Strengthening primary health care in Europe with digital solutions.

This article provides an in-depth analysis of digital transformation in European primary healthcare (PHC). It assesses the impact of digital technology on healthcare delivery and management, highlighting variations in digital maturity across Europe. It emphasizes the significance of digital tools, especially during the COVID-19 pandemic, in enhancing accessibility and efficiency in healthcare. It discusses the integration of telehealth, remote monitoring, and e-health solutions, showcasing their role in patient empowerment and proactive care. Examples are included from various countries, such as Greece's ePrescription system, Lithuania's adoption of remote consultations, Spain's use of risk stratification solutions, and the Netherlands' advanced use of telemonitoring solutions, to illustrate the diverse implementation of digital solutions in PHC. The article offers insights into the challenges and opportunities of embedding digital technologies into a multidisciplinary healthcare framework, pointing towards future directions for PHC in Europe.

Superusers' Engagement in Asthma Online Communities: Asynchronous Web-Based Interview Study.

BACKGROUND: Superusers, defined as the 1% of users who write a large number of posts, play critical roles in online health communities (OHCs), catalyzing engagement and influencing other users' self-care. Their unique online behavior is key to sustaining activity in OHCs and making them flourish. Our previous work showed the presence of 20 to 30 superusers active on a weekly basis among 3345 users in the nationwide Asthma UK OHC and that the community would disintegrate if superusers were removed. Recruiting these highly skilled individuals for research purposes can be challenging, and little is known about superusers. OBJECTIVE: This study aimed to explore superusers' motivation to actively engage in OHCs, the difficulties they may face, and their interactions with health care professionals (HCPs). METHODS: An asynchronous web-based structured interview study was conducted. Superusers of the Asthma UK OHC and Facebook groups were recruited through Asthma UK staff to pilot and subsequently complete the questionnaire. Open-ended questions were analyzed using content analysis. RESULTS: There were 17 superusers recruited for the study (14 patients with asthma and 3 carers); the majority were female (15/17). The age range of participants was 18 to 75 years. They were active in OHCs for 1 to 6 years and spent between 1 and 20 hours per week reading and 1 and 3 hours per week writing posts. Superusers' participation in OHCs was prompted by curiosity about asthma and its medical treatment and by the availability of spare time when they were off work due to asthma exacerbations or retired. Their engagement increased over time as participants furthered their familiarity with the OHCs and their knowledge of asthma and its self-management. Financial or social recognition of the superuser role was not important; their reward came from helping and interacting with others. According to the replies provided, they showed careful judgment to distinguish what can be dealt with through peer advice and what needs input from HCPs. Difficulties were encountered when dealing with misunderstandings about asthma and its treatment, patients not seeking advice from HCPs when needed, and miracle cures or dangerous ideas. Out of 17 participants, only 3 stated that their HCPs were aware of their engagement with OHCs. All superusers thought that HCPs should direct patients to OHCs, provided they are trusted and moderated. In addition, 9 users felt that HCPs themselves should take part in OHCs. CONCLUSIONS: Superusers from a UK-wide online community are highly motivated, altruistic, and mostly female individuals who exhibit judgment about the complexity of coping with asthma and the limits of their advice. Engagement with OHCs satisfies their psychosocial needs. Future research should explore how to address their unmet needs, their interactions with HCPs, and the potential integration of OHCs in traditional healthcare.

Considering patient safety in autonomous e-mental health systems - detecting risk situations and referring patients back to human care.

BACKGROUND: Digital health interventions can fill gaps in mental healthcare provision. However, autonomous e-mental health (AEMH) systems also present challenges for effective risk management. To balance autonomy and safety, AEMH systems need to detect risk situations and act on these appropriately. One option is sending automatic alerts to carers, but such 'auto-referral' could lead to missed cases or false alerts. Requiring users to actively self-refer offers an alternative, but this can also be risky as it relies on their motivation to do so. This study set out with two objectives. Firstly, to develop guidelines for risk detection and auto-referral systems. Secondly, to understand how persuasive techniques, mediated by a virtual agent, can facilitate self-referral. METHODS: In a formative phase, interviews with experts, alongside a literature review, were used to develop a risk detection protocol. Two referral protocols were developed - one involving auto-referral, the other motivating users to self-refer. This latter was tested via crowd-sourcing (n = 160). Participants were asked to imagine they had sleeping problems with differing severity and user stance on seeking help. They then chatted with a virtual agent, who either directly facilitated referral, tried to persuade the user, or accepted that they did not want help. After the conversation, participants rated their intention to self-refer, to chat with the agent again, and their feeling of being heard by the agent. RESULTS: Whether the virtual agent facilitated, persuaded or accepted, influenced all of these measures. Users who were initially negative or doubtful about self-referral could be persuaded. For users who were initially positive about seeking human care, this persuasion did not affect their intentions, indicating that a simply facilitating referral without persuasion was sufficient. CONCLUSION: This paper presents a protocol that elucidates the steps and decisions involved in risk detection, something that is relevant for all types of AEMH systems. In the case of self-referral, our study shows that a virtual agent can increase users' intention to self-refer. Moreover, the strategy of the agent influenced the intentions of the user afterwards. This highlights the importance of a personalised approach to promote the user's access to appropriate care.

#Deathbedlive: the end-of-life trajectory, reflected in a cancer patient's tweets.

BACKGROUND: Understanding physical and psycho-social illness trajectories towards the end of life can help in the planning of palliative and supportive care. With terminal patients increasingly seeking and sharing health information and support via social media, it is timely to examine whether these trajectories are reflected in their digital narratives. In this exploratory study, we analysed the Twitter feed of prominent cancer sufferer and physician, Kate Granger, over the final 6 months of her life. METHODS: With the consent of Kate's widower, Chris Pointon, 1628 Twitter posts from @GrangerKate were manually screened. The 550 tweets judged relevant to her disease were qualitatively content analysed with reference to the six modifiable dimensions of the patient experience in Emanuel and Emanuel's 'framework for a good death'. The frequency of each tweet category was charted over time and textual content was examined and cross-referenced with key events, to obtain a deeper understanding of its nature and significance. RESULTS: Tweets were associated with physical symptoms (N = 270), psychological and cognitive symptoms (N = 213), social relationships and support (N = 85), economic demands and care giving needs (N = 85), hopes and expectations (N = 51) and spiritual beliefs (N = 7). While medical treatments and procedures were discussed in detail, medical information-seeking was largely absent, likely reflecting Kate clinical expertise. Spirituality was expressed more as hope in treatments or "someone out there listening", than in religious terms. The high value of Kate's palliative care team was a dominant theme in the support category, alongside the support she received from her online community of fellow sufferers, friends, family and colleagues. Significant events, such as medical procedures and hospital stays generated the densest Twitter engagement. Transitions between trajectory phases were marked by changes in the relative frequency of tweet-types. CONCLUSIONS: In Kate's words, "the power of patient narrative cannot be underestimated". While this analysis spanned only 6 months, it yielded rich insights. The results reflect theorised end-of-life dimensions and reveal the potential of social media data and digital bio-ethnography to shine a light on terminal patients' lived experiences, coping strategies and support needs, suggesting new opportunities for enhancing personalised palliative care and avenues for further research.

Public responses to the sharing and linkage of health data for research purposes: a systematic review and thematic synthesis of qualitative studies.

BACKGROUND: The past 10 years have witnessed a significant growth in sharing of health data for secondary uses. Alongside this there has been growing interest in the public acceptability of data sharing and data linkage practices. Public acceptance is recognised as crucial for ensuring the legitimacy of current practices and systems of governance. Given the growing international interest in this area this systematic review and thematic synthesis represents a timely review of current evidence. It highlights the key factors influencing public responses as well as important areas for further research. METHODS: This paper reports a systematic review and thematic synthesis of qualitative studies examining public attitudes towards the sharing or linkage of health data for research purposes. Twenty-five studies were included in the review. The included studies were conducted primarily in the UK and North America, with one study set in Japan, another in Sweden and one in multiple countries. The included studies were conducted between 1999 and 2013 (eight studies selected for inclusion did not report data collection dates). The qualitative methods represented in the studies included focus groups, interviews, deliberative events, dialogue workshops and asynchronous online interviews. RESULTS: Key themes identified across the corpus of studies related to the conditions necessary for public support/acceptability, areas of public concern and implications for future research. The results identify a growing body of evidence pointing towards widespread general-though conditional-support for data linkage and data sharing for research purposes. Whilst a variety of concerns were raised (e.g. relating to confidentiality, individuals' control over their data, uses and abuses of data and potential harms arising) in cases where participants perceived there to be actual or potential public benefits from research and had trust in the individuals or organisations conducting and/or overseeing data linkage/sharing, they were generally supportive. The studies also find current low levels of awareness about existing practices and uses of data. CONCLUSIONS: Whilst the results indicate widespread (conditional) public support for data sharing and linkage for research purposes, a range of concerns exist. In order to ensure public support for future research uses of data greater awareness raising combined with opportunities for public engagement and deliberation are needed. This will be essential for ensuring the legitimacy of future health informatics research and avoiding further public controversy.

Understanding key factors affecting electronic medical record implementation: a sociotechnical approach.

BACKGROUND: Recent health care policies have supported the adoption of Information and Communication Technologies (ICT) but examples of failed ICT projects in this sector have highlighted the need for a greater understanding of the processes used to implement such innovations in complex organizations. This study examined the interaction of sociological and technological factors in the implementation of an Electronic Medical Record (EMR) system by a major national hospital. It aimed to obtain insights for managers planning such projects in the future and to examine the usefulness of Actor Network Theory (ANT) as a research tool in this context. METHODS: Case study using documentary analysis, interviews and observations. Qualitative thematic analysis drawing on ANT. RESULTS: Qualitative analyses revealed a complex network of interactions between organizational stakeholders and technology that helped to shape the system and influence its acceptance and adoption. The EMR clearly emerged as a central 'actor' within this network. The results illustrate how important it is to plan innovative and complex information systems with reference to (i) the expressed needs and involvement of different actors, starting from the initial introductory phase; (ii) promoting commitment to the system and adopting a participative approach; (iii) defining and resourcing new roles within the organization capable of supporting and sustaining the change and (iv) assessing system impacts in order to mobilize the network around a common goal. CONCLUSIONS: The paper highlights the organizational, cultural, technological, and financial considerations that should be taken into account when planning strategies for the implementation of EMR systems in hospital settings. It also demonstrates how ANT may be usefully deployed in evaluating such projects.

Open access publishing - noble intention, flawed reality.

For two decades, the international scholarly publishing community has been embroiled in a divisive debate about the best model for funding the dissemination of scientific research. Some may assume that this debate has been thoroughly resolved in favour of the Open Access (OA) model of scientific publishing. Recent commentaries reveal a less settled reality. This narrative review aims to lay out the nature of these deep divisions among the sector's stakeholders, reflects on their systemic drivers and considers the future prospects for actualising OA's intended benefits and surmounting its risks and costs. In the process, we highlight some of inequities OA presents for junior or unfunded researchers, and academics from resource-poor environments, for whom an increasing body of evidence shows clear evidence of discrimination and injustice caused by Article Processing Charges. The authors are university-appointed researchers working the UK and South Africa, trained in disciplines ranging from medicine and epidemiology to social science and digital science. We have no vested interest in any particular model of scientific publication, and no conflicts of interest to declare. We believe the issues we identify are pertinent to almost all research disciplines.

A Digital Health Intervention for Concussion: Development and Clinical Feasibility Study.

BACKGROUND: Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery. OBJECTIVE: This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach. METHODS: This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it. RESULTS: Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement. CONCLUSIONS: Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories. TRIAL REGISTRATION: ClinicalTrials.gov NCT05069948; https://clinicaltrials.gov/ct2/show/NCT05069948.

Continuity, but at what cost? The impact of telemonitoring COPD on continuities of care: a qualitative study.

BACKGROUND: Continuity of care is widely regarded as an important marker of quality in the management of patients with long-term conditions. New services that integrate telemonitoring into care pathways have potential to change aspects of continuity in both positive and negative ways. AIMS: A telemonitoring service for patients with chronic obstructive pulmonary disease (COPD) was introduced in Lothian, Scotland, in 2009. A qualitative study, nested within the TELESCOT COPD randomised control trial, was undertaken to explore the views of patients and professionals on telemonitoring. The perceived impact of telemonitoring on continuity of care was investigated as part of the research. METHODS: Semi-structured interviews were undertaken with 38 patients (47% male, mean age 67.5 years). A maximum variation sample in relation to age, sex, socio-economic background, disease severity, and compliance with telemonitoring was recruited. Thirty-two stakeholders (healthcare professionals and managers) were interviewed. Transcribed coded data were analysed thematically using the framework approach. Interpretation was supported by multidisciplinary discussion. RESULTS: Patients and healthcare professionals considered that relationship-based continuity of care was important in the delivery of telemonitoring services. Managers placed emphasis on improved continuity of clinical management as a means of reducing healthcare costs. However, professionals described many operational challenges arising from the 'bolting-on' of telemonitoring provision to existing usual care provision which, they considered, resulted in the proliferation of additional managerial discontinuities. CONCLUSIONS: Managers and healthcare professionals face major challenges in meeting demands for both relationship continuity and continuity of clinical management in the development of telemonitoring services.

Piloting tele-monitoring in COPD: a mixed methods exploration of issues in design and implementation.

BACKGROUND: In 2008 NHS Lothian implemented a COPD tele-monitoring service incorporating a touch-screen computer for daily recording of symptoms and weekly oximetry and spirometry measurement. Data were transmitted by secure broadband link to a call centre where trained workers monitored data and contacted clinicians according to an agreed algorithm. AIMS: To explore the perceptions of patients and professionals about the pilot implementation of the COPD tele-monitoring service. METHODS: In-depth interviews were undertaken with patients and professionals before and after installation of the tele-monitoring equipment. Interviews were recorded, transcribed and thematically analysed. Data on use of healthcare resources were obtained from primary care records. RESULTS: Twenty of the 27 patients in the pilot and 25 professionals participated. (n=55 interviews and one focus group). Patients were generally positive about the technology, which they perceived enabled earlier recognition of exacerbations and facilitated access to clinical advice. In contrast, clinicians had concerns about false positive symptom scores, difficulties in interpreting physiological data, overtreatment (reflected in a large increase in antibiotics and steroid prescribing), and an increased workload. CONCLUSIONS: Tele-monitoring was perceived by patients as improving access to professional care, but raised concerns for clinicians about possible over-treatment and how best to organise services to support the technology.

Psychosocial implications of avatar use in supporting therapy for depression.

Help4Mood is a novel intervention to support the treatment of depressive disorder using an embodied communicative agent (Avatar) to engage the user with therapy tasks. We conducted 10 focus groups with patients and mental health professionals, in the UK, Spain and Romania, in order to explore issues around usability and contextual fit. Emergent themes related to the design and use of Avatars indicated the value of configurability for optimising personalisation and perceived trustworthiness; the importance of supplementing rather than replacing face-to-face interaction, and perceptions of the agent as therapeutic ally or supportive friend. The use of Avatars in psychotherapy is relatively new and its acceptability, value and risks are unknown. These results indicate that users wish to engage with Avatars that meet their personal preferences and fit appropriate role expectations. The perception of Avatar as colleague or friend raises conceptual and ethical issues which merit further research.

Exploring the Equity Impact of Current Digital Health Design Practices: Protocol for a Scoping Review.

BACKGROUND: The field of digital health has grown rapidly in part due to digital health tools' potential to reduce health inequities. However, such potential has not always been realized. The design approaches used in digital health are one of the known aspects that have an impact on health equity. OBJECTIVE: The aim of our scoping review will be to understand how design approaches in digital health have an impact on health equity. METHODS: A scoping review of studies that describe how design practices for digital health have an impact on health equity will be carried out. The scoping review will follow the methodologies laid out by Arksey and O'Malley, the Joanna Briggs Institute, and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The PubMed, Embase, Web of Science, and ACM Digital Library databases will be searched for peer-reviewed papers. The ProQuest Dissertations and Theses and Global Index Medicus databases will be searched for gray literature. The results will be screened against our inclusion and exclusion criteria. Subsequently, the data extracted from the included studies will be analyzed. RESULTS: As of March 2022, a preliminary search of the peer-reviewed databases has yielded over 4900 studies, and more are anticipated when gray literature databases are searched. We expect that after duplicates are removed and screening is completed, a much smaller number of studies will meet all of our inclusion criteria. CONCLUSIONS: Although there has been much discussion about the importance of design for lowering barriers to digital health participation, the evidence base demonstrating its impacts on health equity is less obvious. We hope that our findings will contribute to a better understanding of the impact that design in digital health has on health equity and that these findings will translate into action that leads to stronger, more equitable health care systems.

The impact of eHealth on the quality and safety of health care: a systematic overview.

BACKGROUND: There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care. METHODS AND FINDINGS: We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking. CONCLUSIONS: There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.

Telehealthcare for asthma: a Cochrane review.

BACKGROUND: Telehealthcare has the potential to provide care for long-term conditions that are increasingly prevalent, such as asthma. We conducted a systematic review of studies of telehealthcare interventions used for the treatment of asthma to determine whether such approaches to care are effective. METHODS: We searched the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including CENTRAL (the Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PsycINFO, as well as other electronic resources. We also searched registers of ongoing and unpublished trials. We were interested in studies that measured the following outcomes: quality of life, number of visits to the emergency department and number of admissions to hospital. Two reviewers identified studies for inclusion in our meta-analysis. We extracted data and used fixedeffect modelling for the meta-analyses. RESULTS: We identified 21 randomized controlled trials for inclusion in our analysis. The methods of telehealthcare intervention these studies investigated were the telephone and video- and Internet-based models of care. Meta-analysis did not show a clinically important improvement in patients' quality of life, and there was no significant change in the number of visits to the emergency department over 12 months. There was a significant reduction in the number of patients admitted to hospital once or more over 12 months (risk ratio 0.25 [95% confidence interval 0.09 to 0.66]). INTERPRETATION: We found no evidence of a clinically important impact on patients' quality of life, but telehealthcare interventions do appear to have the potential to reduce the risk of admission to hospital, particularly for patients with severe asthma. Further research is required to clarify the cost-effectiveness of models of care based on telehealthcare.

Telehealthcare for chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a disease of irreversible airways obstruction in which patients often suffer exacerbations. Sometimes these exacerbations need hospital care: telehealthcare has the potential to reduce admission to hospital when used to administer care to the pateint from within their own home. OBJECTIVES: To review the effectiveness of telehealthcare for COPD compared with usual face-to-face care. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register, which is derived from systematic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; last searched January 2010. SELECTION CRITERIA: We selected randomised controlled trials which assessed telehealthcare, defined as follows: healthcare at a distance, involving the communication of data from the patient to the health carer, usually a doctor or nurse, who then processes the information and responds with feedback regarding the management of the illness. The primary outcomes considered were: number of exacerbations, quality of life as recorded by the St George's Respiratory Questionnaire, hospitalisations, emergency department visits and deaths. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data. We combined data into forest plots using fixed-effects modelling as heterogeneity was low (I(2) < 40%). MAIN RESULTS: Ten trials met the inclusion criteria. Telehealthcare was assessed as part of a complex intervention, including nurse case management and other interventions. Telehealthcare was associated with a clinically significant increase in quality of life in two trials with 253 participants (mean difference -6.57 (95% confidence interval (CI) -13.62 to 0.48); minimum clinically significant difference is a change of -4.0), but the confidence interval was wide. Telehealthcare showed a significant reduction in the number of patients with one or more emergency department attendances over 12 months; odds ratio (OR) 0.27 (95% CI 0.11 to 0.66) in three trials with 449 participants, and the OR of having one or more admissions to hospital over 12 months was 0.46 (95% CI 0.33 to 0.65) in six trials with 604 participants. There was no significant difference in the OR for deaths over 12 months for the telehealthcare group as compared to the usual care group in three trials with 503 participants; OR 1.05 (95% CI 0.63 to 1.75). AUTHORS' CONCLUSIONS: Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. However, further research is needed to clarify precisely its role since the trials included telehealthcare as part of more complex packages.

Digital health and primary care: Past, pandemic and prospects.

This article reflects on the breadth of digital developments seen in primary care over time, as well as the rapid and significant changes prompted by the COVID-19 crisis. Recent research and experience have shone further light on factors influencing the implementation and usefulness of these approaches, as well as unresolved challenges and unintended consequences. These are considered in relation to not only digital technology and infrastructure, but also wider aspects of health systems, the nature of primary care work and culture, patient characteristics and inequalities, and ethical issues around data privacy, inclusion, empowerment, empathy and trust. Implications for the future direction and sustainability of these approaches are discussed, taking account of novel paradigms, such as artificial intelligence, and the growing capture of primary care data for secondary uses. Decision makers are encouraged to think holistically about where value is most likely to be added, or risks being taken away, when judging which innovations to carry forward. It concludes that, while responding to this public health emergency has created something of a digital 'big bang' for primary care, an incremental, adaptive, patient-centered strategy, focused on augmenting rather than replacing existing services, is likely to prove most fruitful in the longer term.

Mobile devices and wearable technology for measuring patient outcomes after surgery: a systematic review.

Complications following surgery are common and frequently occur the following discharge. Mobile and wearable digital health interventions (DHI) provide an opportunity to monitor and support patients during their postoperative recovery. Lack of high-quality evidence is often cited as a barrier to DHI implementation. This review captures and appraises the current use, evidence base and reporting quality of mobile and wearable DHI following surgery. Keyword searches were performed within Embase, Cochrane Library, Web of Science and WHO Global Index Medicus databases, together with clinical trial registries and Google scholar. Studies involving patients undergoing any surgery requiring skin incision where postoperative outcomes were measured using a DHI following hospital discharge were included, with DHI defined as mobile and wireless technologies for health to improve health system efficiency and health outcomes. Methodological reporting quality was determined using the validated mobile health evidence reporting and assessment (mERA) guidelines. Bias was assessed using the Cochrane Collaboration tool for randomised studies or MINORS depending on study type. Overall, 6969 articles were screened, with 44 articles included. The majority (n = 34) described small prospective study designs, with a high risk of bias demonstrated. Reporting standards were suboptimal across all domains, particularly in relation to data security, prior patient engagement and cost analysis. Despite the potential of DHI to improve postoperative patient care, current progress is severely restricted by limitations in methodological reporting. There is an urgent need to improve reporting for DHI following surgery to identify patient benefit, promote reproducibility and encourage sustainability.

Why Canada Is in Court to Protect Healthcare for All: Global Implications for Universal Health Coverage.

Countries worldwide are currently endeavoring to safeguard the long-term health of their populations through implementing Universal Health Coverage (UHC), in line with the United Nation's 2015-30 Sustainable Development Goals (SDGs). Canada has some of the world's strongest legislation supporting equitable access to care for medically necessary hospital and physician services based on need, not ability to pay. A constitutional challenge to this legislation is underway in British Columbia (BC), led by a corporate plaintiff, Cambie Surgeries Corporation (CSC). This constitutional challenge threatens to undermine the high bar for UHC protection that Canada has set for the world, with potential adverse implications for equitable international development. CSC claims that BC's healthcare law-the Medicare Protection Act (MPA)-infringes patients' rights under Canada's constitution, by essentially preventing physicians who are enrolled in BC's publicly-funded Medicare plan from providing expedited care to patients for a private fee. In September 2020, after a trial that ran for 3.5 years and included testimony by more than 100 witnesses from around the world, the court dismissed the plaintiffs' claim. Having lost their case in the Supreme Court of BC, the plaintiffs' appealed in June 2021. The appellate court's ruling and reasons for judgment are expected sometime in 2021. We consider the evidence before the court from the perspective of social epidemiology and health inequalities, demonstrating that structural features of a modern society that exacerbate inequalities, including inequitable access to healthcare, can be expected to lead to worse overall societal outcomes.

Digital health interventions in palliative care: a systematic meta-review.

Digital health interventions (DHIs) have the potential to improve the accessibility and effectiveness of palliative care but heterogeneity amongst existing systematic reviews presents a challenge for evidence synthesis. This meta-review applied a structured search of ten databases from 2006 to 2020, revealing 21 relevant systematic reviews, encompassing 332 publications. Interventions delivered via videoconferencing (17%), electronic healthcare records (16%) and phone (13%) were most frequently described in studies within reviews. DHIs were typically used in palliative care for education (20%), symptom management (15%), decision-making (13%), information provision or management (13%) and communication (9%). Across all reviews, mostly positive impacts were reported on education, information sharing, decision-making, communication and costs. Impacts on quality of life and physical and psychological symptoms were inconclusive. Applying AMSTAR 2 criteria, most reviews were judged as low quality as they lacked a protocol or did not consider risk of bias, so findings need to be interpreted with caution.