Ebook: Transforming Healthcare Through Innovation in Digital Health

The Global Telehealth 2018 (GT2018) International Conference is the 7th meeting of this series, established in 2010. We are privileged this year to have the event co-located with the Asia Pacific Association for Medical Informatics (APAMI) 2018 Regional Conference and its satellite events in Colombo, Sri Lanka. This year also marks the formal involvement of the International Medical Informatics Association (IMIA) in the organising of Global Telehealth, through its longstanding Telehealth Working Group. The 2018 conference has also been endorsed by the International Society for Telemedicine and eHealth (ISfTeH), and the Australasian College of Health Informatics (ACHI). The financial support of University of Colombo towards publication costs of this book is greatly appreciated.

The contributions offered here from GT2018 encompass numerous aspects of the event multi-conference theme, “Transforming Healthcare Through Innovation in Digital Health”. The contained papers encompass a range of health situations from public health and primary care through to consumer health informatics, and deal with a variety of themes from data collection and analysis to design of interventions and delivery mechanisms. The work presented includes technical aspects of implementation and algorithm design, to social aspects such as privacy and ethical considerations. The implicit message from this diversity is that innovation is necessary and indeed is happening on many fronts in the broader Telehealth domain.

The format for this Global Telehealth meeting expanded on the previous format of only providing a platform for contributed papers. As in the past, this proceedings book contains only the accepted full-paper, double-blinded, peer-reviewed contributions received for the conference, as judged by the international expert review panel, as well as the editor-reviewed invited keynote papers. Approximately 50% of the total initial submissions were accepted. However, the conference sessions also included a greater variety of content, by introducing short presentations on work in progress and case studies of telehealth systems, accepted on the basis of committee-vetted abstracts. Delegates also attended bonus plenary sessions from the main APAMI conference, and attended an information and planning session held by the IMIA Telehealth Working Group to expose its work to a wider audience.

The conference organisers wish to acknowledge the generous support of the local conference organisers in their inclusion of GT2018 delegates in the main conference, the strong support of the overall event coordinator Prof. Vajira H.W. Dissanayake, and the guidance of the GT2018 General co-Chairs, Dr Shashi B. Gogia and Dr Rohana B. Marasinghe. We also acknowledge the efforts of our two sub-editors, Kerry Yu Fang and Rajvir Kaur, who completed the final format editing of the papers. And last but not least, we sincerely thank the members of the international review committee for their detailed consideration and extensive comments to assist in the selection and improvement of the papers submitted.

Jeewani A. Ginige and Anthony J. Maeder

GT2018 Programme co-Chairs

Introduction: Behaviour change is a key point in weight management. Digital health interventions are attractive tools to deliver behaviour interventions for weight loss, due to the potential to reach a large number of people. We aimed to report how the Behaviour Change Wheel (BCW) was used to develop and implement a web platform to promote weight loss in Brazilian adults with overweight and obesity. Moreover, we aimed to describe the first 12 weeks of usage of the platform in a randomized controlled trial.

Methods: The BCW framework was used to define intake of fruit/vegetables, ultra-processed products and sweetened beverages, leisure physical activity and sitting time as target behaviours. The BCW components of behaviour-capability, opportunity and motivation were used to make a behaviour diagnosis of the population and BCW second layer oriented the selection of information, goal setting, self-monitoring, feedback, social support and incentives as behaviour techniques. Using these behaviour techniques, a 24-week behaviour intervention delivered by seven different platform functionalities was developed. The platform was tested in a three-arm parallel (basic platform versus enhanced platform versus minimal intervention control group) randomized controlled trial from September 2017 to April 2018. In the present analysis, we classified the platform functionalities according to the BCW behaviour component (capability, opportunity and behaviour) and used descriptive statistics and Spearman correlations to report functionalities usage according to the BCW behaviour component over the first 12 weeks of the trial. The study was approved by the Ethics Committee of the Federal University of Minas Gerais, Brazil and was registered under NCT 03435445.

Results: Over the first 12 weeks of the RCT, the 809 participants (619, 76.5% women; mean age 33.7 years, SD 10.3; mean BMI 29.9 kg/m², SD 4.3) were enrolled for use of the basic and enhance versions of the platform. Capability-driven functionalities were accessed by 455 (56.2%) users with median access of 1 (IQR 1–6) times, whereas opportunity-driven platform functionalities were accessed by 592 participants with 8 (IQR 1–27) median access times and motivation-driven functionalities were accessed by 560 (69.2%) participants with 13 (IQR 1–30) median times of access. Spearman correlations between the use of capability and opportunity functionalities, capability and motivation functionalities and opportunity and motivation functionalities were 0.74 (95% CI 0.70–0.77), 0.74 (95% CI 0.70–0.78), 0.89 (95% CI 0.87–0.91), respectively.

Discussion: BCW provided a systematic approach to planning, designing and implementing a complex weight loss intervention based on behaviour change. Moreover, it promoted a clear understanding of the relation between platform functionalities and behaviour determinants. The low use of the capability-driven functionalities might have been related to lack of accuracy in the behaviour diagnosis, as well as to implementation issues. The high correlation between the functionalities use suggests that the BCW approach did not determine the platform usage profile.

Conclusion: The BCW provided a framework for an evidence-based intervention on weight loss delivered by a web platform. Using the framework led to a clear understanding of the behaviour determinants and their relation to the platform features.

A range of telehealth applications have been developed. In Canada, telehealth shows considerable promise given the country's large geographical area and need for support in rural areas. In this paper, the authors describe our method for ensuring the quality and safety of telehealth applications by applying clinical simulations. These simulations allow for testing and fine-tuning of telehealth applications before they are released on a large scale. Two applications are briefly described, one involving tele-triage and a second involving tele-nursing. The potential of the approach is discussed along with considerations in its application to ensure the quality and safety of telehealth technologies.

Patients with multiple sclerosis (PwMS) were shown to greatly benefit from multipronged exercise interventions comprising aerobic, resistance and corrective therapeutic components which result in endurance and strength improvement and reduction of fatigue and spasticity. However, telerehabilitation support of multipronged exercise programs in PwMS with significant mobility impairment has received limited attention. It is not clear whether severely disabled PwMS can successfully operate a telerehabilitation system at home independently. The goal of this study was to design a telerehabilitation system for individualized multipronged exercise programs and to assess the feasibility of the initial prototype in PwMS with significant mobility impairment. Usability assessment was based on the evaluation of patient ability to successfully carry out a standardized list of common tasks necessary to operate the system. For each task, time to completion, perceived difficulty and satisfaction were documented. Our results indicated a high level of acceptance of the system by these patients. On average, it took 83±41 seconds to complete all the major tasks necessary to operate the telerehabilitation system. After the initial introduction, all patients were able to successfully use the system and follow their individualized exercise prescription independently. A definitive systematic evaluation in a randomized clinical trial is warranted to demonstrate potential clinical impact of telerehabilitation in PwMS.

The intent of this paper is to identify and provide insight on key enablers for successful implementation of telehealth services in severely under-resourced and rural populations. The case study presented is in the context of the U.S. Affiliated Pacific Islands that represent resilient and innovative communities who face many challenges of isolation, tiny populations, and developing economies. Long-standing telecommunication hindrances and lack of supporting resources are fundamental barriers to telehealth advancement. New undersea fiber optic developments present opportunities for reliable connectivity needed for telehealth applications. This paper reviews the emergence of telehealth champions in the region and reviews key elements that contribute to rapid and successful implementation of telehealth applications and services.

Small island developing states (SIDS) have much to gain from the use of Health Information Technology (HIT) and telehealth to improve care, improve population health, increase access to care, and lessen costs. At the same time, planning, implementing, and operationalizing HIT is costly and requires significant technical, human, financial and planning resource infrastructure to support implementation and operations. This paper provides a broad overview of how HIT and telehealth has evolved in the U.S. Affiliated Pacific Islands (USAPI) SIDS, the progress that has been achieved, the role of political affiliations and international assistance, and the many challenges that remain. The paper highlights the differences in treatment between the territories and the nations affiliated with the United States through the Compacts of Free Association (COFA), and the important roles of other donor countries, regional, and international organizations. The paper also raises questions of how advances in HIT and telehealth can be further achieved and sustained in the USAPIs. Finally, the paper identifies the need for the building of knowledge and skills to develop careful plans so pitfalls of silos, proprietary systems, and inadequate technical support can be lessened or avoided in the grand challenge of adoption and maturing of HIT and telehealth.

This paper presents a framework upon which medical applications can be evaluated both in terms of basic functionality, and their target area of users. The study was conducted on 40 mobile applications that were published within Google Play and Apple App store targeted for clinicians, medical practitioners and students. It was important to first classify the mobile apps selected because there are many generic applications, and some focus on special areas within the medical field. The classification process included determining the specialist areas of these applications such as educational and training, nursing, diagnosis and treatment, patient monitoring, testing and laboratories, and social networking. After the classification, a criterion to evaluate applications within individual categories, as well as in more general aspects such as their performance, security, user interface, and other software quality attributes, was developed. Test data was used to test the applications using the developed evaluation criteria, and the results were then used to determine the apps with surpassing features. As per the category-wise results, Medicine References and Education & Training categories had applications that had better scores than other categories. However, an equally important finding concluded that there are not enough applications to help with lab testing, and this gap needs to be filled. Most applications lacked the usability aspect and needed work in user interface (UI) and user experience (UX) areas.

Selfies, self-taken photographs using mobile phones or tablet computers, have become a way of life. People are now sending selfies to health professionals for medical advice or dermatology triage or postoperative wound assessment. These selfies may be unsolicited and sent to clinicians with whom the patient may or may not have a prior doctor-patient relationship or on the instruction of the attending doctor or even to social media groups. They may be sent by email, or by mobile phone and instant messaging applications, or sent to Websites, or telemedicine specific application sites. These photographs and accompanying information are legal documents, should form part of the patient's record, and should be securely transmitted and stored to maintain patient confidentiality and privacy. This paper reviews the legal, ethical and regulatory issues associated with the different forms of selfie telemedicine.

Method: A scoping literature review was undertaken using PubMed, Scopus, Science Direct, Ebsco Host and Google Scholar which were searched for Selfie and any of medicine, telemedicine, telehealth, eHealth, or mHealth. Inclusion criteria were that the paper was in English and described the use of a selfie in relation to healthcare. These were then reviewed for reference to legal, ethical issues and regulatory issues.

Results: 68 papers met the inclusion criteria. Legal and ethical issues identified were consent, confidentiality, privacy, the doctor-patient relationship, data security, responsibility, record keeping, licensure, continuity of care, quality of care, image quality, concordance, phone stewardship and patient satisfaction.

Conclusion: The literature provides little guidance on how legal and ethical issues and shortcomings of selfie telemedicine should be addressed especially the responsibilities of the patient and physician for unsolicited requests. Nor does it provide advice on how records are to be kept, or how images and information stored and sent to and from mobile phones or computers are to be managed. The new issues that arise need to be addressed.

In this paper I will engage with the discussion on Citizen and Health Data, and look specifically at challenges in citizen-centered digital health information management, if the goal is to stimulate self-management, support holistic trajectories of health and wellbeing, and implement new practice models with efficient use of health care services. A focus will be citizens' opportunities to engage in activities to a) collect, b) curate, c) control access to personal Health Data and relate these activities to telehealth locally and globally.

The use of smartphones and IM has the potential to transform the delivery of health services by providing an easy to use, cost-effective tool for remote doctor-to-doctor and patient-to-doctor consultation and diagnosis. Whilst the introduction of new technologies has improved access to healthcare, it has also created new challenges. The aim of this paper was to review the literature on the use of Instant Messaging (IM) and IM applications (apps) in dermatology.

Method: PubMed, Scopus, and Science Direct were searched for multiple terms for 20 individual IM apps linked to the terms telehealth, telemedicine, ehealth, e-health, mhealth, or m-health. After title and abstract review, 31 papers met the inclusion criteria of IM use in dermatology.

Results: Three papers, all from the developing world reported the benefits of using IM in a clinical dermatology service. Other uses included behavioural change, disease management, diagnosis, triage, screening, diagnoses, home monitoring, education, and administrative. Little mention was made of medico-legal issues such as consent, confidentiality, privacy and data security and storage.

Conclusion: Currently there is little use of IM in clinical dermatology services, but its potential is great. There is need to address ethical and medico-legal concerns and develop guidelines for its use. IM is a simple, cheap and effective solution for the developing world.

There is a growing body of evidence highlighting the benefits of mobile health in terms of cost effectiveness, efficiency and patient satisfaction. These benefits have been further enhanced through the development of Instant Messaging (IM) applications (apps) that enable the transmission of images and text messages. The aim of this paper is to review the use of IM in clinical services, and to understand the medico legal concerns with regard to the security and management of protected health information on doctors' phones.

Method: PubMed was searched using the various IM apps as a search term. Inclusion criteria were that the paper was in English and described the use of IM in a clinical service.

Results: 39 papers met the inclusion criteria. Data are at risk at several levels, including during transmission, storage on servers en route, and on the sender's and receiver's phones. Consent is seldom obtained for instant messaging, and confidentiality, privacy, data security and record keeping remain areas of concern.

Conclusion: The use of IM, and in particular WhatsApp, is now commonplace amongst clinicians and used extensively across different clinical services. Security concerns have created barriers preventing the global adoption of IM in healthcare. Guidelines in the management and use of IM need to be developed in order to prevent the unwanted consequences of non-compliance by uninformed clinicians. With improved security, IM has proven to be a viable option in the developing world.

Background and aims: Effective strategies are needed to address the need for scheduling support in the unique setting of a home rehabilitation service, providing home based therapy, as well as telerehabilitation. One approach is an electronic avatar-directed scheduling and memory aid in the form of an app. The aim of this study is to investigate clinician perspectives on the use of this type of technology.

Methods: In this mixed method study a total of sixteen clinicians from various disciplines based at a metropolitan hospital in Adelaide (SA, Australia) participated in 2 semi-structured focus groups aimed to explore experiences and attitudes towards scheduling support in the form of an avatar-directed app, perceptions on the usefulness of the app, as well as acceptability. Thematic analysis was undertaken on focus groups' transcripts. Self-reported technology proficiency, perceived usefulness (PU), and perceived ease of use (PEOU) were assessed quantitatively. Summary statistics were used to analyse the quantitative data and Spearman's correlation was used to explore the relationship between participant characteristics and individual and mean scores for PU and PEOU.

Results: Four themes emerged from the focus groups: effectiveness versus efficiency, patient empowerment, practicality and ease of use, and likability of the avatar. Clinicians experienced time constraints, and welcomed technology that could assist with reliable scheduling of appointments and therapy sessions. They liked the concept of the avatar and found the app interesting, novel and fun. However, although the app was reasonably easy to use, the setting up was problematic and time consuming. Clinicians did not see the app as beneficial to their patients, and felt that the technology did not add value to the delivery of care. The older, more experienced, clinicians found the app more difficult to use, but neither the level of technological competency, nor gender, was found to be associated with PU or PEOU.

Discussion: Although clinicians appreciated the concept of an avatar-directed scheduling and memory app, they did not see it as a useful tool in the provision of scheduling assistance in this particular setting providing short-term rehabilitation services. Clinicians felt time-poor and emphasized the importance of a time-efficient solution. Perceived lack of usefulness in this context and poor likeability of the avatar highlight the need for clinician involvement in the design process before an app can be successfully implemented in a clinical setting.

This paper presents an approach for describing personal movement patterns for typical daily activities undertaken by subjects within free living structured environments (e.g. home or office). Conventionally this requires specialized technology for personal movement monitoring involving measurement of location and motion, and results in the collection of large datasets in order to provide sufficient descriptive power. Here we advocate the preferential observation of sentinel activities based on the expectation of routine and repetitive personal movement episodes, which can be considered as ‘habits’. These identified habitual patterns provide a useful context for understanding the dominant characteristics of typical daily activities, enabling purposeful design of behaviour change interventions to improve healthy living. This approach has been applied here to office stepcount data from consumer wearables.

Continuous monitoring of patient's physiological signs has the potential to augment traditional medical practice, particularly in developing countries that have a shortage of healthcare professionals. However, continuously streamed data presents additional security, storage and retrieval challenges and further inhibits initiatives to integrate data to form electronic health record systems. Blockchain technologies enable data to be stored securely and inexpensively without recourse to a trusted authority. Blockchain technologies also promise to provide architectures for electronic health records that do not require huge government expenditure that challenge developing nations. However, Blockchain deployment, particularly with streamed data challenges existing Blockchain algorithms that take too long to place data in a block, and have no mechanism to determine whether every data point in every stream should be stored in such a secure way. This article presents an architecture that involves a Patient Agent, coordinating the insertion of continuous data streams into Blockchains to form an electronic health record.

Workplace health is of concern to management and employees alike. Managers are concerned about the impact of health and wellbeing on productivity, while employees are concerned about impacts on quality of life. In the past two decades, there has been growing concern about the impact of sedentary behaviour at work. Before any interventions can be made to encourage physical activity at work proactively, it is desirable to understand the baseline characteristics of office based physical activity at work. Consumer wearable technology has provided a new and convenient mechanism for using personal monitoring to achieve remote observation of lifestyle related health behaviours. This paper describes how this technology can potentially be used to characterize different levels of workplace physical activity.