Quality Frameworks for Virtual Care: Expert Panel Recommendations.

Given the significant advance of virtual care in the past year and half, it seems timely to focus on quality frameworks and how they have evolved collaboratively across health care organizations. Massachusetts General Hospital's (MGH) Center for TeleHealth and Mass General Brigham's (MGB) Virtual Care Program are committed to hosting annual symposia on key topics related to virtual care. Subject matter experts across the country, health care organizations, and academic medical centers are invited to participate. The inaugural MGH/MGB Virtual Care Symposium, which focused on rethinking curriculum, competency, and culture in the virtual care era, was held on September 2, 2020. The second MGH/MGB Virtual Care Symposium was held on November 2, 2021, and focused on virtual care quality frameworks. Resultant topics were (1) guiding principles necessary for the future of virtual care measurement; (2) best practices deployed to measure quality of virtual care and how they compare and align with in-person frameworks; (3) evolution of quality frameworks over time; (4) how increased adoption of virtual care has impacted patient access and experience and how it has been measured; (5) the pitfalls and barriers which have been encountered by organizations in developing virtual care quality frameworks; and (6) examples of how quality frameworks have been applied in various use cases. Common elements of a quality framework for virtual care programs among symposium participants included improving the patient and provider experience, a focus on achieving health equity, monitoring success rates and uptime of the technical elements of virtual care, financial stewardship, and clinical outcomes. Virtual care represents an evolution in the access to care paradigm that helps keep health care aligned with other modern industries in digital technology and systems adoption. With advances in health care delivery models, it is vitally important that the quality measurement systems be adapted to include virtual care encounters. New methods may be necessary for asynchronous transactions, but synchronous virtual visits and consults can likely be accommodated in traditional quality frameworks with minimal adjustments. Ultimately, quality frameworks for health care will adapt to hybrid in-person and virtual care practices.

The Structure and Organizations of ICHD-3 Differential Diagnoses through DiffNet: A Pilot Study.

Differential diagnosis is fundamental to medicine. Using DiffNet, a differential diagnosis generator, as a model, we studied the structure and organization of how collections of diagnoses (i.e., sets of diagnoses) are related in the ICHD3. Furthermore, we explored the clinical and theoretical implication of these answers. METHODS: DiffNet is a freely distributed differential diagnosis generator for headaches using graph theoretical properties of ICHD3: (1) DiffNet considers each ICHD3 diagnosis as a node. (2) An edge exists between two ICHD3 diagnoses if they are connected by either classification hierarchy or are cross-referenced in ICHD3 comment section. In the current project, we generated a set of differential diagnoses using DiffNet for each ICHD3 diagnosis. We then determined algorithmically the set/subset relationship between these sets. We also determined the smallest list of ICHD3 diagnosis whose differential diagnoses would encompass the totality of ICHD3 diagnoses. RESULTS: All ICHD3 diagnoses can be represented by a minimum of 92 differential diagnosis sets. Differential diagnosis sets for 10 of the 14 first digit subcategories of ICHD3 are represented by more than one differential diagnosis sets. Fifty-one of the 93 differential diagnosis sets contain multiple subset relationships; the remaining 42 do not enter into any set/subset relationship with other differential diagnosis sets. Finally, we included a hierarchical presentation of differential diagnosis sets in ICHD3 according to DiffNet. CONCLUSION: We propose a way of interpreting headache differential diagnoses as partial ordered sets (i.e., poset). For clinicians, fluency in the 93 diagnoses and their differential, as put forth here, implies a complete description of ICHD3. On a theoretical level, interpreting ICHD3 differential diagnosis as poset allows for researchers to translate differential diagnoses sets topologically, algebraically, and categorically.

Can Physical Therapy Deliver Clinically Meaningful Improvements in Pain and Function Through a Mobile App? An Observational Retrospective Study.

Objective: To examine the effect of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions. Design: An observational, longitudinal, retrospective study using survey data collected pre- and postdigital PT to estimate multilevel models with random intercepts for patient episodes. Setting: Privately insured employees participating in app-based PT as an employer health care benefit. Participants: The study sample included 814 participants (N=814) 18 years or older who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9±11.89 years, 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees, and 13% for neck. Interventions: Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app. Main Outcome Measures: Pain was measured by the visual analog scale from 0 "no pain" to 10 "worst pain imaginable" and physical function by the Patient-Specific Functional Scale on a scale from 0 "completely unable to perform" to 10 "able to perform normally." Results: After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity, and severity, the results from multilevel random intercept models showed decreased pain (-2.69 points; 95% CI, -2.86 to -2.53; P<.001) and increased physical function (+2.67 points; 95% CI, 2.45-2.89; P<.001) after treatment. Conclusions: Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. These early data are an encouraging indicator of the clinical benefit of digital PT.

Mobile health and neurocognitive domains evaluation through smartphones: A meta-analysis.

BACKGROUND: Mobile health (mHealth) have significantly advanced evaluating neurocognitive functions; but, few reports have documented whether they validate neurocognitive impairments as well as paper-and-pencil neuropsychological tests. OBJECTIVE: To meta-analyze the correlation between mobile applications for neuropsychological tests and validated paper-and-pencil neuropsychological tests for evaluating neurocognitive impairments. METHOD: We used PubMed, Embase, Cochrane, Web of Science, and IEEE Explorer through January 2020 to identify studies that compared mobile applications for neuropsychological tests vs. paper-and-pencil neurophysiological tests. We used random-effects models via the DerSimonian and Laird method to extract pooled Pearson's correlation coefficients and we stratified by study design. RESULT: Nine out of 4639 screened articles (one RCT and eight prospective longitudinal case series) were included. For the observational studies, there was a statistically significant strong and direct correlation between mobile applications for neuropsychological test scores and validated paper-and-pencil neuropsychological assessment scores (r = 0.70; 95% CI 0.59, 0.79; I2 = 74.5%; p- heterogeneity <0.001). Stronger results were seen for the RCT (r = 0.92; 95% CI 0.77, 0.97). CONCLUSION: This meta-analysis showed a statistically significant correlation between mobile applications and the validated paper-and-pencil neuropsychological assessments analyzed for the evaluation of neurocognitive impairments.

Written exposure therapy and app-delivered mindfulness-based meditation for PTSD and subthreshold PTSD in China: Design of a randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) and subthreshold PTSD are still major global concerns, especially in developing areas short of mental health resources. Written exposure therapy (WET), a brief 5-session treatment, has been found to be effective in reducing PTSD symptoms, but no studies have examined it in an Eastern context. Mindfulness-based meditation mobile application may be a promising approach to reduce insomnia comorbid with PTSD. The current study aims to: 1) examine the effectiveness of WET for Chinese PTSD and subthreshold PTSD patients, and 2) examine the effectiveness of adding a mindfulness-based application (MBA) to WET for reducing comorbid insomnia. METHODS: The randomized controlled trial will enroll 150 adults with subthreshold/full PTSD and comorbid insomnia. Participants will be randomly assigned to written exposure therapy plus mindfulness-based application condition (WET + MBA, n = 50), written exposure therapy alone (WET, n = 50), or minimal contact control (MMC, n = 50). Clinical interview of the primary outcome (PTSD symptoms) will be administrated at baseline, posttreatment, 3- and 6- month follow-up, while self-reported PTSD symptoms and secondary outcomes (insomnia severity) will be administrated at baseline, every week and all follow-ups. DISCUSSION: This is the first study applying WET in Chinese PTSD patients, as well as examining a mindfulness-based mobile application as a treatment add-on for comorbid insomnia. Study findings will contribute to the knowledge of the effectiveness of WET and a mindfulness-based mobile application, and the development of a culture-adapted treatment protocol. TRIAL REGISTRATION: ChiCTR, ChiCTR2000034119. Registered 24 June 2020, http://www.chictr.org.cn/showproj.aspx?proj=55,467.

mHealth Intervention Applications for Adults Living With the Effects of Stroke: A Scoping Review.

OBJECTIVE: To conduct a scoping review of mobile health (mHealth) application (app) interventions to support needs of adults living with the effects of stroke reported in the literature. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were systematically searched for peer-reviewed publications. Articles were published between January 2007 and September 2020 and met predefined inclusion and exclusion criteria. STUDY SELECTION: Articles included were written in English language, involved adults older than 18 years, and described an mHealth app specifically tested and/or developed as an intervention for someone with stroke to be used remotely and/or independently without constant provider supervision or assistance. Articles were excluded if they focused on acute management of stroke only, focused on primary prevention, were animal studies, were not an app for smartphone or tablet, and did not describe an empirical study. DATA EXTRACTION: Two researchers independently screened titles and abstracts for inclusion. The full-text articles were then reviewed for eligibility by the research team. Data were extracted and verified by a third reviewer. DATA SYNTHESIS: The search yielded 2123 studies and 49 were included for data extraction. The findings reveal that a global surge of studies on mHealth apps for people with stroke have emerged within the past 2 years. Most studies were developed for persons with stroke in the United States and the primary content foci included upper extremity function (31.5%); lower extremity function (5.3%); general exercise, physical activity, and/or functional mobility (23.7%); trunk control (5.3%); medical management and secondary prevention (26.3%); language and speech skills (20.5%); cognitive skills (7.9%); general disability and activities of daily living (5.3%); and home safety (2.6%). Of the included studies, a majority were preliminary in nature, with 36.7% being categorized as pilot or feasibility trials and 24.4% discussing initial design, development, and/or refinement. CONCLUSIONS: Results from this study reveal that the number of apps specifically developed for people with stroke and described in the scientific literature are growing exponentially. The apps have widely varied content to meet the needs of persons with stroke; however, the studies are generally preliminary in nature, focusing on development, usability, and initial pilot testing. This review highlights the need for additional research and development of mHealth apps targeted for adults with stroke. Development should consider the various and complex needs of people living with the effects of chronic stroke, while large-scale trials are needed to build on the existing evidence.

Inpatient Virtual Vision Clinic Improves Access to Vision Rehabilitation Before and During the COVID-19 Pandemic.

OBJECTIVE: To describe and evaluate a secure video call system combined with a suite of iPad vision testing apps to improve access to vision rehabilitation assessment for inpatients. DESIGN: Retrospective. SETTING: Two acute care inpatient rehabilitation hospitals and 1 long-term acute care (LTAC) hospital. PARTICIPANTS: Records of inpatients seen by the vision service. INTERVENTIONS: Records from a 1-year telemedicine pilot performed at acute rehabilitation (AR) hospital 1 and then expanded to AR hospital 2 and LTAC hospital during coronavirus disease 2019 (COVID-19) were reviewed. In the virtual visits, an occupational therapist measured the patients' vision with the iPad applications and forwarded results to the off-site Doctor of Optometry (OD) for review prior to a video visit. The OD provided diagnosis and education, press-on prism application supervision, strategies and modifications, and follow-up recommendations. Providers completed the telehealth usability questionnaire (10-point scale). MAIN OUTCOME MEASURES: Vision examinations per month at AR hospital 1 before and with telemedicine. RESULTS: With telemedicine at AR hospital 1, mean visits per month significantly increased from 10.7±5 to 14.9±5 (P=.002). Prism was trialed in 40% of cases of which 83% were successful, similar to previously reported in-person success rates. COVID-19 caused only a marginal decrease in visits per month (P=.08) at AR1, whereas the site without an established program (AR hospital 2) had a 3-4 week gap in care while the program was initiated. Cases at the LTAC hospital tended to be more complex and difficult to manage virtually. The telehealth usability questionnaire median category scores were 7 for Ease of Use, 8 for Interface Quality, 6 for Reliability, and 9 for Satisfaction and Future Use. CONCLUSIONS: The virtual vision clinic process improved inpatient access to eye and visual neurorehabilitation assessment before and during the COVID-19 quarantine and was well accepted by providers and patients.

Validation of an algorithm for automated classification of migraine and tension-type headache attacks in an electronic headache diary.

BACKGROUND: This study evaluates the accuracy of an automated classification tool of single attacks of the two major primary headache disorders migraine and tension-type headache used in an electronic headache diary. METHODS: One hundred two randomly selected reported headache attacks from an electronic headache-diary of patients using the medical app M-sense were classified by both a neurologist with specialisation in headache medicine and an algorithm, constructed based on the ICHD-3 criteria for migraine and tension-type headache. The level of agreement between the headache specialist and the algorithm was compared by using a kappa statistic. Cases of disagreement were analysed in a disagreement validity assessment. RESULT: The neurologist and the algorithm classified migraines with aura (MA), migraines without aura (MO), tension-type headaches (TTH) and non-migraine or non-TTH events. Of the 102 headache reports, 86 cases were fully agreed on, and 16 cases not, making the level of agreement unweighted kappa 0.74 and representing a substantial level of agreement. Most cases of disagreement (12 out of 16) were due to inadvertent mistakes of the neurologist identified in the disagreement validity assessment. The second most common reason (3 out of 16) was insufficient information for classification by the neurologist. CONCLUSIONS: The substantial level of agreement indicates that the classification tool is a valuable instrument for automated evaluation of electronic headache diaries, which can thereby support the diagnostic and therapeutic clinical processes. Based on this study's results, additional diagnostic functionalities of primary headache management apps can be implemented. Finally, future research can use this classification algorithm for large scale database analysis for epidemiological studies.

Personalised nutrition: the role of new dietary assessment methods.

Food records or diaries, dietary recalls and FFQ are methods traditionally used to measure dietary intake; however, advancing technologies and growing awareness in personalised health have heightened interest in the application of new technologies to assess dietary intake. Dietary intake data can be used in epidemiology, dietary interventions and in the delivery of personalised nutrition advice. Compared with traditional dietary assessment methods, new technologies have many advantages, including their ability to automatically process data and provide personalised dietary feedback advice. This review examines the new technologies presently under development for the assessment of dietary intakes, and their utilisation and efficacy for personalising dietary advice. New technology-based methods of dietary assessment can broadly be categorised into three key areas: online (web-based) methods, mobile methods and sensor technologies. Several studies have demonstrated that utilising new technologies to provide tailored advice can result in positive dietary changes and have a significant impact on selected nutrient and food group intakes. However, comparison across studies indicates that the magnitude of change is variable and may be influenced by several factors, including the frequency and type of feedback provided. Future work should establish the most effective combinations of these factors in facilitating dietary changes across different population groups.