Telemonitoring of Real-World Health Data in Cardiology: A Systematic Review

Design Requirements for Cardiac Telerehabilitation Technologies Supporting Athlete Values: Qualitative Interview Study

BACKGROUND

Cardiac telerehabilitation (CTR) interventions can provide accessible and affordable remote rehabilitation services. However, as cardiac rehabilitation (CR) primarily targets inactive patients, little is known about the experiences with CR of highly active patients (ie, recreational athletes or, simply, athletes) with established coronary artery disease. Consequently, existing CTR interventions do not address the specific needs of the athletic subpopulation. Understanding the needs and values of athletes is crucial for designing meaningful CTR interventions that enhance user acceptance and engagement, thereby facilitating effective rehabilitation for this patient subgroup.

OBJECTIVE

This study aimed to inform the design of technologies that facilitate CTR for athletes. We intended to identify athletes' values related to CR, including health and sports tracking, as well as high-level requirements for technologies that can facilitate the CTR of athletes according to the identified values.

METHODS

We used value-sensitive design with a human-centric design approach to elicit design requirements for CTR that can serve athletes with established coronary artery disease. To identify athletes' values, we conducted 25 value-oriented semistructured interviews with 15 athletic patients and 10 health care professionals involved in CR programs. In a second phase, we conducted 6 card-sorting focus group sessions with 13 patients and 7 health care professionals to identify desired CTR features. Finally, we derived high-level CTR technology requirements connected to the athletes' needs and values.

RESULTS

We defined 12 athlete values divided into 3 categories: body centric, care centric, and data and technology centric. We clustered findings from the card-sorting activity into CTR technology requirements, such as remotely monitored sport-specific training and training data representations next to clinical limitations, and paired them with corresponding values.

CONCLUSIONS

Athletes have distinct values and health goals in CR compared to general populations targeted by CTR interventions. Designing patient-centric CTR interventions that address these needs is crucial to support optimal recovery, safe return to sports, and adherence to CTR technologies in the home environment.

Exploring the Needs and Preferences of Athletes in Cardiac (Tele)Rehabilitation to Enhance Rehabilitation Outcome: A Qualitative Study

Purpose

To define the user needs and preferences of the athletic population in cardiac (tele)rehabilitation (CTR).

Patients and Methods

In this qualitative study, we included athletes with established coronary artery disease (CAD) who participated in a cardiac rehabilitation (CR) program and health care professionals involved in CR. All athletes engaged in sports for at least four hours per week. Fourteen male and one female athlete (mean age 63 ± 10.6 years) participated in CR after an acute coronary syndrome, percutaneous coronary intervention and/or coronary bypass surgery. The twelve healthcare professionals invited included cardiac nurse practitioners, cardiologists, sports physicians, physiotherapists, and a clinical psychologist. This study consists of four phases: a stakeholder identification session, twenty-five semi-structured individual interviews, six card-sorting focus groups and a data analysis phase with thematic analysis.

Results

User needs for athletes in CR encompass personalized exercise plans featuring clear and quantifiable exercise recommendations and limitations. Additionally, there is a need for monitoring health and exercise data; measuring progression and performance longitudinally; easy-to-use, and reliable healthcare information systems with accurate sensors and data; as well as clinical supervision and validation of information and data. Social support from both peers and family is also identified as a crucial need. The preferred technological features for a CTR system tailored for athletes include periodic digital consultations with clinicians, home-based training specific to one's sport, utilization of technology to monitor workouts, data sharing and remote feedback, personalized exercise recommendations and online educational materials.

Conclusion

This research explored the user needs and preferences of athlete patients in CR. The findings indicated that enhancing CR for athletes necessitates a personalized and sport-specific methodology. The integration of various technological features within a CTR program can play a pivotal role in assisting athletes with CAD to maintain an active lifestyle and regain their previous athletic performance levels.

A Remote Patient Monitoring System With Feedback Mechanisms Using a Smartwatch: Concept, Implementation, and Evaluation Based on the activeDCM Randomized Controlled Trial

BACKGROUND

Technological advances allow for recording and sharing health-related data in a patient-centric way using smartphones and wearables. Secure sharing of such patient-generated data with physicians would enable close management of individual health trajectories, monitoring of risk factors, and asynchronous feedback. However, most remote patient monitoring (RPM) systems currently available are not fully integrated into hospital IT systems or lack a patient-centric design.

OBJECTIVE

The objective of this study was to conceptualize and implement a user-friendly, reusable, interoperable, and secure RPM system incorporating asynchronous feedback mechanisms using a broadly available consumer wearable (Apple Watch). In addition, this study sought to evaluate factors influencing patient acceptance of such systems.

METHODS

The RPM system requirements were established through focus group sessions. Subsequently, a system concept was designed and implemented using an iterative approach ensuring technical feasibility from the beginning. To assess clinical feasibility, the system was used as part of the activeDCM prospective randomized interventional study focusing on dilated cardiomyopathy. Each patient used the system for at least 12 months. The System Usability Scale was used to measure usability from a subjective patient perspective. In addition, an evaluation was conducted on the objective wearable interaction frequency as well as the completeness of transmitted data classified into sensor-based health data (SHD) and patient-reported outcome measures (PROMs). Descriptive statistics using box plots and bootstrapped multiple linear regression with 95% CIs were used for evaluation analyzing the influence of age, sex, device experience, and intervention group membership.

RESULTS

The RPM system comprised 4 interoperable components: patient devices, a data server, a data viewer, and a notification service. The system was evaluated with 95 consecutive patients with dilated cardiomyopathy (28/95, 29% female; mean age 50, SD 12 y) who completed the activeDCM study protocol. The system's app achieved a mean System Usability Scale score of 78 (SD 17), which was most influenced by device experience. In total, 87% (83/95) of the patients could integrate the use of the app well or very well into their daily routine, and 71% (67/95) saw a benefit of the RPM system for management of their health condition. On average, patients interacted with the wearable on 61% (SD 26%) of days enrolled in the study. SHD were available on average for 78% (SD 23%) of days, and PROM data were available on 64% (SD 27%) of weeks enrolled in the study. Wearable interaction frequency, SHD, and PROM completeness were most influenced by intervention group membership.

CONCLUSIONS

Our results mark a first step toward integrating RPM systems based on a consumer wearable device for primary patient input into standardized clinical workflows. They can serve as a blueprint for creating a user-friendly, reusable, interoperable, and secure RPM system that can be integrated into patients' daily routines.

Standardized assessment of evidence supporting the adoption of mobile health solutions: A Clinical Consensus Statement of the ESC Regulatory Affairs Committee: Developed in collaboration with the European Heart Rhythm Association (EHRA), the Association of Cardiovascular Nursing & Allied Professions (ACNAP) of the ESC, the Heart Failure Association (HFA) of the ESC, the ESC Young Community, the ESC Working Group on e-Cardiology, the ESC Council for Cardiology Practice, the ESC Council of Cardio-Oncology, the ESC Council on Hypertension, the ESC Patient Forum, the ESC Digital Health Committee, and the European Association of Preventive Cardiology (EAPC)

Mobile health (mHealth) solutions have the potential to improve self-management and clinical care. For successful integration into routine clinical practice, healthcare professionals (HCPs) need accepted criteria helping the mHealth solutions' selection, while patients require transparency to trust their use. Information about their evidence, safety and security may be hard to obtain and consensus is lacking on the level of required evidence. The new Medical Device Regulation is more stringent than its predecessor, yet its scope does not span all intended uses and several difficulties remain. The European Society of Cardiology Regulatory Affairs Committee set up a Task Force to explore existing assessment frameworks and clinical and cost-effectiveness evidence. This knowledge was used to propose criteria with which HCPs could evaluate mHealth solutions spanning diagnostic support, therapeutics, remote follow-up and education, specifically for cardiac rhythm management, heart failure and preventive cardiology. While curated national libraries of health apps may be helpful, their requirements and rigour in initial and follow-up assessments may vary significantly. The recently developed CEN-ISO/TS 82304-2 health app quality assessment framework has the potential to address this issue and to become a widely used and efficient tool to help drive decision-making internationally. The Task Force would like to stress the importance of co-development of solutions with relevant stakeholders, and maintenance of health information in apps to ensure these remain evidence-based and consistent with best practice. Several general and domain-specific criteria are advised to assist HCPs in their assessment of clinical evidence to provide informed advice to patients about mHealth utilization.

The PICOTS-ComTeC Framework for Defining Digital Health Interventions: An ISPOR Special Interest Group Report

OBJECTIVES

Digital health definitions are abundant, but often lack clarity and precision. We aimed to develop a minimum information framework to define patient-facing digital health interventions (DHIs) for outcomes research.

METHODS

Definitions of digital-health-related terms (DHTs) were systematically reviewed, followed by a content analysis using frameworks, including PICOTS (population, intervention, comparator, outcome, timing, and setting), Shannon-Weaver Model of Communication, Agency for Healthcare Research and Quality Measures, and the World Health Organization's Classification of Digital Health Interventions. Subsequently, we conducted an online Delphi study to establish a minimum information framework, which was pilot tested by 5 experts using hypothetical examples.

RESULTS

After screening 2610 records and 545 full-text articles, we identified 101 unique definitions of 67 secondary DHTs in 76 articles, resulting in 95 different patterns of concepts among the definitions. World Health Organization system (84.5%), message (75.7%), intervention (58.3%), and technology (52.4%) were the most frequently covered concepts. For the Delphi survey, we invited 47 members of the ISPOR Digital Health Special Interest Group, 18 of whom became the Delphi panel. The first, second, and third survey rounds were completed by 18, 11, and 10 respondents, respectively. After consolidating results, the PICOTS-ComTeC acronym emerged, involving 9 domains (population, intervention, comparator, outcome, timing, setting, communication, technology, and context) and 32 optional subcategories.

CONCLUSIONS

Patient-facing DHIs can be specified using PICOTS-ComTeC that facilitates identification of appropriate interventions and comparators for a given decision. PICOTS-ComTeC is a flexible and versatile tool, intended to assist authors in designing and reporting primary studies and evidence syntheses, yielding actionable results for clinicians and other decision makers.

On-Field Deployment and Validation for Wearable Devices

Wearable sensors are an important tool in the study of head acceleration events and head impact injuries in sporting and military activities. Recent advances in sensor technology have improved our understanding of head kinematics during on-field activities; however, proper utilization and interpretation of data from wearable devices requires careful implementation of best practices. The objective of this paper is to summarize minimum requirements and best practices for on-field deployment of wearable devices for the measurement of head acceleration events in vivo to ensure data evaluated are representative of real events and limitations are accurately defined. Best practices covered in this document include the definition of a verified head acceleration event, data windowing, video verification, advanced post-processing techniques, and on-field logistics, as determined through review of the literature and expert opinion. Careful use of best practices, with accurate acknowledgement of limitations, will allow research teams to ensure data evaluated is representative of real events, will improve the robustness of head acceleration event exposure studies, and generally improve the quality and validity of research into head impact injuries.

Wearable Devices for Physical Monitoring of Heart: A Review

Cardiovascular diseases (CVDs) are the leading cause of death globally. An effective strategy to mitigate the burden of CVDs has been to monitor patients' biomedical variables during daily activities with wearable technology. Nowadays, technological advance has contributed to wearables technology by reducing the size of the devices, improving the accuracy of sensing biomedical variables to be devices with relatively low energy consumption that can manage security and privacy of the patient's medical information, have adaptability to any data storage system, and have reasonable costs with regard to the traditional scheme where the patient must go to a hospital for an electrocardiogram, thus contributing a serious option in diagnosis and treatment of CVDs. In this work, we review commercial and noncommercial wearable devices used to monitor CVD biomedical variables. Our main findings revealed that commercial wearables usually include smart wristbands, patches, and smartwatches, and they generally monitor variables such as heart rate, blood oxygen saturation, and electrocardiogram data. Noncommercial wearables focus on monitoring electrocardiogram and photoplethysmography data, and they mostly include accelerometers and smartwatches for detecting atrial fibrillation and heart failure. However, using wearable devices without healthy personal habits will cause disappointing results in the patient's health.

Nighttime Sleep Awakening Frequency and Its Consistency Predict Future Academic Performance in College Students

Although the relationship between sleep and academic performance has been extensively examined, how sleep predicts future academic performance (e.g., 2-3 years) remains to be further investigated. Using wearable smartwatches and a self-report questionnaire, we tracked sleep activities of 45 college students over a period of approximately half a month to see whether their sleep activities predicted their academic performance, which was estimated by grade point average (GPA). Results showed that both nighttime sleep awakening frequency and its consistency in the tracking period were not significantly correlated with the GPA for the courses taken in the sleep tracking semester (current GPA). However, both nighttime sleep awakening frequency and its consistency inversely predicted the GPA for the rest of the courses taken after that semester (future GPA). Moreover, students with more difficulty staying awake throughout the day obtained lower current and future GPAs, and students with higher inconsistency of sleep quality obtained lower future GPA. Together, these findings highlight the importance of nighttime sleep awakening frequency and consistency in predicting future academic performance, and emphasize the necessity of assessing the consistency of sleep measures in future studies.

Telemedicine in Cardiology: Modern Technologies to Improve Cardiovascular Patients’ Outcomes—A Narrative Review

The registration of physical signals has long been an important part of cardiological diagnostics. Current technology makes it possible to send large amounts of data to remote locations. Solutions that enable diagnosis and treatment without direct contact with patients are of enormous value, especially during the COVID-19 outbreak, as the elderly require special protection. The most important examples of telemonitoring in cardiology include the use of implanted devices such as pacemakers and defibrillators, as well as wearable sensors and data processing units. The arrythmia detection and monitoring patients with heart failure are the best studied in the clinical setting, although in many instances we still lack clear evidence of benefits of remote approaches vs. standard care. Monitoring for ischemia is less well studied. It is clear however that the economic and organizational gains of telemonitoring for healthcare systems are substantial. Both patients and healthcare professionals have expressed an enormous demand for the further development of such technologies. In addition to these subjects, in this paper we also describe the safety concerns associated with transmitting and storing potentially sensitive personal data.