Furthermore, after RPMS treatment, children will exhibit improved weight status, health outcomes, dietary intake, physical activity, health-related quality of life, self-efficacy, and home-food environment compared to before treatment. These gains are expected to persist at follow-up.

CONCLUSIONS

This study is novel in that it is the first to design, implement, and examine an RPMS in a pediatric obesity clinic. If the RPMS is feasible, effective, and easily accessible, it may prove to be a practical, acceptable, and cost-effective weight management treatment for youth seeking treatment for severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04029597; https://clinicaltrials.gov/ct2/show/NCT04029597.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29858.

Telehealth and COVID-19: Using technology to accelerate the curve on access and quality healthcare for citizens in India

The current COVID-19 pandemic has reinstated the importance of telehealth as a business model for accelerating the accessibility of healthcare and improving the quality of healthcare for citizens of a country. Telehealth service has a tremendous potential in a developing country like India where the healthcare facilities in India are heavily concentrated in urban cities while their majority (67%) of the population resides in rural areas. At the same time, a high teledensity of almost 90% supports telehealth overall reach. However, the growth of telehealth in India till now has been sluggish but the corona virus (COVID-19) crisis has redefined the telehealth ecosystem by reducing the risk of infection through person-to-person contact. In this study, we explore the perception of healthcare users towards telehealth services and analyze the key enablers for the telehealth services in the current scenario. We collected data from 1170 participants through personal interview. The results of the study shows a considerable segment of the population is having high healthcare need, have aspirations for accessing better healthcare for themselves and their family members and use ICT to a significant extent. At the same time, they have positive attitude towards telehealth and socio-demographic factors like age, geographical location, educational qualification, family size affects the attitude towards telehealth services. The results of the study shows there is a significant market for telehealth services in India to be explored by the technology firms, hospitals and other healthcare stakeholders and going forward it has an enormous capability to transform the complete healthcare ecosystem, especially in developing countries like India post the COVID-19 crisis.

Assessing the Feasibility of a Novel mHealth App in Hematopoietic Stem Cell Transplant Patients

Hematopoietic stem cell transplantation (HCT) is a curative treatment option for patients with hematologic conditions but presents many complications that must be managed as a complex, chronic condition. Mobile health applications (mHealth apps) may permit tracking of symptoms in HCT. In seeking strategies to manage the complexities of HCT, our team collaborated with Sicklesoft, Inc., to develop an mHealth app specifically for HCT patients to allow for daily evaluation of patient health, Technology Recordings to better Understand Bone Marrow Transplantation (TRU-BMT). The primary value of this application is that of potentially enhancing the monitoring of symptoms and general health of patients undergoing HCT, with the ultimate goal of allowing earlier detection of adverse events, earlier intervention, and improving outcomes. To first evaluate patient interest in mHealth apps, we designed and administered an interest survey to patients at the 2017 BMT-InfoNet reunion. As a follow-up to the positive feedback received, we began testing the TRU-BMT app in a Phase 1 pilot study. Thirty patients were enrolled in this single-arm study and were given the TRU-BMT mHealth app on a smartphone device in addition to a wearable activity tracker. Patients were followed for up to 180 days, all the while receiving daily app monitoring. Adherence to TRU-BMT was approximately 30% daily and 44% weekly, and greater adherence was associated with increased meal completion, decreased heart rate, and shorter hospital stay. TRU-BMT assessments of symptom severity were significantly associated with duration of hospital stay and development of chronic graft-versus-host disease. Our findings suggest that using TRU-BMT throughout HCT is feasible for patients and established a proof-of-concept for a future randomized control trial of the TRU-BMT application in HCT. © 2021 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

How does telehealth shape new ways of co-creating value?

Purpose

The rise of telehealth is evident worldwide, especially now with the COVID-19 pandemic situation, and is providing extensive opportunities for health-care organisations to create added value for different stakeholders. However, even in this extreme situation, the progress of telehealth is quite slow and insufficient. In this context, it is necessary to consider how the application of telehealth services allows co-creating additional value for different stakeholders. Consequently, the purpose of this paper is to explore telehealth services and the added value that they co-create for various stakeholders across publicly and privately oriented health-care ecosystems.

Design/methodology/approach

This paper adopted a qualitative research design based on an explorative and comparative approach to study the perceived added value that is co-created during telehealth encounters. The authors deployed a semi-structured interview research design. Interviews were carried out in two settings that have different health-care systems: Lithuania (publicly oriented health care) and the California Bay Area, USA, (privately oriented health care). The research covers telehealth services from the point of view of different stakeholders in the health-care ecosystem.

Findings

The paper emphasises that value-in-use is essential in the case of telehealth; however, value-in-exchange is relevant to describe the relationships between public and private insurers and health-care providers. The findings point out that despite the type of health-care system, telehealth added value-in-use was perceived quite similar in both research settings, and differences could be distinguished mainly at the sub-dimensional level. The added value-in-use for patients comprises economic, functional and emotional value; physicians potentially get functional added value-in-use. The authors also highlight that patients and physicians get relational functional and social value-in-use. The added value-in-use for health-care providers consists of economic (in both research settings) and functional value (in Lithuania). The research findings show that there is still an evident lack of health insurance companies ready to recognise telehealth as a valuable service and to reimburse similarly to in cases of in-person visits. Thus, the added value-in-exchange is hardly created and this impedes co-creation of the added value-in-use.

Originality/value

This paper contributes to the field mainly by transferring the business research applied concept of value co-creation into the social-purpose driven health-care industry. The findings are beneficial for the health-care management stream of the literature, which considers health care as a value-based industry. To the best of the authors’ knowledge, this is the first attempt to structure the perceived telehealth added value from the perspectives of different stakeholders and two different health-care ecosystems. This paper also gives a clearer understanding of the role of the value-in-exchange in such complex ecosystems as health care and gives reasons when it could be created in synergy with co-creation of the value-in-use. In this sense, the findings are beneficial from both marketing and innovation theoretical perspectives, as they give a special attention to value creation and co-creation phenomena analysis.

Telemedicine Technologies for Confronting COVID-19 Pandemic: A Review

Telemedicine (TM) is used to treat patients in a remote location by using telecommunication technology. It exchanges the medical information and data from one location to another through advanced technological innovation. During this COVID-19 pandemic, there is a lockdown in almost all countries. TM is beneficial to healthcare to minimize social distance. This review paper briefs about TM and discusses how this technology works for the COVID-19 pandemic and its significant benefits. An extensive search is made on the known research engines of PubMed, SCOPUS, Google Scholar, and ResearchGate using the appropriate keywords to extract meaningful and relevant articles. Ten major applications of TM for COVID-19 are identified and discussed with a brief description of each provided. The major technological processes involved in TM, which create advancement in the medical field, are also discussed. This technology helps avoid visits to the doctor and hospital during the lockdown and provides a suitable treatment option. It collects the medical information and data, which can be helpful for better treatment of the patient. Telemedicine adopts virtualized treatment approaches for the patient. Now patients can receive better quality treatment without leaving their homes during COVID-19 lockdown.

Silicon Nanofluidic Membrane for Electrostatic Control of Drugs and Analytes Elution

Individualized long-term management of chronic pathologies remains an elusive goal despite recent progress in drug formulation and implantable devices. The lack of advanced systems for therapeutic administration that can be controlled and tailored based on patient needs precludes optimal management of pathologies, such as diabetes, hypertension, rheumatoid arthritis. Several triggered systems for drug delivery have been demonstrated. However, they mostly rely on continuous external stimuli, which hinder their application for long-term treatments. In this work, we investigated a silicon nanofluidic technology that incorporates a gate electrode and examined its ability to achieve reproducible control of drug release. Silicon carbide (SiC) was used to coat the membrane surface, including nanochannels, ensuring biocompatibility and chemical inertness for long-term stability for in vivo deployment. With the application of a small voltage (≤ 3 V DC) to the buried polysilicon electrode, we showed in vitro repeatable modulation of membrane permeability of two model analytes-methotrexate and quantum dots. Methotrexate is a first-line therapeutic approach for rheumatoid arthritis; quantum dots represent multi-functional nanoparticles with broad applicability from bio-labeling to targeted drug delivery. Importantly, SiC coating demonstrated optimal properties as a gate dielectric, which rendered our membrane relevant for multiple applications beyond drug delivery, such as lab on a chip and micro total analysis systems (µTAS).

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis

BACKGROUND

Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings.

OBJECTIVES

To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature.

REVIEW METHODS

A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies.

RESULTS

Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases.

CONCLUSION

The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care.

Timely Interventions for Children with ADHD through Web-Based Monitoring Algorithms

The aim of this study was to evaluate an automated trigger algorithm designed to detect potentially adverse events in children with Attention-Deficit/Hyperactivity Disorder (ADHD), who were monitored remotely between visits. We embedded a trigger algorithm derived from parent-reported ADHD rating scales within an electronic patient monitoring system. We categorized clinicians’ alert resolution outcomes and compared Vanderbilt ADHD rating scale scores between patients who did or did not have triggered alerts. A total of 146 out of 1738 parent reports (8%) triggered alerts for 98 patients. One hundred and eleven alerts (76%) required immediate clinician review. Nurses successfully contacted parents for 68 (61%) of actionable alerts; 46% (31/68) led to a change in care plan prior to the next scheduled appointment. Compared to patients without alerts, patients with alerts demonstrated worsened ADHD severity (β = 5.8, 95% CI: 3.5–8.1 [p < 0.001] within 90 days prior to an alert. The trigger algorithm facilitated timely changes in the care plan in between face-to-face visits.

Characterization of Patient Interest in Provider-Based Consumer Health Information Technology: Survey Study

BACKGROUND

Consumer health information technology can improve patient engagement in their health care and assist in navigating the complexities of health care delivery. However, the consumer health information technology offerings of health systems are often driven by provider rather than patient perspectives and inadequately address patient needs, thus limiting their adoption by patients. Consideration given to patients as stakeholders in the development of such technologies may improve adoption, efficacy, and consumer health information technology resource allocation.

OBJECTIVE

The aims of this paper were to measure patient interest in different health system consumer health information technology apps and determine the influence of patient characteristics on consumer health information technology interest.

METHODS

Patients seen at the Cleveland Clinic Neurological Institute were electronically surveyed on their interest in using different consumer health information technology apps. A self-efficacy scale, Patient Health Questionnaire-9 depression screen, and EuroQol 5 dimensions health-related quality of life scale were also completed by patients. Logistic regression was used to determine the influence of patient characteristics on interest in consumer health information technology in the categories of self-management, education, and communication.

RESULTS

The majority of 3852 patient respondents had an interest in all technology categories assessed in the survey. The highest interest was in apps that allow patients to ask questions of providers (3476/3852, 90.24%) and to schedule appointments (3211/3839, 83.64%). Patient interest in consumer health information technology was significantly associated with greater depression symptoms, worse quality of life, greater health self-efficacy, and smartphone ownership (P<.001 for all listed).

CONCLUSIONS

Patients should be viewed as active stakeholders in consumer health information technology development and their perspectives should consistently guide development efforts. Health systems should consider focusing on consumer health information technologies that assist patients in scheduling appointments and asking questions of providers. Patients with depression should also be considered for targeted consumer health information technology implementation. Health self-efficacy is a valid predictor of consumer health information technology interest and may play a role in the utilization of consumer health information technologies. Health systems, broadly, should put forth greater effort to understand the needs and interests of patients in the consumer health information technology development process. Consumer health information technology design and implementation may be improved by understanding which technologies patients want.

Care coordination in a business-to-business and a business-to-consumer model for telemonitoring patients with chronic diseases

Introduction

For telemonitoring to support care coordination, a sound business model is conditional. The aim of this study is to explore the systemic and economic differences in care coordination via business-to-business and business-to-consumer models for telemonitoring patients with chronic diseases.

Methods

We performed a literature search in order to design the business-to-business and business-to-consumer telemonitoring models, and to assess the design elements and themes by applying the activity system theory, and describe the transaction costs in each model. The design elements are content, structure, and governance, while the design themes are novelty, lock-in, complementarities, and efficiency. In the transaction cost analysis, we looked into all the elements of a transaction in both models.

Results

Care coordination in the business-to-business model is designed to be organized between the places of activity, rather than the participants in the activity. The design of the business-to-business model creates a firm lock-in but for a limited time. In the business-to-consumer model, the interdependencies are to be found between the persons in the care process and not between the places of care. The differences between the models were found in both the design elements and the design themes.

Discussion

Care coordination in the business-to-business and business-to-consumer models for telemonitoring chronic diseases differs in principle in terms of design elements and design themes. Based on the theoretical models, the transaction costs could potentially be lower in the business-to-consumer model than in the business-to-business, which could be a promoting economic principle for the implementation of telemonitoring.

Innovative and successful approaches to improving care transitions from hospital to home

Effective transitions to home care have been identified as among the factors leading to reducing hospital readmissions within 30 days of discharge and improvements on various other quality measures. Innovative applications of published evidence-based models and best practices designed to improve care transitions have been implemented in various settings across the country in an effort to enhance quality performance. For this article, The Joint Commission collected a series of case examples to examine how evidence-based innovations in care transitions are reducing readmissions and improving other quality outcomes. The organizations providing the case examples were interviewed and asked to provide performance data demonstrating quality improvement, as well as information about their care processes and data-gathering techniques. Their innovative approaches are reducing hospital readmissions; improving patient safety, satisfaction, and engagement; and contributing to other positive outcomes.

A comparison of how four countries use health IT to support care for people with chronic conditions

Countries around the globe are investing in health information and communications technologies (ICTs) as critical tools for improving care for chronically ill patients. We profiled four high-income nations with varied health ICT strategies--Australia, Canada, Denmark, and the United States--to describe their use of ICTs to improve chronic care. Our goal was to identify common challenges and opportunities for cross-national learning. We found four key themes. First, although all four countries have a national strategy for health ICT adoption, strategies are implemented and adapted to chronic care needs regionally, which creates the challenge of spreading successful efforts across regions. Second, each country struggles with how to ensure that clinical information follows patients seamlessly between care settings. Third, although each nation is pursuing telehealth solutions as a component of chronic care, the telehealth initiatives are usually stand-alone efforts that are not well integrated into other ICT solutions, such as electronic health records. Finally, countries have made progress in improving patients' access to their clinical data but have not fully succeeded in engaging patients to apply the data to improve care. These common themes suggest that although the four nations have different health care systems and ICT strategies, all of them face a similar set of challenges, creating an opportunity for cross-national learning.

Searching for a Role of Nursing Personnel in Developing Landscape of Ehealth: Factors Determining Attitudes toward Key Patient Empowering Applications

Introduction

Nurses may play an important role in the delivery of medical services based on the use of ehealth tools. Nevertheless, their taking an active role in an ehealth environment depends on their possessing the appropriate skills and mindset. The main objective of this paper was to assess nurses’ opinions and to analyze the predictors of their acceptance of ehealth features relevant to patient empowerment with a strong focus on chronic care.

Methods

A survey was conducted among nurses from hospital centers of south-eastern Poland based on a questionnaire designed to assess their attitudes toward the ehealth domain. The predictors of the nurses’ acceptance of ehealth usage within specific contexts were assessed with uni- and multivariate logistic regression.

Results

An analysis was performed on data from 648 questionnaires retained after a quality check. The duration of Internet use was consistently related to higher acceptance of ehealth applications and more certainty regarding the reliability of health-related information available on the Internet. Nurses from urban medical centers were more skeptical about the use of specific ehealth solutions.

Conclusion

Previous experience in using information technologies is the main factor influencing the acceptance of specific ehealth solutions relevant for care provided to patients suffering from chronic conditions.

Technology-based innovation for independent living: policy and innovation in the United Kingdom, Scandinavia, and the United States

Interest in utilizing technology to help older adults remain living at home is growing; however, uptake remains low. We present a conceptual framework for understanding independent living technology innovation within health and social services. Public policy and innovation in the United States, the United Kingdom, and Scandinavia are profiled as case studies. In all profiled countries, independent living technology is more rapidly advancing than associated state policy, regulation, and payment systems. The findings from this comparative analysis reveal areas for further exploration, including policy subsystem environments in which technologies and services are regulated, as well as trends and desires of older adults and their caregivers within particular cultural contexts.

A cross-sectional study assessing determinants of the attitude to the introduction of eHealth services among patients suffering from chronic conditions

BACKGROUND

Provision of care to patients with chronic diseases remains a great challenge for modern health care systems. eHealth is indicated as one of the strategies which could improve care delivery to this group of patients. The main objective of this study was to assess determinants of the acceptance of the Internet use for provision of chosen health care services remaining in the scope of current nationwide eHealth initiative in Poland.

METHODS

The survey was carried out among patients with diagnosed chronic conditions who were treated in three health care facilities in Krakow, Poland. Survey data was used to develop univariate and multivariate logistic regression models for six outcome variables originating from the items assessing the acceptance of specific types of eHealth applications. The variables used as predictors were related to the sociodemographic characteristics of respondents, burden related to chronic disease, and the use of the Internet and its perceived usefulness in making personal health-related decisions.

RESULTS

Among 395 respondents, there were 60.3% of Internet users. Univariate logistic regression models developed for six types of eHealth solutions demonstrated their higher acceptance among younger respondents, living in urban areas, who have attained a higher level of education, used the Internet on their own, and were more confident about its usefulness in making health-related decisions. Furthermore, the duration of chronic disease and hospitalization due to chronic disease predicted the acceptance of some of eHealth applications. However, when combined in multivariate models, only the belief in the usefulness of the Internet (five of six models), level of education (four of six models), and previous hospitalization due to chronic disease (three of six models) maintained the effect on the independent variables.

CONCLUSIONS

The perception of the usefulness of the Internet in making health-related decision is a key determinant of the acceptance of provision of health care services online among patients with chronic diseases. Among sociodemographic factors, only the level of education demonstrates a consistent impact on the level of acceptance. Interestingly, a greater burden of chronic disease related to previous hospitalizations leads to lower acceptance of eHealth solutions.

Usability and Feasibility of an mHealth Intervention for Monitoring and Managing Pain Symptoms in Sickle Cell Disease: The Sickle Cell Disease Mobile Application to Record Symptoms via Technology (SMART)

Patients with sickle cell disease frequently experience severe pain events that lead to unplanned healthcare utilization. Mobile health tools (mHealth) may help prevent these events by providing remote monitoring and self-management support. This article describes the feasibility of the Sickle cell disease Mobile Application to Record symptoms via Technology (SMART), an mHealth app developed to help sickle cell disease patients monitor and manage their day-to-day symptoms. Fifteen patients recorded their pain intensity using a paper visual analog scale (VAS) and then repeated this measurement using an electronic VAS pain measure on SMART. Patients continued using SMART to record clinical symptoms, pain intensity, location and perceived severity, and treatment strategies for at least 28 days. Patient median age was 29 years (range 16-54); 60.0% were male. There was a high intraclass correlation between pain measurements entered on the paper VAS and SMART on the iPhone and the iPad We found a strong association between patient perceived pain severity and pain intensity entries using SMART (b = 1.71; p < 0.01). Daily compliance with SMART entries was a mean 75.0%, with a high of 85.7% in week 1 and low of 57.9% in week 4; however, one-third (n = 5) of the patients were 100.0% compliant even in week 4. Patients who were over age 35 or used an iPad for the study had the highest compliance rates. This study showed that SMART is a useable and feasible method for monitoring daily pain symptoms among adolescents and adults with sickle cell disease-related pain.

Client satisfaction with telehealth services in home health care agencies

We assessed client satisfaction with the home telemonitoring service provided by 14 home health care agencies in five US states. Clients were randomised to two groups. Telehealth services (health monitoring and patient safety) were provided to 450 experimental subjects. Control subjects (n = 409) received usual care. Clients were asked to rate their satisfaction with their service providers on 25 items, at baseline, 6 months post-discharge (to home) and 12 months post-discharge. The mean age of the clients was 78 years. Out of the initial 859 subjects, 490 had dropped out of the study by the 12-month follow-up, an overall attrition rate of 57%. There were similar proportions of clients reporting high satisfaction with external systems at baseline and at 6 months; at 12 months, there were significantly more clients in the experimental group who reported high satisfaction ( P = 0.049). There were similar proportions of clients reporting high satisfaction with internal systems at baseline and at 12 months; at 6 months, there were significantly more clients in the experimental group who reported high satisfaction ( P = 0.031). Clients with home monitoring were more satisfied with health-related and medical services post-discharge than those receiving usual care over a 6–12 month period.

Hospital utilization after a telemonitoring program: a pilot study

The long-term effects of remote monitoring on hospital utilization and health care costs are understudied in home health care. The researchers performed a retrospective study, in a hospital-based home health care agency, to consider the effects of remote monitoring in 326 patients with heart failure 90 days after discharge from services. While statistical significance was not noted, clinical significance suggests that there was a decreased hospital utilization rate and decreased average cost per hospitalization in the remote monitoring group.

Web-based, self-management enhancing interventions with e-diaries and personalized feedback for persons with chronic illness: a tale of three studies

OBJECTIVE

Chronic illness places high demands on patients. Interventions supporting self-management and providing personalized feedback might help patients to gain new perspectives and enhance use of constructive self-management strategies. We developed three comparable web-based CBT-grounded interventions including e-diaries and feedback delivered through PDAs/smartphones. The feasibility and efficacy of these interventions have been investigated for patients with irritable bowel syndrome (in an RCT), chronic widespread pain (RCT) and type 2 diabetes (feasibility study).

METHODS

This is a descriptive study that summarizes the content, feasibility and efficacy of the interventions and discusses issues relevant for implementing this type of web-based therapeutic interventions in clinical practice.

RESULTS

The web-based interventions appear feasible, acceptable and supportive. In a short and midterm time frame, the interventions promote self-management.

CONCLUSION

Booster sessions may be needed for prolonged effects. Given the physical and mental symptoms of the patients under study and the nature of the intervention, providers who deliver the feedback need a health care background and training in this specific way of counseling.

PRACTICE IMPLICATIONS

The results of the three studies suggest that personalized web-based interventions are effective and have the potential to support self-management in daily healthcare. Studies concerning clinical significance and implementation are needed.

The acceptance of e-health solutions among patients with chronic respiratory conditions

OBJECTIVE

The main objective of this study was to assess the acceptance of the use of e-health applications by patients suffering from bronchial asthma and other chronic respiratory conditions.

SUBJECTS AND METHODS

The questionnaire, consisting of 73 items, was distributed among 200 patients remaining under the care of a tertiary-care pulmonology center in Krakow, Poland (return rate, 82.5%; n=165).

RESULTS

The mean age (standard deviation) of respondents was 50.8 (14.9) years. Of the respondents, 48.5% (n=80) suffered from bronchial asthma, 29.1% (n=48) from chronic obstructive pulmonary disease, and 32.1% (n=53) from other respiratory diseases. The Internet was used by 58.2% (n=96) of respondents. The most frequent types of health-related information searched for online included diseases (59.4%) and treatments (medication, 54.2%; treatment options, 58.3%), as well as information about physicians and healthcare institutions (32.3% and 31.3%, respectively). The differences between acceptance scores for specific e-health applications were significant (analysis of variance, Friedman chi-squared=166.315, p<0.001). The respondents revealed the highest acceptance of e-health solutions allowing them to book appointments with physicians, access laboratory test results, view educational resources, and renew prescriptions. The acceptance of the most popular e-health applications depended on the duration of disease, respondent's age and education, and his or her use of computers and the Internet.

CONCLUSIONS

Patients suffering from chronic respiratory conditions demonstrate higher levels of acceptance of e-health applications such as appointment booking, prescription renewal, and access to information (laboratory test results, educational resources) than of solutions directly related to medical care (communication with healthcare providers, disease monitoring).

An information technology framework for strengthening telehealthcare service delivery

OBJECTIVE

Telehealthcare has been used to provide healthcare service, and information technology infrastructure appears to be essential while providing telehealthcare service. Insufficiencies have been identified, such as lack of integration, need of accommodation of diverse biometric sensors, and accessing diverse networks as different houses have varying facilities, which challenge the promotion of telehealthcare. This study designs an information technology framework to strengthen telehealthcare delivery.

MATERIALS AND METHODS

The proposed framework consists of a system architecture design and a network transmission design. The aim of the framework is to integrate data from existing information systems, to adopt medical informatics standards, to integrate diverse biometric sensors, and to provide different data transmission networks to support a patient's house network despite the facilities. The proposed framework has been evaluated with a case study of two telehealthcare programs, with and without the adoption of the framework.

RESULTS

The proposed framework facilitates the functionality of the program and enables steady patient enrollments. The overall patient participations are increased, and the patient outcomes appear positive. The attitudes toward the service and self-improvement also are positive.

CONCLUSIONS

The findings of this study add up to the construction of a telehealthcare system. Implementing the proposed framework further assists the functionality of the service and enhances the availability of the service and patient acceptances.

Plug-and-play, single-chip photoplethysmography

Remote patient monitoring (RPM) relies on low-cost, low-power, wearable sensors for continuous physiological assessment. Photoplethysmographic (PPG) sensors generally require >10 components, occupy an area >300 mm(2), consume >10 mW power, and cost >$20 USD. Although the principle of PPG sensing is straightforward, in practice, a robust implementation requires a careful design including optical alignment, analog circuits, ambient light cancellation, and power management. This paper reports the first use of digital optical proximity sensors (OPS) for "plug-and-play" PPG. OPS have traditionally been used for distance sensing in smartphones and factory automation. Here we show that a digital OPS can perform PPG functions in a single 4×4 mm package which also provides a direct digital interface to a microcontroller. By exploiting its key features, a digital OPS can provide substantial performance advantages over existing state-of-the-art PPGs, including: i) 10X lower power consumption (200 µW) due to pulse operation; ii) high signal to noise ratio (>90), as a result of built-in optical barriers, filters, and ambient light cancellation; iii) 10X lower cost ($2 USD); and iv) 12X smaller area. We show single wavelength PPG measurements in multiple anatomical locations, including fingertips and earlobes. The results suggest that a digital OPS can provide an elegant solution for battery-powered, wearable physiological monitors. To the authors' knowledge, this is the smallest and lowest power PPG sensor reported to date.

The impact of remote patient monitoring (telehealth) upon Medicare beneficiaries with heart failure

OBJECTIVE

To study the impact of remote patient monitoring (RPM) upon the most frequent diagnosis in hospitalized patients over 65 years of age-heart failure (HF). We examined the effect of RPM on hospital utilization and Medicare costs of HF patients receiving home care.

MATERIALS AND METHODS

Two studies were simultaneously conducted: A randomized and a matched-cohort study. In the randomized study, 168 subjects were randomly assigned (after hospitalization) to home care utilizing RPM (live nursing visits and video-based nursing visits) or to home care receiving live nursing visits only. In the matched-cohort study, 160 subjects receiving home care with RPM (live nursing visits and video-based nursing visits) were matched with home care subjects receiving live nursing visits only.

RESULTS

Regardless of whether outcomes were being analyzed for all subjects (intention to treat) or for hospitalized subjects only, hospitalization rates, time to first admission, length of stay, and costs to Medicare did not differ significantly between groups in either study at 30 or 90 days after enrollment. A notable trend, however, emerged across studies: Although time to hospitalization was shorter in the RPM groups than the control groups, RPM groups had lower hospitalization costs.

CONCLUSIONS

RPM, when utilized in conjunction with a robust management protocol, was not found to significantly differ from live nursing visits in the management of HF in home care. Shorter hospitalization times and lower associated costs may be due to earlier identification of exacerbation. These trends indicate the need for further study.

Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings

Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program's impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7-13.3 percent ($312-$542) per person per quarter. These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.

Situation, motivation, implementation and results of telehealth-enabled health care

Well-implemented telehealth systems can reduce the total costs of care by reducing emergency hospital visits and unnecessary treatment. Telehealth is especially well-suited to supporting patients with chronic, complex or co-morbid conditions. A substantial body of research – much from the USA – documents the value of a commercially-available system which supplements remote monitoring with daily questions about the patient's health and behaviours. However, there are still very few large scale deployments of telehealth because the best practices needed to implement it are still being developed.

Care management's challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults

Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.