Ebook: The Promise of New Technologies in an Age of New Health Challenges

The 5th Global Telehealth Conference was held in Auckland on 1st and 2nd November 2016, hosted by the Health Informatics New Zealand (HiNZ) organisation. The choice of venue allowed a return to the Asia-Pacific arena for the conference, following its previous two years in South Africa (2014) and Canada (2015). It is hoped that the event will continue to find new locations year by year, in order to bring the benefits of globally-relevant research in Telehealth and associated areas to new audiences.

This volume provides a record of contributed papers presented at the above conference. The 18 papers included here were accepted on the basis of a blinded peer-review process which provided independent expert appraisal by members of the Scientific Programme and Review Committee. The acceptance rate for the conference was approximately 60% of papers submitted, ensuring publication of the highest quality of work. These papers cover a wide variety of topics, from theoretical and abstract contributions through to discussion of practical projects and highly specific applied contributions. In addition, two invited papers are included, which were also accepted through the reviewing pathway. These detail some recent contributions towards two global issues in which Telehealth plays a major role: universal health coverage and personal health monitoring.

The theme chosen for Global Telehealth 2016 was “The Promise of New Technologies in an Age of New Health Challenges.” This reflects a change in emphasis which can be noted in many health services, where conventional pressures such as budget and workforce constraints are being augmented by indirect forces of social change and strategic direction, which portend longer term and more flexible approaches. Telehealth, as well as many other technology-based health care assistive elements, offers demonstrably effective and sustainable solutions to issues such as access to care and quality of care, by enabling different models of care and care delivery channels to be employed.

New Zealand was a fitting choice of venue for the conference, as it has held a longstanding commitment to Telehealth as a mechanism for health care delivery nationally and in the wider Pacific region. This position was reaffirmed earlier this year with the release by the New Zealand Ministry of Health of the document entitled “New Zealand Health Strategy: Future Direction”. This refreshed national health strategy acknowledges the need to work differently to meet changing health needs, with Health IT including Telehealth identified as a key enabler of such change. The strategy endorses the direction set by New Zealand programmes in electronic referral, shared care planning and tele-consultation as enablers of efficient and well-coordinated health delivery. Furthermore, the strategy emphasizes the ability of Telehealth – especially as exemplified by patient portals, and mental health and well-being tools – to strengthen health consumers' direct role in the healthcare system.

Anthony J. Maeder

Kendall Ho

Alvin Marcelo

Jim Warren

In recent years, Smart Homes have become a solution to benefit impaired individuals and elderly in their daily life settings. In healthcare applications, pervasive technologies have enabled the practicality of personal monitoring using Indoor positioning technologies. Radio-Frequency Identification (RFID) is a promising technology, which is useful for non-invasive tracking of activities of daily living. Many implementations have focused on using battery-enabled tags like in RFID active tags, which require frequent maintenance and they are costly. Other systems can use wearable sensors requiring individuals to wear tags which may be inappropriate for elders. Successful implementations of a tracking system are dependent on multiple considerations beyond the physical performance of the solution, such as affordability and human acceptance. This paper presents a localisation framework using passive RFID sensors. It aims to provide a low cost solution for subject location in Smart Homes healthcare.

Exercise gaming has been receiving a significant interest from both consumers and researchers. Be it for the purposes of weight loss, physical fitness or even just enjoyment, the potential of games to support rehabilitation has also been under investigation for a while. Due to our aging society, game based therapies could be a solution for optimizing resources and reducing rehabilitation costs. This paper aims to discuss the potential capacity of games as systems to enhance the relation of physical exercise and cognition for the rehabilitation of Parkinson Disease. Our investigation demonstrates that there is no established methodology for games in rehabilitation of Parkinson's addressing how games can encapsulate physical exercise strategies while providing safety, continuous monitoring and cognitive development exercises in facilitation of rehabilitation. Since rehabilitation with games is trending, yet to be developed rehabilitation strategies would benefit from new insights into the relationship between game worlds, physical exercise and motor-cognitive training. Therefore, it is useful to do further research into realizing (1) a relational model that demonstrates the relation between game world (composed of game features including formal game elements, audio-visual features, mechanics and dynamics), motor skills, cognition and physical exercise for both generic and specific rehabilitation purposes, (2) a structured task creation approach for game features that reconciles specific rehabilitation outcomes, correct level of engagement, task difficulty and safety requirements for target demographic.

Background: In order to improve access to critical patient data in case of emergency, many countries have begun or intend to implement emergency datasets. In Germany, the German Medical Association developed a medical emergency dataset (MED), which provides the possibility to store information on prior diagnoses, medications, allergies and other emergency-relevant information on the German Electronic Health Card.

Objectives: The aim of the study is to evaluate how the MED can be used internationally.

Methods: A total of 64 paper-based emergency data sets were completed by primary care physicians in Germany, and were then evaluated by German clinicians, emergency physicians, and paramedics on the basis of fictitious emergency scenarios. Thirty randomly selected MEDs were then translated into English and will be evaluated by international emergency physicians and paramedics.

Results: In Germany, clinicians, emergency physicians and paramedics rated the emergency data set as very useful or useful in more than 70% of the reviewed cases. The international evaluation will start in September 2016, so these results are pending at this time.

Conclusion: The first study results from Germany indicate high potential benefits of the emergency data set in real patient care situations. The subsequent tests will show whether the MED is also suitable for international use.

When people with long term health issues transition from illness to health, or move from hospital to home after an exacerbation they feel vulnerable, unsafe, uncertain, lost, and unsupported. Transitions are life experiences that result in change. Telehealth gives easier access to care and increases patient involvement and self-awareness for self-care and improved outcomes. The purpose of our research was to explore how telehealth tools and processes lend themselves to nursing of patients through transitions.

Methods: A multimethod study with before and after questionnaires consisting of validated questionnaires. These were triangulated with nurse field notes, nurse assessment of each participant, exit interviews with participants, and questionnaire for referring clinicians about their experience of the service. Twenty patients, their five doctors, and two telehealth nurses, participated.

Results: PACIC questions revealed that participants felt more involved in decision making, self-care planning, referrals to other services, and understood more clearly their health issues. The Quality of Life questions showed improvement, and their health issues bothered them less after telehealth. The Perceived Health Competence questions showed an improvement in how they rated their health, and their ability to influence their health. Clinicians indicated that the service worked well, was appropriate and useful, and should continue. The interviews revealed that participants learned how to do self-care with insight, made the transition from hospital to home and from illness to a new way of being well, and referred the service to others like them.

Discussion and conclusion: We conclude that our experienced nurses used the tools of telehealth (monitoring of self-care and videoconferencing) to coach, supervise, guide, and accompany patients through an organizational transition for half our participants (from hospital to home) and all the participants through an illness to a new way of being well.

Poor adherence to medication can lead to negative health outcomes and increased financial burdens. We present a literature review on electronic medication reminders used for medication adherence in self care settings, to identify current and possible future trends. A structured PubMed search based on extracted MeSH terms provided a total of 45 publications which were identified as most relevant. Three main categories of electronic solutions were identified: mobile phone reminders, in-home electronic reminder devices, and portable reminder devices.

Healthcare systems globally continue to face challenges surrounding patient identification. Consequences of misidentification include incomplete and inaccurate electronic patient health records potentially jeopardizing patients' safety, a significant amount of cases of medical fraud because of inadequate identification mechanisms, and difficulties affiliated with the value of remote health self-management application data being aggregated accurately into the user's Electronic Health Record (EHR). We introduce a new technique of user identification in healthcare capable of establishing a global identifier. Our research has developed algorithms capable of establishing a Unique Health Identifier (UHID) based on the user's fingerprint biometric, with the utilization of facial-recognition as a secondary validation step before health records can be accessed. Biometric captures are completed using standard smartphones and Web cameras in a touchless method. We present a series of experiments to demonstrate the formation of an accurate, consistent, and scalable UHID. We hope our solution will aid in the reduction of complexities associated with user misidentification in healthcare resulting in lowering costs, enhancing population health monitoring, and improving patient-safety.

Since the 1978 Declaration of Alma-Ata affirming health as a fundamental human right, policy-makers and stakeholders have proposed many different strategies to achieve the goal of ‘health for all’. However, globally there still remains a lack of access to health information and quality health care, especially in low- and middle-income countries (LMIC). Digital health holds great promise to improve access and quality of care. We propose using the “resilient health system framework” as a guide to scale-up digital health as a means to achieve universal health care (UHC) and health for all. This article serves as a call to action for all governments to include population-based digital health tools as a foundational element in on-going health system priorities and service delivery.

Telehealth offers the potential to address inequalities in autism service access for young children living in regional and rural areas with limited access to autism specialists. Our aim was to explore parent and practitioner uses of technology, and views about telehealth, including perceived barriers, for autism early intervention service delivery in a regional town in Australia. Fifteen mothers and 19 front-line autism practitioners completed surveys distributed by local autism service and support providers in the regional town; eight front-line practitioners from one service participated in interviews. Mothers and practitioners had access to technology that could be used for video-communication, but had little or no experience with telehealth. Mothers appeared more willing to try telehealth for receiving autism services than practitioners appeared to believe, and practitioners preferred to use it for consulting with other professionals and professional development. Barriers to telehealth included limited experience and practitioners not knowing what a telehealth service would look like, poor access to reliable and high speed internet, lack of skill and technical supports, and practitioners believing families preferred face-to-face services. The success of telehealth in this regional town will rely on better infrastructure, and upskilling practitioners in evidence-based autism interventions so they can provide the required support remotely. Use of telehealth to upskill practitioners in evidence-based practice could provide a first step in ensuring equitable access to expert autism services to regional and rural families.

Background: Diabetic retinopathy (DR) is regarded as a major cause of preventable blindness, which can be detected and treated if the cases are identified by screening. Screening for DR is therefore being practiced in developed countries, and tele screening has been a prominent model of delivery of eye care for screening DR.

Aim: Our study has been designed to provide inputs on the suitability of a computer-assisted DR screening solution, for use in a larger prospective study.

Methods: Computer-assisted screening technology for grading diabetic retinopathy from fundus images by a set of machine learning algorithms.

Results: The preliminary recommendations from a pilot study of a system built using the public datasets and retrospective images, showed a good sensitivity and specificity.

Conclusion: The machine learning algorithms has to be validated on a larger dataset of a population level study.

Several spontaneous telemedicine services using WhatsApp Messenger have started in South Africa raising issues of confidentiality, data security and storage, record keeping and reporting. This study reviewed the literature on WhatsApp in clinical practice, to determine how it is used, and users' satisfaction.

Methods: Pubmed, Scopus, Science Direct and IEE Expert databases were searched using the search term WhatsApp and Google Scholar using the terms WhatsApp Telemedicine and WhatsApp mHealth.

Results: Thirty-two papers covering 17 disciplines were relevant with the most papers, 12, from India. Seventeen papers reported the use of WhatsApp Groups within departments, 14 of which were surgery related disciplines. Groups improved communication and advice given on patient management. Confidentiality was mentioned in 19 papers and consent in five. Data security was partially addressed in 11 papers with little understanding of how data are transmitted and stored. Telemedicine services outside of departmental groups were reported in seven papers and covered emergency triage in maxillofacial, plastic, neuro and general surgery, and cardiology and telestroke.

Conclusions: WhatsApp is seen to be a simple, cheap and effective means of communication within the clinical health sector and its use will grow. Users have paid little attention to confidentiality, consent and data security. Guidelines for using WhatsApp for telemedicine are required including downloading. WhatsApp messages to computer for integration with electronic medical records.

Recently games in the form of video, computer, or mobile apps have been utilised as an effective component of interventions for health behaviour change. This paper provides an overview of related projects reported in peer-review literature in the period 2006 to 2016. Nine highly relevant references were considered for analysis. The findings are presented according to 3 dimensions of characterisation: health intention, behaviour change principle, and health purpose.

e-Health has grown to become interjurisdictional in scope and in practice. Central to successful implementation and scaling of e-heath solutions is clear and concise communication of ideas and principles, and instructions during construction. This paper addresses the need for an agreed taxonomy and terminology and focuses on explaining, proposing, and recommending terms and action for an international consensus-based terminology for telehealth.

Methods: Two structured database literature searches were performed to identify literature relevant to telehealth/telemedicine taxonomy or terminology.

Results: The terminology search identified 162 resources of which 4 met the inclusion criteria, while the taxonomy search identified 447 resources of which 5 met the inclusion criteria. Using these literature sources, a telehealth terminology was developed.

Discussion: The literature shows clear lack of and need for a common telehealth taxonomy and terminology. Of those proposed in the literature none has been universally adopted or applied.

Conclusions: Proponents of telehealth and those working in or aligned with the field, must develop, agree upon, adopt, and use clear and accurate telehealth terminology to ensure concise and accurate communication in the application of telehealth globally.

Over the past few decades there has been a wealth of published scientific evidence for the physical, cognitive and social health-related benefits of increased physical activity, especially in older adults and people living with chronic disease. Despite the clear evidence base demonstrating the health-related benefits of physical activity, uptake and adherence is often disappointing. Therefore, methods for remote delivery of guided exercise programs are required, both to maximise the reach of physical activity promotion initiatives and programs across the older community and to minimise attrition once people begin to be physically active. One method by which we can increase understanding of the importance of, and compliance with, exercise programs involves the use of fun and engaging videogames. In the following we outline two ways in which we are using games technology in an Australian context.

Modern healthcare systems are undergoing a paradigm shift from in-hospital care to in-home monitoring, leveraging the emerging technologies in the area of bio-sensing, wireless communication, mobile computing, and artificial intelligence. In-home monitoring promises to significantly reduce healthcare spending by preventing unnecessary hospital admissions and visits to healthcare professionals. Most of the in-home monitoring systems, proposed in the literature, focus on monitoring a set of specific vital signs. However, from the perspective of caregivers it is infeasible to maintain a collection of specialized monitoring systems. In this paper, we view the problem of in-home monitoring from the perspective of caregivers and present a framework that supports various monitoring capabilities while making the complexity transparent to the end users. The essential idea of the framework is to define a ‘general purpose architecture’ where the system specifies a particular protocol for communication and makes it public. Then any bio-sensing system can communicate with the system as long as it conforms to the protocol. We then argue that as the system grows in terms of number of patients and bio-sensing systems, artificial intelligence technologies need to be employed for patients' risk assessment, prioritization, and recommendation. Finally, we present an initial prototype of the system designed according to the proposed framework.

Telemedicine has great potential to overcome geographical barriers to providing access to equal health care services, particularly for people living in remote and rural areas in developing countries like Bangladesh. A number of telemedicine systems have been implemented in Bangladesh. However, no significant studies have been conducted to determine either their cost effectiveness or efficiency in reducing travel time required by patients. In addition, very few studies have analyzed the attitude and level of satisfaction of telemedicine service recipients in Bangladesh. The aim of this study was to analyze the cost and time effectiveness of a telemedicine service, implemented through locally developed PC based diagnostic equipment and software in Bangladesh, compared to conventional means of providing those services. The study revealed that the introduced telemedicine service reduced cost and travel time on average by 56% and 94% respectively compared to its counterpart conventional approach. The study also revealed that majority of users were highly satisfied with the newly introduced telemedicine service. Therefore, the introduced telemedicine service can be considered as a low cost and time efficient health service solution to improve health care facilities in the remote rural areas in Bangladesh.

The clinical research industry has yet to fully embrace information technology (IT) for informed consent purposes, even though it is used indispensably in our everyday lives and in other areas of clinical research and healthcare. This paper presents findings of a meta-narrative literature review to discuss the potential for IT to improve the quality of clinical research informed consent. The review reveals three main rationales for including IT in research consent. First, in the current context consent documents frequently fail to be effective decision aids for patients, and the lack of patient centricity in the process. Second, social media provides opportunities for patients to consult with a broader community during research consent to seek broader support, and potential to participate in creating a more patient centric process. Third, multimedia tools provide opportunities for improved patient education, engagement and decision making during research consent. IT offers opportunities to achieve more meaningful research consent, but more research is needed to create an evidence base, policies and economic analyses on the return on investment of using IT in the process.

Nearly 80% of the world's population live in developing countries in Asia, Africa, and Latin America. Many of these countries must face a triple or quadruple burden of disease with severely limited resources and health systems. South Africa (SA) is one such country, and recognises the potential for e-health to moderate these limitations. Dermatological issues remain a concern in SA and globally. Indeed, the World Health Organisation (WHO) has recognised that a number of diseases are most likely to manifest themselves through a dermatological problem before becoming full-blown. However, there is an acute shortage of dermatologists in SA. Teledermatology has promise as a service delivery intervention. This study reports on the current status of teledermatology services in the public health sector of SA.

Methods: The study adopted a qualitative, inductive research approach based on a structured literature review of teledermatology in SA. A modified Momentum-Treat tool was used to critique identified teledermatology services.

Results: 159 resources were identified, of which 68 were excluded. The remaining 91 resources revealed a history of ad hoc teledermatology services, of which few remained active. Requests for teledermatology service confirmations provided some feedback, together with follow-up meetings and interviews.

Discussion: No evidence of scaling of teledermatology services and integration into routine healthcare was found. Of eight services, 4 remain active. Review and modified Momentum-Treat critique showed opportunities for improved readiness assessment, programme governance, and alignment to government policy direction, in order to improve scaling and sustainability.

Conclusions: Full-scale teledermatology integration is possible, but stronger programme development is needed. Findings will inform development of a teledermatology scale-up framework to assist with future integration of teledermatology into routine healthcare.

This paper describes development of a prototype data analytics portal for analysis of accumulated screening results from eCHAT (electronic Case-finding and Help Assessment Tool). eCHAT allows individuals to conduct a self-administered lifestyle and mental health screening assessment, with usage to date chiefly in the context of primary care waiting rooms. The intention is for wide roll-out to primary care clinics, including secondary school based clinics, resulting in the accumulation of population-level data. Data from a field trial of eCHAT with sexual health questions tailored to youth were used to support design of a data analytics portal for population-level data. The design process included user personas and scenarios, screen prototyping and a simulator for generating large-scale data sets. The prototype demonstrates the promise of wide-scale self-administered screening data to support a range of users including practice managers, clinical directors and health policy analysts.