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mHealth for Cardiac Patients Telemonitoring and Integrated Care.

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In the majority of developing economies there has been limitation to rapid growth of technology-rich and expensive broadband telecommunication infrastructure (e.g. optical fiber networks), which is prerequisite of e-Health. However, along with the emergence of broadband mobile communication networks, mHealth seems advantageous and cost-efficient mode of e-Health in those countries, likewise Georgia. The first mHealth project in Georgia on m-Telemonitoring (MTM-1) of Cardiac arrhythmia - 54 patients with main medical results, Quality of Service (QoS), Quality of Experience (QoE), cost-efficiency and remaining challenges - is presented, as well as the outline of its continuation - MTM-2 project, which aims improvement of decision making for emergency cardiac patients and usage of mHealth applications for integrated care provision in remote regions of Georgia.
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mHealth for Cardiac Patients Telemonitoring and Integrated Care
Zviad Kirtava1,2, Tea Gegenava1,2, Maka Gegenava1,2
1 Partners for Health NGO, 2 Tbilisi State Medical University, Dept of Internal Medicine
zkirtava@nilc.org.ge
Abstract In the majority of developing economies
there has been limitation to rapid growth of technology-
rich and expensive broadband telecommunication
infrastructure (e.g. optical fiber networks), which is
prerequisite of e-Health. However, along with the
emergence of broadband mobile communication
networks, mHealth seems advantageous and cost-
efficient mode of e-Health in those countries, likewise
Georgia. The first mHealth project in Georgia on m-
Telemonitoring (MTM-1) of Cardiac arrhythmia - 54
patients with main medical results, Quality of Service
(QoS), Quality of Experience (QoE), cost-efficiency and
remaining challenges - is presented, as well as the
outline of its continuation - MTM-2 project, which aims
improvement of decision making for emergency cardiac
patients and usage of mHealth applications for
integrated care provision in remote regions of Georgia.
Keywords mHealth, e-Health,
telecardiology, telemedicine, m-telemonitoring,
arrhythmia, coronary artery disease, integrated
care, Georgia (Rep. of)
I. INTRODUCTION
For last decade World Health Organization (WHO) puts
more and more emphasis on e-Health (Electronic Health,
Telehealth) or Health realized through Information and
Communication Technologies (ICT)”, as one of the
potential and powerful solution to dealing with existing
challenges of healthcare services disparities globally and
locally and as a main tool promoting integrated and
efficient patient-centered healthcare. e-Health encompasses
a range of services or systems that are on the edge of
medicine/healthcare and ICT, including (but not limited
to): Health Management Information Systems (HMIS),
Electronic Medical Records (EMR) and e-Registries;
telemedicine; e-Learning; consumer health informatics;
health knowledge management; mHealth [1-2].
Telemedicine is used when the patient is far from qualified
medical personnel and transportation issue must be decided
quickly. E.g., healthcare in mountainous regions
(especially in snowy winters) and other hard-to-reach
areas. Telemonitoring (remote monitoring) regards the
situations when people with certain, potentially life-
threatening risks are outdoor (tour, picnic), or a person
with a serious disease (e.g., myocardial infarction and/or
arrhythmia) needs case management either at pre-hospital
stage, or after being discharged from the hospital, when
deterioration of condition cannot be excluded and
monitoring is desirable. For different groups of patients
(lonely mothers, patients with dementia or arthritis, etc.)
m-telemonitoring is certainly more comfortable, as
concomitant life-threatening conditions can be controlled
at homes [2]. As cardiovascular diseases represent one of
the leading morbidity and, especially, mortality cause
throughout the world [4], telemonitoring of cardiac patients
is one of the important parts of e-Health and mHealth [5,6].
WHO’s notion of integrated healthcare carries the promise
of cost containment through shortening of hospital stay and
reduction of inappropriate hospitalizations and admissions
to long-term care, at the same time creating conditions for
seamless and timely referral of a patient from primary
healthcare (PHC) system to secondary or tertiary level
hospital whenever needed [1]. Integrated healthcare is
based on continuity of care, which is often subdivided in 4
components: 1. Continuity of information (through
electronic medical records), 2. Primary-Secondary-Tertiary
care interaction (vertical integration), 3. Multidisciplinary
teams approach (horizontal integration), 4. Provider
continuity. All these can be better realized with the
emergence and implementation of e-Health [1,3].
mHealth (mobile health, m-telemedicine) represents an
important recent sub-segment of e-Health and a rapidly
growing branch of telemedicine, which covers the practice
of medical and public health, supported by mobile devices,
such as mobile phones and PDAs, for health services and
information [2]. In process of mHealth broadband mobile
connectivity (GPRS, 3G, 4G) is used as communication
means to transfer data between medical professionals and
patients. Thanks to growing spreading of cell phones in
developing economies (e.g., mobile penetration in Georgia
has grown from 19% in 2004 to 100% in 2012,
www.gncc.ge), increase in coverage zones (>98% of
populated territory of Georgia, www.gncc.ge), bandwidth
rich applications, technical and financial affordability of
broadband applications, mHealth is evolving as an
advantageous and cost-effective tool, especially in
emerging economies, where limitation to rapid growth of
technology-rich and expensive infrastructure for years was
a main barrier to telemedicine development, whereas there
are already existing mobile communication networks now.
Broadband mobile telemonitoring can be provided from
anywhere not only from fiber-optic cable-connected top-
notch hospitals, but also from patient’s home, workplace or
from any outdoor location, street, or place of accident [1-
3].
21
One of the most important elements of e-Health/mHealth
service regards the best possible ICT support, which would
enable better Quality of Service (QoS). However, user
perception and user acceptance, defined as Quality of
Experience (QoE), seem to be an even more important
aspect and determinant of e-Health/mHealth development
[7]. Eventually both technology adjustability and QoE
would define exact growth of m-Health, which bears an
impressive business opportunity by different market
researches [3,8]. So far, Health Research Institute (HRI)
estimates the annual consumer market for remote/mobile
monitoring devices to be $7.7 billion to $43 billion [8].
In this paper we present data about feasibility of m-
Telemonitoring for Cardiac Arrhythmia (CArr) patients in
Georgia (MTM-1 project, 2010), typical most useful
scenarios of m-telemonitoring, some data on Quality of
Service (QoS) and Quality of Experience (QoE), cost
efficiency of arrhythmia m-Health monitoring, discuss
advantages/challenges of m-telemonitoring for arrhythmia
patients and marketing challenges. We will also shortly
outline our recent grant project application MTM-2
(2013-2015) - mHealth based telemonitoring for
improving decision-making and integrated care for
remote cardiac patients: Pilot study for Adjara and
Kakheti regions in Georgia.
II. CARDIAC ARRHYTHMIA M-TELEMONITORING
(MTM-1):
A classical example demonstrating the impact of
telemedicine on diagnosis and treatment is the event
recording of arrhythmias. Monitoring of arrhythmias on an
ambulant basis seems to be cost effective and a promising
concept for homecare and rehabilitation. Arrhythmia
telemonitoring allows the patient to move free on the ward
without staying in bed. The advantages for physicians and
medical staff is the combined monitoring of different
patients, an alarm management for different parameters
(heart rate, blood pressure, respiration and oxygen
saturation), online diagnostics of arrhythmias and post
procedural supervision. For out-of-hospital monitoring of
cardiovascular patients loop recorders and event recorders
are available. The use of event recorders with a direct
transmission of ECG’s can reduce the time of admission to
hospital for risk groups, particularly for arrhythmia
patients, facilitate the diagnosis on an ambulant basis and
reduce costs [5,6,9].
Material and Methods:
During 06/2010-12/2012, we investigated 54 outpatients
with different types of arrhythmia (M/F=32/22, age 12-
80 y), among them 10 patients with concomitant epilepsy,
6 patients after radiofrequency catheter ablation(RFA), 4
patients after coronary artery bypass graft surgery (CABG)
and 10 patients with unexplained syncope. Control group -
7 clinically healthy sportsmen (all men, 15-17 y), during
30 min veloergometer stress-test). Selection of control
group aimed to test mHealth monitoring during vigorous
physical exercise. Investigations were made by 3-lead ECG
Loop Recorder (Vitaphone BT 3300, Vitasystems GmbH,
Germany) in automatic recording/transmitting mode, using
special LRMA software (MDT s.r.o., Czech Republic) pre-
recorded at Nokia 6730 (Symbian) phone. Since 2012 we
also use Huawei U8180 IDEOS X1(Android) phone.
Arrhythmia m-telemonitoring process chain is presented at
Fig. 1:
Fig.1: Communication means used in MTM-1 project
The memory of the Vitaphone 3300 BT is large enough for
the continuous recording of 40 minutes of a 3-channel
ECG. The oldest ECG data are overwritten (loop function).
Intelligent LRMA software automatically detects and
records rhythm disturbance events by recognizing R-R
interval irregularities. Then loop recorder transfers event
ECGs through Bluetooth to mobile phone. The recorder
and mobile telephone can be in up to 10 meters range from
each other to secure Bluetooth wireless transfer. LRMA
software then allows phone to send data by 3G
communication to Tele-ECG REMOS server in Chemnitz
(Germany). With a low-level signal the ECG recorder
interacts with phone, which with the same low-level beep
confirms sending-receiving of recorded ECG. As it is done,
the REMOS web-server, as well as doctor’s e-mail gets
new mail with .pdf type ECG file. That provides
ubiquitous service provision (anywhere anytime), besides,
all ECGs could be transferred and safely stored for patient
data dynamics review. In case of electrode detachment or
low battery the loop recorder issues high level pitch signal
(3 beeps). If the fault is not recovered the equipment is
switched off in two minutes.
Results:
Arrhythmias were registered/monitored during 7-68 hours
of observation. Number of automatically recorded ECG
events varied between 3 and 170 per observation or 0.4-
10.7 hourly. Minor artifacts have been recorded as mainly
first minutes of recording (in 9%) or during vigorous
physical exercise (around 12%, mainly - in sportsmen
group). Cases of sinus brady- and tachyarrhythmia, sick
sinus syndrome, atrial fibrillation (AF), supraventricular
tachycardia (SVT), supraventricular premature complexes
(SVPCs) and ventricular premature complexes (VPCs)
have been correctly recognized by automatic recognition
22
software and recorded. There have been 2 patients (3.7%)
when m-telemonitoring couldn’t reveal previously
diagnosed arrhythmia (SVT or VPCs), but that could be
due to transitory character of those abnormalities. On the
other hand in 7 patients (13%) the diagnosis was
modified/clarified based on m-telemonitoring findings.
52% of arrhythmia episodes were asymptomatic.
Arrhythmia relapse (SVT or SVPCs) was detected in n=3
(from n=6) patients who underwent radiofrequency
catheter ablation, and mostly they were asymptomatic.
Asymptomatic episodes of VPCs were often detected in
patients who underwent CABG surgery.
From n=10 patients with epilepsy we discovered n=3
patients with supraventricular tachycardia (SVT) and n=2
patients with sinus tachycardia.
Among n=10 patients with unexplained syncope, we
revealed n=2 patients with sinus tachycardia, n=2 patients
with SVT and n=1 patient with sick-sinus syndrome.
III. TELEMONITORING SCENARIOS
Following real-case scenarios demonstrate benefits of
mHealth telemonitoring for cardiac arrhythmia patients:
Scenario #1: Natia is 32 year old
young mother of 2.5-year old twin
boys. Being medical doctor herself
she is not working currently with
limited chance both to find the job
and also to have somebody to
provide care for kids, whom she
lovely calls “bandits”. During last
year she often had heart palpitation
and dizziness, which lasts around
30-120 sec and then stops,
sometimes, a feeling of strong
heartbeats, after whichthe heart
stops. She made regular ECG
twice, which has shown no
abnormalities. She was advised to have inpatient care at cardiac
ward, but that was expensive, besides she couldn’t leave the kids.
We have discovered by mHealth telemonitoring (45 hours
observation) that Natia has episodes of Sinus Tachycardia and
non-frequent SVPCs, mainly during night times or during home
work (laundry). She was given medication and was advised to
check thyroid hormones (which proved to be normal). She was
very happy by having chance of m-telemonitoring and said she
was always worried that she could have had something really
serious, but was unable to go to the hospital. It was very
convenient to be at home with kids, walking them around and
doing usual work and at the same time being confident that her
health status is being observedNatia said after investigation.
#2: Natela is a 77 year old pensioner, on post-ER rehab at home
after strong 3rd episode of Ischemic stroke for last 1.5 years. As
previous treatment with Aspirin proved ineffective, now on
Fraxiparin and then Warfarin anticoagulation treatment. She has
speech impairment and left-hand motor deficiency, uses notepad
for communication with the hired caregiver. With last two stroke
episodes she had persistent atrial fibrillation (AF), which was
transformed by Amiodarone treatment back to sinus rhythm (SR).
At 2nd day of Warfarin she again developed AF and as
cardioversion invasive treatment was dangerous at this stage with
risk of recurrent emboli and stroke, we started m-telemonitoring
which has shown tachysystolic AF with risk or paroxysmal flatter.
Beta-blocker treatment was started and we carefully monitored
her heart rate going down from avg. 136 to avg. 56. After that
dosage of b-blocker was halved and after 2 weeks SR was
restored. In this situation it was risky to move patient back to
hospital, but she certainly needed an extended monitoring.
Thorough m-telemonitoring was investigation of choice.
Scenario #3: Zviad is 12 year old boy from Western Georgian
village. He has epilepsy and due to nodular tachycardia (NT) has
passed radiofrequency catheter ablation 2 years ago. Recently he
has started to have episodes of palpitation and chest pain again.
m-telemonitoring has revealed recidive of NT, which means he
either needs to pass RFA again, or to reconsider his main
treatment (antiepileptic drugs are often causing CArr). This was
one of the first m-telemonitoring in Georgian rural district.
Side Effects: 49 patients have passed investigation without
side effects, whilst in 5 cases (4 women, 1 - man) light
insomnia and nervousness (expecting signal during night)
was reported. In two patients with neurosis (both elderly
men, 1 with concomitant epilepsy) we had to stop the
investigation due to patients’ anxiety/agitation related with
technology and/or idea of constant monitoring.
Technical Faults: Bluetooth miscommunication between
ECG loop recorder and mobile phone - only 19 such
events out of 2751 events (0.7%). Minor artifacts have
been recorded mainly at first minutes of recording (in 9%)
or during vigorous physical exercise (around 12%, mainly
- in sportsmen group). Low voltage in one of 3 recorded
channels (mainly during night-time, in 3 patients - <6%)
presumably due to loose contact of electrode during sleep.
Stop of recording due to electrode dis-contact has
happened in 6 patients (11%, mainly in night-time 4/6).
Loop recorder cannot register all events of arrhythmia,
because after recording (usual mode - 25 sec before and 15
sec after the event) the equipment is “deaf” for another 40
sec, therefore it can only register maximum 30-40 events
hourly, but that is acceptable. However, in addition to that
we have noted that sometimes the software misses the
event, which is then recorded in the next “pre-event”
period. We have noted that approximately in 10% of cases.
The event recognition rate is even lower in AF which is a
situation when R-R interval is constantly changing and
virtually all episodes could be regarded as “events”. But
the software has problems to assess the “average” R-R
interval due to that.
Quality of Service (QoS) data:
Total 2751 sessions were recorded, 72% of which in 2010.
Average traffic per session 12.65 Kb (11.6-13.7). The
whole “cycle” of event recording-transfer to server-
reflection on web-server/transfer to physician’s e-mail (we
used corporate Gmail) takes 47-51 sec. Such delay is
acceptable. Of this cycle recording was taking 16-17 sec,
authorization/sending (including both Bluetooth and
3G/3.5G communication) 14-15 sec, and back-route of
pdf file report 17-18 sec. According to MagtiCom
technical service 3G/3.5G communication including
authorization with server required 5-6 sec, of which greater
part (app. 80%-90%) was authorization part. As the sent
information was very small in size 11-13 Kb, the
23
significant difference in throughput between various types
of connectivity and in various parts of Tbilisi
(GPRS/EDGE 30-250 kb/s and HSDPA 0.8-6.4 Mb/s)
resulted in nearly no difference for traffic delay. The report
from Remos server in pdf file format was about 10 times
larger than sent information 120-138 Kb, so the main
challenges and delays happened at 3rd part of the route to
physician’s laptop, or particularly Smartphone and that
was mainly pending on type of the OS (e.g. Android 2.2
slower than Android 4.0) or hardware (e.g. Motorola
Milestone significantly worse than recent iPhone, HTC,
Sony Xperia or Samsung Galaxy).
Quality of Experience (QoE): Survey results (by 26
patients and 7 doctors) are presented in Table 1 & 2:
Cost Efficiency: is presented in Table 3:
MTM-1 project commercialization and marketing
Challenges
We have planned to have cardiac arrhythmia m-
Telemonitoring as commercial service since 2011.
However, due to hospital privatization program of previous
government and drastic changes in TSMU clinical bases
we had to change our location since 2011 three times.
Currently we have the service available at three private
clinics and plan major change in marketing and
sustainability since November of 2013 when our team
moves to Chapidze Heart Center, a pioneer of invasive
cardiology in Georgia (www.chapidze.ge).
IV. MTM-2 PROJECT - M-TELEMONITORING
FOR IMPROVING DECISION MAKING AND
INTEGRATED CARE FOR REMOTE CARDIAC
PATIENTS
There is significant imbalance in institutional and human
resources of healthcare between Tbilisi and regions.
According to governmental decision arrangement of
different capacity hospitals in regions and districts will
elevate institutional imbalance by end of 2013, but
imbalance in human resources may still exist for years.
The project aims to develop guidelines and assess cost-
efficiency of the model for integrated care provision to
cardiac patients in two regions of Georgia based on their
m-telemonitoring, teleconsultation, evidenced-based
decision-making and tertiary level/interventional
cardiology support either at nearest certified point-of-care
or at central university clinics in Tbilisi with organized
transportation by the State Referral Service. Three major
life-threatening cardiac conditions are chosen for mHealth
monitoring: CADwhen potential Coronary Angioplasty
CA or CABG surgical interventions is thought, CArr
with vision of potential Radiofrequency Catheter Ablation
(RFA); and AHfor administering AH Individualized
Treatment Schemes (HITS).
MTM-2 Project objectives:
- m-telemonitoring of 120 patients with CAD, CArr
and AH (both inpatients and outpatients) in selected
regional/district hospitals under the supervision of
contracted by project research-associates;
- Based on pre-validated guidelines for cardiac
patients telemonitoring selection and developed schemes
for risk stratification and inclusion/exclusion criteria to
screen those patients with the above-mentioned conditions
which require emergency interventions (CA/CABG for
CAD, RFA for CArr or HITS for AH).
- To determine the site of intervention and emergency
transportation to specialized tertiary care unit;
- To re-assess those patients with CAD, CArr and AH
which undergone invasive/specialized treatment;
- Estimation of cost benefit of m-telemonitoring of
cardiac patients and development of National Guideline.
V. DISCUSSION
New Strategy of Government of Georgia towards building
modern and efficient Health Management Information
24
System (HMIS) Healthy Georgia Connected to You!” -
was produced and presented (2011) with support from the
US AID. This vision provides the framework within which
various entities (both private and public) will operate in
future across the health sector. Electronic Health
Management Information System (HMIS) will connect all
medical and healthcare provide institution, health
insurance companies, laboratories and pharmaceutical
companies along with regulatory bodies to improve
communication, data reliability and integrated care for
achieving the ultimate goal of patient-centered healthcare
better monitoring, better management, better safety and
better outcome, thus creating cost-efficient, high-quality
healthcare system accessible for every member of the
society. mHealth solutions will greatly enhance and ease
implementation of this strategy.
mHealth creates a win-win situation for the patient, doctor
(GP and remote specialist), hospital and insurance. A
patient is reassured that his/her health is in good hands, by
being silently monitored all the time and transferred to
high-tech clinic in case of emergency intervention decided
appropriate. Doctors can pursue other activities or manage
different patients whilst still can be easily reached
anywhere/anytime and providing better advice and
integrated care with access to electronic medical records.
Hospitals can discharge patients early, or transfer patient to
more specialized/high-tech university clinic, if needed.
And insurance companies have better patient safety with
improved outcome and patient satisfaction, and do save
funds with reduced number of hospitalizations, shorter in-
hospital staying and lower-cost m-telemonitoring at home.
The post-hospital use of m-telemonitoring significantly
shortens in-patient hospitalizations for purposes of clinical
cardiology diagnostics and treatment. However, there are
some pitfalls some patients may feel discomfort with
complexity of telemonitoring technology self-management
[10]. We consider that due to substantial cost of
equipment, limitations of existing insurance schemes and
yet very few mHealth systems enrolled in Georgia,
operation cost might be economically non-viable for long-
term (> 1 week) m-telemonitoring scenarios. However,
deployment and coordinated management of multiple
mHealth systems, as well as employment of
telecardiological functional diagnosis, in pre- and post-
hospital care opens new economic horizons: therapy, based
on its data and findings, quite often brings tangible rewards
later on.
VI. CONCLUSIONS:
1. Our study confirmed that mHealth represents
feasible methodology to monitor cardiac arrhythmia in
outpatients in Georgia, promoting earlier discharge of non-
life-threatening cases, improving patients’ comfort of life
and increasing their mobility with enhanced safety.
2. According to QoE survey results both patients and
physicians assessed arrhythmia m-telemonitoring as highly
satisfactory, convenient, acceptably priced and easy to use
service, which was perceived by great majority of them
better than expected. Doctors also noted substantial
preference of m-telemonitoring vs. regular ECG, whilst
patients specifically noted comfort of life and easiness of
service. However, few elderly patients disliked technology,
night time alarms and/or idea or constant monitoring.
3. The service of m-telemonitoring could improve
many aspects of systems interrelationship between
insurance, physicians, inpatient and outpatient care-
provider institutions, and the patient. Future studies are
planned for service enhancement for different groups of
patients (elderly patients, patients with limited mobility)
and for secondary prevention.
4. Finally, in remote areas patients monitoring by
mHealth methodology would improve quality of care by
timely provision of second opinion in cases, when local
expertise is not sufficient, and by establishing protocols
and routes for patient emergency evacuation and timely
provision of integrated care in those cases, when invasive
cardiology solutions are thought as appropriate choice.
ACKNOWLEDGMENTS:
- MTM-1 project (2010) was funded by joint grant from CRDF-
Global (www.crdfglobal.org), GRDF (www.grdf.ge) and
Georgian Rustaveli NSF (www.rustaveli.org.ge).
- MTM-2 project (2013-15) has been presented to Georgian NSF
(www.rustaveli.org.ge). 1st stage selection passed, final
decision Dec 2013.
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This report describes the development of and emerging trends in electronic health (eHealth) in the WHO European Region in 2016. Its content and key messages are based on data collected from the 2015 WHO Global eHealth Survey and the assistance of a number of key practitioners in the field. The report gives case examples to illustrate success stories in countries and the practical application of eHealth in various settings. The key outcomes given provide evidence of an increasing appetite for eHealth and indicate tangivle progress in the mainstreaming of technology solutions across the European Region to improve public health and health-service delivery. Together, the findings and analysis provided in this report offer a detailed insight into the development of eHealth in Europe. Through the recommendations and proposed actions, WHO echoes its commitment to supporting Member States in developing their national eHealth environments as a strategic component in the achievement of universal health coverage and the policy objectives of Health 2020 in the European Region.
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Nowadays, medical misdiagnose propagates widely, due to among other reasons, a serious lack of cloud support software. Many patients have difficulty finding either their condition or the appropriate treatment. This paper presents a cyber-medicine service for medical diagnosis based on IoT and cloud infrastructure. It is elastic, on-demand, and reliable medical service offered for both patients and specialists. For patients, it can diagnose a disease based on symptoms and provide a convenient treatment based on a patient’s conditions. The analysis of patients’ conditions is started by optionally taking medical measurements of heart rate using sensors. After then, the service starts to interact with the patients to get the symptoms and search for a diagnosis. For prentice doctors, many features are provided as an on-demand disease description, scientific paper search, and symptoms displaying. Finally, to get an unrecognized combination of symptoms, web crawling and multiple classifiers are used.
Chapter
The digital revolution in healthcare presents day after day new solutions to us. As one of the major roles in healthcare is the prevention of being diseased by the popularization of healthier living and doing sports, a vast majority of digital applications aims at self-monitoring and activity tracking via new wearable gadgets and smartphone apps. Also there are solutions for making the work of physicians and medical specialists easier and change their attitude for digital resolutions. This article gives an overview of mobile healthcare status respect to general and multimedia-related solutions and highlights the importance of the respect of Quality of Experience in these applications.
Conference Paper
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Skin cancers and melanoma represent one of the most common cancer types, and their incidence is growing in last decades, especially, among Caucasians and in places with strong ultraviolet insolation. Early stage diagnosis significantly improves patients' survival rates. We aimed to evaluate the efficiency of m-Health and e-Health methodologies (e-registry, mobile teleconsultations and teledermoscopy) among dermatological outpatients with different pigmented lesions for skin cancer screening and follow-up. 584 outpatients from Tbilisi (301 pts) and seaside rural region - Adjara (283 pts) have been engaged in TeleDerm project. Total 2811 teledermoscopic investigations (5.1 per patient) have been carried out. In 91.9% benign and in 8.1% malignant pathologies were mostly correctly diagnosed by teledermoscopic investigation. As a result of teleconsultations of remote patients initial clinical diagnosis was confirmed by teledermoscopy in 65.6% and modified/corrected - in 34.4%. Problems of mobile communication - delay/stacking of transferring large dermoscopic images - were registered in 9% of the cases. Cost of teledermatology consultation was 3.7-55 times lower than in a traditional settings. According to Quality of Experience surveys, 62.5%–86.5% of patients and 70%–90% of physicians ranked TeleDerm service as beneficial, cost- and time-efficient, and improving their confidence in qualified medical care provision. Teledermatology with teledermoscopy could be regarded as a method of choice for skin cancer screening, dermatology patients' full-scale e-registry development and follow-up in case of onco-vigilance. m-Teledermoscopy represents feasible and cost-efficient methodology, particularly - for regional healthcare institutions with limited specialized diagnostic tools.
Conference Paper
This study presents a systematic review of the nature and magnitude of outcomes associated with e-Health of cardiac diseases. Methods: A comprehensive literature search was conducted on Medline and the Cochrane Library to identify relevant articles published between 2000 and 2014 in which the outcome measure used was one or more of health outcome, proxy health outcome, patient compliance or cost. Studies identified were subjected to narrative review. The magnitude and significance of the Home e-Health effects on patients’ conditions (e.g., early detection of symptoms, decrease in blood pressure, adequate medication, reduced mortality) still remain inconclusive for cardiac diseases. However, the results of this study suggest that regardless of their nationality, socioeconomic status, or age, patients comply with Home e- Health programs and the use of technologies. Importantly, the Home e-Health effects on clinical effectiveness outcomes (e.g., decrease in the emergency visits, hospital admissions, average hospital length of stay) are more consistent in Heart Failure. Home e-Health of cardiac diseases seems to be a promising patient management approach that produces accurate and reliable data, empowers patients, influences their attitudes and behaviors, and potentially improves their medical conditions. Future studies need to build evidence related to its clinical effects, cost effectiveness, impacts on services utilization, and acceptance by health care providers. © IFIP International Federation for Information Processing 2014.
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The use of end-to-end communication systems as a medium of delivery for electronic healthcare (eHealth) services is considered to be uncertain, with respect to its reliability leading to hesitation in acceptance of such services. There exist different influential dimensions that pose stringent requirements on end-to-end communication systems, influence user perception and might hinder user acceptance. The later is referred to as Quality of Experience (QoE), which among others depends on the Quality of Service (QoS) of the end-to-end communication system. QoE is considered as a key component determining user acceptance. This paper identifies and analyzes characteristics of a set of eHealth services and the influential dimensions resulting in different QoS requirements and potential impact of QoS on QoE. It highlights the role of QoS and QoE for acceptance of these services. The issue of non-uniform views regarding QoS parameter specifications and related requirements, clinically acceptable thresholds and their qualitative representation in eHealth literature is reviewed and presented.
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Abstract As the very first trial of mobile telemedicine in the Republic of Georgia, in June-December 2010 we investigated 35 outpatients with different types of arrhythmia (male/female ratio=16/19; 12-80 years old), among them 5 patients with concomitant epilepsy. The control group comprised 7 clinically healthy sportsmen (soccer players, all men; 15-17 years old), during a 30-min velo ergometer stress test. A three-lead electrocardiogram (ECG) loop recorder (Vitaphone BT 3300; Vitasystems GmbH, Mannheim, Germany) was used in automatic mode, using special LRMA software (MDT, Lázně Bohdaneč, Czech Republic) and a Nokia (Espoo, Finland) model 6730 Symbian phone. Automatically recorded arrhythmia events were transmitted from the loop recorder by Bluetooth(®) (Bluetooth SIG, Inc., Kirkland, WA) to a phone and then by 3G (through our partner mobile operator, MagtiCom Ltd. [Tbilsi, Georgia]) to the Vitasystems server in Germany and were available to Georgian physicians via e-mail/Internet. Arrhythmias were recorded/monitored during 7-68 h of observation. The number of automatically recorded ECG events varied between 3 and 170 per observation, or 0.4-10.7 hourly. Cases of sinus brady- and tachyarrhythmia, sinus node weakness syndrome, atrial fibrillation, supraventricular tachycardia, supraventricular premature complexes, and ventricular premature complexes were correctly recognized by automatic recognition software and recorded. In 3 patients and 1 sportsman previously unspecified (despite multiple investigations), arrhythmias were recorded: paroxysmal tachycardia (n=1), sinus node weakness syndrome (n=1), and ventricular premature complexes (n=2). In 3 cases (all women) light insomnia and nervousness were reported. In 2 patients with neurosis (both elderly men, 1 with epilepsy) we had to stop investigation prematurely because of anxiety/agitation. Mobile telecardiology represents feasible methodology to monitor arrhythmias in outpatients in Georgia, promoting earlier discharge of non-life-threatening cases, improving patients' comfort of life, and increasing their mobility with enhanced safety. Mobile telehealth might also represent significant cost-saving for insurance companies (this is an ongoing study). Finally, in remote areas mobile telemonitoring of patients will improve quality of care by timely provision of a second opinion in cases when local expertise is not sufficient.
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Health care organizations and providers are under constant pressure to do more with less. On the other hand, users of health care services are faced with problems due to errors in communication between professionals, fragmentation of care and gaps in the continuum of care. The aim of this study was to explore the meaning of the term 'integration' with reference to health, and underscore the need for integration of the healthcare systems. The literature study approach was employed. The first part underlines the conceptualizations of integration and methods for healthcare integration in practice. In the second part, the current situation in Slovenia in this field is outlined. Activities are currently underway for laying down the fundamental normative infrastructure and legal bases for implementation of the eHealth projects, establishing a common health information network, and creating the bases for a standardized electronic health medical record. In the 'top-down' method, we concentrate mainly on general organizational changes for the purpose of achieving coherence and optimization. Projects that focus on the needs of individual patient groups belong under the 'bottom-up' process of integration. To achieve an optimal degree of integration, all health professionals have to play a key role in formulating the strategy of integration at all levels of healthcare.
Article
This paper reports on a project aimed at improving our understanding of self-care practices and technology, and at designing solutions to support everyday self-management in chronic disease. Diabetes type 1 self-care practices are here discussed as an illustration of complex issues increasingly seen in our society. Drawing on some literature from Science and Technology Studies and from empirical evidence from an ethnographic study of self-care practice in diabetes, this paper suggests to rethink some of the assumptions of the traditional medical model and shows how these seem to be taken for granted in the design of patient-care systems. In particular, it argues for an approach that acknowledges the uncertainties of chronic self-care and so the need to avoid normative approaches that give voices to the clinical and scientific aspects of the disease but tend to silence the lay perspective of the patient. The idea of cosmopolitanism is introduced to suggest the need to support - by design - different perspectives and expertise in self-care practices. This idea invites us to connect the advantages of different ways of knowing a complex matter by seeking complementarity, integration, dialogues and negotiations among the involved stakeholders. In line with this proposed approach, the paper introduces the Tag-it-Yourself journaling system enabling the personalization of self-monitoring practices in diabetes, and an improved visibility of the patient's perspective, concerns and knowledge.
Article
Radiofrequency catheter ablation (RFA) is an effective treatment of arrhythmias. However, patients often remain symptomatic after the procedure. We aimed to assess the arrhythmia recurrence after successful RFA in relation to patients' symptoms using transtelephonic loop recorders. Thirty-six consecutive patients (age 50 +/- 14 years, 17 males/19 females) were enrolled after successful RFA for atrioventricular (AV) nodal reentrant tachycardia (n = 21), AV reentrant tachycardia (n = 8), atrial tachycardia (n = 2), atrial fibrillation/flutter (n = 4), and ventricular tachycardia (n = 1). During 23 +/- 6 days of follow-up, 679 events were recorded, 246 of which were true arrhythmic events, mostly (56%) asymptomatic. The vast majority of these true arrhythmic events were due to trivial arrhythmias (extrasystoles or sinus tachycardia), equally distributed among symptomatic and asymptomatic episodes. Arrhythmia relapse was shown in four patients, who had a total of nine episodes, eight of which were symptomatic. No high degree AV block was detected. Overall, symptom recurrence had low sensitivity (44%) and high specificity (95%) for the detection of any arrhythmia, and high sensitivity (89%) but low specificity (58%) for the detection of relapse. In conclusion, transtelephonic monitoring was a useful tool for the assessment of symptoms after RFA and its use may be reserved for the most symptomatic patients to detect a relapse or to reassure them for the benign nature of their symptoms.
Article
ECG telemonitoring is the application of single- or multichannel ECGs transmitted by telephone to the physician or an expert center. This enables the control of the health status despite the spatial separation of patient and physician. Cardiac arrhythmias, palpitations of unknown causes, the outcome of antiarrhythmic drug therapy or interventional ablation therapy can be diagnosed using ECG telemonitoring. Even asymptomatic arrhythmias, e.g. paroxysmal atrial fibrillation, may be detected. The use of a multichannel ECG facilitates the early prehospital diagnosis of an acute coronary syndrome and thus helps to optimize the chain of rescue. The telemonitoring of the ECG and additional physiological data enables the tele-care of patients with chronic heart failure. New types of implanted pacemaker or cardioverter/defibrillator devices allow telemonitoring of device data or ECG data for close control.
ECG telemonitoring].[in Ger
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  • J Neuzner
Oeff M, Muller A, Neuzner J et al. [ECG telemonitoring].[in Ger.] Herzschrittmacherther Elektrophysiol. 2008 Sep;19(3):137-45.
Integrating healthcare: The role and value of mobile operators in eHealth
  • K-L Foh
Foh K-L. Integrating healthcare: The role and value of mobile operators in eHealth. 2012. http://www.gsma.com/mobilefordevelopment/wpcontent/uploads/2012/05/Integrating-Healthcare-The-Role-and-Value-of-Mobile-Operators-in-eHealth.pdf (last accessed 12.05.2013)
New business models delivering care anywhere PricewaterHouseCoopers (PwC) report
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