Engineering an EMR System in the Developing WorldNecessity is the Mother of Invention

While Electronic Medical Record (EMR) systems continue to improve the efficacy of healthcare delivery in the West, they have yet to be widely deployed in the developing world, where more than 90% of the global disease burden exists. The benefits afforded by an EMR notwithstanding, there is some skepticism regarding the feasibility of operationalizing an EMR system in a low-resource setting. This dissertation challenges these preconceptions and advances the understanding of the problems faced when implementing EMR systems to support healthcare delivery in a developing-world setting.Our methodology relies primarily on eight years of in-field experimentation and study. To facilitate a better understanding of the needs and challenges, we created a pilot system in a large government central hospital in Malawi, Africa. Learning from the pilot we developed and operationalized a point-of-care EMR system for managing the care and treatment of patients receiving antiretroviral therapy, which we put forth as a demonstration of feasibility in a developing-world setting.The pilot identified many unique challenges of healthcare delivery in the developing world, and reinforced the need to engineer solutions from scratch rather than blindly transplant systems developed in and for the West. Three novel technologies were developed over the course of our study, the most significant of which is the touchscreen clinical workstation appliance. Each of the novel technologies and their contribution towards successful implementation are described in the context of both an engineering and a risk management framework. A small comparative study to address data quality concerns associated with a point-of-care approach concluded that there was no significant difference in the accuracy of data collected through the use of a prototype point-of-care system compared to that of data entered retrospectively from paper records. We conclude by noting that while feasibility has been demonstrated the greatest challenge to sustainability is the lack of financial resources to monitor and support EMR systems once in place

Exploring the potential of using mobile applications in diabetes management

Background Diabetes mellitus is a common chronic disease and a leading cause of morbidity, complications and mortality worldwide. The number of people living with diabetes is projected to rise sharply over the forthcoming decades. Diabetes care is complex and can overburden clinicians and nurses. There is a need for innovative, flexible and cost-effective technologies to enable successful diabetes management. This thesis explores the opportunities and challenges of the mobile application (app) technology as a potential tool to support diabetes care and management. Purpose The purpose was to develop and evaluate a mobile app that supports healthcare professionals (HCPs) in clinical decision-making. Methods A mixed-methods approach was used following the user-centred design (UCD) framework for the design and implementation of all studies. Quantitative and qualitative systematic reviews of studies reporting the use of mobile apps to support diabetes management were undertaken to identify, appraise and summarise available research evidence. An interview study was carried out with diabetes specialist nurses (DSNs), to explore their experiences and views, and to identify user requirements for apps. Lastly, a guidelines-based mobile clinical decision-support app was developed and tested with junior doctors and DSNs in a controlled environment to evaluate its usability and impact on adherence to clinical guidelines, and to explore how participants experienced the app and their suggestions for improvements. Results Both reviews found that the existing evidence base for mobile apps is weak and inadequate to draw conclusions about the impact of their use as interventions in diabetes management. The interview study identified that nurses lack experience in using apps in clinical practice, even though they believed it could facilitate and support their work. ‘Diabetes & CKD’, a simple mobile decision-support app, has been designed and built for the study to assist HCPs in management of patients with diabetes and kidney disease and was tested by 39 junior doctors and 3 DSNs. It had no impact on the accuracy of decisions. Feedback from participants after the pilot session and usability testing indicated a wish to integrate such apps into their clinical practice with a strong willingness to use them in the future. Conclusions Application of UCD methods was efficient as the app was well-accepted by both DSNs and junior doctors. Despite the positive views and the strong willingness to use such apps, they are not widely used. There is a need to regulate the use of medical apps in clinical practice. Further research with rigorous methodology is required upon which policymakers and practitioners can base their decision-making

Young Female College Millennials\u27 Intent for Behavior Change with Wearable Fitness Technology

Among young college-aged females, overweight and obesity, type 2 diabetes, uncontrolled hypertension, and high stress levels have increased, causing overall worse health conditions than previous generations. The use of wearable fitness technology (WFT) by young adults assists in fitness and nutrition monitoring, provides feedback in health statistics, and has shown improvements in reducing health-related issues in young college females. A wide body of literature related to physical activity, nutrition, and health issues in young college females exists; however, the experiences and intent of WFT use for behavior change by young college female millennials has not been well researched. The purpose of this phenomenological study was to examine the lived experiences of young college females\u27 intent for behavior change with WFT. The health belief model was the theoretical framework used for this study. Ten college females, 18-25 years of age, attending colleges in northern West Virginia, who were collecting data from a WFT for a minimum of six months completed individual face-to-face interviews. Data were analyzed using phenomenological thematic analysis. Results from the study revealed young college females use WFT to increase physical activity, identify calorie intake and energy expenditure, and monitor heart rate, sleep, and stress to decrease and prevent health issues. These results can provide evidence for other researchers to address the current health inequalities in young college adults. Positive social change implications could include the value of WFT regarding the growing evidence of the importance of physical activity and nutrition by young female college students related to positive health outcomes and reducing health issues in this specific population

Managing healthcare transformation towards P5 medicine (Published in Frontiers in Medicine)

Health and social care systems around the world are facing radical organizational, methodological and technological paradigm changes to meet the requirements for improving quality and safety of care as well as efficiency and efficacy of care processes. In this they’re trying to manage the challenges of ongoing demographic changes towards aging, multi-diseased societies, development of human resources, a health and social services consumerism, medical and biomedical progress, and exploding costs for health-related R&D as well as health services delivery. Furthermore, they intend to achieve sustainability of global health systems by transforming them towards intelligent, adaptive and proactive systems focusing on health and wellness with optimized quality and safety outcomes. The outcome is a transformed health and wellness ecosystem combining the approaches of translational medicine, 5P medicine (personalized, preventive, predictive, participative precision medicine) and digital health towards ubiquitous personalized health services realized independent of time and location. It considers individual health status, conditions, genetic and genomic dispositions in personal social, occupational, environmental and behavioural context, thus turning health and social care from reactive to proactive. This requires the advancement communication and cooperation among the business actors from different domains (disciplines) with different methodologies, terminologies/ontologies, education, skills and experiences from data level (data sharing) to concept/knowledge level (knowledge sharing). The challenge here is the understanding and the formal as well as consistent representation of the world of sciences and practices, i.e. of multidisciplinary and dynamic systems in variable context, for enabling mapping between the different disciplines, methodologies, perspectives, intentions, languages, etc. Based on a framework for dynamically, use-case-specifically and context aware representing multi-domain ecosystems including their development process, systems, models and artefacts can be consistently represented, harmonized and integrated. The response to that problem is the formal representation of health and social care ecosystems through an system-oriented, architecture-centric, ontology-based and policy-driven model and framework, addressing all domains and development process views contributing to the system and context in question. Accordingly, this Research Topic would like to address this change towards 5P medicine. Specifically, areas of interest include, but are not limited: • A multidisciplinary approach to the transformation of health and social systems • Success factors for sustainable P5 ecosystems • AI and robotics in transformed health ecosystems • Transformed health ecosystems challenges for security, privacy and trust • Modelling digital health systems • Ethical challenges of personalized digital health • Knowledge representation and management of transformed health ecosystems Table of Contents: 04 Editorial: Managing healthcare transformation towards P5 medicine Bernd Blobel and Dipak Kalra 06 Transformation of Health and Social Care Systems—An Interdisciplinary Approach Toward a Foundational Architecture Bernd Blobel, Frank Oemig, Pekka Ruotsalainen and Diego M. Lopez 26 Transformed Health Ecosystems—Challenges for Security, Privacy, and Trust Pekka Ruotsalainen and Bernd Blobel 36 Success Factors for Scaling Up the Adoption of Digital Therapeutics Towards the Realization of P5 Medicine Alexandra Prodan, Lucas Deimel, Johannes Ahlqvist, Strahil Birov, Rainer Thiel, Meeri Toivanen, Zoi Kolitsi and Dipak Kalra 49 EU-Funded Telemedicine Projects – Assessment of, and Lessons Learned From, in the Light of the SARS-CoV-2 Pandemic Laura Paleari, Virginia Malini, Gabriella Paoli, Stefano Scillieri, Claudia Bighin, Bernd Blobel and Mauro Giacomini 60 A Review of Artificial Intelligence and Robotics in Transformed Health Ecosystems Kerstin Denecke and Claude R. Baudoin 73 Modeling digital health systems to foster interoperability Frank Oemig and Bernd Blobel 89 Challenges and solutions for transforming health ecosystems in low- and middle-income countries through artificial intelligence Diego M. López, Carolina Rico-Olarte, Bernd Blobel and Carol Hullin 111 Linguistic and ontological challenges of multiple domains contributing to transformed health ecosystems Markus Kreuzthaler, Mathias Brochhausen, Cilia Zayas, Bernd Blobel and Stefan Schulz 126 The ethical challenges of personalized digital health Els Maeckelberghe, Kinga Zdunek, Sara Marceglia, Bobbie Farsides and Michael Rigb

Efficacy and pharmacokinetics of intravenous paracetamol in the critically ill patient

Introduction: Paracetamol (PCM) is a drug with analgesic and antipyretic properties. Despite its frequent use, little is known about its efficacy and pharmacokinetics (PK) when intravenously administered in the critically ill patient. A previous study suggests that therapeutic concentrations are not always reached [1]. The primary aim of this open-label, multiple-dose study was to evaluate intravenous PCM therapy in critically ill, secondary aim was to study the PK of intravenous PCM. Methods: Ventilated patients needing PCM treatment according to our ICU protocol (1 g PCM intravenously four times daily) were eligible for inclusion. Excluded were those with severe liver failure and those treated with PCM on the time of admission to the ICU. Blood samples were collected at 0, 30, 60, 180 and 300 minutes after the first and, if possible, the fifth and 21st doses. A computerized model was used to estimate population PK. Results: Nineteen patients were included of which 13 were male, with a mean APACHE IV score of 94.8. No antipyretic effect could be measured in any of the patients. PK parameters have been calculated for all patients after the first PCM dose. The half-life was 2.2 hours, the volume of distribution was 1.03 l/kg, and the clearance was 0.33 l/kg/hour. Data from 15 patients could be analysed after the fifth dose and from five patients after the 21st dose. The PK of intravenous PCM in our population show a biphasic profile (Figure 1). One hour after the dose, the mean serum concentration level was below the therapeutic level. In 18 out of 19 patients serum concentration dropped below 5 mg/ml before the next dose, resulting in a lack of build-up of a suitable therapeutic level of PCM after multiple dosages. Conclusions: The recommended dose of 1 g intravenous PCM four times daily is not sufficient to achieve a therapeutic effect in critically ill patients. This can be explained by the low serum levels reached. These results warrant the development of an adequate dosing scheme for intravenous PCM followed by a large clinical trial studying the effects and safety of this regimen in critically ill patients