Telecare and self-management: a guideline for anticipating future care in scenario-based design

An important aim of telecare technologies for chronic patients is supporting self-management. Although patient involvement is crucial for successful implementation, any adaptation of telecare systems to needs of users requires explicit reflection regarding which form of self-management it should support. Scenario-based methods (SBDs) are proposed to involve users in the earlier phases of development. This paper aims to extend SBDs by incorporating explicit exploration of self-management forms. We first analyzed what self-management forms were inscribed in the design of a telecare system for COPD patients. These were mainly based on compliance to medical treatment. However, our study shows that many patients thrive better on self-management based on cooperation and concordance with healthcare professionals. To overcome this discrepancy between design and use practices we developed a guideline enabling designers to anticipate and reflect on which form of self-management is desirable to incorporate in the design of telecare technologies for chronic patients

eVisits in the digital era of Swedish primary care

Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,and subsequent care utilization in the digital era of primary care in Sweden.Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studiesevaluating the eVisit platform Flow in various clinical contexts.- Paper I was a comparative study of digital triage decisions when presented with automated patienthistory reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in apanel of five physicians was compared to triage decisions by a machine learning model trained usingdata labelled by an expert primary care physician.- Paper II was a qualitative focus group study of nurse and physician experiences of digitalcommunication at three primary health care centers using the platform. Themes were generated usingqualitative content analysis as described by Graneheim and Lundman.- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adultpatients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit controlgroup was recruited retrospectively using letters. Paper III primarily compared antibiotic prescriptionrates per sore throat visit, while paper IV primarily compared subsequent physical health careutilization within two weeks for patients in the Skåne Region.Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learningmodel. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium ofcommunication highlighting challenges in interpreting symptoms through text as well as alterations in practiceworkflow using asynchronous communication. Antibiotics prescription rate within three days was not higher aftereVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). Nosignificant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization ofphysical health care when assessing common infectious symptoms. Given staff experiencing uncertainties ininterpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of manymodalities to access primary care, with focus placed on facilitating patient-centered professional judgement bystaff, rather than automation of complex decisions

Examining the impact of a symptom assessment application on patient-physician interaction among self-referred walk-in patients in the emergency department (AKUSYM): study protocol for a multi-center, randomized controlled, parallel-group superiority trial

Background: Due to the increasing use of online health information, symptom checkers have been developed to provide an individualized assessment of health complaints and provide potential diagnoses and an urgency estimation. It is assumed that they support patient empowerment and have a positive impact on patient-physician interaction and satisfaction with care. Particularly in the emergency department (ED), symptom checkers could be integrated to bridge waiting times in the ED, and patients as well as physicians could take advantage of potential positive effects. Our study therefore aims to assess the impact of symptom assessment application (SAA) usage compared to no SAA usage on the patient-physician interaction in self-referred walk-in patients in the ED population. Methods: In this multi-center, 1:1 randomized, controlled, parallel-group superiority trial, 440 self-referred adult walk-in patients with a non-urgent triage category will be recruited in three EDs in Berlin. Eligible participants in the intervention group will use a SAA directly after initial triage. The control group receives standard care without using a SAA. The primary endpoint is patients’ satisfaction with the patient-physician interaction assessed by the Patient Satisfaction Questionnaire. Discussion: The results of this trial could influence the implementation of SAA into acute care to improve the satisfaction with the patient-physician interaction. Trial registration: German Clinical Trials Registry DRKS00028598. Registered on 25.03.2022

Appraisal of free online symptom checkers and applications for self-diagnosis and triage: An Australian evaluation

The internet has impacted society and changed the way companies and individuals operate on a daily basis. Seeking information online via computer or mobile device is common practice. The phrase ‘Google it’ is now part of modern vernacular and is a resource increasingly utilised by young and old alike. Around 80% of Australian’s search health-related information online as it is convenient, cheap, and available 24/7. Symptom checkers are one tool used by consumers to investigate their health issues. Symptom checkers are automated online programs which use computerised algorithms, asking a series of questions to help determine a potential diagnosis and/or provide suitable triage advice. Recent evidence suggests symptom checkers may not work the way they are intended. Inferior or incorrect healthcare information can potentially have serious consequences on the consumer’s wellbeing and may not have the desired effect of directing consumers to the appropriate point of care. This research evaluated the clinical performance of 36 symptom checkers found on websites and smartphone applications that are freely available for use by the Australian general public. Symptom checkers were exposed to 48 clinical vignettes, generating 1858 symptom checker vignette tests (SCVT). Diagnosis was assessed on the inclusion of the correct diagnosis in the first, the top three or top ten differential diagnoses (n = 1,170 SCVT). Triage advice was assessed on whether the triage category recommended was concordant with our assessment (n = 688 SCVT). The correct diagnosis was listed first in 36% (95% CI 31–42) of SCVT, within the top three in 52% (95% CI 47–59) and within the top ten in 58% (95% CI 53–65). Symptom checkers which claimed to utilise artificial intelligence (AI) outperformed non-AI with the first listed diagnosis being accurate in 46% (95% CI 40–57) versus 32% (95% CI 26–38) of SCVT. Individual symptom checker performance varied considerably, with the average rate of correct diagnosis provided first ranging between 12%–-61%. Triage advice provided was concordant with our assessment in 49% (95% CI 44–54) of SCVT. Appropriate triage advice was provided more frequently for emergency care SCVT at 63% (95% CI 52–71) than for non-urgent SCVT at 30% (95% CI 11–39). Symptom checker performance varied considerably in relation to diagnosis. Triage advice was risk-averse, typically recommending more urgent care pathways than necessary. Given this, symptom checkers may not be working to alleviate demand for health services (particularly emergency services) within Australia—counter to marketing materials of some organisations’ symptom checkers. It is important that symptom checkers do not further burden the healthcare system with inappropriate referrals or incorrect care advice. Although, a balance must be struck as avoiding unsuitable triage advice could potentially result in life-threatening consequences for consumers. Nonetheless, the results of this research make clear that the accuracy of diagnosis and triage advice provided from readily available symptom checkers for the Australian public require improvements before everyday consumers can rely entirely on health information provided via these mediums

Effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified: study protocol of a randomized controlled trial

Background: Disordered eating behavior and body dissatisfaction affect a large proportion of the Dutch population and account for severe psychological, physical and social morbidity. Yet, the threshold for seeking professional care is still high. In the Netherlands, only 7.5% of patients with bulimia nervosa and 33% of patients with anorexia nervosa are treated within the mental health care system. Easily accessible and low-threshold interventions, therefore, are needed urgently. The internet has great potential to offer such interventions. The aim of this study is to determine whether a web-based treatment program for patients with eating disorders can improve eating disorder psychopathology among female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified. Methods/design: This randomized controlled trial will compare the outcomes of an experimental treatment group to a waiting list control group. In the web-based treatment program, participants will communicate personally and asynchronously with their therapists exclusively via the internet. The first part of the program will focus on analyzing eating attitudes and behaviors. In the second part of the program participants will learn how to change their attitudes and behaviors. Participants assigned to the waiting list control group will receive no-reply email messages once every two weeks during the waiting period of 15 weeks, after which they can start the program. The primary outcome measure is an improvement in eating disorder psychopathology as determined by the Eating Disorder Examination Questionnaire. Secondary outcomes include improvements in body image, physical and mental health, body weight, self-esteem, quality of life, and social contacts. In addition, the participants’ motivation for treatment and their acceptability of the program and the therapeutic alliance will be measured. The study will follow the recommendations in the CONSORT statement relating to designing and reporting on RCTs. Discussion: This study protocol presents the design of a RCT for evaluating the effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified

Digital dermatology in general practice:Past, present and future

General practitioners (GPs) serve as gatekeepers for patients seeking specialized dermatology care and play a crucial role in triaging patients with skin lesions. To support GPs in diagnosing these (suspicious) skin lesions in general practice, they can seek the advice of a teledermatologist through digital dermatology services. This thesis aimed to contribute to understand the value of store-and-forward digital dermatology consultation in Dutch general practice. Furthermore, this thesis aimed to provide insights into experienced facilitators and barriers in the uptake of these digital dermatology services by GPs since its introduction in primary care. First, we investigated the status of two decades of teledermatology worldwide by performing a literature review (Part I). Second, we researched the impact and added value of performing store-and-forward teledermoscopy for GPs in Dutch GP practice (Part II). Finally, we developed and validated a quality feedback tool (SAF-TSUQ) to determine GPs’ perspectives about store-and-forward telemedicine services. We applied and extended this SAF-TSUQ to reveal the factors that facilitate or impede the successful implementation and use of teledermatology, teledermoscopy and dermatology home consultation services in Dutch GP practice (Part III). The evidence from this thesis showed that teledermatology and teledermoscopy are of added value for GPs. These services save cost and time compared to traditional dermatology care and support GPs in their referral decisions for benign and malignant skin lesions. Barriers hinder the full potential of digital dermatology services and addressing these sociotechnical challenges is crucial for enhancing and expanding these services in future general practices

Self-service kiosk-based anamnesis system for emergency departments

Dissertação de mestrado integrado em Engenharia InformáticaEmergency departments have a higher number of visits compared to other hospital de partments. Technology has played a crucial role in promoting improvements in hospital management and clinical performance. The number of visits to emergency departments has increased considerably, giving rise to crowding situations that cause several adverse effects. This situation negatively affects the provision of emergency services, impairs the quality of health care and increases the time patients wait for medical check-up. One of the leading causes contributing to the crowding is the high number of patients with low severity clinical condition. These are referred to as non-urgent or inappropriate patients, whose clinical situation should be taken care through self-care or primary health care. It is the responsibility of the institutions to analyse and quantify the possible causes of crowding to find the best solution to mitigate the adverse effects caused. It is believed that non-urgent patients can use the time spent in the waiting room more productively, namely by using a self-service kiosk to which they can provide valuable information to facilitate and accelerate the clinical processing. This work proposes a solution to be used in the waiting room of emergency departments, which aims to reduce the period of medical check-up. The solution uses a self-service kiosk for the patient to provide relevant clinical data that would otherwise have to be collected by the physician during the clinical observation process. In particular, the kiosk will collect vital signs, past medical history, main complaint and usual medication. This data will be processed and provided to the physician in a structured and uniform way before each medical check-up. The primary purpose of this solution is to reduce the period of patients’ medical check-up and thus improve the response capacity of the emergency departments with the same resources. During the Master’s work period, an Android application was implemented for patients to enter the clinical data mentioned above, and a Web application for physicians to access it. Additionally, a data warehouse was implemented to store the data in a consolidated way to discover hidden relationships and patterns in the data. The first moment of evaluation, undertaken in a non-hospital facility, shows positive acceptability by participants, with a large majority considering the system user-friendly. Due to the pandemic, it was impossible to perform the second planned evaluation moment in a real emergency environment.Os serviços de urgência apresentam um número de visitas superior em comparação com outros serviços presentes nas instituições hospitalares. A afluência aos serviços de urgências tem vindo a aumentar consideravelmente, dando origem a situações de lotação que provocam diversos efeitos negativos nas instituições hospitalares. No geral, este fenômeno afeta negativamente a prestação dos serviços de urgência, prejudica a qualidade dos cuidados de saúde e faz aumentar o tempo que os doentes aguardam pela observação clínica na sala de espera. Uma das principais causas apontadas para o surgimento da lotação é o elevado número de doentes com condição clínica de baixa gravidade. Estes são designados como doentes não-urgentes ou inapropriados, cuja condição clínica poderia ser resolvida, idealmente, com recurso ao auto-cuidado ou a cuidados de saúde primários. É da responsabilidade das instituições analisar e quantificar as possíveis causas de lotação, de forma a encontrar a melhor solução para atenuar os efeitos negativos provocados. Acredita-se que os doentes não-urgentes tenham a capacidade de utilizar o tempo na sala de espera de forma mais produtiva, através da utilização de um quiosque self-service. Neste sentido e aliada à tecnologia, esta dissertação contextualiza uma solução para ser utilizada na sala de espera dos serviços de urgência, visando reduzir o período de observação clínico. Esta solução vem complementar a realização do procedimento inicial efetuado pelo médico, no consultório, através do uso de um quiosque. Assim, a recolha dos sinais vitais, história médica prévia, queixa principal e medicação habitual será efetuada pelos doentes no quiosque. Estes dados vão ser fornecidos de forma estruturada e organizada ao médico antes da realização da consulta. O objetivo principal desta solução é reduzir o período de observação clínico e assim melhorar a capacidade de resposta dos serviços de urgência com os mesmos recursos hospitalares. Durante o período da dissertação, foi implementada uma aplicação Android para os pacientes registarem os dados clínicos acima mencionados, e uma aplicação Web para os médicos acederem aos mesmos. Foi implementado também um data warehouse para a descoberta de relações e padrões escondidos nos dados. O primeiro momento de avaliação, realizado num ambiente não hospitalar, mostrou uma aceitabilidade positiva pelos partici pantes, com grande maioria a considerar o sistema user-friendly. Devido à pandemia, não foi possível realizar o segundo momento de avaliação planeado num serviço de urgências

Web-Based Cognitive Behavioral Therapy for Female Patients With Eating Disorders: Randomized Controlled Trial

Background: Many patients with eating disorders do not receive help for their symptoms, even though these disorders have severe morbidity. The Internet may offer alternative low-threshold treatment interventions.\ud \ud Objective: This study evaluated the effects of a Web-based cognitive behavioral therapy (CBT) intervention using intensive asynchronous therapeutic support to improve eating disorder psychopathology, and to reduce body dissatisfaction and related health problems among patients with eating disorders.\ud \ud Methods: A two-arm open randomized controlled trial comparing a Web-based CBT intervention to a waiting list control condition (WL) was carried out among female patients with bulimia nervosa (BN), binge eating disorder (BED), and eating disorders not otherwise specified (EDNOS). The eating disorder diagnosis was in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and was established based on participants’ self-report. Participants were recruited from an open-access website, and the intervention consisted of a structured two-part program within a secure Web-based application. The aim of the first part was to analyze participant’s eating attitudes and behaviors, while the second part focused on behavioral change. Participants had asynchronous contact with a personal therapist twice a week, solely via the Internet. Self-report measures of eating disorder psychopathology (primary outcome), body dissatisfaction, physical health, mental health, self-esteem, quality of life, and social functioning were completed at baseline and posttest.\ud \ud Results: A total of 214 participants were randomized to either the Web-based CBT group (n=108) or to the WL group (n=106) stratified by type of eating disorder (BN: n=44; BED: n=85; EDNOS: n=85). Study attrition was low with 94% of the participants completing the posttest assignment. Overall, Web-based CBT showed a significant improvement over time for eating disorder psychopathology (F97=63.07, P<.001, d=.82) and all secondary outcome measures (effect sizes between d=.34 to d=.49), except for Body Mass Index. WL participants also improved on most outcomes; however, effects were smaller in this group with significant between-group effects for eating disorder psychopathology (F201=9.42, P=.002, d=.44), body dissatisfaction (F201=13.16, P<.001, d=.42), physical health (F200=12.55, P<.001, d=.28), mental health (F203=4.88, P=.028, d=.24), self-esteem (F202=5.06, P=.026, d=.20), and social functioning (F205=7.93, P=.005, d=.29). Analyses for the individual subgroups BN, BED, and EDNOS showed that eating disorder psychopathology improved significantly over time among Web-based CBT participants in all three subgroups; however, the between-group effect was significant only for participants with BED (F78=4.25, P=.043, d=.61).\ud \ud Conclusions: Web-based CBT proved to be effective in improving eating disorder psychopathology and related health among female patients with eating disorder

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Objective The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis. Methods We have conducted a rapid framework-based evidence synthesis approach. Five separate reviews were conducted linked to themes in the NHS England review. A general and five theme specific database searches were conducted for the years 1995-2014. Relevant systematic reviews and additional primary research papers were included with narrative assessment of evidence quality was conducted for each review. Results The review was completed in six months. In total 45 systematic reviews and 102 primary research studies have been included across all 5 reviews. The key findings for each reviews were 1) Demand - there is little empirical evidence to explain increases in demand for urgent care, 2) Telephone triage - Overall, these services provide , appropriate and safe decision making with high patient satisfaction but required clinical skill mix and effectiveness in a system is unclear , 3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital. 4)ED – The evidence on co-location of GP services with ED indicates there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed. 5) There is no empirical evidence to support the design and development of urgent care networks. Limitations Although there is a large body of evidence on relevant interventions much of it is weak with only very small numbers of randomised controlled trials identified. Evidence is dominated by single site studies many of which were uncontrolled. Conclusions The evidence gaps of most relevance to the delivery of services are 1) more detailed understanding and mapping of the characteristics of demand to inform service planning, 2) assessment of the current state of urgent care network development and evaluation of effectiveness of different models, and 3) Expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning