Telehealth as a Component of One Health: a Position Paper.

INTRODUCTION: One Health (OH) refers to the integration of human, animal, and ecosystem health within one framework in the context of zoonoses, antimicrobial resistance and stewardship, and food security. Telehealth refers to distance delivery of healthcare. A systems approach is central to both One Health and telehealth, and telehealth can be a core component of One Health. Here we explain how telehealth might be integrated into One Health. METHODS: We have considered antimicrobial resistance (AMR) as a use case where both One Health and telehealth can be used for coordination among the farming sector, the veterinary services, and human health providers to mitigate the risk of AMR. We conducted a narrative review of the literature to develop a position on the inter-relationships between telehealth and One Health. We have summarised how telehealth can be incorporated within One Health. RESULTS: Clinicians have used telehealth to address antimicrobial resistance, zoonoses, food borne infection, improvement of food security and antimicrobial stewardship. We identified little existing evidence in support of the usage of telehealth within a One Health paradigm, although in isolation, both are useful for the same purpose, i.e., mitigation of the significant public health risks posed by zoonoses, food borne infections, and antimicrobial resistance. CONCLUSIONS: It is possible to integrate telehealth within a One Health framework to develop effective inter-sectoral communication essential for the mitigation and addressing of zoonoses, food security, food borne infection containment and antimicrobial stewardship. More research is needed to substantiate and investigate this model of healthcare.

Self-care intervention using mobile apps for sexual and reproductive health in the WHO Eastern Mediterranean Region.

Sexual and reproductive health (SRH) concerns physical, mental, and social well-being as related to sexual and reproductive systems. Self-care, which is the ability to promote health without the support of a health-care provider, can advance SRH, especially for fragile populations. Mobile health (mHealth) solutions can be used to raise awareness about SRH. We performed a structured literature review and analysis of mHealth-based approaches for delivering self-SRH services and interventions in the WHO Eastern Mediterranean Region (EMR). A fuzzy-based framework for assessing those mHealth apps was proposed. We identified 6 out of 737 papers, and 23 (5.7%) out of 400 mHealth apps retrieved from app-stores, describing mHealth use for self SRH with only 10 apps developed in EMR countries, namely Morocco, Pakistan, Egypt, Iran, and Jordan. Our fuzzy-based framework proposes guidelines regarding the implementation of self-care interventions to help project leaders promote their adoption in the SRH systems.

Recommendations of the International Medical Informatics Association (IMIA) on Education in Biomedical and Health Informatics: Second Revision.

BACKGROUND: The purpose of educational recommendations is to assist in establishing courses and programs in a discipline, to further develop existing educational activities in the various nations, and to support international initiatives for collaboration and sharing of courseware. The International Medical Informatics Association (IMIA) has published two versions of its international recommendations in biomedical and health informatics (BMHI) education, initially in 2000 and revised in 2010. Given the recent changes to the science, technology, the needs of the healthcare systems, and the workforce of BMHI, a revision of the recommendations is necessary. OBJECTIVE: The aim of these updated recommendations is to support educators in developing BMHI curricula at different education levels, to identify essential skills and competencies for certification of healthcare professionals and those working in the field of BMHI, to provide a tool for evaluators of academic BMHI programs to compare and accredit the quality of delivered programs, and to motivate universities, organizations, and health authorities to recognize the need for establishing and further developing BMHI educational programs. METHOD: An IMIA taskforce, established in 2017, updated the recommendations. The taskforce included representatives from all IMIA regions, with several having been involved in the development of the previous version. Workshops were held at different IMIA conferences, and an international Delphi study was performed to collect expert input on new and revised competencies. RESULTS: Recommendations are provided for courses/course tracks in BMHI as part of educational programs in biomedical and health sciences, health information management, and informatics/computer science, as well as for dedicated programs in BMHI (leading to bachelor's, master's, or doctoral degree). The educational needs are described for the roles of BMHI user, BMHI generalist, and BMHI specialist across six domain areas - BMHI core principles; health sciences and services; computer, data and information sciences; social and behavioral sciences; management science; and BMHI specialization. Furthermore, recommendations are provided for dedicated educational programs in BMHI at the level of bachelor's, master's, and doctoral degrees. These are the mainstream academic programs in BMHI. In addition, recommendations for continuing education, certification, and accreditation procedures are provided. CONCLUSION: The IMIA recommendations reflect societal changes related to globalization, digitalization, and digital transformation in general and in healthcare specifically, and center on educational needs for the healthcare workforce, computer scientists, and decision makers to acquire BMHI knowledge and skills at various levels. To support education in BMHI, IMIA offers accreditation of quality BMHI education programs. It supports information exchange on programs and courses in BMHI through its Working Group on Health and Medical Informatics Education.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis.

BACKGROUND: Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings. OBJECTIVE: This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies. METHODS: A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine "Google Scholar," and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games). RESULTS: From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003). CONCLUSIONS: Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969.

"Digital Health Diplomacy" in Global Digital Health? A call for critique and discourse.

Actualizing the vision of Global Digital Health is a central issue on the Global Health Diplomacy agenda. The COVID-reinforced need for accelerated digital health progress will require political structures and processes to build a foundation for Global Digital Health. Simultaneously, Global Health Diplomacy uses digital technologies in its enactment. Both phenomena have driven interest in the term "Digital Health Diplomacy." A review of the literature revealed 2 emerging but distinct definitions that have been published very recently, each with its associated discourse and practice. This multiplicity of ideas demonstrates the myriad ways in which global digital and political systems are becoming increasingly entangled. Untangling these, this paper proposes and discusses 3 dimensions of Digital Health Diplomacy: "Diplomacy for digital health," "Digital health for diplomacy," and "Digital health in diplomacy." It calls upon digital health professionals, diplomats, political and social scientists, epidemiologists, and clinicians to discuss, critique, and advance this emerging domain.

The impact of e-health system implementation on UNWRA health services: an observational study.

BACKGROUND: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary-health-care services to more than 5 million Palestinian refugees in five operational fields (Jordan, Syria, Lebanon, West Bank, and Gaza) through 144 health centres. UNRWA developed its electronic health records (e-Health) system to improve monitoring and facilitation of health services provided to Palestinian refugees. By the end of 2017, the system had been deployed in 129 health centres, included the health files of 3 million patients, and managed more than 8 million visits per year. We assessed whether preventive-health-care services had improved following implementation of the system. METHODS: This observational study used three key performance indicators to assess preventive-health-care services reported in UNRWA's annual reports in 2012-17: the percentage of targeted people aged 40 years and older screened for diabetes; the percentage of pregnant women with a livebirth who attended at least four antenatal visits; and the prevalence of growth problems (underweight, stunting, wasting, and overweight or obesity) in children younger than 5 years. Simple descriptive analysis was conducted with Microsoft Excel 2010. Ethical approval was obtained from the UNRWA Headquarters Department of Health. FINDINGS: Screening for diabetes significantly increased from 13% in 2012 to 21% in 2017 (p<0·0001) since the e-Health system started sending alerts to clerks at health centres. The percentage of pregnant women with a livebirth who attended at least four antenatal visits, increased from 87% in 2012 to 92% in 2017, when the e-Health System allowed health-care providers to log all pregnant women who missed their appointments to enable follow-up. Additionally, an electronic maternal and child health mobile application, sends regular reminders to mothers about appointments for themselves and their children. The percentages of underweight, stunting, wasting, and overweight or obesity among children younger than 5 years increased respectively from 3%, 4%, 2%, and 2% in 2014 to 5%, 7%, 4%, and 5% in 2017, but this was due to the increased detection of growth problems through the e-Health system. INTERPRETATION: The e-Health system improved detection and monitoring by UNRWA health-care providers and access to health services for Palestinian refugees in all three indicator categories. This study has several limitations. It is an observational study based on assessing health records of children rather than a prospective study over time. The focus of the study was to assess the impact of the eHealth system on health-care delivery and not to assess the changes in health-care delivery itself. The electronic health records that were reviewed are for the Palestine refugees who are registered at UNRWA health clinics and not for other refugees or residents of the five countries. Strengths of the study are that it is based on electronic health records which contain data recorded by the treating staff; the e-health system used by UNRWA clinics staff is centralised and the data are aggregated agency wide; and the growth monitoring indicators used by UNRWA were derived from the WHO Multi-center Growth Reference Study to assess the growth of children from birth up to age 5 years. FUNDING: None.

Digital Health during COVID-19: Informatics Dialogue with the World Health Organization.

BACKGROUND: On December 16, 2020 representatives of the International Medical Informatics Association (IMIA), a Non-Governmental Organization in official relations with the World Health Organization (WHO), along with its International Academy for Health Sciences Informatics (IAHSI), held an open dialogue with WHO Director General (WHO DG) Tedros Adhanom Ghebreyesus about the opportunities and challenges of digital health during the COVID-19 global pandemic. OBJECTIVES: The aim of this paper is to report the outcomes of the dialogue and discussions with more than 200 participants representing different civil society organizations (CSOs). METHODS: The dialogue was held in form of a webinar. After an initial address of the WHO DG, short presentations by the panelists, and live discussions between panelists, the WHO DG and WHO representatives took place. The audience was able to post questions in written. These written discussions were saved with participants' consent and summarized in this paper. RESULTS: The main themes that were brought up by the audience for discussion were: (a) opportunities and challenges in general; (b) ethics and artificial intelligence; (c) digital divide; (d) education. Proposed actions included the development of a roadmap based on the lessons learned from the COVID-19 pandemic. CONCLUSIONS: Decision making by policy makers needs to be evidence-based and health informatics research should be used to support decisions surrounding digital health, and we further propose next steps in the collaboration between IMIA and WHO such as future engagement in the World Health Assembly.

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response.

OBJECTIVES: Telehealth implementation is a complex systems-based endeavour. This paper compares telehealth responses to (COrona VIrus Disease 2019) COVID-19 across ten countries to identify lessons learned about the complexity of telehealth during critical response such as in response to a global pandemic. Our overall objective is to develop a health systems-based framework for telehealth implementation to support critical response. METHODS: We sought responses from the members of the International Medical Informatics Association (IMIA) Telehealth Working Group (WG) on their practices and perception of telehealth practices during the times of COVID-19 pandemic in their respective countries. We then analysed their responses to identify six emerging themes that we mapped to the World Health Organization (WHO) model of health systems. RESULTS: Our analysis identified six emergent themes. (1) Government, legal or regulatory aspects of telehealth; (2) Increase in telehealth capacity and delivery; (3) Regulated and unregulated telehealth; (4) Changes in the uptake and perception of telemedicine; (5) Public engagement in telehealth responses to COVID-19; and (6) Implications for training and education. We discuss these themes and then use them to develop a systems framework for telehealth support in critical response. CONCLUSION: COVID-19 has introduced new challenges for telehealth support in times of critical response. Our themes and systems framework extend the WHO systems model and highlight that telemedicine usage in response to the COVID-19 pandemic is complex and multidimensional. Our systems-based framework provides guidance for telehealth implementation as part of health systems response to a global pandemic such as COVID-19.

Ethics in Telehealth: Comparison between Guidelines and Practice-based Experience -the Case for Learning Health Systems.

OBJECTIVES: To understand ethical issues within the tele-health domain, specifically how well established macro level telehealth guidelines map with micro level practitioner perspectives. METHODS: We developed four overarching issues to use as a starting point for developing an ethical framework for telehealth. We then reviewed telemedicine ethics guidelines elaborated by the American Medical Association (AMA), the World Medical Association (WMA), and the telehealth component of the Health Professions council of South Africa (HPCSA). We then compared these guidelines with practitioner perspectives to identify the similarities and differences between them. Finally, we generated suggestions to bridge the gap between ethics guidelines and the micro level use of telehealth. RESULTS: Clear differences emerged between the ethics guidelines and the practitioner perspectives. The main reason for the differences were the different contexts where telehealth was used, for example, variability in international practice and variations in the complexity of patient-provider interactions. Overall, published guidelines largely focus on macro level issues related to technology and maintaining data security in patient-provider interactions while practitioner concern is focused on applying the guidelines to specific micro level contexts. CONCLUSIONS: Ethics guidelines on telehealth have a macro level focus in contrast to the micro level needs of practitioners. Work is needed to close this gap. We recommend that both telehealth practitioners and ethics guideline developers better understand healthcare systems and adopt a learning health system approach that draws upon different contexts of clinical practice, innovative models of care delivery, emergent data and evidence-based outcomes. This would help develop a clearer set of priorities and guidelines for the ethical conduct of telehealth.

Evidence-Based Health Informatics as the Foundation for the COVID-19 Response: A Joint Call for Action.

BACKGROUND: As a major public health crisis, the novel coronavirus disease 2019 (COVID-19) pandemic demonstrates the urgent need for safe, effective, and evidence-based implementations of digital health. The urgency stems from the frequent tendency to focus attention on seemingly high promising digital health interventions despite being poorly validated in times of crisis. AIM: In this paper, we describe a joint call for action to use and leverage evidence-based health informatics as the foundation for the COVID-19 response and public health interventions. Tangible examples are provided for how the working groups and special interest groups of the International Medical Informatics Association (IMIA) are helping to build an evidence-based response to this crisis. METHODS: Leaders of working and special interest groups of the IMIA, a total of 26 groups, were contacted via e-mail to provide a summary of the scientific-based efforts taken to combat COVID-19 pandemic and participate in the discussion toward the creation of this manuscript. A total of 13 groups participated in this manuscript. RESULTS: Various efforts were exerted by members of IMIA including (1) developing evidence-based guidelines for the design and deployment of digital health solutions during COVID-19; (2) surveying clinical informaticians internationally about key digital solutions deployed to combat COVID-19 and the challenges faced when implementing and using them; and (3) offering necessary resources for clinicians about the use of digital tools in clinical practice, education, and research during COVID-19. DISCUSSION: Rigor and evidence need to be taken into consideration when designing, implementing, and using digital tools to combat COVID-19 to avoid delays and unforeseen negative consequences. It is paramount to employ a multidisciplinary approach for the development and implementation of digital health tools that have been rapidly deployed in response to the pandemic bearing in mind human factors, ethics, data privacy, and the diversity of context at the local, national, and international levels. The training and capacity building of front-line workers is crucial and must be linked to a clear strategy for evaluation of ongoing experiences.

Discussion of "Representation of People's Decisions in Health Information Systems: A Complementary Approach for Understanding Health Care Systems and Population Health".

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Representation of People's Decisions in Health Information Systems: A Complementary Approach for Understanding Health Care Systems and Population Health" written by Fernan Gonzalez Bernaldo de Quiros, Adriana Ruth Dawidowski, and Silvana Figar. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the paper of de Quiros, Dawidowski, and Figar. In subsequent issues the discussion can continue through letters to the editor.

Development and Deployment of an e-Health System in UNRWA Healthcare Centers (HCs): The Experience and Evidence.

UNRWA recognized the need to develop and introduce eHealth programme based on needs assessment. The web-based e-Health application was developed and deployed in 116 out of 143 HCs in the five fields of operation. Evaluation of the application revealed positive outcomes in terms of reporting requirements, statistics, time saving, efficiency, drug compliance and workflow in general.

Discussion of "The New Role of Biomedical Informatics in the Age of Digital Medicine".

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "The New Role of Biomedical Informatics in the Age of Digital Medicine" written by Fernando J. Martin-Sanchez and Guillermo H. Lopez-Campos [1]. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the paper of Martin-Sanchez and Lopez-Campos. In subsequent issues the discussion can continue through letters to the editor.

Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction.

BACKGROUND: The world is short of 7.2 million health-care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource-limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students' satisfaction and attitudes towards eLearning. METHODS: We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health-related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students' knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach. FINDINGS: Forty-nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases. CONCLUSIONS: Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage.

Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction.

BACKGROUND: Health systems worldwide are facing shortages in health professional workforce. Several studies have demonstrated the direct correlation between the availability of health workers, coverage of health services, and population health outcomes. To address this shortage, online eLearning is increasingly being adopted in health professionals' education. To inform policy-making, in online eLearning, we need to determine its effectiveness. METHODS: We performed a systematic review of the effectiveness of online eLearning through a comprehensive search of the major databases for randomised controlled trials that compared online eLearning to traditional learning or alternative learning methods. The search period was from January 2000 to August 2013. We included articles which primarily focused on students' knowledge, skills, satisfaction and attitudes toward eLearning and cost-effectiveness and adverse effects as secondary outcomes. Two reviewers independently extracted data from the included studies. Due to significant heterogeneity among the included studies, we presented our results as a narrative synthesis. FINDINGS: Fifty-nine studies, including 6750 students enrolled in medicine, dentistry, nursing, physical therapy and pharmacy studies, met the inclusion criteria. Twelve of the 50 studies testing knowledge gains found significantly higher gains in the online eLearning intervention groups compared to traditional learning, whereas 27 did not detect significant differences or found mixed results. Eleven studies did not test for differences. Six studies detected significantly higher skill gains in the online eLearning intervention groups, whilst 3 other studies testing skill gains did not detect differences between groups and 1 study showed mixed results. Twelve studies tested students' attitudes, of which 8 studies showed no differences in attitudes or preferences for online eLearning. Students' satisfaction was measured in 29 studies, 4 studies showed higher satisfaction for online eLearning and 20 studies showed no difference in satisfaction between online eLearning and traditional learning. Risk of bias was high for several of the included studies. CONCLUSION: The current evidence base suggests that online eLearning is equivalent, possibly superior to traditional learning. These findings present a potential incentive for policy makers to cautiously encourage its adoption, while respecting the heterogeneity among the studies.

On the Internet of Things, smart cities and the WHO Healthy Cities.

This article gives a brief overview of the Internet of Things (IoT) for cities, offering examples of IoT-powered 21st century smart cities, including the experience of the Spanish city of Barcelona in implementing its own IoT-driven services to improve the quality of life of its people through measures that promote an eco-friendly, sustainable environment. The potential benefits as well as the challenges associated with IoT for cities are discussed. Much of the 'big data' that are continuously generated by IoT sensors, devices, systems and services are geo-tagged or geo-located. The importance of having robust, intelligent geospatial analytics systems in place to process and make sense of such data in real time cannot therefore be overestimated. The authors argue that IoT-powered smart cities stand better chances of becoming healthier cities. The World Health Organization (WHO) Healthy Cities Network and associated national networks have hundreds of member cities around the world that could benefit from, and harness the power of, IoT to improve the health and well-being of their local populations.