Fully digital self-screening for atrial fibrillation with patch electrocardiogram.

AIMS: Atrial fibrillation (AF) is the most common arrhythmia worldwide. The AF is associated with severe mortality, morbidity, and healthcare costs, and guidelines recommend screening people at risk. However, screening methods and organization still need to be clarified. The current study aimed to assess the feasibility of a fully digital self-screening procedure and to assess the prevalence of undetected AF using a continuous patch electrocardiogram (ECG) monitoring system. METHODS AND RESULTS: Individuals ≥65 years old with at least one additional risk factor for stroke from the general population of Norway were invited to a fully digital continuous self-screening for AF using a patch ECG device (ECG247 Smart Heart Sensor). Participants self-reported clinical characteristics and usability online, and all participants received digital feedback of their results. A total of 2118 individuals with a mean CHA2DS2-VASc risk score of 2.6 (0.9) were enrolled in the study [74% women; mean age 70.1 years (4.2)]. Of these, 1849 (87.3%) participants completed the ECG self-screening test, while 215 (10.2%) did not try to start the test and 54 (2.5%) failed to start the test. The system usability score was 84.5. The mean ECG monitoring time was 153 h (87). Atrial fibrillation was detected in 41 (2.2%) individuals. CONCLUSION: This fully digitalized self-screening procedure for AF demonstrated excellent feasibility. The number needed to screen was 45 to detect one unrecognized case of AF in subjects at risk for stroke. Randomized studies with long-term follow-up are needed to assess whether self-screening for AF can reduce the incidence of AF-related complications. CLINICAL TRIALS: NCT04700865.

The Evidence Base for an Ideal Care Pathway for Frail Multimorbid Elderly: Combined Scoping and Systematic Intervention Review.

BACKGROUND: There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored. OBJECTIVE: This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes. METHODS: We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects. RESULTS: Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects. CONCLUSIONS: Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

Critical issues for employees in inter-municipal health care services: a multiple case study.

BACKGROUND: Traditional, hierarchical government structures have recently been challenged by increased complexity, fragmented services and heavy public demand. When healthcare services become fragmented and decentralised, they require redesign. Inter-municipal cooperation is a strategy to deal with current challenges and future demographic changes. Few studies exist that can help us conceptualize challenges regarding employment in this context and inform managers in the involved municipalities. This study aims to identify critical issues for employees in inter-municipal health care services and to elaborate on how and why these issues are experienced. METHODS: A multiple qualitative case study was conducted with data from interviews, observation studies, a participant workshop and inter-municipal healthcare service project documents and reports. The study involved two districts in Norway and six cases including 17 informants. First, a within-case analysis was conducted for all cases; second, a cross-case analysis was conducted in each district to examine replication, contrasts and extension to emergent findings; and, eventually, replicated findings in Districts 1 and 2 were analysed across districts. RESULTS: Three critical issues were identified: support, differences, and geographical distances. Employees working in teams experienced fewer challenges than did those working as isolated individuals. CONCLUSIONS: Critical issues for employees represent an important aspect of inter-municipal cooperation, and additional research should be undertaken to inform future policy and practice.

Barriers to exchanging healthcare information in inter-municipal healthcare services: a qualitative case study.

BACKGROUND: In recent years, inter-municipal cooperation in healthcare services has been an important measure implemented to meet future demographic changes in western countries. This entails an increased focus on communication and information sharing across organisational borders. Technology enables efficient and effective solutions to enhance such cooperation. However, the systems in the healthcare sector tend not to communicate with one another. There is a lack of literature focusing on communication and information sharing in inter-municipal healthcare services. The aim of this article is to investigate both the characteristics of communication and information sharing, and the factors that serve as barriers to communication and information sharing for employees in inter-municipal healthcare services. METHODS: In this study, a qualitative case study approach is used to investigate both characteristics of communication and information sharing, and factors enabling barriers to communication and information sharing for employees in newly established inter-municipal healthcare services. Data collection methods were individual interviews, focus group interviews, observation studies and a workshop. A total of 18 persons participated in the study. The interviews, observations and workshop were conducted over a period of ten months. RESULTS: Communication and information sharing practices were found to be complex and characterised by multiple actors, information types and a combination of multiple actions. Findings indicate that 1. IT capability and usability 2. Differences 3. Privacy, confidentiality and security and 4. Awareness are all factors enabling barriers to communication and information sharing in inter-municipal healthcare services. Specifically, these barriers were related to lack of EHR usability, inadequate workflow processes, digital systems incompatibility, the understanding of needs in different systems and knowledge and practices regarding privacy and confidentiality. CONCLUSION: By focusing on the context of inter-municipal cooperation when assessing communication and information sharing in healthcare services, this article contributes to close a gap in existing knowledge. The perspective of the employees provides useful insight, and findings can be relevant for future theory development and for managers and policymakers in inter-municipal services.

Important challenges for coordination and inter-municipal cooperation in health care services: a Delphi study.

BACKGROUND: Demographical changes have stimulated a coordination reform in the Norwegian health care sector, creating new working practices and extending coordination within and between primary and hospital care, increasing the need for inter-municipal cooperation (IMC). This study aimed to identify challenges to coordination and IMC in the Norwegian health care sector as a basis for further theorizing and managerial advice in this growing area of research and practice. METHODS: A Delphi study of consensus development was used. Experts in coordination and IMC in health care services were selected by the healthcare manager or the councillor in their respective municipalities. In the first round, an expert panel received open-ended questions addressing possible challenges, and their answers were categorized and consolidated as the basis for further validation in the second round. The expert panel members were then asked to point out important statements in the third round, before the most important statements ranked by a majority of the members were rated again in the fourth round, including the option to explain the ratings. The same procedure was used in round five, with the exception that the expert panel members could view the consolidated results of their previous rankings as the basis for a new and final rating. The statements reaching consensus in round five were abstracted and themed. RESULTS: Nineteen experts consented to participate. Nine experts (47%) completed all of the five rounds. Eight statements concerning coordination reached consensus, resulting in four themes covering these challenges: different culture, uneven balance of power, lack of the possibility to communicate electronically, and demanding tasks in relation to resources. Three statements regarding challenges to IMC reached consensus, resulting in following themes: coopetition, complex leadership, and resistance to change. CONCLUSIONS: This study identified several important challenges for coordination and it supports previous research. IMC in health care services deals with challenges other than coordination, and these must be addressed specifically. Our study contributes to extended knowledge of theoretical and practical implications in the field of coordination and IMC in health care sector.

Remote ECG Monitoring by ECG247 Smart Heart Sensor.

BACKGROUND: Heart rhythm disorders are common and may be associated with serious complications. The quality of the ECG signal is crucial to detect and classify arrhythmias. Most available devices for assessment arrhythmias do not allow for remote monitoring. The Norwegian ECG247 Smart Heart Sensor is a new remote patch monitor developed to simplify the assessment of arrhythmias. This study was aimed at evaluating the quality of the ECG signal from the ECG247 Smart Heart Sensor compared to standard 12-lead ECG. METHODS: ECG recordings with ECG247 Smart Heart Sensor and a standard 12-lead ECG recorder were performed in 97 volunteers at Sorlandet Hospital, Arendal, Norway, in 2019. All ECGs were analysed by two independent cardiologists. RESULTS: A total of 97 participants (53% men, age 48 (±14) years) were included in the study. The ability for both systems to use recorded ECG data for arrhythmia detection was good (100%). The quality of the P-wave (mean score 1.1 vs. 1.5) and the QRS complex (mean score 1.0 vs. 1.0) from the ECG247 Smart Heart Sensor and that from the 12-lead ECG were comparable (scale: 1: extremely good, 9: not accepted). Noise artefacts were a minor issue in all recordings. CONCLUSIONS: The ECG quality from the ECG247 Smart Heart Sensor was comparable to the ECG quality from the standard 12-lead ECG. The ECG247 Smart Heart Sensor may enable easy and remote diagnostics of heart rhythm disorders. This trial is registered with NCT04700865.

Diagnostic Accuracy and Usability of the ECG247 Smart Heart Sensor Compared to Conventional Holter Technology.

Background: Heart rhythm disorders, especially atrial fibrillation (AF), are increasing global health challenges. Conventional diagnostic tools for assessment of rhythm disorders suffer from limited availability, limited test duration time, and usability challenges. There is also a need for out-of-hospital investigation of arrhythmias. Therefore, the Norwegian ECG247 Smart Heart Sensor has been developed to simplify the assessment of heart rhythm disorders. The current study aimed to evaluate the diagnostic accuracy and usability of the ECG247 Smart Heart Sensor compared to conventional Holter monitors. Methods: Parallel tests with ECG247 Smart Heart Sensor and a Holter monitor were performed in 151 consecutive patients referred for out-of-hospital long-term ECG recording at Sorlandet Hospital Arendal, Norway. All ECG data were automatically analysed by both systems and evaluated by hospital physicians. Participants were asked to complete a questionnaire scoring usability parameters after the test. Results: A total of 150 patients (62% men, age 54 (±17) years) completed the study. The ECG quality from both monitors was considered satisfactory for rhythm analysis in all patients. AF was identified in 9 (6%) patients during the period with parallel tests. The diagnostic accuracy for automatic AF detection was 95% (95% CI 91-98) for the ECG247 Smart Heart Sensor and 81% (95% CI 74-87) for the Holter system. The proportion of false-positive AF was 4% in tests analysed by the ECG247 algorithm and 16% in tests analysed by the Holter algorithm. Other arrhythmias were absent/rare. The system usability score was significantly better for ECG247 Smart Heart Sensor compared to traditional Holter technology (score 87.4 vs. 67.5, p < 0.001). Conclusions: The ECG247 Smart Heart Sensor showed at least comparable diagnostic accuracy for AF and improved usability compared to conventional Holter technology. ECG247 allows for prolonged monitoring and may improve detection of AF. This trial is registered with https://clinicaltrials.gov/ct2/show/NCT04700865.

An Evaluation of Telemedicine Systems in Patient-Centred Care Teams.

The research project 3P- Patients and Professionals in Productive Teams has studied different patient-centred teamwork models for patients with chronic conditions and multi-morbidities. This paper presents outcomes from a qualitative study on the information flow and technology use in patient-centred care teams utilizing telemedicine, located in three health regions of Norway and Denmark. The aim was to identity barriers for collaborative work and propose models for the e-solutions of the future. The study showed fragmentation in information storage with limited interoperability causing that several systems had to be used for telemedicine follow-up and there was limited teamwork support functionality.

How to Enhance Digital Support for Cross-Organisational Health Care Teams? A User-Based Explorative Study.

Health care service provision of individualised treatment to an ageing population prone to chronic conditions and multimorbidities is threatened. There is a need for digitally supported care, that is, (1) person-centred, (2) integrated, and (3) proactive. The research project 3P, Patients and Professionals in Productive Teams, aimed to validate and verify the prerequisites for health care systems run with patient-centred service models. This paper presents an explorative study of the digital support of a cross-organisational health care team in Norway, providing services to elderly frail people with multimorbidities in hospital discharge transition. Qualitative research methods were employed, with interviews and observations to map and evaluate the information flow and the digital support of collaborative work across organisations. The evaluation showed a lacking interoperability between the digital systems and a limited support for cross-organisational teamwork, causing raised manual efforts to maintain the information flow. Tools for coordination and planning across organisations were lacking. To enhance the situation, principles for a cloud-based health portal are proposed with a shared workspace, teamwork functionality for cross-organisational health care teams, and automatic back-end synchronisation of stored information. The main implications of this paper lie in the proposed principles which are transferable to a multitude of clinical contexts, where ad-hoc based access to shared medical information is of importance for decision-making and life-saving treatment.

Patient Experiences and Digital Involvement in Patient-Centred Care Models.

The provision of individualised treatment and care from health care services to patients with chronic conditions and multi-morbidities is under pressure because of an increasing elderly population. There is a need for services that are: 1) person-centred, 2) integrated and 3) proactive, and supported by digital technology. The research project 3P-Patients and Professionals in Productive Teams aims to study different patient-centred teamwork models in Norway and Denmark. This paper presents a study on patients' experiences and digital involvement in patient-centred care teams. Qualitative research methods were applied with interviews and demonstrations of technology use made at patient's homes. The results showed that the patients were satisfied with the patient-centred service models and had an increased feeling of safety. A constraint was information sharing between the patient-centred health care team and the patients. Most of them did not have access to read own medical information and mainly verbal information was shared between the patients and the health providers.

Evaluation of Technology Use in an Inter-Disciplinary Patient-Centered Health Care Team.

Health care services are facing challenges with carrying out individualised treatment to an ageing population prone to chronic conditions and multi-morbidities. The research project Patients and Professionals in Productive Teams aims to study different patient-centered teamwork service models. This paper presents an evaluation on the technology support in a patient-centered health care team providing services to elderly people with chronic conditions and multi-morbidities in the transition from hospital to a home setting. The team had employees both from a university hospital and municipal health services. Qualitative research methods were applied in the evaluation of the technology use and information flow. The results showed that two information systems were used, that were not integrated and caused double manual work and registrations by the health care professionals. A benefit was that information sharing was improved between the hospital and municipal health care services, but the constraint was added workload.

The EU project "United4Health": Results and experiences from automatic health status assessment in a Norwegian telemedicine trial system.

INTRODUCTION: Patients with chronic obstructive pulmonary disease require help in daily life situations to increase their individual perception of security, especially under worsened medical conditions. Unnecessary hospital (re-)admissions and home visits by doctors or nurses shall be avoided. This study evaluates the results from a two-year telemedicine field trial for automatic health status assessment based on remote monitoring and analysis of a long time series of vital signs data from patients at home over periods of weeks or months. METHODS: After discharge from hospital treatment for acute exacerbations, 94 patients were recruited for follow-up by the trial system. The system supported daily measurements of pulse and transdermal peripheral capillary oxygen saturation at patients' homes, a symptom-specific questionnaire, and provided nurses trained to use telemedicine ("telenurses") with an automatically generated health status overview of all monitored patients. A colour code (green/yellow/red) indicated whether the patient was stable or had a notable deterioration, while red alerts highlighted those in most urgent need of follow-up. The telenurses could manually overwrite the status level based on the patients' conditions observed through video consultation. RESULTS: Health status evaluation in 4970 telemonitor datasets were assessed retrospectively. The automatic health status determination (subgroup of 33 patients) showed green status at 46% of the days during a one-month monitoring period, 28% yellow status, and 19% red status (no data reported at 7% of the days). The telenurses manually downrated approximately 10% of the red or yellow alerts. DISCUSSION: The evaluation of the defined real-time health status assessment algorithms, which involve static rules with personally adapted elements, shows limitations to adapt long-term home monitoring with adequate interpretation of day-to-day changes in the patient's condition. Thus, due to the given sensitivity and specificity of such algorithms, it seems challenging to avoid false high alerts.

The Technology Use and Information Flow at a Municipal Telemedicine Service.

Health care services facechallenges with providing individualised treatment to an ageing population prone to chronic conditions and multi-morbidities. The research project Patients and Professionals in Productive Teams aims to study patient-centred teamworkservice models. This paper presents an evaluation of a telemedicine service for chronic obstructive pulmonary disease patients integrated with municipal health care services. Qualitative methods were used to study the technology use and information flow. The results showed that the telemedicine technology was a standalone system, not integrated with the electronic health record of the municipality. A benefit of the system was a function to provide the patient with written instructions on agreements and advices. As a constraint for the patient-centred team approach, the information in the telemedicine system was available only for the telemedicine nurses and not to other health care professionals.

Evaluation of a Telemedicine Service Run with a Patient-Centred Care Model.

The number of patients with chronic conditions and multi-morbidities is increasing, addressing a need for patient-centred care. The research project Patients and Professionals in Productive Teams aims to study patient-centred teamwork for this patient group. This paper presents an evaluation of a telemedicine service for chronic obstructive pulmonary disease patientsrun with a patient-centred care model. Observations and interviews were made to study the technology use and information flow. The results showed that the technology worked well in a patient-centred care perspective, even though the system was a standalone system for telemedicine services. The information in the system was only available for professionals providing the telemedicine services and was not shared with other health care providers.

Point of Care Solutions: Implementation of Sustainable Service Models.

Recent health reforms and strategies have urged Norwegian municipalities to re-organize their services to prepare for new ways of combining traditional home-based services with technology-assisted point of care interventions. This paper presents the outcomes from a qualitative study on modelling the municipal health care services for the future. The aim was to study the organisation and operation of point of care solutions and identify critical factors for how to model the services of the future.

User Evaluation of a Smartphone Application for Anticoagulation Therapy.

Anticoagulation therapy with Warfarin is used for specific cardiovascular diseases to control the ability of blood clotting. Traditional ways of self-management therapy are based on paper forms and procedures. This paper presents an evaluation of the smartphone application Warfarin Guide, a computer-assisted decision-support system used to help patients in their management of anticoagulation therapy related to International Normalized Ratio (INR) values. The evaluation consisted of a usability test with 4 participants and a field test with 14 participants who used the application at home during four months. A mixed methods research approach included quantitative and qualitative analysis of the test results. The results showed that participants evaluated the Warfarin Guide as 'useful' for self-management of anticoagulation therapy, reporting key issues for further improvement.

A Case Study of the Technology Use and Information Flow at a Hospital-Driven Telemedicine Service.

Health care services face the challenge of providing individualised treatment to a growing ageing population prone to chronic conditions and multi-morbidities. The research project Patients and Professionals in Productive Teams aims to study health care services that are run with a patient-centred teamwork approach. In this context, a case study was made of a hospital-driven telemedicine service for chronic obstructive pulmonary disease patients after hospital discharge, with a focus on information flow and technology use. The methods used were observation and interviews with key informants. The results showed that the technology was perceived as well-functioning for telemedicine support, but the technology used was a standalone system and not integrated with the electronic health record of the hospital. In addition, there was lack of support to provide the patients at home with written instructions on advices of medical treatment and care. The electronic information used for this telemedicine services, allowed shared access of information for teamwork between professional only within the hospital.

Warfarin Guide: Co-Design of a Mobile Computer-Assisted Anticoagulant Therapy.

Patients with some types of cardiovascular disease are prescribed anticoagulation therapy with Warfarin in order to control the ability of blood clotting. This work presents a co-designed mobile application, called Warfarin Guide, for a computer-assisted anticoagulant therapy. The application addresses the challenges that unexperienced patients may find when having to remember to regularly check their INR values and make temporary adjustments for INR value fluctuations that are not easy to interpret without direct medical advice.

Method for automatic escalation of access rights to the electronic health record.

In an emergency situation, it can be vital for rescuing personnel to have access to fragmented parts of patients Electronic Health Record (EHR) shared between patients and health care services. In such situations, can Spatial Role Based Access Control combined with measurements of vital sign parameters recorded from a wireless monitoring system used by the patient and patient's physiological situation be used to facilitate for medical personnel automatic access to parts of the EHR.

The EU-project United4Health: User-centred design of an information system for a Norwegian telemedicine service.

INTRODUCTION: Organizational changes of health care services in Norway brought to light a need for new clinical pathways. This study presents the design and evaluation of an information system for a new telemedicine service for chronic obstructive pulmonary disease patients after hospital discharge. METHODS: A user-centred design approach was employed composed of a workshop with end-users, two user tests and a field trial. For data collection, qualitative methods such as observations, semi-structured interviews and a questionnaire were used. RESULTS: User workshop's outcome informed the implementation of the system initial prototype, evaluated by end-users in a usability laboratory. Several usability and functionality issues were identified and solved, such as the interface between the initial colour scheme and the triage colours. Iterative refinements were made and a second user evaluation showed that the main issues were solved. The responses to a questionnaire presented a high score of user satisfaction. In the final phase, a field trial showed satisfactory use of the system. DISCUSSION: This study showed how the target end-users groups were actively involved in identifying the needs, suggestions and preferences. These aspects were addressed in the development of an information system through a user-centred design process. The process efficiently enabled users to give feedback about design and functionality. Continuous refinement of the system was the key to full development and suitability for the telemedicine service. This research was a result of the international cooperation between partners within the project United4Health, a part of the Seventh Framework Programme for Research of the European Union.