Ebook: Global Telehealth 2014

e-Health – in its many forms – continues to be implemented throughout the globe, yet sound evidence of its ‘value’ to healthcare systems remains limited, and achieving its successful, sustained integration is a challenge. Telehealth, one component of e-health, also suffers from the same shortcomings, and has not yet reached the necessary tipping point for assuring its universal adoption. Health consultations delivered via videoconferencing, store-and-forward solutions for remote provision of health services, and home monitoring of patients for telecare are examples of some diverse areas of Telehealth that offer gains in quality and efficiency. In contrast, the recent spontaneous growth of mobile healthcare solutions as smartphones become more common amongst healthcare providers, and creation of web-based wellness promotion and health management tools has opened up whole new areas for Telehealth to provide future benefits.

It is becoming crucial that a thorough understanding of global Telehealth activity and opportunity for inter-jurisdictional alignment be developed, in order to allow mutual improvement to be achieved. The developed world can provide interim clinical and educational support as the developing world establishes the necessary capacity to continue to build its own capacity, while the developing world can provide inexpensive and truly innovative solutions to the developed world through reverse innovation. Venues such as Global Telehealth provide a platform for the exchange and development of common understanding of clinical needs and technologically appropriate Telehealth solutions.

Global Telehealth 2014 (GT2014) was the 3rd International Conference in the series, held in conjunction with the ICT4Health Conference 2014 in Durban, South Africa. This year the conference theme was “Integrated, Innovative, Scalable and Sustainable Solutions”, emphasizing the importance of these aspects in achieving wider acceptance and adoption of e-Health and Telehealth. A total of 28 papers were accepted by the international expert reviewer panel for presentation at the event. This book contains selected full papers from those accepted, that align well with the conference theme, and will be informative to those in the global Telehealth community.

Anthony J. Maeder

Maurice Mars

Richard E. Scott

Telehealth is seen as a key component of 21^st century healthcare, and studies have explored its cost effectiveness and impact on hospital admissions. Research has been carried out into how to best implement it, and the barriers to its adoption. The impact of telehealth on self-management however has been a neglected area. An evaluation of the implementation of a telehealth programme in one area in the South of England found that some patients were using the telehealth equipment provided to enhance their own self management abilities. Whilst the nurses managing the scheme felt that they had an education role they did not involve their patients in setting goals. The patients equally did not feel that were being educated by their nurses. Patients were using the monitoring equipment independently of the nurses and the scheme to support their self-management strategies. Therefore the concept of graduating from telehealth once good self-management is established needs to be rethought. Patients in this study experienced less face to face contact with their nurse, but also reported that they were happy with the changes. This suggests that for some patients the contact with the nurse may well be able to be reduced or withdrawn however removing the monitoring equipment will remove the very tools essential to continued self-management.

Many mobile health (mHealth) projects, typically deploying pilot or small scale implementations, have been undertaken in developing world settings and reported with a widely varying range of claims being made on their effectiveness and benefits. As a result, there is little evidence for which aspects of such projects lead to successful outcomes. This paper describes a literature review of papers from PubMed undertaken to identify strong contributions to execution and evaluation of mHealth projects in developing world settings, and suggests a template for classifying the main success factors to assist with collating evidence in the future.

The purpose of this study is to develop an understanding in the use of mobile devices in administering telemedicine services within the public health care sector of South Africa. An online questionnaire was developed and distributed amongst medical officers, specialists, students and medical staff of one of the health districts of South Africa. This paper describes the design of the questionnaire as well as the most significant outcomes. Results are presented in terms of reasons why healthcare workers use mobile devices, as well as perceptions in terms of transmission security and quality of transmitted information.

Doctors can experience difficulty in accessing medical information of new patients. One reason for this is that, the management of medical records is mostly institution-centred. The lack of access to medical information may affect patients in several ways, such as: new medical tests may be carried out at a cost to the patient, and doctors may prescribe drugs to which the patient is allergic. This paper presents the design and implementation of a ubiquitous Personal Health Record system for South Africa. The design was informed by a literature review of existing personal health record standards, applications and the need to ensure patient privacy. Three medical practices in Port Elizabeth were interviewed with the aim of contextualizing the personal health record standards from the literature study. The findings of this research provide an insight as to how patients can bridge the gap created by institution-centred management of medical records.

A new mHealth service, Clinic Finder, was designed to provide a location-based service for any cellphone user in South Africa dialing a dedicated USSD string to find the nearest public primary health care facility. The service was funded by a European Union grant to Cell-Life to support the National Department of Health. Clinic Finder's aims were to provide a reliable and accurate service, and to assess both the most effective means of advertising the service as well as interest in the service. Users dialing the USSD string are asked to agree to geo-location (Vodacom and MTN users) or asked to enter their province, town and street (virtual network users and those choosing not to geo-locate). The service provider, AAT, sends the data to Cell-Life where an SMS with details of the nearest public primary health care facility is sent to the user by Cell-Life's open-source Communicate platform. The service was advertised on 3 days in 2014 using two different means: a newspaper ad on 20 May 2014 and Please Call Me ads on 30 July 2014 and 14 August 2014. 28.2% of unique users on 20 May 2014, 10.5% of unique users on 30 July 2014 and 92.8% of unique users on 14 August 2014 who agreed to geo-location successfully received SMSs. However, only 4.2%, 0.5%, and 2.4% of unique users responding to each advertisement who did not geo-locate then received an SMS. A small survey of users following the 20 May 2014 newspaper ad found overall interest in the idea of Clinic Finder, though unsuccessful users were more likely to dislike the service. The overall experience of using location based services and USSD for Clinic Finder suggests a need in the field of mHealth for wider availability of data on service usability and effectiveness.

Objectives. This paper describes an evaluation of a community-based fall-detection project using smart phone based tri-axial accelerometry to identify factors that affect adoption and use of such technology by elderly people.

Methods. A mixed methods study using questionnaires and semi-structured interviews was conducted to evaluate attitudes of the elderly people participating, as well as project stakeholders involved in the project. Information registered in a web-based fall management system was analyzed both qualitatively and quantitatively, using an adapted version of Unified Theory of Acceptance and Use of Technology (UTAUT).

Results. Adoption rate was 61.7% and attrition rate was 57%, the most common reasons for attrition being health deterioration (50%) and problems with the device and the network (26.2%).

Conclusion. We identified a number of challenges that affected the success of this project, including problems with the software, usability issues with the device, coverage of the network, training of participants, and inadequacy of providing participants with a strong sense of safety and security.

Recent attempts at a collective understanding of how to develop an e-Health strategy have addressed the individual organisation, collection of organisations, and national levels. At the national level the World Health Organisation's National eHealth Strategy Toolkit serves as an exemplar that consolidates knowledge in this area, guides practical implementations, and identifies areas for future research. A key implication of this toolkit is the considerable number of organisational changes required to successfully apply their ideas in practice. This study looks critically at the confluence of change management and e-Health strategy using metaphors that underpin established models of change management. Several of Morgan's organisational metaphors are presented (highlighting varied beliefs and assumptions regarding how change is enacted, who is responsible for the change, and guiding principles for that change), and used to provide a framework. Attention is then directed to several prominent models of change management that exemplify one or more of these metaphors, and these theoretical insights are applied to evaluate the World Health Organisation's National eHealth Strategy Toolkit. The paper presents areas for consideration when using the WHO/ITU toolkit, and suggestions on how to improve its use in practice. The goal is to seek insight regarding the optimal sequence of steps needed to ensure successful implementation and integration of e-health into health systems using change management models. No single model, toolkit, or guideline will offer all the needed answers, but clarity around the underlying metaphors informing the change management models being used provides valuable insight so potentially challenging areas can be avoided or mitigated.

To ensure the benefits of e-Health are maximised, e-Health capacity building requires a formal and logical structure that describes broad areas that must be addressed. In this paper a Conceptual Framework for e-Health Training is derived that could guide well-thought-out and consistent development of future capacity building efforts. Consideration of e-health education needs is the mandate of the International Society for Telemedicine and eHealth (ISfTeH) Education Working Group. Through this Group a structured but generic 2 – 3 day telehealth training programme for healthcare professionals was developed and trialed, and the Group has been asked to develop a telehealth curriculum. Ongoing debate and feedback has made it clear that this is insufficient. In an effort to establish an Conceptual Framework for e-Health Training four aspects or levels of instruction are considered necessary at this time: ‘education’ of a small number of personnel leading to an academic graduate qualification (MSc, PhD); ‘instruction’ of a slightly larger number of personnel (e.g., to provide proficient network managers); ‘teaching’ of a still larger number of personnel in terms of the use of specific technologies, devices, and services; and ‘awareness’ of the general populace. Collectively this is referred to as e-health ‘training’. If implemented in a coordinated and structured manner, such an approach would stimulate e-health growth and application globally. It would generate demand (awareness), allow that demand to be filled (teaching) and guided (instruction), with the focus on technologically appropriate and needs-based solutions (education). The Education Working Group intends to develop outlines of recommended instructional and informational content for training at each level. Here the four levels are highlighted and the terms, hierarchy, and descriptions of the Education Working Group's proposed approach to its Conceptual Framework for e-Health Training, are formalised.

Given that e-health (including telehealth) is an opportunity cost (i.e., redirecting already scarce healthcare resources away from more traditional healthcare delivery needs), performing needs assessment ensures that investment of resources in e-health is appropriate. Yet the current literature shows research is on clever, narrow, or ‘one disease’ telehealth applications (e.g., telediabetes; telesurgery), or creation of electronic records (e.g., EHR's; EMRs; HIS's) and accumulation of ‘big data’ (e.g. biosurveillance). Given the reality of comorbidity, the complexity of telesurgery, and the lack of successful country-wide EHR implementations, are we using our investments in e-health wisely? The requirement for needs assessment to guide selection and implementation of evidence-based and needs-based e-health solutions is seldom adhered to. We must refocus our efforts on more pragmatic needs. Where might insight to evidence-based health needs come from? Using South Africa as an example, this paper highlights several readily available resources, and how they may guide future telehealth implementations in South Africa and elsewhere.

Remote provision of supportive mechanisms for preventive health is a fast-growing area in eHealth. Web-based interventions have been suggested as an effective way to increase adoption and maintenance of healthy lifestyle behaviours. This paper describes results obtained in the “Walk 2.0” trial to promote physical activity through a self-managed walking programme, using a social networking website that provided an online collaborative environment. Engagement of participants with the website was assessed by monitoring usage of the individual social networking functions (e.g. status post). The results demonstrate that users generally preferred contributing non-interactive public posts of information concerned with their individual physical activity levels, and more occasionally communicating privately to friends. Further analysis of topics within posts was done by classifying word usage frequencies. Results indicated that the dominant topics are well aligned with the social environment within which physical activity takes place. Topics centred around four main areas: description of the activity, timing of the activity, affective response to the activity, and context within which the activity occurs. These findings suggest that strong levels of user awareness and communication occur in the social networking setting, indicative of beneficial self-image and self-actualisation effects.

An increasing number of individuals are living with long term health conditions which they manage most of the time by themselves. This paper evaluates the use of information and communications technology platforms to provide evidence-based programs to help people with chronic disease to self-management these. It describes two different self-management strategies for chronic conditions, and the evaluation of their implementation in clinical trials, specifically in terms of reach, implementation fidelity, adoption and user perceptions. It also discusses the challenges in replicating trial findings in the real world, using the RE-AIM framework.