Digital Care Pathway for Patients With Sleep Apnea in Specialized Care: Mixed Methods Study

BACKGROUND

Sleep apnea is a significant public health disorder in Finland, with a prevalence of 3.7%. Continuous positive airway pressure (CPAP) therapy is the first-line treatment for moderate or severe sleep apnea. From November 18, 2019, all patients who started their CPAP therapy at Oulu University Hospital were attached to a sleep apnea digital care pathway (SA-DCP) and were instructed on its use. Some patients still did not use the SA-DCP although they had started their CPAP therapy.

OBJECTIVE

We aimed to study health care professionals' (HCPs') perspectives on the SA-DCP and its usefulness for their work; whether the main targets of SA-DCP can be reached: shortening the initial guiding sessions of CPAP therapy, reducing patient calls and contact with HCPs, and improving patients' adherence to CPAP therapy; and patients' perspectives on the SA-DCP and its usefulness to them.

METHODS

Overall, 6 HCPs were interviewed in May and June 2021. The survey for SA-DCP users (58/91, 64%) and SA-DCP nonusers (33/91, 36%) was conducted in 2 phases: from May to August 2021 and January to June 2022. CPAP device remote monitoring data were collected from SA-DCP users (80/170, 47.1%) and SA-DCP nonusers (90/170, 52.9%) in May 2021. The registered phone call data were collected during 2019, 2020, and 2021. Feedback on the SA-DCP was collected from 446 patients between February and March 2022.

RESULTS

According to HCPs, introducing the SA-DCP had not yet significantly improved their workload and work practices, but it had brought more flexibility in some communication situations. A larger proportion of SA-DCP users familiarized themselves with prior information about CPAP therapy before the initial guiding session than nonusers (43/58, 74% vs 16/33, 49%; P=.02). Some patients still had not received prior information about CPAP therapy; therefore, most of the sessions were carried out according to their needs. According to the patient survey and remote monitoring data of CPAP devices, adherence to CPAP therapy was high for both SA-DCP users and nonusers. The number of patients' phone calls to HCPs did not decrease during the study. SA-DCP users perceived their abilities to use information and communications technology to be better than nonusers (mean 4.2, SD 0.8 vs mean 3.2, SD 1.2; P<.001).

CONCLUSIONS

According to this study, not all the goals set for the introduction of the SA-DCP have been achieved. Despite using the SA-DCP, some patients still wanted to communicate with HCPs by phone. The most significant factors explaining the nonuse of the SA-DCP were lower digital literacy and older age of the patients. In the future, more attention should be paid to these user groups when designing and introducing upcoming digital care pathways.

Hoitoprosessien uudistamattomuus haastaa terveydenhuollon digitalisaatiota

Suomi tavoittelee digitalisaation edelläkävijyyttä uudistamalla julkisten palvelujen prosesseja ja sähköistämällä palveluja. Terveydenhuollossa sähköisten asiointipalvelujen käyttöönotolla tavoitellaan yhä parempia terveydenhuollon palveluita ja kustannushyötyjä. Sähköisten asiointipalveluiden käyttö on viime vuosina lisääntynyt, mutta käyttömäärä on edelleen alhainen digitalisaation toteutumiseksi. Sähköisten asiointipalveluiden käytön lisääntymisen yhdeksi haasteeksi on havainnoitu hoitoprosessien uudistamattomuus. Etelä-Pohjanmaan sähköisten asiointipalveluiden parantamiseksi, tämän tutkimuksen tavoitteena oli selvittää, miten terveydenhuollon hoitoprosessit huomioidaan sähköisten asiointipalveluiden kehittämistyössä Etelä-Pohjanmaalla. Tavoitteen saavuttamiseksi tutkittiin, millaisia sähköisiä asiointipalveluja terveydenhuollossa on käytössä ja kehitteillä, millaiseksi sähköisten asiointipalveluiden käytön yleisyys arvioidaan, millainen sähköisten asiointipalveluiden ja terveydenhuollon hoitoprosessien yhteenliittymä on, millä tavoin sähköisten asiointipalveluiden kehittämistyötä toteutetaan ja mitkä ovat Covid-19-pandemian vaikutukset sähköisiin asiointipalveluihin terveydenhuollossa. Tutkimuksen lähtökohta kuvattiin kirjallisuuskatsauksella, jossa haettiin tietoa terveydenhuollon sähköisistä palveluista Pohjoismaista. Tiedot terveydenhuollon hoitoprosessien huomioimisesta sähköisten asiointipalveluiden kehittämistyössä kerättiin terveydenhuollon ja tietohallinnon ammattilaisten haastatteluista. Terveydenhuollossa on käytössä erilaisia sähköisiä asiointipalveluja, joita on tarpeen kehittää sujuvamman asiointikokemuksen mahdollistamiseksi. Sähköisten asiointipalveluiden käyttöönottojen yhteydessä tehdään muutoksia hoitoprosesseihin, mutta prosesseja ei uudisteta suunnittelemalla, miten sähköisten palvelujen hyödyt saavutetaan. Sähköisten asiointipalveluiden kehittämistyötä toivottiin edistettävän ja sisällyttämään työhön prosessisuunnittelu entistä vahvemmin. Sähköisten palveluiden ja prosessien muotoilulle yhtenäiseksi kokonaisuudeksi on olemassa hyvät edellytykset. Tulevaisuudessa on tärkeää määritellä sähköisten asiointipalveluiden hyötytavoitteet ja tehdä strategia niiden saavuttamiseksi. Sähköisten asiointipalveluiden hyödyt konkretisoituvat, kun määritellyt prosessivaiheet digitalisoidaan siten, että ne ovat osa työkäytänteitä ja kansalaisten asiointia.

National Development and Regional Differences in eHealth Maturity in Finnish Public Health Care: Survey Study

Background

eHealth increasingly affects the delivery of health care around the world and the quest for more efficient health systems. In Finland, the development of eHealth maturity has been systematically studied since 2003, through surveys conducted every 3 years. It has also been monitored in several international studies. The indicators used in these studies examined the availability of the electronic patient record, picture archiving and communication system, health information exchange, and other key eHealth functionalities.

Objective

The first aim is to study the national development in the maturity level of eHealth in primary health care and specialized care between 2011 and 2020 in Finland. The second aim is to clarify the regional differences in the maturity level of eHealth among Finnish hospital districts in 2020.

Methods

Data for this study were collected in 2011, 2014, 2017, and 2020, using web-based questionnaires from the Use of information and communication technology surveys in Finnish health care project. In total, 16 indicators were selected to describe the status of eHealth, and they were based on international eHealth studies and Finnish eHealth surveys in 3 areas: applications, regional integration, and data security and information and communications technology skills. The indicators remain the same in all the study years; therefore, the results are comparable.

Results

All the specialized care organizations (21/21, 100%) in 2011, 2014, 2017, and 2020 participated in the study. The response rate among primary health care organizations was 86.3% (139/161) in 2011, 88.2% (135/153) in 2014, 85.8% (121/141) in 2017, and 95.6% (130/136) in 2020. At the national level, the biggest developments in eHealth maturity occurred between 2011 and 2014. The development has since continued, and some indicators have been saturated. Primary health care lags behind specialized care organizations, as measured by all the indicators and throughout the period under review. Regionally, there are differences among different types of organizations.

Conclusions

eHealth maturity has steadily progressed in Finland nationally, and its implementation has also been promoted through various national strategies and legislative changes. Some eHealth indicators have already been saturated and achieved an intensity of use rate of 100%. However, the scope for development remains, especially in primary health care. As Finland has long been a pioneer in the digitalization of health care, the results of this study show that the functionalities of eHealth will be adopted in stages, and deployment will take time; therefore, national eHealth strategies and legislative changes need to be implemented in a timely manner. The comprehensive sample size used in this study allows a regional comparison in the country, compared with previous country-specific international studies.

Informing the Product Development of an mHealth Solution for People with Multiple Sclerosis Through Early Health Technology Assessment

The potential of mHealth is enormous for chronic conditions, yet the integration of these technologies into the clinical infrastructures and healthcare pathways remains an ongoing challenge. Digi-HTA has been developed to support health technology assessment activities for novel digital healthcare technologies. The use of Early Health Technology Assessment (EHTA) can help product development. The present study describes the way in which EHTA can guide the development of a product to anticipate future needs and market access.

Digi-HTA, assessment framework for digital healthcare services: information security and data protection in health technology – initial experiences

It is well-known that security issues in medical devices, services and applications have potentially catastrophic consequences. To avoid compromising patient data or information systems, it is essential that healthcare services and products meet the relevant information security and data protection requirements. For these reasons, the Digi-HTA assessment includes information security and data protection assessment domains. The outcome of the Digi-HTA process is a recommendation that decision-makers can use during the procurement process. We present results and experiences from the first assessments made in the Digi-HTA process. We have assessed six products so far and multiple assessments are in progress. The results indicate that healthcare product manufacturers have found the process useful, and usually, the manufacturers have had to improve the security of their product during the Digi-HTA process to get a favourable recommendation for their product. The assessment processes have taken longer than expected due to shortcomings and ambiguities in the provided self-assessment forms, and due to feedback cycles and meetings prompted by assessment findings. Of the six assessed products, four received a green light in information security and data protection, whereas two have received a yellow light due to issues that were not fixed during the process. In addition to shortcomings in adhering to best practices, we have also found exploitable security issues.

Regional health information exchange outside of the centralized national services for public health care in Finland: A national survey

Health information exchange (HIE) is the mobilization of health care information electronically across organizations within a region, community, or hospital system. Nordic countries have been developing their health portals including national HIE services systematically. In Finland HIE begun with various regional health information exchange (RHIE) pilots in since 1998. The Kanta patient data repository component in the national HIE has been adopted in routine use since 2012. The current role of non-Kanta RHIE in relation to Kanta services is somewhat unclear. Our research questions are following: 1) Has the availability of RHIE services changed during 2017-2020? 2) What functional types of RHIE are there in Finland in 2020? 3) From the point of view of healthcare provider organizations, at what level is the availability to combine regional information seamlessly into the same view of local patient record systems? Data used in this study were collected using web-based questionnaires in 2017 and 2020 as part of the surveys for monitoring and assessment of social welfare and health care information system services in Finland. This study reported in this article covers all 21 public hospital districts and nearly all public primary health care centers. The quantitative data provided by the organizations were analyzed using SPSS software (version 25). The availability of a particular service or function was calculated as a percentage of all respondents in each sector. The results of this study show that the overall availability of RHIE services has not markedly changed 2017-2020. Functional types of RHIE meaning the role, use and types of RHIE in hospital districts in Finland varies greatly in 2020. We recognized three different types of non-Kanta RHIE in the non-combination organizations (one-way, symmetrical, full symmetrical). Seamless integration of at least some Kanta data into the same view as the main patient health record system data was more common than seamless integration of at least some non-Kanta regional data.

Potilastietojärjestelmiin liitetyt erikoisalakohtaiset erillisjärjestelmät julkisessa erikoissairaanhoidossa 2014–2020

Terveydenhuollossa on käytössä useita erilaisia tietojärjestelmiä. Niistä keskeisimpänä voidaan mainita potilastietojärjestelmät, joita käytetään niin potilaiden hoitotietojen kirjaamiseen kuin palvelujen ja toimenpiteiden ajanvaraamiseenkin. Terveydenhuollon tietojärjestelmiin kuuluvat oleellisina myös erillisjärjestelmät, jotka ovat erityistä toimintaprosessia tai erikoisalaa varten hankittuja järjestelmiä. Erillisjärjestelmiä on Suomessa eri lähteiden ja määritelmien mukaan kymmenistä jopa tuhansiin, ja erilaisten tietojärjestelmien suuri määrä ja pirstaloitunut tietojärjestelmäkokonaisuus haittaavat muun muassa kliinisen työn sujuvuutta. Tämän tutkimuksen tavoitteena oli saada käsitys erillisjärjestelmien tuotemerkkien ja käytön tämänhetkisestä tilanteesta julkisessa erikoissairaanhoidossa sekä selvittää erillisjärjestelmien integraatioaste eli missä määrin ne ovat käytettävissä ydinpotilastietojärjestelmän kautta. Lisäksi tarkoituksena oli tehdä ajallista vertailua pyrkimyksenä muodostaa kuva siitä, mihin suuntaan erillisjärjestelmien käytössä ollaan menty ja mihin suuntaan mahdollisesti ollaan menossa. Tutkimus toteutettiin analysoimalla vuonna 2020 kerättyä terveydenhuollon organisaatiokyselyn osa-aineistoa sekä vertailemalla sitä vuoden 2017 ja 2014 aineistoihin vastaavilta osin. Tutkimuksen perusteella erillisjärjestelmien integraatioaste on kasvanut vuodesta 2017 ja voidaan olettaa, että sen suunta on vastaisuudessakin samanlainen. Kolmen viimeisimmän kyselyn aikana erillisjärjestelmien käyttö eri erikoisaloilla on kaikkiaan yleistynyt sairaanhoitopiirien keskuudessa, ja käytössä olevien tuotemerkkien määrä on niin ikään pääasiassa lisääntynyt. Niiden osalta valtakunnalliset uudistukset ja hankkeet terveydenhuollossa saattavat kuitenkin muuttaa kehityksen suunnan jatkossa. Tulosten perusteella erikoisalakohtaisten erillisjärjestelmien käytön yleisyys sairaanhoitopiireissä ei kulje käsi kädessä tuotemerkkien määrän tai integraatioasteen kanssa, ja erikoisalojen välillä oli havaittavissa isojakin eroja näiden muuttujien osalta. Erillisjärjestelmien runsaasta määrästä voidaan päätellä, että erikoisalakohtaisten järjestelmien kliininen tarve on yhä olemassa. Laaja järjestelmäkirjo aiheuttaa kuitenkin haasteita, mikä ilmeni ristiriitaisissa vastauksissa koskien erityisesti integraatioastetta.

Finnish e-health services intended for citizens – national and regional development

Electronic health care (e-health) services intended for Finnish citizens have been recently developed nationally, regionally, and locally through several projects and programs. This study aimed to investigate the development and availability of e-health services for Finnish citizens in specialized and primary health care and private medical service providers from 2011 to 2020. In addition, the differences between the availability of services in different sectors and regional differences between hospital districts were investigated. Data were collected using web-based questionnaires in 2011, 2014, 2017, and 2020 from “Use of information and communication technology surveys in Finnish health care”. This study covers all 21 hospital districts, nearly all primary health care centers, and a sample of private medical service providers. Quantitative data were analyzed using SPSS software (version 25). The availability of an e-health service was calculated as a percentage of all respondents in each sector. The results of this study show that public and private health care organizations extensively offered health care services on their websites. Almost all organizations had information on well-being, provided services, contact methods, and locations, as well as options to send electronic feedback. Remote consultation, electronic appointment booking services, and telephone counseling were also extensively offered. This study revealed that the volume of e-health services increased from 2011 to 2020. For instance, remote consultation services and information exchange through encrypted email increased rapidly during follow-up periods in all service sectors. Comparing service sectors revealed that specialized health care covers e-health services more extensively than do primary health care and private service providers. According to this study, there are also clear differences in the availability of services between hospital districts and no hospital district offered all studied services. These results suggest the need to clarify national and regional development responsibilities and standardize the availability of e-health services within and between hospital districts.

Digi-HTA: Health technology assessment framework for digital healthcare services

Health technology assessment (HTA) refers to the systematic evaluation of the properties, effects, and/or impacts of health technology. The main purpose of the assessment is to inform decisionmakers in order to better support the introduction of new health technologies. New digital healthcare solutions like mHealth, artificial intelligence (AI), and robotics have brought with them a great potential to further develop healthcare services, but their introduction should follow the same criteria as that of other healthcare methods. They must provide evidence-based benefits and be safe to use, and their impacts on patients and organizations need to be clarified. The first objective of this study was to describe the state-of-the-art HTA methods for mHealth, AI, and robotics. The second objective of this study was to evaluate the domains needed in the assessment. The final aim was to develop an HTA framework for digital healthcare services to support the introduction of novel technologies into Finnish healthcare. In this study, the state-of-the-art HTA methods were evaluated using a literature review and interviews. It was noted that some good practices already existed, but the overall picture showed that further development is still needed, especially in the AI and robotics fields. With the cooperation of professionals, key aspects and domains that should be taken into account to make fast but comprehensive assessments were identified. Based on this information, we created a new framework which supports the HTA process for digital healthcare services. The framework was named Digi-HTA.

How to improve communication using technology in emergency medical services? A case study from Finland

The field of emergency medical services (EMS) is a challenging environment for ensuring fluent information exchange between stakeholders because several different kinds of organizations are involved in EMS missions. Solutions for information and communication technology can vary significantly depending on the organization. This study aims to identify current communication bottlenecks between EMS professionals, understand the technological challenges behind them, and describe technologies that can improve EMS communication in the future. Information for the study about current EMS processes, technologies, and technology needs was collected from EMS professionals during three workshops, five personal interviews, and one email questionnaire. All surveyed health care professionals were working in the county of Northern Ostrobothnia. Information about proposed technologies for EMS was obtained from literature and interviews with five technology companies. The principal problem in EMS communication is scattered health data. This leads to a lack of common situational awareness for professionals and incomplete medical histories for patients. The reasons behind those problems are different information systems which do not communicate with each other and the lack of a common electronic patient care record (ePCR) for use by stakeholders. Personal health measurements, sensors, telemedicine, and artificial intelligence will create opportunities for further improving the flow of communication in EMS, provided those tools can be integrated into decision-making systems. 

A significant role of sarcoplasmic reticulum in cardiac contraction of a basal vertebrate, the river lamprey (Lampetra fluviatilis)

AIM

Cardiac contraction and relaxation are mediated by rapidly changing calcium concentration around the myofibrils. In comparison with endotherms, ectothermic hearts are more strongly dependent on extracellular calcium for contraction suggesting this trait might represent the primitive vertebrate mode of cardiac activation. This study tests the hypothesis that intracellular calcium stores play a minor role in cardiac excitation-contraction coupling of a basal vertebrate, the lamprey (Lampetra fluviatilis).

METHODS

Contribution of sarcoplasmic reticulum to cardiac calcium management was examined by measuring the ryanodine sensitivity of contraction, determining the number of cardiac ryanodine receptors and their calcium sensitivity, assessing the size of sarcoplasmic reticulum calcium stores in enzymatically isolated cardiac myocytes and qualitative electron microscopic observations of sarcoplasmic reticulum in cardiac muscle.

RESULTS

An extensive network of nonjunctional sarcoplasmic reticulum around myofibrils and numerous junctional sarcoplasmic reticulum couplings at the periphery of the myocytes was present in atrial and ventricular muscle of the lamprey heart. High numbers of ryanodine receptors were present in atrial (0.16 ± 0.04 nmol mg(-1) prot) and ventricular membranes (0.27 ± 0.03) (P < 0.01), and 10 μm ryanodine inhibited large part of contraction force in atrial (37.8 ± 5.7%) and ventricular (49.2 ± 6.5%) muscle.

CONCLUSION

Sarcoplasmic reticulum is well developed in the lamprey heart and plays a significant role in cardiac calcium management. This suggests that in the common ancestor of vertebrates, cardiac excitation-contraction coupling could have been fairly strongly dependent on sarcoplasmic reticulum calcium stores. Functionally, this trait might be associated with high cardiac output and active predatory lifestyle of the lamprey.

Electrophysiological properties and expression of the delayed rectifier potassium (ERG) channels in the heart of thermally acclimated rainbow trout

In ectotherms, compensatory changes in ion channel number and activity are needed to maintain proper cardiac function at variable temperatures. The rapid component of the delayed rectifier K+current ( IKr) is important for repolarization of cardiac action potential and, therefore, crucial for regulation of cellular excitability and heart rate. To examine temperature plasticity of cardiac IKr, we cloned the ether-à- go- go-related gene (ERG) channel and measured its electrophysiological properties in thermally acclimated rainbow trout ( Oncorhynchus mykiss; omERG). The present findings demonstrate a complete thermal compensation in the whole cell conductance of the atrial IKrin rainbow trout acclimated to 4°C (cold acclimation) and 18°C (warm acclimation). In situ hybridization indicates that transcripts of the omERG channel are present throughout the muscular tissue of the heart, and quantitative PCR shows increased expression of the omERG in cold-acclimated trout compared with warm-acclimated trout. In both acclimation groups, omERG expression is higher in atrium than ventricle. In addition, the omERG has some functional features that support IKractivity at low temperatures. Voltage dependence of steady-state activation is completely resistant to temperature changes, and steady-state inactivation and activation kinetics are little affected by temperatures below 11°C. Collectively, these findings suggest that high density of cardiac IKris achieved by cold-induced increase in the number of functional omERG channels and inherent insensitivity of the omERG to temperature below 11°C. These adaptations are probably important in maintaining high heart rates and proper excitability and contractility of trout cardiac myocytes in the cold.

Fish cardiac sodium channels are tetrodotoxin sensitive

AIM

Sodium current (I(Na)) of the mammalian heart is resistant to tetrodotoxin (TTX) due to low TTX affinity of the cardiac sodium channel (Na(v)) isoform Na(v)1.5. To test applicability of this finding to other vertebrates, TTX sensitivity of the fish cardiac I(Na) and its molecular identity were examined.

METHODS

Molecular cloning and whole-cell patch-clamp were used to examine alpha-subunit composition and TTX inhibition of the rainbow trout (Oncorhynchus mykiss) cardiac Na(v) respectively.

RESULTS

I(Na) of the trout heart is about 1000 times more sensitive to TTX (IC50 = 1.8-2 nm) than the mammalian cardiac I(Na) and it is produced by three Na(v)alpha-subunits which are orthologs to mammalian skeletal muscle Na(v)1.4, cardiac Na(v)1.5 and peripheral nervous system Na(v)1.6 isoforms respectively. Oncorhynchus mykiss (om) omNa(v)1.4a is the predominant isoform of the trout heart accounting for over 80% of the Na(v) transcripts, while omNa(v)1.5a forms about 18% and omNa(v)1.6a only 0.1% of the transcripts. OmNa(v)1.4a and omNa(v)1.6a have aromatic amino acids, phenylalanine and tyrosine, respectively, in the critical position 401 of the TTX binding site of the domain I, which confers their high TTX sensitivity. More surprisingly, omNa(v)1.5a also has an aromatic tyrosine in this position, instead of the cysteine of the mammalian TTX-resistant Na(v)1.5.

CONCLUSIONS

The ortholog of the mammalian skeletal muscle isoform, omNa(v)1.4a, is the predominant Na(v)alpha-subunit in the trout heart, and all trout cardiac isoforms have an aromatic residue in position 401 rendering the fish cardiac I(Na) highly sensitive to TTX.