Ebook: Telehealth Innovations in Remote Healthcare Services Delivery

This Global Telehealth 2020 volume marks the tenth year for the series, which was conceived in 2010 with a regional academic meeting held under the auspices of the Australasian Telehealth Society. The series has evolved since then to take on a somewhat different character each year, sometimes based on formal conference events such as a track or satellite of a major international meeting, and sometimes based on specialist workshops convened on contemporary topics of interest. Cooperative organisation of these events has been undertaken with the support of a variety of professional bodies, including the International Medical Informatics Association through its Telehealth Working Group and its Asia-Pacific regional arm, as well as several of its national member societies, and also the International Society for Telemedicine and eHealth.

This year necessitated a different approach due to the prevailing COVID-19 pandemic and its severe impact in restricting normal academic meeting activities. After exploring several virtualised options, it was decided that a conventional conference model would not be feasible. Instead a general call for contributions was issued, with the intention of attracting a wide cross section of contributions indicative of the breadth of different aspects of telehealth internationally, and especially targeting many past Global Telehealth sources which have continued to contribute productively in the expansion of telehealth theory and practice. We were encouraged and supported in this endeavour by numerous colleagues from the IMIA Telehealth WG who provided many members of the expert reviewer panel. We also benefitted from new collaborations within the Asia-Pacific region, fostered through several active telehealth interest groups associated with the University of Hawai’i.

The resulting volume offers a number of snapshots of research projects and service experience studies, from projects in five continents: Africa, Asia, Australia, North America, and South America. There is an emphasis on delivering benefits in regional settings, following the book theme of “Telehealth Innovations in Remote Healthcare Services Delivery”. The contributions range from descriptions of particular telehealth networks and clinical service instances such as cardiac health, mental health, pathology, several of these in Pacific rim settings, to more generic direction and position papers on the evolution of such services as well as some commentaries on innovative considerations for telehealth such as the emergence of the concept of virtual care, the suitability of health apps, and the status of eHealth readiness in the developing world.

We hope that this volume continues to add to the body of knowledge on current telehealth research interests and trends through the broad sample of cases provided here. The need to promote academic activities in telehealth remains a high priority as it expands its influence in new areas of healthcare. Although not selected as a direct topic for this book, the COVID-19 pandemic response has been an excellent example of the rapid diversification and impact attainable with telehealth, and may kindle a new momentum for accelerated service design and adoption processes in the future.

We acknowledge the substantial financial and in-kind support provided to this endeavour by the Flinders Digital Health Research Centre at Flinders University Tonsley Campus, Adelaide and by the Pacific Basin Telehealth Resource Center at University of Hawai’i Manoa Campus, Honolulu. We also thank the members of the international review committee for their thorough and insightful critique of the papers submitted and in making the final selection of those included on a peer review basis.

Anthony Maeder, Christina Higa, Maayken van den Berg and Claire Gough

Global Telehealth 2020 co-Editors

The COVID-19 pandemic has quickly and radically transformed health systems worldwide. The challenges are imposed by the need for social distance, remote management of less severe cases, and the constant need for updating health care professionals and the population with reliable information. We aim to describe the experiences and developments of a Brazilian telehealth public service during the pandemic. Numerous tools have been developed and made available, to be used in an integrated manner, by both health professionals and the general public. Those included a chatbot for guidance, a teleconsultation platform combined with a telemonitoring system, a teleconsulting service, and a tele-education program. The TNMG services appear to be efficient and robust during the health crisis of COVID-19, through different tools and methodologies focused on both professionals and users of the health systems.

Gastroenterology, as a sub-speciality in medicine, has been widely developed across the Pacific Nations during the last decade as a result of ‘hub’ training in Suva, Fiji. Professional isolation for trained pacific gastroenterologists has remained an issue due to the high cost of travel, limited in-country workforce, and recently COVID-19 border closures. Whereas Telehealth solutions have been used for decades across many Pacific Island Nations as a means to improve the clinical outcomes in Pacific Island patients, only recently has this technology been cleverly adopted in fostering education and skill development in Pacific gastroenterology. In this paper, we describe the evolution of these various methods and discuss their use and adaptation in various clinical situations. Herein we consider the future of telehealth programs and the potential for positive impact on Pacific Island healthcare.

For the past thirty years, the United States Office for the Advancement of Telehealth has promoted the use of technology for health care, education, and health information services, and funds the National and Regional Telehealth Resource Centers (TRCs) to provide technical assistance to support stakeholder telehealth adoption. To assess the challenges and opportunities for the TRCs to advance telehealth, we reviewed publications, national and regional telehealth strategies, guidance from government agency reports and the TRC websites. We summarized information about the mission, funding and structure of the TRC program in terms of the shared service center model of organizational functioning, followed by a description of the TRCs’ recent response to the COVID-19 Public Health Emergency.

Background:

Dizziness is one of the most common symptoms following concussion and requires a thorough vestibular assessment. However, due to limited tools and evidence on remote vestibular assessment and intervention, people unable to attend in-person consults cannot receive effective care.

Objective:

This study aims to describe the design and development process of MOVE-IT. MOVE-IT is a mobile phone application with an associated head mount device and clinician dashboard which aims to enhance vestibular assessments and intervention via telehealth by enabling clinicians to clearly observe client’s eye movements.

Methods:

This study used a Living Labs methodology including the use of a scoping review, user engagement, multi stakeholder engagement, real-life settings, and co-creation. MOVE-IT was developed in three phases: Exploration, Experimentation and Evaluation. This paper describes the Exploration and Experimentation process. Exploration included a scoping review, focus group and consultation interviews. Experimentation included the co-creation of a minimum viable product in a real-life setting with regular feedback from multi-stakeholders.

Outcome:

MOVE-IT includes three components: a mobile phone application, head mount device and clinician dashboard. MOVE-IT aims to enhance the use of telehealth for vestibular assessments by: (1) using the head mount device to enable video recording of client’s eyes during assessment, (2) allowing clinicians to view client’s eye movements via the clinician dashboard whilst (3) a support person assists in the physical aspect of the vestibular assessment by a step-by-step guided video in the mobile application.

Conclusion:

The Living Lab method was a useful strategy for developing MOVE-IT. MOVE-IT meets all predefined functionality requirements and potentially provides a solution for remote vestibular assessment and intervention in the concussion population. The Evaluation phase will be conducted next to test usability, reliability and validity of MOVE-IT.

The design and development of a motivational embodied conversational agent for brain injury rehabilitation is discussed. Results for initial prototype design and implementation, and alpha and beta testing phases are presented. Key aspects identified during development included supporting user engagement via personalization and choice-making; integrating behaviour change principles into dialogues; addressing clinical needs of cognitive fatigue and memory loss within conversation structure; and optimizing feasibility of use in a real-life clinical setting.

Increasing life expectancy and rates of chronic conditions place increasing demands on aged care health and support services. One response preferred by older adults and seen as cost effective is aging in place, whereby older people remain in their own homes and avoid aged residential care. For this to take place, it is crucial that older people maintain effective relationships with support networks and that older adults and these networks have adequate information to support patient centred health and wellness care at home. This study explored how smart home telehealth, a form of telehealth where health care is provided at a distance using smart home digital technology (sensors), could assist older people to age in place and enhance their health and wellbeing. It was a two-phase project, preceded by a workshop with experts:1) 41 interviews with older adults and their informal support networks, seven focus groups with 44 health providers working with older adults, which informed 2) a pilot implementation of a co-designed telehealth system, addressing key barriers identified in Phase 1. The system used low cost, easily accessible, and commercially available sensors, transferring information via email and/or text messaging. It was successfully piloted with five older adults and twelve of their respective support networks for six months, who reported an increased feeling of security and improved interpersonal communication. The findings indicate that smart home telehealth could assist aging in place, and the study provides insights into successful co-design of smart home telehealth services at scale that could be implemented and deployed in contexts wider than aged care.

Poor healthcare infrastructure is the main barrier for providing quality healthcare services to rural communities in developing countries. Thus, these populations remain unreached, and there is a need to establish a method for ensuring the provision of appropriate and adequate healthcare services to these individuals. The portable health clinic (PHC) system has been developed as an effective telemedicine system to meet this objective. A trained village health worker can use this simple system for collecting vital information of the patient, upload the data to the online server, and connect village patients with a remote doctor to enable the provision of online consultancy using video conferencing. Although the PHC was initially developed to ensure primary healthcare service with a focus on non-communicable diseases, a major cause of death, gradually, tele-pathology, tele-eye care, maternal and child health care, and COVID-19 care modules have been added to provide special treatment in these areas as per local needs. The modular PHC system will continue to grow with the addition of novel features that aim to address the local needs. The low-cost and easy operation of the PHC system make it ideal for ensuring global health coverage in communities where inadequate medical facilities and poor-quality healthcare resources remain major issues.

Background:

e-Health readiness has been described as the preparedness of healthcare institutions, communities, or individuals for the anticipated change brought by programmes related to ICT use. Assessment of e-health readiness prior to the implementation of e-health innovations can therefore facilitate the process of change for individuals and organisations to adopt e-health programmes and avoid disappointment. The literature shows that although many e-health readiness assessment frameworks and tools exist, none meet all the requirements for e-health readiness assessment in developing countries. The aim of this study was to develop an e-health readiness assessment framework applicable to developing countries.

Methods:

A three-step process gleaned from the e-health literature (literature review / material collection; analysis / content analysis; consolidation / conceptual framework synthesis), together with iterative and reflective processes based on prior research undertaken by this group, guided framework conceptualisation and design.

Results:

An evidence-based framework was developed that: incorporates the need to assess readiness for each e-health component separately; identifies government’s central role in engaging all relevant stakeholders; and the need to assess the adequacy of a country’s infrastructure and infostructure prior to e-health planning and possible implementation. Also addressed by the framework is a need for an e-health readiness assessment to be undertaken using separate tools for technical and non-technical individuals. A country’s e-Readiness is highlighted as an important indicator for e-health readiness.

Conclusions:

The intent of the final framework is to inform and assist policy and decision makers, and facilitate future successful implementation of e-health initiatives in the developing world.

Tripler Army Medical Center (TAMC), located in Honolulu, Hawaii, serves as the US military’s tertiary medical referral center for the Western Pacific. Over 20 years ago, the TAMC Department of Pediatrics developed an asynchronous provider-to-provider teleconsultation pilot program, eventually named the Pacific Asynchronous TeleHealth (PATH) system. A secure teleconsultation platform for pediatric sub-specialty provider-to-provider advice, the platform grew based on the needs of users, eventually expanding to serve all age-groups, with over 60 different specialties based at TAMC providing teleconsultation. Eventually, the success of PATH drove further expansion to serve military clinicians located in other overseas locations beyond the Asia-Pacific. This cost-effective model can be applied to civilian healthcare settings, particularly where geographic distance or limited connectivity are challenges to delivery of synchronous telehealth or in-person specialty care.

Background:

Recently there has been a steady increase in the use of Instant Messaging (IM) as a means of providing health and healthcare services. This growth has been particularly rapid during the ongoing COVID-19 pandemic. Many reports indicate informal services using IM, in particular WhatsApp, have arisen spontaneously, in the absence of any formal guidelines and little consideration of consent. This study documents the consent practices of healthcare professionals using IM for clinical activities in District Hospitals in KwaZulu-Natal, South Africa and compares these practices with the literature.

Methods:

As part of a larger audit of telemedicine activity in KwaZulu-Natal a survey questioned clinicians’ use of IM, including consent practices and awareness of regulatory guidelines. Concomitantly multiple electronic databases were searched for papers on WhatsApp use in clinical service. Inclusion criteria were: papers written in English, reported on WhatsApp in clinical use or potential clinical use, and addressed consent.

Results:

The survey confirmed anecdotal reports of widespread informal use of WhatsApp in District Hospitals. Most clinicians were unaware of regulatory guidelines, and few obtained consent for taking photographs or sharing of images and information with colleagues for consultation. The literature review found that consent was mentioned in only 28 papers. Of these 11 reported that written consent was obtained, of which 5 were for taking photographs and 4 for sharing information with colleagues.

Discussion:

The survey showed that more than half of the respondents who used IM did not consider this to be telemedicine, with the corresponding ethical requirements governed by national guidelines, thereby risking legal exposure. However, South Africa’s regulatory guidelines do not align with common clinical practice. The literature shows that the majority of doctors shared patient information by IM without obtaining any form of consent.

Conclusion:

Practical guidelines are urgently required in South Africa and worldwide that balance practical conduct of medical care with sound contemporary ethical principles. Prudent guidance will ensure clinicians do not inadvertently breach patient privacy and confidentiality laws whilst permitting continued health-related use of instant messaging.

Background:

Only 20–40% of candidates actually attend cardiac rehabilitation programs in Australia, with attendance numbers remaining unchanged in the last 20 years. Common barriers to cardiac rehabilitation are geographical isolation, work responsibilities and transportation. Web-based cardiac rehabilitation can provide an alternative, patient centred, flexible delivery option.

Objective:

The objective of this study was to describe how patient-generated input, through a workshop on desired content and features, informs technology and implementation specifications for the patient portal of a cardiac rehabilitation website.

Methods:

UX Design theoretical framework, using a co-design workshop, with thematic analysis and a survey.

Results:

We recruited 7 participants and 1 cardiac rehabilitation coordinator. The median age of participants was 75.0 (IQR 74.0–78.0), 4 (57.1%) were male and all had completed a cardiac rehabilitation program. Most used a smart phone (5, 71.4%) and Facebook (6, 85.7%). Four themes were identified: input information, format of information, usability and support of health behavior change, informing the next iteration of the workshops and contribute to the cardiac rehabilitation patient website development.

The COVID-19 pandemic has brought telehealth into the limelight. Telehealth is not a new word but since the pandemic, for many day-to-day users of the healthcare system, this term has become a household term. For IT enthusiasts, it is refreshing to see the uptake in telehealth. In most cases the uptake in telehealth came from the forced necessity of minimizing the spread of the virus. The positive outcomes have taken healthcare by surprise. It is not surprising then to see healthcare service providers transitioning to telehealth at an exponential rate. However, the upcoming COVID-19 normal state will demand more than the transitioning of ‘brick and mortar’ clinical practices to video or tele consult, making telehealth a natural predecessor of virtual care. This is a position paper presenting the current state of telehealth by outlining its benefits, limitations, looking beyond telehealth to address some of the recurring healthcare pain points and potential solutions to move towards patient-centered care via the adoption of virtual care.

The current COVID-19 pandemic has highlighted the limitations of relying solely on in-person contact for diagnosis, monitoring and treatment of mental health conditions. Mobile health approaches can be used to monitor mental health patients remotely, but they are not properly integrated with existing models of healthcare service delivery. We present findings from a case study of a mobile app enabled cloud-based software program rolled out in a phone based psychological service to enable real-time/temporal monitoring. The program offered patients an app to record measures of symptoms in everyday contexts and provided clinicians with access to an accompanying dashboard to use information from the app to tailor treatments and monitor progress and ultimately facilitate earlier and personalised care decisions. Feedback related to implementation and utility was gathered from clinicians through a focus group conducted two months post-roll-out. Findings identified that the system is valuable and feasible, however implementation issues were identified. These are discussed in order to inform future work in this area to support the delivery of timely and responsive mental health care in the community.

Objective:

To identify and review phone applications (apps) that could be used by care workers to help them plan and provide palliative care in the aged and community care setting.

Methods:

A scoping review. Searches were conducted in App Store and Google Play to identify apps relevant to care workers in the context of palliative and end of life care provision. Relevant apps were downloaded and evaluated. Apps allowing full access were additionally ranked against the Mobile Application Rating Scale (MARS). Information relating to the app as listed in the app stores were also extracted.

Results:

Of the 1,168 identified apps, only eight could be shortlisted for inclusion. The included apps were mostly English language and developed in high-income countries. The apps were primarily aimed at information provision, with limited content on palliative and end of life care. It was unclear if any of the apps were underpinned by evidence or theoretical frameworks, and none disclosed information on the app development process including involvement of end-users. The mean MARS score for full-access apps was 3.94, with the app iNotice for Carers scoring the highest score of 4.1.

Conclusion:

Currently available care worker apps appear to have limited functionality and scope in relation to palliative and end of life care. There is opportunity for a co-designed care-worker app development endeavour that is underpinned by robust evidence, and has high-level usability and relevance.

We have been conducting pathological diagnosis of routine cases in the Federated States of Micronesia by telepathology since 2018, using realtime screen sharing via the Internet with Japan. The number of cases covered in the last three years was 378, and by specimen type, gynecologic specimens were the most common, followed by oral cavity / ENT, skin, and mammary gland. Thirty four out of 60 oral cavity cases were diagnosed as malignant including suspicious. The turnaround time between submission of the specimen and the report of pathological diagnosis was markedly decreased. For the continuous development of global telepathology, it is necessary not only to build a system but also to recruit or train those who perform it.