Connected health: a review of the literature

A randomized controlled trial to evaluate a behavioral economic strategy for improving mobility in veterans with chronic pain

Rates of chronic pain and daily opioid use are higher among veterans relative to civilian populations. Increasing physical activity can reduce pain severity and decrease opioid use among patients with chronic pain. Behavioral economic strategies can improve physical activity levels but have been undertested in veterans with chronic pain. The objective of this study was to evaluate if a financial incentive combined with a loss aversion component-a "regret lottery" in which veterans could win money if they met a set goal or told how much they could have won had they met their goal-would increase physical activity levels among veterans with chronic pain. A 12-week single-blinded randomized controlled trial (ClinicalTrials.gov: NCT04013529) was designed. Veterans with chronic pain (N = 40) receiving care at a specialty pain clinic were eligible for participation, and were randomly assigned (1:1) to either (a) activity trackers and daily text message reminders to increase physical activity ("control arm"), or (b) the same plus a weekly regret lottery ("intervention arm"). For those in the intervention arm, participants who met their activity goal, had a chance to win a small ($30) or large ($100) gift card incentive; those who did not meet their goals were informed of what they would have won had they met their goal. The primary outcome, physical activity, was measured using self-reported physical activity and step counts using activity trackers. Secondary outcomes included changes in physical function, chronic pain severity, depression and opioid use. The sample was primarily white, male and disabled, with an average age of 57 years. No between-arm differences were noted for physical activity, physical function, chronic pain severity, depression or opioid use. Regret lottery-based approaches may be ineffective at increasing physical activity levels in veterans with chronic pain. Trial Registry: NCT04013529.

"It was an unexpected bond": How an emerging participant-driven online social network may be enhancing an eLearning nutrition education & supplemental produce intervention

Objective

The purpose of this paper is to describe a participant-driven, online text message-based social support network that emerged from an eLearning nutrition education and supplemental produce intervention.

Methods

Adults (n = 20) who utilized a safety-net clinic for their healthcare participated in a 12-week smartphone-based nutrition education eLearning program using loaned smartphones. Participants also received a box of fresh produce weekly. Participants received weekly text message reminders to collect their produce, and from this researcher-initiated reminder text, a supportive, participant-led, all-group text message thread commenced. Researchers collected all 471 text messages in this all-group thread and included them in the qualitative content analysis of pre and post intervention focus groups.

Results

The original design of the eLearning nutrition education program was to asynchronously engage learners with nutrition education resources. However, participants themselves initiated a robust group text message support system through which they shared encouragement, recipes, grocery shopping tips, and images of food they prepared with the produce box amongst themselves for the duration of the 12-week intervention.

Conclusion

The novel nature by which these participants voluntarily engaged in this peer-to-peer nutrition education-focused text message conversation exemplifies participants becoming agents in their own learning experience and will be used to enhance future eLearning nutrition education experiences developed by our team.

The Extent and Coverage of Current Knowledge of Connected Health: Systematic Mapping Study

Background

This study examines the development of the connected health (CH) research landscape with a view to providing an overview of the existing CH research. The research field of CH has experienced rapid growth coinciding with increasing pressure on health care systems to become more proactive and patient centered.

Objective

This study aimed to assess the extent and coverage of the current body of knowledge in CH. In doing so, we sought to identify specific topics that have drawn the attention of CH researchers and to identify research gaps, in particular those offering opportunities for further interdisciplinary research.

Methods

A systematic mapping study that combined scientific contributions from research in the disciplines of medicine, business, computer science, and engineering was used. Overall, seven classification criteria were used to analyze the papers, including publication source, publication year, research type, empirical type, contribution type, research topic, and the medical condition studied.

Results

The search resulted in 208 papers that were analyzed by a multidisciplinary group of researchers. The results indicated a slow start for CH research but showed a more recent steady upswing since 2013. The majority of papers proposed health care solutions (77/208, 37.0%) or evaluated CH approaches (49/208, 23.5%). Case studies (59/208, 28.3%) and experiments (55/208, 26.4%) were the most popular forms of scientific validation used. Diabetes, cancer, multiple sclerosis, and heart conditions were among the most prevalent medical conditions studied.

Conclusions

We conclude that CH research has become an established field of research that has grown over the last five years. The results of this study indicate a focus on technology-driven research with a strong contribution from medicine, whereas the business aspects of CH have received less research attention.

Connected Health Services: Framework for an Impact Assessment

Background

Connected health (CH), as a new paradigm, manages individual and community health in a holistic manner by leveraging a variety of technologies and has the potential for the incorporation of telehealth and integrated care services, covering the whole spectrum of health-related services addressing healthy subjects and chronic patients. The reorganization of services around the person or citizen has been expected to bring high impact in the health care domain. There are a series of concerns (eg, contextual factors influencing the impact of care models, the cost savings associated with CH solutions, and the sustainability of the CH ecosystem) that should be better addressed for CH technologies to reach stakeholders more successfully. Overall, there is a need to effectively establish an understanding of the concepts of CH impact. As services based on CH technologies go beyond standard clinical interventions and assessments of medical devices or medical treatments, the need for standardization and for new ways of measurements and assessments emerges when studying CH impact.

Objective

This study aimed to introduce the CH impact framework (CHIF) that serves as an approach to assess the impact of CH services.

Methods

This study focused on the subset of CH comprising services that directly address patients and citizens on the management of disease or health and wellness. The CHIF was developed through a multistep procedure and various activities. These included, as initial steps, a literature review and workshop focusing on knowledge elicitation around CH concepts. Then followed the development of the initial version of the framework, refining of the framework with the experts as a result of the second workshop, and, finally, composition and deployment of a questionnaire for preliminary feedback from early-stage researchers in the relevant domains.

Results

The framework contributes to a better understanding of what is CH impact and analyzes the factors toward achieving it. CHIF elaborates on how to assess impact in CH services. These aspects can contribute to an impact-aware design of CH services. It can also contribute to a comparison of CH services and further knowledge of the domain. The CHIF is based on 4 concepts, including CH system and service outline, CH system end users, CH outcomes, and factors toward achieving CH impact. The framework is visualized as an ontological model.

Conclusions

The CHIF is an initial step toward identifying methodologies to objectively measure CH impact while recognizing its multiple dimensions and scales.

Mobile Health and Technology Usage by Patients in the Diabetes, Nutrition, and Weight Management Clinic at an Urban Academic Medical Center

Background: Low-income, minority, and underserved populations are often excluded from mobile health (mHealth) research. This cross-sectional study sought to define how patients at an urban, academic safety net hospital use technology in their daily lives in an effort to incorporate mHealth into clinical care and research. Methods: Patients receiving care in the Diabetes and Weight Management subspecialty clinic at Boston Medical Center were asked to complete a 17-question survey on technology usage. It was modeled on a Pew Research Center survey and available in English, Portuguese, and Spanish. Results: Of the 394 survey respondents, 279 (70.8%) completed all questions. Majority of respondents were female (76.4%) and between 30 and 49 years old (42.9%). Respondents self-identified primarily as black/African American (35.8%), white/Caucasian (28.2%), and not Hispanic/Latino (46.4%). Over 90% owned a smartphone and more than 85% accessed the Internet on a mobile device at least once per day. Regarding mHealth usage, 33.5% and 23.1% reported current use of health- and weight loss-centric applications (apps), respectively, while only 19.6% of patients with diabetes used smartphone apps as diabetes self-management tools. Nearly three-quarters (73.3%) reported interest in using apps to manage health. Respondents preferred e-mail (48.7%), phone (39.6%), and in-person communication (36.3%) as research recruitment tools. Conclusions: The overwhelming majority of an urban, underserved minority population cared for in a subspecialty clinic have access to mHealth-compatible devices and are either using or interested in using mHealth technology.

Accelerating Research With Technology: Rapid Recruitment for a Large-Scale Web-Based Sleep Study

Background

Participant recruitment can be a significant bottleneck in carrying out research studies. Connected health and mobile health platforms allow for the development of Web-based studies that can offer improvement in this domain. Sleep is of vital importance to the mental and physical health of all individuals, yet is understudied on a large scale or beyond the focus of sleep disorders. For this reason and owing to the availability of digital sleep tracking tools, sleep is well suited to being studied in a Web-based environment.

Objective

The aim of this study was to investigate a method for speeding up the recruitment process and maximizing participant engagement using a novel approach, the Achievement Studies platform (Evidation Health, Inc, San Mateo, CA, USA), while carrying out a study that examined the relationship between participant sleep and daytime function.

Methods

Participants could access the Web-based study platform at any time from any computer or Web-enabled device to complete study procedures and track study progress. Achievement community members were invited to the study and assessed for eligibility. Eligible participants completed an electronic informed consent process to enroll in the study and were subsequently invited to complete an electronic baseline questionnaire. Then, they were asked to connect a wearable device account through their study dashboard, which shared their device data with the research team. The data were used to provide objective sleep and activity metrics for the study. Participants who completed the baseline questionnaires were subsequently sent a daily single-item Sleepiness Checker activity for 7 consecutive days at baseline and every 3 months thereafter for 1 year.

Results

Overall, 1156 participants enrolled in the study within a 5-day recruitment window. In the 1st hour, the enrollment rate was 6.6 participants per minute (394 per hour). In the first 24 hours, the enrollment rate was 0.8 participants per minute (47 participants per hour). Overall, 1132 participants completed the baseline questionnaires (1132/1156, 97.9%) and 1047 participants completed the initial Sleepiness Checker activity (1047/1156, 90.6%). Furthermore, 1000 participants provided activity-specific wearable data (1000/1156, 86.5%) and 982 provided sleep-specific wearable data (982/1156, 84.9%).

Conclusions

The Achievement Studies platform allowed for rapid recruitment and high study engagement (survey completion and device data sharing). This approach to carrying out research appears promising. However, conducting research in this way requires that participants have internet access and own and use a wearable device. As such, our sample may not be representative of the general population.

Participatory Technology Development to Enhance Community Resilience

Objective

To assess the feasibility of a novel, partnered technology development process to co-create mobile health applications (apps) addressing community health priorities, using psychoeducation of cognitive behavioral therapy (CBT) principles for enhancing resilience as an example.

Design

Stakeholder engagement, workgroups, pilot feasibility study using mixed methods during October 2013 through January 2016 over three phases: 1) defining the vision of the project and increasing technical capacity, 2) co-development and pilot testing of the app, and 3) planning for sustainability.

Setting

An academic-community partnership in South Los Angeles, California.

Participants

Eight stakeholders; 30 pilot participants from the community.

Main Outcome Measures

Qualitative analysis of audio-recordings of the app development process and stakeholder interviews, surveys of stakeholders' perception of the development process, app use data, and feedback from pilot participants.

Results

The participatory technology development process resulted in creation and pilot-testing of a resiliency-focused text messaging app. Of the 1,107 messages sent, 23 out of 30 (77%) app users responded to explore interactive content. Stakeholders reported increased perceived competency in creating mobile apps and that the process fostered a culture of co-leadership. There was also sustained engagement in mobile app development by stakeholders beyond the initial project period.

Conclusions

This is the first study, to our knowledge, to demonstrate the feasibility of participatory technology development, an approach involving direct participation in the development, tailoring and maintenance of a mobile app by a broad set of stakeholders with high representation from racial/ethnic minorities from an under-resourced community. Participatory technology development is a promising approach for creating sustainable, relevant and engaging health technologies across different technological, clinical and community settings.

Technology Interventions for Nonadherence: New Approaches to an Old Problem

Nonadherence to asthma medications is well recognized. Interventions to improve adherence, however, have been only moderately successful and are not often adopted because of limited provider time, training, or institutional support. The potential for mobile communication technology to improve adherence has gathered sharply growing interest. Technology-based adherence tracking devices have been in existence for almost 3 decades, but have only recently reached a level of reliability and utility to be considered in allergy practice. Adherence intervention technology includes smartphones, apps, and a growing number of potential new asthma uses such as inhaler technique assessment, portable fractional exhaled nitric oxide devices, and GPS activity trackers with environmental contaminant alerts. As technology has advanced, new capability has emerged including drawing information from electronic health records to tailor automated interventions, give real-time feedback to patients, leverage incentives, utilize predictive logarithms that identify patients at exacerbation risk, and initiate an intervention. Technology development moves faster than clinical trial tests of these new interventions, and gaps in evidence will need to be closed. As researchers establish cost effectiveness, sustainability, and patient and provider acceptance, technology-based adherence intervention systems are likely to be increasingly adopted into small and large practice settings.

Diabetes Data Management System to Improve Glycemic Control in People With Type 1 Diabetes: Prospective Cohort Study

Background

Smartphone and Web technology can improve the health care process, especially in chronic diseases.

Objective

The aim of this study was to investigate whether the use of blood glucose (BG) data management system, which enables connection to smartphones, the Web, the cloud, and downloading, can improve glycemic control in subjects with type 1 diabetes mellitus (T1DM).

Methods

This study was a prospective, single-arm, cohort feasibility study with 6 months of duration. T1DM subjects enrolled had experience in self-monitoring blood glucose, but were download data naïve. Fasting BG and glycated hemoglobin (HbA_1c) were collected at the enrollment and at follow-up. Subjects were divided into Downloader (DL) and No-downloader (NDL).

Results

A total of 63 subjects were analyzed, of which 30 were classified as DL and 33 as NDL. At the end of the study, DL had significantly lower HbA_1c, mean daily glucose, standard deviation, percentage of BG values above target, and pre- and postprandial (lunch and dinner) values compared with NDL (all P<.05). The percentage of BG values within treatment target was significantly higher in DL compared with NDL (47% [SD 9] vs 37% [SD 13]; P=.001).

Conclusions

The findings suggest that, in T1DM, downloading of BG from data management system, which enables connection to smartphones, the Web, and the cloud, might be a valuable contributor to improved glycemic control.